Rapid warming in Tibet, China: public perception, response and coping resources in urban Lhasa
© Bai et al.; licensee BioMed Central Ltd. 2013
Received: 30 March 2013
Accepted: 25 August 2013
Published: 27 August 2013
Tibet, average altitude more than 4,000 meters, is warming faster than anywhere else in China. The increase in temperatures may aggravate existing health problems and lead to the emergence of new risks. However, there are no actions being taken at present to protect population health due to limited understanding about the range and magnitude of health effects of climate change.
The study was a cross-sectional survey of 619 respondents from urban Lhasa, Tibet in August 2012 with the aim to investigate public perceptions of risk, heat experiences, and coping resources.
Respondents are aware of the warming that has occurred in Lhasa in recent years. Over 78% reported that rising temperature is either a “very” or “somewhat” serious threat to their own health, and nearly 40% reported they had experienced heat-related symptoms. Sex, age, education and income influenced perceived risks, health status, and heat experience. The vast majority of respondents reported that they had altered their behaviour on hot summer days. Bakuo, a sub-district at the city center, is considered especially vulnerable to heat because of sparse vegetation, high population density, poor dwelling conditions and a high proportion of low-income population. However, neighborhood social ties were stronger in Bakuo than other study locations.
The study suggests that actions are needed now to minimize downside effects of rapid warming in Tibet, because of increasing human exposure to high temperatures and uneven distribution of the resources needed to cope.
KeywordsClimate change Global warming Perceptions Human health Tibet Vulnerability
Heat is a threat to human health in many parts of the world [1, 2]. The Fourth Assessment Report of the Intergovernmental Panel on Climate Change (IPCC) points out that climate change is already exacerbating the global burden of disease and premature deaths and the impact of high temperatures is expected to increase in the future . A large amount of research has investigated the effects of heat on public health and vulnerability to heat . Most of these studies were conducted in developed countries and less information is available from developing countries though these are considered to be most vulnerable to climate change and climate variability.
Tibet of China, lying at an average altitude of more than 4,000 meters, covers more than 1,228,400 square kilometers, and accounts for one eighth of China’s total land mass. It has been called “the third pole of the world” and “the Asian water tower” . In recent years, Tibet has faced a number of environmental challenges, including changes in the climate [5–7]. Average temperatures in Tibet have been rising 0.32°C every decade since the 1960s, four times faster than elsewhere in China and twice the global average increase . Winter temperatures in Tibet have been increasing at a faster rate than any other inland areas of China, between 0.29°C ~ 1.04°C every decade . Indeed, the Tibetan plateau, a region which contributes minimal carbon dioxide emissions, is likely to be one of the areas most sensitive to global warming . Changes are evident in the capital city, Lhasa. In 2009, on the hottest summer day, the maximum temperature in Lhasa reached 30.4°C. Before this, the highest record was 29.9°C in 1971. An enhanced urban heat island effect has been observed in Lhasa, especially in winter . If warming continues it is projected that Tibetans and millions of people in western China will be exposed to more frequent severe weather events .
Previous research has suggested that an individual’s perceived risk is closely related to daily mitigating actions and adaptive behaviour changes . However, despite the increase of epidemiological studies of heat and health, little work has been done on how the public perceives heat [11–15], particularly in developing regions. To our knowledge, no research to date has been conducted in Tibet to examine public views of the health impacts of rising temperatures. The goal of the study was to explore public perceptions, experiences of heat-related symptoms and behaviour changes in four urban sub-districts in Lhasa. The study also evaluated coping resources in the four study locations, based on dwelling conditions, the prevalence of home air conditioning and relationships with neighbours.
Population density of four study locations provided by Sub-district Offices.
Data collection and analysis
To measure perceptions of climatic warming and responses among the urban population in Lhasa, we developed a questionnaire based on previous studies of climate change and human health risks [11–15]. In order to localize the survey and make it culturally acceptable, the questionnaire was developed in consultation with public health officials of Tibet CDC (Center for Disease Control and Prevention). All questions in the survey were close-ended questions using different Likert-type items or other categorial items such as “Yes”, “No”, “Don’t know” or “Don’t remember”.
Section ‘A’ asked several questions about heat perceptions including whether the weather in Lhasa is getting warm and will become warmer in future, how large a health risk due to climatic warming was perceived to be, for human beings in general and for themselves, which natural disasters were biggest threat to themselves and how dangerous future warming was perceived. Previous epidemiologic studies have linked heat-related illness to chronic conditions, particularly pre-existing cardiovascular and respiratory illness. Section ‘B’ asked questions on health status of the respondents and experiences of heat. A question was included on what types of information would be helpful to cope with heat-related illness. Section ‘C’ included questions on how people modify their behavior on hot days, and this was followed by a series of questions regarding economic and social resources for dealing with heat covering dwelling quality, air conditioning and/or a fan at home, and neighborhood social ties, as reported in a previous heat vulnerability study . The final section ‘E’ sought socio-demographic information from the respondent.
We pre-tested the instrument to ensure all questions were clear and understandable. More than forty field interviewers (including our research team members, local public health staff and staff working with sub-district offices and community committees) were then trained by the first author and corresponding author. All local interviewees were able to speak both Mandarin and Tibetan. Training lasted five hours and included an item-by-item review of the questionnaire, survey methods, communication skills and social and cultural sensitivity. Interviewees practised the survey scripts with a paired partner. The first author and corresponding author reviewed each interviewee’s survey, pointed out inappropriate methods, manners and choice of words, and inspected the quality of each survey script.
Surveys were administered to residents older than 18 years who lived in the four urban sub-districts all year around. After consulting with local Community Committees, we realized that it was not possible to recruit participants by random sampling due to local cultural sensitivities. Also, the study was carried out during daylight hours because it is not culturally acceptable by Tibetans residents to conduct interviews at other times. Three days before the surveys started, the staff of each Community Committee informed all residents living in the community about the purpose, period and location of the survey and encouraged them to participate. Those who agreed to be interviewed then came to the Community Committee to complete the survey during the study period.
In order to avoid possible bias, we developed face-to-face questionnaire surveys which were filled out by trained interviewees after asking questions one by one. In order to improve representativeness, the age ratio of the Sixth Census of Lhasa in 2010 was used as the reference in selecting the number in each age group. We obtained ethical approval from the Ethical Review Committee of Chinese Center for Disease Control and Prevention (No. 201214). Written informed content was obtained from all participants prior to survey and all data obtained were anonymized. The data were analyzed by EpiData 3.1 and SPSS18.0. A χ2 test was used to calculate the difference between groups. A stepwise multivariate regression was also applied to examine variables which were significantly associated with having had a heat-related illness in this summer.
Demographic characteristics of respondents
Total(N = 619)
College and above
Monthly income (RMB)
Don’t want to say
To the question “how worried would you be if you hear about an excessive heat warning issue in Lhasa in the near future?” 23% reported that they would be very worried, and 61% reported they would be somewhat worried. Only 3% would be not worried at all. Not surprisingly, those who felt the temperature increase was very dangerous to them were more likely to report that they would be very worried about future heat warnings than those who did not believe they were in danger (47% vs. 5%). Respondents in Bakuo sub-district were slightly more likely than those in the other three sub-districts to report that they were ‘very’ or ‘somewhat’ worried about a heat warning in Lhasa. Lastly, participants were provided with several health-related risks and asked to select the biggest threat to them. Although the results indicated a wide recognition of climatic warming as a risk to human health among respondents, few of them (5%) believed extreme heat was the biggest threat of all. Over half reported that they were most fearful of natural disasters such as earthquakes. Air pollution, fires and traffic accidents were named by 17%, 14% and 8% respectively. Once again, the response varied among different income groups. The overwhelming majority of low income respondents were more likely to report that the natural disasters were the biggest threat, while those with relatively high incomes tended to select other risks apart from the natural disasters.
Health status and heat-related condition
Respondents were asked about their health status, history of chronic illness and health-risk behaviors. Overall, 62% reported that they were ‘healthy’ and 32.3% felt their health status were ‘so so’, and the rest of them (5.7%) considered themselves having bad health. Thirty six per cent of the sample reported they were affected by chronic diseases. This group was more likely to report their health status was fair or bad and to perceive that heat was dangerous to them. Results differed across four sub-districts (p = 0.011), with the sample from Zhaxi (39.9%) reporting more pre-existing medical conditions than from others (Gongdelin 28.6%, Gamagongsang 29.8% and Bakuo 36.3%), mainly due to the higher proportion of elderly respondents in that sub-district. Chronic conditions included high blood pressure (47%), cardiovascular diseases (32%), respiratory diseases (18%), diabetes (3%) and cancer (1%). Moreover, 58.3% reported that they had been admitted to a hospital or taken to the emergency room because of the illness. Only 2.4% reported they drank liquor every day, and 15.7% smoked daily.
Stepwise multivariate regression
Having chronic diseases
When participants were asked about the type of climate change and health information they may want to receive, most participants (72.5%) wanted to know about heat-related symptoms and illnesses, followed by 62.5% who wanted to know how to reduce the risks of heat-related illness, 56.4% who wanted to know what to do if you or others have any symptoms and 36.8% who wanted to know how does temperature increase affect human health. Very few respondents (1.3%) reported that they did not want to receive any information.
Of those that responded that they did nothing in particular (6.1%) on excessively hot days, reasons included “the heat does not affect me” (n = 29), “don’t know what to do” (n = 10), “too much troubles” (n = 6) and “financial considerations” (n = 2). Behavior changes among participants on days when it was hot were associated with their perceived risk. Those who felt the rising temperature was not dangerous to them at all were more likely not to modify their behavior on hot days. Similarly, few persons who would be not at all worried about the heat warnings changed their behavior.
Dwelling conditions of four sub-districts [%(n)]
(n = 156)
(n = 155)
(n = 140)
(n = 168)
(N = 619)
2000 and after
Single family House
Public rental housing
Number of room
Four and more
Air-conditioner in home
Fan in home
Heat-related illness and availability of air conditioning and fan at home
Has had heat-related illness during this summer (row percentage)
AC at home
Fan at home
This study is the first in Tibet to investigate public perceptions, experience, behaviour and coping resources regarding high temperatures and future climate change. The findings will inform subsequent quantitative studies including a map-based human health risk assessment and management plan. Overall, we found widespread awareness in the local population of rising temperatures and their effects on health. Some segments of the population are likely to be at greater risk due to environmental differences, demographic factors and limited coping resources.
Previous studies of this kind have been undertaken mainly in developed countries including the USA [11, 12, 15, 17, 18], Australia [19, 20], and Canada [12, 13]. Such studies can provide important information to policy makers and assist in developing and promoting practical adaptation measures. Our study has added a valuable dimension to the existing literature as little has been written previously about perceptions in relation to climate change in developing countries [14, 21]. In many developed country studies there are high levels of knowledge and awareness about climate change  and heat warnings [11, 15]. In Tibet, despite the lack of a heat plan or any educational program, we found that survey respondents were well aware of the rise in temperatures that has occurred and the effects this might have on health. This is consistent with another study conducted in Bangladesh, a developing country which has been identified as one of the most vulnerable to climate change . In Bangladesh there was widespread awareness of global warming among respondents who were mostly rural people with little formal education. We surmise that people in low-income settings may be more likely to regard themself as vulnerable to heat than those in developed countries who live in more comfortable circumstances, are protected by advanced public health infrastructure and are informed via pervasive media coverage. If this is indeed the case, then there is both a need and an opportunity to introduce community-based heat adaption program in regions such as Tibet.
In our study, age and health status were found to be good indicators of perceived risk to heat. Older respondents, along with people with pre-existing chronic diseases saw themselves at greater risk from heat. Those with high incomes were also more likely to consider themselves to be sensitive to the heat, although it is low income groups who in fact are likely to be more vulnerable because of limited coping resources and access to information . However, perception of risk does not mean that rising temperatures are the issue that most concerns people. Earthquakes were named as the biggest threat by most respondents which is understandable given local circumstances. In China’s recent history earthquakes have killed hundreds of thousands of people, and these tragedies have made a big impact on the Chinese population. On the other hand, in Phoenix, already one of the hottest cities in the US, over half of respondents treated increasing heat as the biggest threat, and fewer than 10% of them named earthquakes .
Previous papers addressing the effects of heat on health have concentrated on persons aged 65 years and over [22, 23], and other age-groups have received much less attention. Our findings suggest that middle aged persons in Lhasa may be significantly affected the high temperatures: self-reported heat-related illness was most common in persons aged 42–65. There may be two reasons: this is an age group commonly affected by chronic medical conditions particularly cardiovascular diseases; and, unlike the elderly, most middle age people are still at work and thus may be exposed to more outdoor heat. Our finding is consistent with a model-based quantitative study which reported a marked effect of heat on mortality among person aged 45–64 . The finding that people with chronic diseases reported a higher incidence of heat-related illness than those who do not have chronic medical conditions is in agreement with results from a recent Canadian survey . Over 60% of respondents in our survey with chronic conditions felt their symptoms had been worsened because of the heat. In Tibet, there are unique environmental factors such as extreme altitude and low oxygen pressure that create special challenges to the health of local people. Chronic mountain sickness (CMS) is common, and is marked by hypoxia, high red cell count, and associated heart diseases [25–27], all of which reduce heat tolerance and make Tibetan people even more vulnerable to the rising temperatures forecast under climate change.
A most surprising result in this study is that the vast majority of respondents reported modifying their behaviour because of high summer temperatures. This is totally contrary to a previous study in North America suggesting that few people altered their behaviour during heat events, even if a heat warning or a heat advisory was issued . We further observed that the widespread behaviour changes may exist on a common sense basis since measures most cited by respondents to deal with the heat are drinking more fluids, along with wearing light clothing and staying indoors. These measures are more convenient, easier and somewhat cheaper than moving out of town to a cooler place, going swimming, using a home air-conditioner or seeking an air-conditioned location. It is important in developing regions such as Tibet to take into account cost, convenience, accessibility to adaptive facilities, and the common behaviours of local people when developing and implementing education programs. Finding out about these enabling factors may require in-depth field studies. Moreover, given the demographic differences in behaviour that showed up in our survey, it is equally important to develop specific coping instructions in relation to those at most risks to heat including babies, the elderly, outdoor workers, and people with medical conditions. As expected, a correlation between behaviour changes and perceived risk is observed in our study, and this has been identified by previous research as well . Those who reported not modifying their behaviour on hot days were prone to perceive themselves as immune to the heat and have low or no sense of worry about rising temperatures in Lhasa.
Populations living in urban areas where temperatures tend to be higher than in suburban and rural locations are at greater risk of heat stress. Lack of adequate social and material resources further adds to their vulnerability. Harlan et al.  evaluated residents’ vulnerability to thermal environments of urban neighborhoods by analyzing the relationships between outdoor human thermal comfort index (HTCI), population characteristics and coping resources. They reported that neighborhoods with high population density, sparse vegetation and no open space were exposed to more extreme temperatures. Moreover, local residents, particularly low socio-economic groups, in those warmer neighborhoods, are more vulnerable due to limited resources. In order to understand whether or not people living in urban sub-districts in Lhasa face the same issues, we looked for inequalities in resources across our four study locations. Bakuo, located at the urban core, which is the most densely populated, crowded and noisy sub-district with few green and open spaces is expected to be the hottest area in Lhasa. Bakuo may also be most vulnerable because of the higher proportions of poor people and old dwellings with poor ventilation, small living spaces and low comfort level. The prevalence of home air conditioning is low in urban Lhasa, and lowest of all in Bakuo. We note that air conditioning at home was not found to be a strong protector against heat-related illness in our survey, and this is consistent with at least one previous study .
However, the strongest neighborhood social ties were seen in Bakuo sub-district. The great majority of respondents reported having a close relationship with their neighbors. Other studies in developed countries found that people on a low income suffer from poorer health than richer groups in a society because of either material poverty or a lack of social relationships and support [28–30], while our results indicated the neighbour bonding was weakest in those upper-income people. A possible explanation is that relatively well-off people are prone to isolate themselves from others in their neighborhood and make their social connections with people of similar socio-economic status in other parts of the city, or further afield. Importantly, Perry and Lindell  note that opinions based on personal experience of natural disaster tend to be enhanced through neighbors, friends and strong social networks. The strong neighbour ties that we observed in all sub-districts in Lhasa probably serve to promote information exchange and may be one explanation for the widespread perception of risk due to heat and the high level of reported behaviour changes. Again, for developing regions including Tibet, this indicates a heat adaptation program may be most effective in communities where people have a sense of competence and good neighbor bonding.
Apart from close relationships among neighbors, strong family connections were also observed in Lhasa. Social isolation or living alone, which is identified as a high risk factor in heat events , is not common in Tibet. Most of the households in this study included two or three generations, with an average size of four persons. Unlike other Chinese inland cities with a rapid increasing number of elderly persons living alone, old people in Lhasa normally live with their children and help to look after grandchildren. However, the small proportion (9.4%) of single person households in this study may be an under-estimate, since older people with chronic disease or other conditions that restrict their mobility are less likely to come out and participate in surveys. A more in-depth understanding of local circumstances and vulnerable populations is most important for developing practical adaptive measures and prioritizing actions.
Several limitations of the study should be noted. The study was conducted on a convenience basis due to local factors that prevented strictly random sampling. Older individuals and other subjects at high risk may be underrepresented in our sample. The study was only conducted within four urban sub-districts in Lhasa, so caution should be applied in generalizing the results to other parts of Tibet, particularly rural and remote areas. Additionally, as with all studies of this kind, the answers may be affected by a social desirability bias, meaning that participants are prone to report what they think to be the socially accepted answers, not necessarily their real perceptions.
We recommend either a regional plan or targeted programs to address public health implications of heat or other climate extremes in Tibet, China. Our study suggests that actions are needed now to minimize the downside effects of rapid warming in Tibet, especially in urban areas, because of increasing human exposure to summer higher temperatures and uneven distribution of the resources needed to cope. There are important opportunities for local governments act on risks from heat. Firstly, the high levels of perceived risk show that the population believes temperatures are rising and are likely to affect livelihoods and health. This is a firm basis for public health surveillance to monitor heat-related conditions, paying particular attention to vulnerable groups, so that targeted interventions can be appropriately initiated and prioritized. Other steps to reduce heat stress include upgrading infrastructure in communities, improving the quality of existing old dwellings and increasing public green spaces and parks. Lastly, it is a positive sign that the majority of respondents reported that they wanted to obtain more information on heat and health. This indicates an opportunity for education programs to provide practical tips and information to better prepare for and cope with high temperatures.
Intergovernmental panel on climate change
Center for disease control and prevention
Chronic mountain sickness
Human thermal comfort index.
This study was supported by the National Basic Research Program of China (973 Program) (Grant No. 2012CB955504).
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