International Journal of Disaster Risk Reduction 29 (2018) 94–102

Contents lists available at ScienceDirect

International Journal of Disaster Risk Reduction

journal homepage: www.elsevier.com/locate/ijdrr

Integrated health education in disaster risk reduction: Lesson learned from T

disease outbreak following natural disasters in Indonesia
⁎
Dyshelly Nurkartika Pascapurnamaa,b, , Aya Murakamia, Haorile Chagan-Yasutanb,c,
Toshio Hattorid, Hiroyuki Sasakia, Shinichi Egawaa,b
a
Division of International Cooperation for Disaster Medicine, International Research Institute of Disaster Science (IRIDeS), Tohoku University, 2-1 Seiryo-machi, Aoba-ku,
Sendai 980-8573, Japan
b
International Post-Graduate Program in Human Security, Tohoku University, 2-1 Seiryo-machi, Aoba-ku, Sendai 980-8573, Japan
c
Division of Disaster-related Infectious Diseases, IRIDeS, Tohoku University, 2-1 Seiryo-machi, Aoba-ku, Sendai 980-8573, Japan
d
Graduate School of Health Science and Social Welfare, Kibi International University, Takahashi 716-0018, Japan

A R T I C L E I N F O A B S T R A C T

Keywords: Along with large-scale loss of life, infrastructural damage, and material losses, health issues have become a
Disaster risk reduction crucially important problem after natural disasters. Survivors must confront the threat of health risks, especially
Disaster education infectious diseases, as a result of limited health supplies, services, and facilities. Limited knowledge about health
Health education risks following disasters, in addition to lack of awareness, contributes to the occurrence of infectious diseases
Outbreak prevention
that are fundamentally preventable. This study was conducted to review eight major natural disasters in
Post-disaster health issues
Indonesia that were followed by outbreaks of infectious disease. Results emphasize the importance of integrated
health education in schools and community-based disaster risk reduction (DRR) plans, including information
dissemination, to create resilient communities. Water-borne and air-borne infectious diseases were the most
common illnesses following the eight major natural disasters as a result of aftereffects. Facing the challenges,
schools and community centers can be agents to disseminate health promotion information so that people be-
come more aware of health risks and conduct good practices related to prevention, response, and recovery.
Health education and promotion can be integrated into curriculum-based or training-based DRR programs as
modules, short courses, drills, and printed and visual media.

1. Introduction Development Report 1994 [3]. Health resilience is strongly promoted

Dramatic disruptions such as terrorism, anthropogenic and natural
disasters, and pandemics can create a crisis for countries and increase
pressure on stakeholders that require prompt responses [1]. The crisis
itself can increase people's vulnerability to numerous potential threats
such as food, energy, and health security problems. Good practices in
three cyclical stages are crucially important to address crises: preven-
tion and preparedness, emergency response, and recovery and re-
construction [2]. Especially, those actions in every phase can reduce
risks that occur after natural disasters. Some threats have been ame-
liorated by the humanitarian community, but investment in risk re-
duction after natural disasters remains limited [1].
Increased vulnerability after a crisis is specifically examined in this
study. After natural disasters, people are threatened by potential health
risks. They need well-prepared preventive measures and protection.
Health has become a human security domains, as described in Human
throughout The Report of the UN High-Level Panel on Threats, Chal-
lenges and Change of 2004 because health problems including disease
outbreak pose a threat to human security and to life chances [4]. Health
is also prioritized in the Sendai Framework for Disaster Risk Reduction,
which recommends integration of disaster risk management into each
level of health care and national health systems [5]. Moreover, because
the linkage between health and security is related to the emergence and
re-emergence of infectious diseases, ending the epidemics of AIDS, tu-
berculosis, malaria, and neglected tropical diseases, while combating
hepatitis, water-borne diseases and other communicable diseases by
2030 has become a Sustainable Development Goal [6].
We studied some natural disasters in Indonesia to develop ideas on
how to minimize health risks following natural disasters and to ensure
good quality of life for people. For the past decade, Indonesia, a dis-
aster-prone country, has been struck by natural disasters that have
produced huge numbers of casualties, direct losses, and damaged

⁎
Corresponding author at: Division of International Cooperation for Disaster Medicine, International Research Institute of Disaster Science (IRIDeS), Tohoku University, 2-1 Seiryo-
machi, Aoba-ku, Sendai 980-8573, Japan.
E-mail address: dyshelly.nurkartika@gmail.com (D.N. Pascapurnama).

http://dx.doi.org/10.1016/j.ijdrr.2017.07.013
Received 31 March 2017; Received in revised form 25 July 2017; Accepted 28 July 2017
Available online 29 July 2017
2212-4209/ © 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
D.N. Pascapurnama et al.
infrastructure. Two natural disasters have been widely devastating: an
earthquake followed by tsunami in Aceh and North Sumatra Province in
December 2004, also known as Indian Ocean Tsunami; and an earth-
quake in Yogyakarta and Central Java Province in May 2006. In addi-
tion to those two major natural disasters, natural disasters have oc-
curred such as floods, earthquakes, tsunami, landslides and volcanic
eruptions in the country. Each has created substantial effects on the
affected areas.
Following such natural disasters, aside from the number of deaths
and damaged infrastructure, the threat posed by health risks also looms,
especially the emergence of infectious diseases. Some of following in-
fectious diseases are likely to occur: diarrhea, acute respiratory infec-
tions (ARI) which may interfere normal breathing and caused by virus
or bacteria, dengue, malaria, measles, and tetanus. Natural disasters
also result in “aftereffects” such as displaced populations (including
internally displaced persons (IDPs) and refugees), poor sanitation,
overcrowded space, and limited health supplies in evacuation center
that might increase the possibility of infectious disease outbreak and
worsen conditions for survivors [7]. Aftereffects increase the trans-
mission of infectious disease among survivors. The spread of a disease
becomes more likely as the number of evacuated people increases.
Aside from environmental changes and poor situations at evacuation
centers, it is considered that people's knowledge and awareness of
health risks also becomes one factor determining the occurrence of the
infectious diseases [8]. To tackle these and other challenges, colla-
boration for undertaking preventive measures of post-disaster in-
fectious diseases should be integrated into disaster risk reduction (DRR)
and management plans, and must be done not only by government,
non-government organization (NGO) and non-profit organization
(NPO), but also by public health and humanitarian professionals for the
community [9].
Although results of our research on the tetanus outbreak that oc-
curred after Aceh and Yogyakarta disasters suggest that health educa-
tion is necessary to raise public awareness of the health risks that
prevail after a natural disaster, the actual situation and gaps for health
education and promotion must be investigated further [10]. Therefore,
we conducted a systematic review of major natural disasters in In-
donesia for 13 years (2004–2016), particularly addressing the emer-
gence of infectious diseases after disasters. This study was conducted to
elucidate recommendations for how preventive measures of infectious
diseases can be accomplished through the dissemination of health
education to the community as strategic targets by public health and
humanitarian professionals. Accordingly, those recommendations are
expected in the future to minimize health risks related to infectious
diseases following natural disasters.
2. Material and methods
2.1. Comprehensive literature review
Original publications such as articles, reports and documents were
screened during June 2016 – August 2016 using PubMed, Google
Scholar, the World Health Organization (WHO) website, the govern-
ment of Indonesia's websites, textbooks about disaster management,
and Sphere Project Handbook as available resources. Searches were
conducted using several keywords, including ‘Indian Ocean Tsunami
2004′, ‘Yogyakarta Earthquake 2006′, ‘natural disasters’, ‘infectious
diseases’, ‘outbreak’, ‘prevention’, ‘health education’, and ‘disaster risk
reduction’.
2.2. Selection criteria
For documents published in 2004 or later, only those specifically
including the keywords were examined further. Reports that included
limited data, which were unrelated to disaster education, or which did
not describe health risks posed by infectious diseases after a disaster
95
International Journal of Disaster Risk Reduction 29 (2018) 94–102
were excluded. The search revealed related publications, with the ad-
dition of ‘The Sphere Project’ Handbook, ‘Koenig and Schultz's Disaster
Medicine’, ‘Human Security and Natural Disasters (Routledge
Humanitarian Studies)’, and ‘Disaster Management: International
Lessons of Risk Reduction, Response, and Recovery’ textbooks.
References were selected critically by identifying the contents and valid
data related to disaster events, infectious diseases related to events, and
disaster risk management in Indonesia.
2.3. Selection of DIBI data
Data presented herein were obtained from the “Data dan Informasi
Bencana Indonesia” (Indonesia's Disaster Data and Information, DIBI)
by Badan Nasional Penanggulangan Bencana (Indonesian National
Board for Disaster Management, BNPB) website in http://dibi.bnpb.go.
id/. Data related to disasters were filtered using the times of the dis-
asters (2004–2016), types of disaster (particularly addressing natural
disasters), and the numbers of casualties and IDPs. Data related to the
number of casualties, IDPs, and damaged infrastructure were used to
determine the major disasters occurring within the past 13 years in
Indonesia. We selected the disasters with > 100 casualties and/
or > 1000 IDPs with information in WHO and selected publications
related to infectious disease.
3. Findings
3.1. Major disasters in Indonesia (2004–2016) and infectious diseases
following natural disasters
Screening of DIBI data and identification of infectious disease re-
lated information revealed that eight major natural disasters occurred
during 2004–2016 in Indonesia [11]. The natural disasters mostly took
place in Sumatra and Java islands (Fig. 1), producing death, injury,
IDPs, and damaged infrastructure. Because Sumatra and Java islands
are the most populous islands in Indonesia, the events threatened large
populations and produced strong aftereffects. Those natural disasters
were followed by the occurrence of infectious diseases.
3.1.1. Earthquake and tsunami in Aceh and North Sumatra Province
On December 26, 2004, a M 9.3 earthquake followed by tsunami,
known as the Indian Ocean Tsunami of 2004, hit the northern island of
Sumatra. This third-largest earthquake ever recorded produced its
worst effects in Aceh and Sumatra provinces [12]. The total number of
deaths reached almost 170,000, in addition to 6244 missing, and
around half a million IDPs. Houses, public facilities, and other infra-
structure were damaged severely [11]. Health risks posed by infectious
disease included diarrhea, hepatitis A and E, ARI, measles, meningitis,
malaria and dengue fever among affected people. An uncommon te-
tanus outbreak followed the disaster [7,10,12,13], with at least 100
cases. The outbreak is considered to have been caused by contaminated
wounds that were prevalent at the time of the disaster or during its
aftermath as a result of the survivors’ scavenging activities or searching
for dead bodies around rubble and debris without wearing protection
such as boots and gloves [14]. The fact that most of the confirmed cases
occurred in males, because they had important roles in those activities
(62%, with 22% dead), demonstrates that men also became vulnerable
in the absence of appropriate prevention and protection.
3.1.2. Earthquakes in Aceh and North Sumatra Province
The Indian Ocean tsunami 2004 was followed by a second earth-
quake three months later. The M 8.6 earthquake occurred along the
Island Nias in March 2005 [12]. Categorized as a large natural disaster,
the event killed 915 people, with more than 100,000 people displaced,
and more than 50,000 facilities left damaged (Table 1) [11]. Later,
WHO reported at least 987 confirmed malaria cases and 15 dengue
cases directly attributable to the Indian Ocean tsunami of 2004. These
D.N. Pascapurnama et al.
Fig. 1. Eight major natural disasters associated with infectious disease occurred during 2004–2016 in Indonesia. Boxes with dates show the incident date in each province. Most are
located on Sumatra and Java islands. Data were filtered and summarized from “Indonesia's Disaster Data and Information” [11].
numbers were less than a half of those occurring under normal cir-
cumstances in 2001. However, because the dengue vector breeding sites
might have been increased by debris from the tsunami such as dis-
carded containers and water storage jars filled with rainwater, vector
control action was recommended to reduce the risk [12]. Another re-
port by WHO also mentions increased incidence of diarrhea and
measles [15].
3.1.3. Earthquakes in Central Java and Yogyakarta Province
A destructive M 6.4 earthquake struck Central Java and Yogyakarta
Province on May 27, 2006. The BNPB reported that the disaster killed at
least 5689 people, with more than 30,000 injured, almost two million
people evacuated and around 100,000 houses destroyed (Table 1) [16].
Some infectious diseases such as ARI, measles, diarrhea, dengue, ty-
phoid fever were reported following the earthquake. There was also an
outbreak of tetanus [17–19]. The causes were estimated as poor sani-
tation and limited water supplies, in addition to lack of awareness of
health risks because personal protection was not used. People were
simply unaware of the disease symptoms [20].
3.1.4. Flooding and landslides in South Sulawesi Province
Two days of heavy rain caused flooding and landslides in Sinjai
region, South Sulawesi Province on June 19, 2006, killing 223 people
and necessitating the evacuation of almost 10,000 people (Table 1)
[16]. Following the event, diarrhea occurred among evacuees as a
consequence of sanitation problems: people became unable to use
regular toilets because water systems had been completely destroyed
[21].
3.1.5. Earthquake and tsunami in West Java, Central Java, and
Yogyakarta Province
On July 17, 2006, a M 7.7 earthquake and tsunami struck West Java
Province, and Central Java and Yogyakarta provinces. The epicenter,
offshore near the trench of Sunda subduction of Java, produced a
powerful tsunami [22] that killed 650 people (Table 1), created more
than 75,000 evacuees, and damaged thousands of infrastructure facil-
ities [16,23]. The high number of casualties is likely to be the result of
the weakly felt earthquake in these regions: people did not expect the
tsunami until they saw it. Health officials, worried about risks posed by
infectious diseases following the events, started the mass vaccinations
of measles, tetanus, cholera, and other diseases [23]. This prevention
96
International Journal of Disaster Risk Reduction 29 (2018) 94–102
strategy was effective, but clusters of ARI and diarrhea occurred be-
cause of poor sanitation and crowded shelters [24].
3.1.6. Earthquake in West Sumatra Province
A 7.6 M earthquake struck the center of Padang city, West Sumatra
on September 30, 2009. It killed 1195 people. Thousands were evac-
uated. More than 100,000 houses were damaged (Table 1) [16]. Be-
cause it struck a major population center, it caused huge aftereffects
that affected the health environment. Crowded shelters and limited
facilities for garbage disposal exacerbated the transmission and increase
of dengue-vector breeds. Because the earthquake occurred immediately
before the rainy season, the environmental change after the disaster
increased mosquito activity, and increased the spread of vector-borne
disease. For at least three months following the event, dengue cases
increased in Padang, West Sumatra. Compared with a report of August
2010 – for which there were only around 50 dengue cases, the number
of cases reportedly climbed to approximately 250 cases in December
2010 [25]. Although no widespread outbreak of disease occurred fol-
lowing the disaster, more cases of diarrhea and dengue were reported
during the several days after the event [26].
3.1.7. Earthquake and tsunami in West Sumatra Province
On October 25, 2010, an earthquake occurred and a tsunami struck
Mentawai Island. The disaster contributed to devastation of the areas:
447 people died, more than 15,000 people were displaced, and almost a
thousand infrastructure facilities were damaged. People became more
vulnerable after the natural disaster. They were threatened with health
risks related to aftereffects [27,28]. The evacuees suffered from ARI
because of crowded shelters and poor air conditions. Some patients
were diagnosed with pneumonia. Others were suspected of having tu-
berculosis (TB) (Table 1) [28]. Still others had open wounds and severe
fever. The lack of proper sanitation in the facilities exacerbated the
conditions: patients were unable to obtain proper treatment. Food and
water scarcity also presented risks. Some people contracted infectious
diseases after in advertently swallowing dirty water when they were
swept away by the tsunami. To avoid ARI outbreak, it is necessary to
isolate a suspected carrier of disease to minimize the chance of trans-
mission. Reportedly, the limited number of rooms at medical posts did
not allow medical teams to isolate all patients [28].
D.N. Pascapurnama et al. International Journal of Disaster Risk Reduction 29 (2018) 94–102

3.1.8. Volcanic eruption in Central Java and Yogyakarta Province

respiratory diseases (pneumonia, TB),

measles, meningitis, tetanus, malaria,
The Mt. Merapi volcanic eruption in Central Java and Yogyakarta

Diarrhea, measles, malaria, dengue

Diarrhea, hepatitis A and E, ARI,
provinces during October–November 2010 was the largest since 1872.
Infectious Disease (s) Following

ARI, measles, diarrhea, tetanus,

Malaria, dengue fever, measles,

The DIBI data reported explosions killed at least 300 people (Table 1),
whereas the total two months after the disaster caused 1369 deaths in

Diarrhea, dengue fever

dengue, typhoid fever
all, with nearly 300,000 IDPs [29]. Those people were exposed to re-
suspended ash during clean-up and rebuilding activities. The large
Natural Disaster

amount of ash contributed to the high risk of ARI. The crystalline silica

ARI, diarrhea
content in the ash fall perhaps increased the severity of pulmonary
Diarrhea

diarrhea
dengue

tuberculosis and other ARI [29]. Following the eruption, there were

ARI
several cases of ARI [27]. The limited knowledge of volcanic ash caused
a lack of awareness, and limited personal protection that exacerbated
the condition, rendering people more vulnerable.
Damaged Infrastructures (incl.
religious, educational, health

3.2. Education plays important roles in disaster risk reduction (DRR) in

Indonesia

Since the post-Indian Ocean tsunami disaster recovery, government

and NGOs have supported enhancement of the capacity on DRR in
facilities)

communities, including establishment of a pilot project called Sekolah

Siaga Bencana (SSB) or School-based Disaster Preparedness (SDP) in
1498

4174
3079

6103
139

381
34

13

2009, which was introduced to five elementary-level schools located in

tsunami-prone areas [30]. This program specifically addresses devel-
Moderate and Minor

opment of structural, non-structural, and functional resilience of school

Damaged Houses

systems. Because the number of SDPs is limited, NGOs tried to develop

other SDPs in areas not covered by the government SSB program.
Furthermore, in 2011, Tsunami and Disaster Mitigation Research
96,576

90,609

91,617
4279

(TDMRC) Syiah Kuala University initiated a program similar to SDP,

430

585

204

454

but the project was brought in the form of training that was in-
Heavily Damaged

dependent from the school curriculum. Mainstreaming disaster risk

reduction is expected to enhance school community members’ knowl-
edge. Through 2014, around 20 schools were certified as SDP by gov-
322,821
Houses

49,234
43,418

48,934

ernment and research institutes.

1759

2465
517
43

The SDP program helped schools enrich their understanding in

disaster preparedness, risk perception, and how they can improve self-
Evacuated

1990,009
440,192

104,167

capacity. For example, students were taught to prepare tsunami eva-

15,353
Eight major natural disasters in Indonesia within 2004–2016 and the infectious disease following those events.

9178

6727

6554

448

cuation map with route to their designated evacuation place. The

common approach was used to build disaster resilience in schools as
Injured

37,728

well as in community. Here, implementing school-based DRR is ex-

2961

6278

1803
520

498

381
35

pected to ease the dissemination of information related to disaster

knowledge, risk perception, and awareness to the student families [31].
Missing

6244

It is considered that the curriculum-based disaster education program

10

33

56

was effective when held in schools [32]. However, many SDP did not
1
0

continue to practice the DRR activities because it was perceived as

166,671
Dead

5689

1195

costly, and schools depended on external actors [30]. Consequently,

915

223

650

447

386

support from governments, research institutes, and NGOs is strongly

needed to encourage schools to continue the program.
Date (mm/

3/28/2005
5/27/2006

6/19/2006

7/17/2006

9/30/2009
dd/yyyy)

Aside from school-based DRR (SSB or SDP), the community can also
12/26/

10/25/

10/26/
2004

2010

2010

be important for attaining good practices in preparedness, emergency

response, and recovery from natural disasters. Community-based DRR
Central Java Special Region

Central Java Special Region

allows community to participate positively and actively in the DRR plan

so that they can become empowered and have improvement of their
West Java Central Java
Aceh North Sumatra

Aceh North Sumatra

capacity to reduce their vulnerability to natural hazards [33]. In In-

Special Region of

donesia, activities in community-based DRR specifically examine de-

South Sulawesi
of Yogyakarta

of Yogyakarta
West Sumatra
West Sumatra

velopment and enhancement of the collaborative mechanisms among

Yogyakarta

local authorities, local communities, and other stakeholders. The ac-

Province

tivity itself usually is held in community center. For example, the

[7,10–12,17,20,25,27,29,34,35].

“Kampung Siaga Bencana” program was held in some disaster-prone

villages in West Java.
Volcanic eruption
Natural Disaster

Earthquake and

Earthquake and

Earthquake and

4. Discussion
Earthquake
Earthquake

Earthquake
Flood and
Landslide
Tsunami

Tsunami

Tsunami
Event

4.1. Disaster preparedness: Implementations after previous disasters

Table 1

After the Indian Ocean tsunami of 2004, the government of

No.

2
3

6
7

Indonesia established a temporary post-disaster surveillance system in

97
D.N. Pascapurnama et al.
collaboration with the Ministry of Health and the Communicable
Diseases Department of the WHO and Global Outbreak Alert and
Response Network (GOARN), called the Early Warning and Response
(EWARN) system for rapid response to acute phase emergencies in-
cluding infectious disease outbreak [14]. The system has a mobile
concept that includes active surveillance, aimed at detecting risks of
infectious diseases and controlling outbreak management. A weekly
epidemiological report will be released including updates about recent
cases of infectious disease.
In the case of the Yogyakarta and Central Java earthquake that
occurred in an urban area, the government reacted quickly in colla-
boration with civil organizations to provide relief and to distribute
health supplies and staff. However, a few outbreaks occurred because
the cases were not properly controlled [9]. In other major natural dis-
asters, cooperation between the government and WHO, especially of
provincial health offices, was conducted to monitor the cluster of in-
fectious events, as well as other health issues.
Aftereffects occurred largely because of the large number of IDPs
evacuated to emergency shelters. Overcrowded conditions created
limited mobility, poor water and sanitation, poor air circulation and
favorable conditions for vector breeding increased the probability of
transmission. These conditions certainly rendered affected people more
susceptible to health risks [7,10]. Ministry of Health took measures to
prevent the post-disaster outbreak, and in some case, the action de-
monstrated the effectiveness of control and prevention of outbreaks.
After a crisis, changes in human conditions, in the ecosystem of
pathogens, and in the environment promote a higher rate of transmis-
sion of infectious diseases, which threaten human life [25]. Key ele-
ments in humanitarian interventions in outbreaks are case management
and surveillance [36]. In response to this, the Ministry of Health un-
dertook several actions such as formulation of humanitarian response
plans in coordination with United Nations [26] as well as work on
health crisis management to prevent future situations. For example,
they inaugurated Pemuda Siaga Peduli Bencana (DASIPENA) or the
Youth Preparedness for Disasters as one of the first medical teams to be
mobilized during the emergency response period. DASIPENA will sup-
port local health services in the handling of victim corpses quickly and
adequately.
4.2. Importance of DRR and health education
People's knowledge and awareness to the health risk also de-
termined the occurrence of infectious diseases after those eight major
natural disasters in Indonesia. For example, people have remained
unaware of the importance of wearing personal protection to prevent
tetanus infection. Some also devote less attention to the vaccination and
did not receive adequate health information, which caused vaccine
program dropping out [10]. The government has made substantial
gains in the integration of DRR into the education sector. It became
included in SDP curricula [30]. The challenge is continuity and pro-
gram sustainability. For that reason, the program should be scaled up to
become more comprehensive [37], particularly because health risks
threaten people after natural disaster. Raising the curiosity of students
about health risks is important to minimize the effects of infectious
diseases emergence following natural disasters. A lack of awareness of
health risks is a crucial point that must be addressed. A possible
workaround is to integrate health education and promotion in DRR
planning in schools and communities.
Disaster education should be taught not only using textbooks but
also through practical and experiential learning activities. The acquired
knowledge should be applied to the actual daily life environment [33].
However, the SDP program focused more on developing structural, non-
structural, and functional school systems for dealing with disaster
preparation, with limited modules of health promotion. We elucidated
from reviewing health risks in previous major disasters that health
promotion plays a crucial role in minimizing health risks after events. In
98
International Journal of Disaster Risk Reduction 29 (2018) 94–102
addition, integrated health promotion and education in the plan is ex-
pected to raise people's awareness about health risks after disasters.
People can contribute active participation in minimizing risks by col-
laboration with government and stakeholders [38,39]. Prevention and
preparedness can be conducted efficiently through good cooperation,
where stakeholders make policies, design prevention, response, and
recovery plans, create empowerment programs, and undertake efforts
to protect people. The community should support the program through
active participation.
Because health risks following natural disasters include actual and
potential problems of communicable and vector-borne diseases, in-
novative DRR measures for health must be developed to minimize risk
and empower communities to be more prepared in the future [40]. A
pilot study by the government of Indonesia and some research institutes
and NGOs related to SDPs indicates that community-based DRR activ-
ities are crucially important to obtain better preparedness, response,
and recovery after a disaster. Integrated health education and promo-
tion will inform the community of the health aspects of disasters and
aid in the development of community resilience. These points demand
greater attention and inclusion in a comprehensive and effective DRR
plan because recent events have heightened awareness of disaster
health issues and have pointed to the need to promote a healthy
workforce to plan for and respond to major incidents [41].
The main target of health promotion and education can be focused
on the community which is divided into small communities in the
neighborhood and especially school children. Children are particularly
vulnerable because of their physical and psychosocial vulnerabilities in
natural disasters compared to adult survivors. In addition, disasters like
earthquakes also make impact in children's regular educational activ-
ities and health, especially in underdeveloped areas. Disaster risk re-
duction measures and education about health-related post-disaster can
create safer environments that will help to prevent mortality and
morbidity and maintain health in children. [50,51].
4.3. Preventing disease after disasters by application of health education in
communities
Some important health-related knowledge is available for commu-
nities to improve their awareness of health issues and infectious dis-
eases after a natural disaster [42]. These topics can be included in the
provision of health education and promotion for the community. Sta-
keholders including the government, public health, and humanitarian
professionals, as well as volunteers who are responsible for providing
health education should consider giving sufficient information about
these matters.
4.3.1. Handling corpses
People believe that corpses can be a reservoir for infectious diseases
after disaster. The numerous deaths, emergency circumstances, and
chaotic conditions after a disaster might delay burial and raise concerns
of survivors. Nevertheless, these hazards after natural disasters are
frequently overstated because the microorganisms which take part in
decaying processes are not pathogenic. Moreover, most human patho-
gens cannot survive for long periods in corpses. Although generally
corpses are not harmful, blood-borne viruses and enteric pathogens that
cause cholera, for example, can survive in corpses. Indeed, to prevent
disease, survivors must devote attention to the burial process. People
who handle dead bodies must wear personal protective equipment
(PPE) such as disposal gloves and masks and maintain hygiene by
performing hand-washing using anti-bacterial soap after handling dead
bodies [7,43]. Because most Indonesian residents are religious, the
provision of burial processes and funerals based on their beliefs is im-
portant.
4.3.2. Sanitation
The community should be educated about the importance of
D.N. Pascapurnama et al.
maintaining hygiene and sanitation, even in emergency situations.
Because evacuation centers are likely to have limited sanitation facil-
ities, it is very possible for infectious diseases such as diarrhea, ARI and
measles to occur. Information about how people should use water ef-
ficiently for their needs (drinking, bathing, washing, excreta disposal)
as well as management of solid waste are useful to prevent those in-
fectious diseases [7]. The provision of health education should also
include information about appropriate and sufficient water containers
because people sometimes are simply not aware that unprotected or
dirty containers can be a source of infection [43]. Health education
providers should encourage communities to use the emergency latrines
in evacuation centers and to avoid open toilets if a disaster occurs. The
importance and function of emergency latrines and how to keep them
clean should also be introduced to communities because personal ex-
creta can be the source of water-borne infectious diseases. For example,
disinfectant processes using chlorine are necessary to prevent patho-
gens.
4.3.3. Importance of hand-washing
Starting from the simplest but essential action in disaster situations,
education related to maintaining hygiene and hand-washing are ex-
tremely important to prevent infectious diseases. Public health and
humanitarian professionals or volunteers who are responsible for pro-
viding health education must ensure that people get used to main-
taining hand hygiene by washing their hands before and after eating
food, using the bathroom, treating wounds, searching or scavenging
around rubble, handling waste, handling animals, and having physical
contact with sick people. Because alcohol or sanitizer gel cannot be a
substitute, sufficient amounts of hand soap must be provided in eva-
cuation centers during emergency situations [43].
4.3.4. Importance of personal protection
After a disaster occurs, survivors who are evacuated but still close to
their former residences are likely to scavenge in the rubble or ruins of
collapsed building hoping to find corpses of relatives, belongings, or to
recover their property. These activities are done mostly without PPE.
Some survivors simply do not notice the importance of PPE to protect
themselves. As a result, after the earthquake and tsunami in Aceh and
North Sumatra provinces in 2004, people were infected by tetanus
through untreated and contaminated wounds to lower limbs sustained
during scavenging activities [10]. Popular awareness of the risk of te-
tanus infection caused by contaminated wounds must be emphasized.
Communities must be educated that wearing PPE is important to pro-
tect them not only from rubble but also from transmission of infectious
diseases that are likely to occur in resource-poor evacuation centers.
Disposable gloves, masks, and boots are necessary for survivors to
prevent infectious disease outbreaks by reducing the probability of
transmission [43].
4.3.5. Managing wound care
Wounds and injuries commonly occur at the time of a disaster or its
aftermath. Untreated wounds, especially those involving exposure to
contaminated soil increases the risk of tetanus infection [44]. As in
some previous disasters, tetanus became a severe threat caused by
contamination of injury wounds. Patients more severely affected by
tetanus were found after disasters because many survivors left wounds
untreated, and received no immediate treatment or booster vaccination
[10]. Health education should provide information that if survivors
become injured or sustain wounds especially to the lower limbs, they
should receive proper and prompt medical treatment and vaccination.
First aid should also be administered as an early action that can be done
by a survivor before paramedics undertake wound treatment.
4.3.6. Education about vaccination
Vaccination issues have become one concern after disasters. The
general public is likely to have limited knowledge about how
99
International Journal of Disaster Risk Reduction 29 (2018) 94–102
vaccination works and why vaccination is important to prevent in-
fectious disease outbreak following a disaster [10]. Some vaccinations
such as measles and tetanus are regarded as given to survivors as a
public health intervention in a disaster setting. The community should
become educated about general vaccination to encourage them and
their families get immunized to prevent infectious diseases not only
after a disaster but also as general policy.
Multiple strategies should be regarded to increase the vaccination
coverage rate. The dissemination of information related to the im-
portance of vaccination is expected to contribute to the increase of
protection, especially in infants, children, and expectant mothers [45].
It also has to be engaged with easy accessibility to vaccination services.
Moreover, improved accessibility in rural areas, and educational dif-
ferentials in health care use are likely to diminish [46].
4.4. Integrated health education in DRR planning
In order to conduct education and health promotion effectively and
efficiently in the field, the program must be comprehensively structured
as to convey the message to the target group. Therefore, stakeholders,
NGOs, volunteers, and sponsors and health sectors should collaborate
and commit to design this program, which can be started from pilot
projects in disaster-prone areas and big cities. Because health education
and promotion aims to prevent, prepare for, and respond to disasters to
increase resilience and mitigate disaster effects on health [42], those
points, in the DRR plan for school and community can be separated into
several modules that are suitable for both school and community based
DRR based on the topics. The activities might include group discussion
about previous cases to make the lessons learned into knowledge. City
health offices in co-operation with city education offices should carry
out the program for activities involving schools. These activities can be
done at the community hall, Pos Pelayanan Terpadu (Posyandu – a
primary health care in community or neighborhood level), and school.
In addition health workers, volunteers working with NGOs, Red Cross,
fire fighters, and parties engaged in WASH, such as companies of sa-
nitation and hygiene products for their corporate social responsibility
(CSR) can also be involved. Furthermore, because active participation
from the community is fundamental for program continuity, various
media such as books, brochures, and audiovisual items (e.g., films,
documentary, health promotion videos) are useful to attract people.
Moreover, e-learning is regarded as effective (e.g., module, task, quiz,
games). Health education and promotion can also be integrated into
case studies and disaster drills to foster more active community parti-
cipation.
Public facilities such as schools and community centers can be as-
signed as venues so people can have easy access to joining programs.
The program itself, which has to include post-disaster prevention and
prevention of health crises, can be held weekly, running concurrently
with teaching and learning activities parallel with school curriculum, or
incorporated into the monthly community activities agenda, for ex-
ample with Posyandu activities coordinated by the neighborhood.
Therefore, with strong commitment, gathering people should not pose a
difficult challenge.
Integrated health education and promotion can improve individual
health behaviors related to health status. The application of a com-
munity empowerment concept [38] can provide stakeholders and
health promotion providers with a useful guideline for understanding
the complex determinants of health. Here, the government and local
authority bodies have important roles to design, conduct, and evaluate
schools and community-based health education programs.
As for school-based program, until now, as well as disaster educa-
tion, there is no specialized curriculum that addresses health promotion
and education [52]. It is usually delivered by the extracurricular ac-
tivities of Youth Red Cross, or integrated into sub chapters in science
lessons, sports, and PLH (Pendidikan Lingkungan Hidup - environ-
mental education) in schools ranging from elementary, junior high
D.N. Pascapurnama et al.
school to high school. Specifically, there are WASH or health related
donor projects at schools in Indonesia which conduct school visit to
educate student about the risk of diseases related to water issues, sa-
nitation and hygiene but run in uncertain period or incidentally.
Meanwhile the curriculum knowledge of post-disaster diseases is not
much discussed [37].
Integration of health promotion and education as well as DRR
program into the curriculum can be done by combining both methods.
Schools is expected to provide time slots to provide opportunities for
health promotion providers such as local health office, NGO volunteers,
or health product sponsors, to conduct school visit and educate students
about the importance of maintaining health especially in seasonal
changes including at the time disaster emergencies. In addition, schools
can provide slots for guest speakers or disaster training and promotion
to some school subjects such as PLH. For example there are regular
weekly or monthly meetings that invite regional disaster agencies, Red
Cross or fire fighters in partnership with the National Disaster
Management Agency (BNPB) -National Agency for Disaster
Management to educate student about disaster management as well as
prevention of health crisis. The selection of guest speakers themselves
can be determined by schools that cooperate with the bodies that have
been determined, of course in coordination with the city or provincial
education office. However, concrete actions to manifest the commit-
ment and the commitment from every stakeholders itself are the main
key of success program. If not so, it is difficult for the program to be
implemented by the schools in the regions (elementary, junior and se-
nior high schools) [52].
Other measures can be taken by stakeholders with more specific
attention to emergency response and recovery, including protection of
people by implementing monitoring programs, establishing emergency
response plans, and designing good management for the distribution of
health supplies and health workers. In response to this, Indonesia has at
least two potential bodies: the Indonesian National Board for Disaster
Management (Indonesian: Badan Nasional Penanggulangan Bencana,
BNPB) and Center for Health Crisis Management, Ministry of Health
Republic of Indonesia.
The BNPB is responsible for providing guidance and direction re-
lated to disaster management efforts that include disaster prevention,
emergency response, rehabilitation, and reconstruction in a fair and
equitable manner. Also BNPB became a spearhead for the formulation
and establishment of disaster management policies and handling of
IDPs to act quickly, appropriately, effectively and efficiently, creating
comprehensive implementation of disaster management [16]. The
Center for Health Crisis Management plays a role in providing assis-
tance and in reducing risks of health crises by conducting health crisis
risk programs. They specifically examine facilitation of districts or cities
that become targets in planning the preparedness of disaster threats in
the form of a response map [47]. Both BNPB and the Center for Health
Crisis Management will support community empowerment by im-
plementing integrated health education and promotion in DRR plans.
Developing the assessment of community empowerment and doc-
umenting its development over time will support evaluation of health
education interventions [38].
4.5. Japan as a role model country in DRR education
Looking to Japan, a country disaster-prone country, disaster edu-
cation itself has been implemented for a long time. The implementation
is divided into two categories, government-funded and voluntarily-
funded program. The government itself is responsible at the municipal,
prefecture and national level to provide public disaster education.
Based on the Basic Disaster Management Plan, the educational frame-
work is adjusted into regional, prefectural and municipal plans so that it
becomes specific in each region based on their needs. The word 'bosai'
which mean disaster prevention is echoed by the Japanese government,
one of which was established 1 September as 'Disaster Prevention Day'
100
International Journal of Disaster Risk Reduction 29 (2018) 94–102
(bosai no hi) and a week earlier was designated 'Disaster Prevention
Week' (bosai shukan). Especially after the Great East Japan Earthquake
and Tsunami, disaster prevention and disaster preparedness movements
are increasingly being implemented through awareness-raising events
and practical training drills. Disaster information is also accessible to
the public via government websites anytime [48].
Meanwhile at the school level, the Japanese government is aware
that students are one of the spearheads in disaster prevention and re-
sponse. In schools, disaster education is regulated under the School
Health and Safety Act, within a multi-hazard policy framework called
'School Safety'. With guidance from the Ministry of Education, the
schools develop and implement a School Safety Plan [48]. The curri-
culum and modules which were introduced to student consists various
aspects (life, sciences, health and physical education, ethics, and home
economics) and different level of education. For example, at the ele-
mentary level, students are taught to recognize the types of disasters, to
know the role of public workers such as fire fighters, and to prevent
injuries when disaster strikes. Junior high school students are taught to
treat wounds, maintain sanitation and hygiene, and learn to do outdoor
cooking. Then at high school, disaster education becomes more detail
and complex. In addition, students are involved in various activities
such as research on disasters and disaster preparedness, cooking for life
in disaster, exercise for rescue and first-aid, and volunteer activity. The
government also provides books and modules either for students and
teachers who first do the training through which they gain scientific
knowledge on disasters as well as first aid and counselling skills [49].
Indonesia should look up to Japan as a role model in the im-
plementation of disaster education and risk reduction. Because the
overall Japan's disaster relief and disaster education looks well estab-
lished and comprehensive. Japan has many well managed collaborative
work among different stakeholders. One of the steps that can be taken
in implementing disaster education as well as promoting the integration
of health education in formal education at school is by providing the
best source of educator, especially the teachers, by organizing training
that not only broaden their knowledge and competency but also
strengthen their willingness to support the program. Each program
needs actions to manifest the commitment of every stakeholder to be
well-implemented.
5. Limitations
Few data and publications described health risks, especially in-
fectious diseases, after natural disasters in Indonesia, except for those
related to the Indian Ocean Tsunami of 2004 and the Yogyakarta
earthquake of 2006. Some WHO original reports were unavailable.
Moreover, some Indonesia government websites were not updated. We
obtained only limited data about the exact relative frequency of each
infectious disease after disaster. Most publications describing DRR are
limited to management and logistics issues. Therefore, for communities
in disaster-prone areas, we suggest further study of matters such as
effective health education as part of DRR.
6. Conclusion
Emergency situations and their aftereffects, lack of awareness, and
limited knowledge about the health risks, render disaster survivors
more vulnerable to infectious diseases. The key point aside from gov-
ernment and NGO or NPO efforts is to educate people and community
to raise and maintain their health status in emergency situations. Public
health and humanitarian professionals and trained volunteers in a
community can provide health education. Integrated health education
and promotion in school-based or community-based DRR can con-
tribute to general understanding and raise awareness to the risk of post-
disaster diseases. Health education and promotion can also be in-
tegrated into curriculum or training-based DRR programs, as module,
short course, drill, printed, and visual media. The disseminated
D.N. Pascapurnama et al.
information is not limited to first aid. It also includes vaccination
campaigns and the importance of maintaining hygiene after disasters.
In this era of globalization, infectious diseases have become a
transnational threat to the survival of people living in our global vil-
lage. Through further study and investigation of the risks and coun-
termeasures of infectious diseases after natural disasters, opportunities
abound for support and contribution of ideas to stakeholders to create
good prevention, response, and recovery. People also have become
educated and more aware of risks that can threaten their quality of life
after facing a crisis. Therefore, it is expected that they will be able to
participate actively and have good future practices of prevention, re-
sponse, and recovery.
Conflict of interest
The authors declare that the research was conducted in the absence
of any commercial or financial relationships that could be construed as
a potential conflict of interest.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Acknowledgements
D.N.P also would like to thank the Indonesian Endowment Fund
Scholarship (LPDP) for scholarship support during her study.
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