Determinants of adaptive behaviors during heatwaves in Pakistan: a study based on personal heatwave experiences and hypothetical scenarios

Climate change is one of the most pressing issues of our time, with a range of associated effects threatening the health and lives of people, including sea level rise, global warming, weather events, and wildfires (IPCC 2022). In particular, climate change-induced heatwaves have significantly increased globally over the last decades, with a 68% rise in heat-related deaths among people over 65 years from 2000 to 2021 (Romanello et al. 2022). A recent review of the literature indicates that high temperatures are consistently associated with a higher risk of mortality and morbidity, particularly from cardiovascular and respiratory diseases (Conti et al. 2022). Several recent heatwaves have resulted in large numbers of deaths. The 2003 European heatwave resulted in 70,000 deaths (Robine et al. 2008), the 2010 Eastern European heatwave resulted in 55,000 deaths in Russia (Barriopedro et al. 2011), and 2500 died in the 2015 India heatwave (Mazdiyasni et al. 2017).

Developing countries are particularly susceptible to heatwave impacts, partly due to inadequate infrastructure and poor adaptation measures. This is especially true in South Asia, where more intense heatwaves, urban heat islands, and heat stress conditions are expected in the near future. According to S. Ullah et al., (2022), an estimated 185 to 492 million people will be exposed to daytime heatwaves, and 204–555 million to nighttime heatwaves in South Asia by the end of the century.

Pakistan is considered one of the most susceptible countries in the world to the effects of heatwaves, which are common from May to September and can exceed 50 °C (Rana et al. 2022). The 2015 heatwave in Karachi alone caused over 1200 deaths and 65,000 heat-related illnesses (Chaudhry et al. 2015). Within the Pakistani context, a heatwave is characterized by a scenario where the daily maximum temperature exceeds the average maximum temperature by 5 °C for a period of five or more consecutive days, with the reference period being 1961–1990 (Chaudhry et al. 2015). Moreover, the increasing trend of heatwaves is expected to be devastating to the country’s economy, as 40% of the labor force is involved in outdoor activities (FAO 2022).

Despite the risk posed by heatwaves in Pakistan, very limited research has been conducted to examine the social and cognitive factors that influence perception and behavioral responses during a heatwave (Bakhsh et al. 2018; Rauf et al. 2017). Similarly, Macktoom et al. (2023) highlighted the urban heat challenges faced by the public in Karachi, exploring the politics of shade and its vital but uneven access among outdoor workers. Abdullah et al. (2022) reported on the compounded vulnerabilities of the urban poor to extreme heat and COVID-19. Anwar et al. (2022) studied the governance of urban heat in Karachi, stressing the need for a holistic approach involving both state and non-state actors, while Abdullah and Macktoom, (2022) analyzed the concept of thermos-politics of urban heat in Karachi and highlighted the complex interplay of responses to heat stress. Growing evidence suggests the importance of implementing adaptive strategies against heatwaves, such as reducing physical activity, increasing water intake, finding cooling shelters, and staying in air-conditioned environments (Alcoforado et al. 2015; Howe et al. 2023).

However, to facilitate adaptation it is essential to thoroughly understand the processes and motivation behind the decisions of people to act or not. Studies on heatwave adaptative behaviors have highlighted different influencing factors such as risk perception, perceived self-efficacy, past experiences, socio-economic norms/beliefs, being old or being female, income, education, and social network among others (Akompab et al. 2013; Esplin et al. 2019; Khare et al. 2015; Rauf et al. 2017). An examination of current adaptative strategies used at a societal level, and an analysis of the challenges and facilitators can provide insights for future planning to effectively adapt to the increasing threat of heatwaves, especially in a heatwave-prone country like Pakistan.

The importance of experience likely depends on factors such as location, intensity, duration, type, and how it's defined (Hau et al. 2010; Ruddell et al. 2012). For climate change-related hazards, personal experience has often been limited to witnessing a specific event or suffering substantial losses from it (Sharma and Patt 2012). Socio-cognitive theories are increasingly being used to explore people’s perceptions and encourage adaptation to climate change-induced risks since knowledge and perception can motivate behavioral change. In this regard, the Health Belief Model (HBM) has been proposed as a useful theoretical framework for studying adaptive behaviors during heatwaves (Akompab et al. 2013; Arsad et al. 2022; Beckmann et al. 2021; Grothmann et al. 2017; Rauf et al. 2017; Richard et al. 2011; Valois et al. 2020; Wang et al. 2022). Briefly, this model postulates that individuals’ desire to take action to protect their health is contingent upon their belief that they are vulnerable to a particular risk, that the resultant consequences would be severe, that they have available options to prevent it, and that the benefits overweight the costs (Green et al. 2020). Therefore, the objective of the present study was to use the HBM to evaluate the factors associated with adopting adaptive behaviors to heatwaves in Pakistan. This study also explored determinants of adaptive behaviors during heatwaves in subgroups such as urban vs rural, heatwave experiences vs hypothetical scenarios, and unemployed, formal, and informal occupations. This approach enables us to comprehensively understand how individuals perceive heatwaves at different population levels and the adaptations they might consider. This study specifically focused on adaptive responses to heatwaves and not chronic heat conditions, with the questionnaire designed to capture heatwave-related perceptions and behaviors among a sample of volunteers registered with the Alkhidmat Foundation across Pakistan.

Heatwaves threaten many communities around the world. Lack of preparedness and poor adaptation, resulting in increasing deaths and illnesses, is concerning. This study provides important insights from a country highly exposed to climate extremes. To the best of our knowledge, this is the first study investigating adaptive behaviors in Pakistan.

This study has both strengths and limitations. Previous research in Pakistan had been limited to urban areas only (Rauf et al. 2017), while our study covered all the regions of Pakistan and obtained responses from both urban and rural participants. Moreover, the study examined adaptive behaviors at both the individual and household levels, yielding valuable insights from both perspectives. Among the possible limitations, it should be noticed that, as the analysis was not based on a random sample of the population, there could be a potential selection bias. The study's reliance and dependence on a small sample of 686 volunteers from an organization limits its reflections on Pakistan's broad demographic diversity, thereby hindering the universality of its findings, introducing considerable biases, and underscoring concerns about its wider applicability. We also acknowledge the fact that since the respondents are volunteers with the Alkhidmat Foundation Pakistan, there might be a possibility that they are more aware of different disasters occurring in Pakistan as they are usually active in the disaster response phase. Another limitation is the analysis of adaptive behaviors by incorporating responses from reported personal experiences and hypothetical scenarios. While self-reported experiences provide valuable insights, responses to hypothetical scenarios might not perfectly reflect actual behaviors during their real heatwave experiences. Future research should explore the use of additional data sources, such as real-time monitoring of actions taken during heatwaves as well as conduct research in areas with recurrent heatwaves across Pakistan, to further refine the understanding of adaptive behaviors. As the study was conducted over a long period, many of the responses will arguably be affected by incomplete/inaccurate memory or patchy retrospective recollections of the heatwave events, hence, future research should address this limitation. Another limitation includes relying on participants' self-reported classification of their residences as urban or rural, potentially introducing subjective biases. Likewise, as the study was conducted in Urdu and English, there is a possibility of linguistic bias because certain people might be more comfortable responding in other regional languages. The Urdu translation of the HBM itself might not perfectly capture the original HBM. The exclusion of the ‘Not Applicable (NA)’ in the Likert scale limits data for questions not universally relevant. For example, ‘wearing a hat when going outside’ might not apply to everyone. Without ‘NA’, participants might choose options that don’t reflect their reality, suggesting a need for more inclusive future survey designs. It is important to acknowledge that family members may not always be in agreement regarding responses to climate change as highlighted by Head et al., (2016). Therefore, it should be noted that responses on household adaptive measures might not necessarily represent the opinion of the whole family, as they often reflect the perspectives of individual family members who participated in the survey. However, it should be also noted that some of the associations were found both at the individual and household levels. Finally, we chose to dichotomize different variables in our analysis because of sample size constraints. Larger studies are warranted in the future to thoroughly evaluate the shape of the relationship between HBM constructs and adaptive measures using more flexible approaches.

Climate change is expected to change the world in the coming decades drastically. Heatwaves frequency, intensity, severity, and duration are predicted to increase in the coming years (IPCC 2022). As such, we need to prepare a resilient society that can meet the increased demand for adaptation during heatwaves. In light of the United Nations Secretary-General António Guterres, describing the latest IPCC report as no less than “a code red for humanity”, calls for decisive changes in our approach to the climate emergency are gaining momentum among scholars (Beckmann et al. 2021; Carman and Zint 2020; Noll et al. 2022; Valente et al. 2022). These calls are directed toward policymakers and decision-makers to engage and foster the implementation of individual and household adaptive behaviors. By examining responses in both actual and hypothetical heatwave scenarios, this research strengthens our understanding of how individuals and households assess heatwave risks and subsequently adopts to heatwaves. This is particularly relevant considering the future projections for South Asia, which suggest a rise in the frequency and intensity of both daytime and nighttime heatwaves (S. Ullah et al. 2022). No statistically significant relationship was observed between risk perception and adaptive behaviors, thus confirming previous findings (Akompab et al. 2013). The study highlights the usefulness of the HBM constructs for understanding heatwave adaptive behaviors. Perceived benefits (e.g., believing staying cool is helpful), and self-efficacy (e.g., confidence in taking cooling measures) strongly influenced individual actions during heatwaves. Along with self-efficacy, cues to action (e.g., warnings or instructions) were most important for household measures during heatwaves. By examining the effect of the constructs of the HBM on adaptive behaviors during heatwaves, this study enhances our understanding of how behavioral change theories can be applied effectively to assess people’s adaptative behaviors. Moreover, unlike other studies on heatwaves, this research applied all six constructs of the HBM, fulfilling a research gap previously identified by scholars. The findings of this study provide valuable insights into how individuals can be motivated to adopt certain behaviors during heatwaves. By leveraging the identified predictor variables, policymakers, disaster managers, health promotion specialists, and urban planners can all design and implement more effective heat health action plans to motivate behavior change during heatwaves.