Adaptation to heat stress: a qualitative study from Eastern India

Heat stress adversely impacts a growing proportion of individuals in India. The heat-related lived experiences of Indians in smaller towns and villages are largely unknown. We conducted seven structured focus group discussions in the town of Dalkhola, West Bengal, India; with 5–10 participants in each group. All conversations were digitally audio recorded, transcribed into Bengali, and then translated to English. Two researchers separately performed a thematic analysis of the transcripts to identify common themes pertaining to the ‘effects of heat’ and ‘coping strategies’ used by participants. A total of 56 (mean age 48.9 ± 17.6; female 61%; Scheduled Tribe 9%) individuals participated. There was wide variation in individual experiences of heat, with some people preferring to work in the winter while others preferred the summer. Housing characteristics, nature of work, gender and access to water and green spaces heavily influenced an individual’s vulnerability to heat stress. Trees were seen as the primary coping strategy for heat stress (regardless of vulnerability), though many participants noted a loss of tree cover in their vicinity. Cool drinking water from public taps and electric fans (particularly table fans) were other preferred coping mechanisms. Many participants did not have adequate access to cool drinking water or electric fans, leading to increased adverse experiences from heat. Based on participant input, several action items were identified for municipal and state/central governments, schools, and private organizations. Individuals affected by heat have a clear preference for nature-based solutions. This is in contrast with the current design of most heat action plans in India, which put more emphasis on infrastructure, information dissemination and behavioral solutions. Various agencies (governments, schools, private organizations) seeking to adapt to increasing heat stress need to better integrate citizen perspectives into their heat action plans.


Introduction
As global temperatures steadily rise above preindustrial levels, the effects of climate change on human wellbeing and health are increasing [1].A major consequence of this is increasing heat stress.Impacts of high temperatures on human mortality are well-established across countries globally [2].India is home to the largest number of people affected by high heat stress, a number only expected to grow with time [3].Anthropogenic sources of increased heat stress are not limited to climate change, but also include the built environment and loss of green and blue spaces [4].Furthermore, the risk to human well-being is the result of an interaction between heat stress exposure and vulnerability [5].Given the multitude of heat stress sources, and the mediating effect of vulnerability on risk, it is important to center the lived experiences of most affected individuals in formulating a societal response.This approach can help prioritize response measures, promote inclusion, and improve equity.
There is a paucity of literature on the lived experiences of Indians in smaller towns and villages, with respect to their experiences of increasing heat [6].Understanding their experiences can also help formulate better heat action plans (HAPs), which are currently not built for local context and are poor at targeting vulnerable groups [6].Adequately incorporating the lived experiences of those most impacted may help HAPs better adapt to local context and needs.For instance, a lived experience report from British Columbia in Canada recommended that the focus of the province should be on cooling infrastructure, not just cooling centers.In addition, they highlighted that rural and urban communities have differing priorities and needs related to heat stress, and the response should be adapted accordingly [7].In India, reports evaluating the experiences of people living in rural Maharashtra not only highlighted their vulnerabilities such as improper housing and outdoor-based occupations, but also demonstrated the importance of focusing on increasing green cover and findings solutions that are less dependent on the built environment [8].Efforts to better understand the lived experiences of people living in small towns and villages of India and learning from their coping mechanisms can help develop HAPs that can effectively cater to the local population.
We therefore conducted a series of FGDs with participants from Dalkhola, West Bengal to understand the effects of heat on their lives and their coping mechanisms.

Study design
The study consisted of FGDs designed to qualitatively assess adaptive measures to heat stress in a single town in India.The study was conducted in Dalkhola, West Bengal, India in 2023 (figure 1) [9].There were seven focus groups of 5-10 participants each, resulting in a total of 56 participants.To facilitate discussion, a semi-structured guide was developed that employs key concepts from the literature on heat stress adaptation.The guide was modified based on discussions with three community health workers (CHWs).In keeping with standard focus group discussion (FGD) methodology, a trained female interviewer of a similar socioeconomic background, with a college degree, led the discussion in the local language, Bengali [10].A second person (AK) was in the room and took notes on nonverbal cues and important dynamics.All conversations were digitally audio recorded, transcribed into Bengali, and then translated to English.At the conclusion of the discussions, subjects were given Rs. 100 as remuneration.All FGDs took place in a community hall at the center of town, accessible to all study participants.One to two FGDs were conducted every day over five days, to ensure participation by diverse members of the community.Ethical approval was obtained from Institutional Ethics Committee of Lord Buddha Koshi Medical College and Hospital, Saharsa, India.All participants provided written, informed consent prior to participating in the discussion.

Selection of participants and groups
Individuals were considered for participation if they resided in Dalkhola, and consented to the study.There were no exclusion criteria.Participants were approached by CHWs in person for recruitment, with the goal of having a wide representation of socioeconomic backgrounds and age groups.We particularly aimed to have an adequate representation of marginalized communities and those with other social and/or economic disadvantage(s).Participants were grouped based on work environment (indoor vs outdoor) and housing type (pucca house, metal house, plastic/tarpaulin dwelling).In addition, senior citizens and homemakers were interviewed in separate groups.

Data analysis
Based on established methods of qualitative research, a thematic analysis was conducted on each question [11].Two researchers (S Y and A K) analyzed the notes and transcripts across each of the seven groups and entered the data into tables.Data tables were organized by question, capturing the frequency of topics, extensiveness of the response across participants, and sample quotes.The notes were supplemented as needed with the audiotapes to glean details from the FGDs.The two researchers met frequently to discuss and reach consensus on response categories, identifying both common and differing themes across groups.

Results
Characteristics of the participants are summarized in table 1.The mean age was 48.9 ± 17.6, with participant age ranging from 24 to 90 years.Sixtyone percent of participants were female.Five participants (9%) were from the Banjara community, a community with Scheduled Tribe status.All five of these participants had unstable housing, and lived in plastic/tarpaulin dwellings.Photographs of the four different types of dwellings used by participants is shown in figure 2.
All participants (100%) agreed that the summer season had increased in length and intensity, with some participants noting that the increase had happened gradually.The most commonly cited reason for this was the lack of trees and lakes, due to cutting of trees and filling of lakes.The term 'Climate change' was not mentioned by any participant.

Effects of heat
Participant reported effects of heat are summarized in table 2. Some participants (12%) noted a preference to work in the summer, while most preferred to work in the winter (88%), as summarized by two participants below, 'My work involves hauling sacks.I prefer to work in the winter as in the summer it gets very hot, and my legs as well as hands get swollen.''I love to work during the summer.In the winter season, we have to wear winter clothes and it is very heavy.Also, we have to wait for some time in the morning to start working (due to the cold).In summer its a little difficult, but the work gets finished early.' Participants noted that it was now hot for nearly 10 months of the year, with only 2 months being cool.People living in metal houses noted that their houses got very hot during the day, which was further worsened by cooking inside the house.They only experienced relief from heat at night, often as late as 11 PM.Conversely, people living in pucca houses noted that their house was cooler during the day, but got very hot at night.On the other hand, people living in a plastic/tarpaulin dwelling uniformly noted that their dwelling got very hot and was unbearable to live in.As one such participant noted, 'When we sleep under the tent, it feels like we are inside a tandoor (traditional Indian cooking vessel).It is very hot, but what can we do.We have to live there.'

Coping strategies used by participants
Coping strategies used by participants are summarized in table 3.By far, trees were seen as the primary coping strategy.Many participants noted a lack of trees, throughout the town and also around their own house.Most participants (67%) thought it was a good idea to have a house surrounded by trees, though some individuals did not have adequate space to plant trees around their house.Tree shade was thought to be more effective than fans by some participants.For people from the Banjara community, their precarious living situation did not allow them any agency in tree plantation, as summarized by one participant, 'How can we plant trees when we are residing in someone else's land?They will not allow us.We have been living here for 10 years.We alternate between living on either side of the road for 10 years.When we are driven from one side, we go to the opposite.If we are driven from the other side, we come back here.'Some outdoor workers (18%) could not carry drinking water when going for work, as shown below, 'We have a bag of 10-20 kg of wares, which is already heavy.Carrying an additional load of drinking water, with one bottle weighing 1 kg, is not feasible for us.We ask for water from houses or shops on the way, and they usually provide it.Usually, it is warm water but sometimes we are able to get cool water.'Pucca house refers to dwellings that are designed to be solid and permanent, and are usually made of concrete, cement and/or brick.Metal house refers to a house where either the walls or roof is made of tin, steel, or aluminum.These houses are usually less sturdy than pucca houses, and are cheaper than pucca houses.Plastic/tarpaulin house refers to people sheltering under a plastic or tarpaulin sheet/tent.Bamboo house refers to low-income housing that is primarily made of bamboo.In this particular situation, it is less sturdy and permanent than pucca houses.
Other participants noted the increasing commercialization of water, particularly cooled water, 'The cold water bottle costs about Rs. 20 per bottle.We poor cannot afford this.'Most participants did not have an air-conditioned (AC) space, at home or work.None of the participants had plans to acquire a personal AC unit, primarily due to the high cost.One participant had a single room with an air-conditioning unit.On hot days, all family members stayed in that room to cool themselves off.
One participant, who worked as a tailor, preferred summer to winter, and was relatively comfortable through the summer (without owning a refrigerator or air-conditioning unit), 'I love to work in the summer season because in winter the day starts late, so I am delayed by two to three hours.The tin roof over my shop gets very hot, so the ceiling fan air also gets very hot.So, I use a table fan for relief from the heat.There is a water tap beside my shop which gives cold water, so I can drink cold water when I am in the shop.But when I am at home, I can only drink hot water.My (pucca) house is surrounded by trees so at the time of power cut, we all go outside and sit below the trees.We do not stay at home for long periods during the summer.Most of the time we are outside (near trees).'

Action items for heat adaptation
To adapt to increasing heat, most participants (67%) noted the need for more trees and water bodies, particularly near residential spaces.They emphasized the need to conserve existing trees, while expanding tree cover.Participants also noted the large role that accessible public cool water taps can play in improving their coping abilities, as summarized by one participant, 'If there is a nearby tap, we can get some cold water and it will help cool us down.When we are tired from work, if we were to get some cool water, it would feel very good.'Some participants noted that due to the COVID-19 related slowdown in economic activity, they felt a perceptible drop in heat stress and more comfortable than previous years.Participants were generally pessimistic about the future, expecting heat stress to increase as a result of increasing concretization, trees being cut down and the absence of water bodies.Climate change was not mentioned as a reason for the expected increase in heat stress.As one participant who lives in a plastic tent and had limited access to water noted, 'They fill the lakes to make houses.Everyone takes a bath inside their house.Where do people like us go?' Table 4 describes action items for heat adaptation, based on participant responses.Responses were categorized based on the most appropriate agency that could implement changes.Using the same responses, an adaptation pyramid was developed and is shown in figure 3.

Discussion
Our study has several important findings.First, there was a clear preference for nature-based solutions to adapt to increasing heat, which did not vary by vulnerability.This preference is in contrast with the current design of most HAPs in India, which put more emphasis on infrastructure, information dissemination and behavioral solutions [6].Second, there is a wide variation in the experience of heat between individuals, with some individuals even preferring the summer season over winter.Outdoor workers and those with unstable housing were most affected by the heat, while individuals who had adequate access to tree shade, cool water and fans were least affected by the summer.Of note, this variation was despite a negligible number of participants having access to AC spaces.Third, most participants focused on proximate causes of increased heat such as concretization, cutting of trees and filling of lakes in their vicinity.Climate change was not cited as a reason for adverse heat experiences.Given the low awareness of climate change, it may be more effective to emphasize co-benefits of climate change action, rather than focus on climate change only.The most frequently reported symptom of heat exposure was dizziness.Dizziness in the setting of heat exposure is suggestive of dehydration, which may be explained by the inadequate access to water for many participants.Repeated episodes of dehydration can also lead to chronic kidney disease, with outdoor unorganized workers in India having a 1.5 fold higher risk of kidney dysfunction, compared to indoor organized workers [12].This underscores the critical importance of water in heat adaptation, particularly cooled water that is available at no cost at point of use.Some participants lamented the loss of public cooled water facilities, and the increasing commercialization of water in the form of bottled cool water.
Anger was the most common mental effect reported, sometimes resulting in physical violence directed at children.While participants did not specifically report physical violence against their female partners, that may have been due to the associated social taboo [13].Epidemiological studies have shown that high ambient temperature are associated with an increased risk of intimate partner violence against women [14].Participant reports of increased anger, frustration and irritation are consistent with these epidemiological findings.They are also consistent with reports of increased hate speech with hot temperature extremes [15].Also, many participants reported that they were unable to participate in family life after work, as a result of increased exhaustion from the heat.The combination of these effects on mental well-being may result in weakened family bonds overall as a result of high ambient temperatures, with disproportionate effects on women and children [16].
The loss of labor productivity as a result of increased heat exposure has been well documented for outdoor workers [17,18].In our study, the effect of heat on self-reported labor capacity was variable among participants.Many participants, particularly those with increased vulnerability, mentioned that they were unable to modify their volume of work based on ambient temperatures, due to their precarious economic condition.Inability of socioeconomically disadvantaged people to reduce work in The denominator represents the number of responses during all FGDs to the particular question.
response to increased heat stress has also been noted in mobility studies from high-income countries [19].Awareness campaigns and heat-health early warning systems implicitly assume capacity for behavior change in response to threat awareness [20].However, this may not be true for the most vulnerable groups.
It is therefore crucial that awareness campaigns and early warning systems are adequately integrated with action plans that enhance the capacity of vulnerable groups to cope with heat.Ensuring adequate green cover in vulnerable communities and access to public cooled water facilities can substantially enhance the coping abilities of vulnerable communities in India.
It is important to note that these are medium to long term measures, and in the absence of these investments, awareness campaigns and early warning systems alone are unlikely to help the most vulnerable groups.Note-spending time under a tree also allowed some individuals a break from the stress of family life.Due to cooking and other household responsibilities, some women are unable to leave their house to escape the heat During a power cut, many individuals went outdoors under a tree shade to cope with the heat Individuals who did not live or work in the vicinity of a tree used a concrete wall for shade, or went inside a shop.They did not find this as comfortable as tree shade, with the concrete wall often radiating more heat to the individual During hot days, children used the shade of a large tree as a play space Individuals who had trees surrounding their house were able to access tree shade for thermal comfort more often Note-Some individuals had a designated mat they used to sit under their favorite tree in the summer Water Bathe more frequently (2-3 times a day), 18% [ Note-given the adverse fan/person ratio, some participants preferred the shade of a tree during hot days Using a hand fan soaked in water, when there is loss of electricity, 6.6% (3/45) Due to concern over electricity costs, electric fan(s) were used sparingly by many participants Note-for some people, the choice was between food costs and cost of electricity For some low-income people, a hand fan was the only fan based cooling aid they had Note-the cost of a hand fan was reported to be Rs.10, making it the only affordable option for some.Some people reported using clothes as a hand fan (Continued.)The denominator represents the number of responses during all FGDs to the particular question.
We found evidence of a disproportionate effect of heat on women.Their coping abilities were constrained by social and cultural norms, increasing their vulnerability.While gendered vulnerability has been well-described before, the mechanisms by which this happens are inadequately understood [6,21].For instance, we found that many women are unable to go outside (to a tree shade) to escape daytime heat within the house, as they are responsible for a large share of household responsibilities such as cooking.Even within the household, cooking (especially with solid fuels) exposes them to more heat stress than other family members.Adding a third layer of vulnerability, women often have to wear more clothes in common spaces (such as a kitchen) than they prefer, due to cultural norms regarding clothing in the presence of in-laws or other men.
Reliance on air-conditioning for relief from heat is unsustainable and marginalizes communities most   vulnerable to heat [22].Moreover, excessive exposure to AC spaces might impair physiological acclimatization to the prevailing environment, showing the limitations of technological and infrastructural adaptations [23].Consistent with this, an observational study of low-income housing occupants in Mumbai showed lower thermal sensitivity and a wider comfort temperature band for occupants, compared to their affluent counterparts [24].None of our participants suggested that governments or non-profits should create AC spaces to provide heat relief, or make air-conditioners more affordable for personal purchase and use.Instead, they repeatedly emphasized the pivotal role of nature-based solutions, and lamented the loss of urban green infrastructure.An analysis of four major Indian cities shows a continuous decline in green and blue spaces in recent years, with corresponding increase in built up area.
Of greater concern, this decline in green and blue spaces is projected to continue over the next decade [25].This is consistent with an overall decline in forest cover in India, along with controversial changes to the methodology of national forest cover reports [26].A goal of at least 30% tree cover for urban areas (distributed equitably) can cool cities considerably, leading to improvements in well-being and premature mortality [27].Most Indian cities do not meet the 30% threshold, though they did so not too long ago.For instance, tree cover in Mumbai has declined from 46% to 26% in just three decades (1991-2018), with a 2 • C rise in temperature over the same time period [28].Steps such as the Mumbai Climate Action Plan, which has a goal of increasing vegetation cover by 30%-40% by the year 2030, within an integrated holistic approach, can provide a path forward for Indian cities [29].
Electric fans are widely used in India for coping with heat.According to the 2019-21 National Family Health Survey, 88% of households reported having one [30].However, our participants noted several caveats in the use of fans for coping with heat.Firstly, they made a clear distinction between ceiling fans and table fans, with most participants finding more thermal comfort with table fans.They pointed out that the ceiling of their single story houses often got hot during the day, leading to the ceiling fan being ineffective in providing relief from heat.However, a table fan continued to provide relief during that time.This shows a need for adequate focus on table fans in policy making, as they are often overlooked in comparison to ceiling fans [31].Second, most participants reported that the number of fans they owned (often one) was not enough to provide relief to all members of the household.Our findings show that the effectiveness of fans for coping with heat depends not just on external temperature and humidity, but also choice of fan (table vs ceiling), fan/person ratio and the household's capacity to afford the costs of electricity.It is also important to note that unlike trees and public cooled water facilities, a substantial number of people, often the most vulnerable, cannot use fans (for instance, our participants in plastic/tarpaulin dwellings).
A major limitation of our study is that this was a single site study.There may be significant regional variations in heat experiences across geographies that preclude a generalized approach to understanding the experience of heat in the entire Indian population.We think the study can serve as a model to carry out similar exercises in different urban and rural environments, to inform municipal and state HAPs.Second, despite the discussions being led by a trained female interviewer of a similar socioeconomic background as the participants, we cannot exclude the possibility of some responses being biased by the communication strategies of the interviewer.To minimize this and other possible biases, we followed standard FGD methodology [10].

Conclusion
We show that individuals in a small town in Eastern India are experiencing a variety of adverse physical and mental effects from heat, including effects on children.Groups who were more vulnerable included women, daily wage laborers and outdoor workers, those living in plastic/tarpaulin dwellings and those with lower access to water and green spaces.Preferred coping mechanisms did not vary significantly by vulnerability.Nature-based solutions, particularly trees, were seen as the primary coping strategy followed by public cool drinking water facilities and electric fans (especially table fans).Very few participants owned a personal air-conditioner, and none of the participants planned to acquire one in the near future, primarily due to cost barriers.Various agencies (governments, schools, private organizations) seeking to adapt to increasing heat stress need to better integrate citizen perspectives into their HAPs.

Figure 1 .
Figure 1.Maximum temperature ( • C) for microregions of India in 2020.Source: This figure was modified from Vieira et al [9] who undertook a statistical analysis of extreme temperatures in India from 1951 to 2020.The figure is available under Creative Commons Attribution 4.0 International License.Reproduced from Vieira et al [9].CC BY 4.0.

Figure 2 .
Figure 2. Photograph of the four different dwellings used by participants.Photo credit Aditya Khetan.

Table 1 .
Characteristics of participants.
Data presented as mean ± SD or % (number).

Table 2 .
Participant reported effects of heat.

Table 3 .
Coping strategies used by participants.

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Note-some individuals did not have access to cool water for bathing.Usual source of cool water for participants was water drawn from underground Drinking

Table 4 .
Action items for heat adaptation, by agency.

Table 4 .
(Continued.)Yearly maintenance (before onset of summer) should be performed on the facilities, with clear signage on the facility Provide table fans to low income households that do not have a fan, provided they have adequate access to electricity For outdoor work, have an early start in the summer (e.g. 6 AM) with adequate breaks during peak periods of heat Normalize season appropriate clothing, especially clothing that is appropriate for summer Many organizations have dress codes that are not appropriate for a tropical climate, and rely on air-conditioning to mitigate the effects of excessive clothing