Climate Change and Health: Effect of Awareness Program on Knowledge, Attitudes and Practices of Community Dwelling Elderly

Background: Climate change is the biggest global health threat of the 21 st century with both direct and indirect effects on human health especially for vulnerable groups as elderly. So, it's important to raise their awareness about climate change to reduce its adverse effect on health. Aim : To evaluate the effect of awareness program on knowledge, attitudes and practices of community dwelling elderly regarding climate change and health. Method: A quasi-experimental, pre and post intervention research design was implemented. A convenience sample of 72 community dwelling elderly attending El-Amal elderly club in Mansoura city. Tools : Five tools were used for data collection; Demographic and Health profile structured interview sheet, Climate change knowledge questionnaire, Elderly's attitude toward climate change self-rating scale, Elderly's self-reported practices about their adaption towards climate change checklist and Elderly's awareness level about climate change and its effect of health questionnaire . Results: There were significant improvement in elderly's total mean score of knowledge, practices, attitudes and awareness after 3 months from implementation of the awareness program than before (P=0.000**). Also, a statistically significant strong positive correlation was found between the total knowledge score of the studied elderly and both total practices scores, total attitudes scores and total awareness score after implementation of the awareness program Conclusion: The awareness program improved knowledge, attitudes and practices of community dwelling elderly about climate change and health. Recommendations: Dissemination of developed illustrated awareness program booklet about climate change and health to all elderly at Mansoura City should be done.


Introduction
Climate change is considered the biggest global health threat of the 21 st century (1) and a universal problem that have wideranging economic, geographical, social, psychological and political consequences .The reasons of climate change are anthropogenic in nature via lifestyles, choices and consumption which pollute and exploit resources in an unjustifiable way (3) .According to the united nation framework convention on climate change (UNFCC), climate change is ""a change of climate which is attributed directly or indirectly to human activity that alters the composition of the global atmosphere and which is in addition to natural climate variability observed over a comparable period time" (4) .Worldwide, by 2030, more than 100 million persons could have health problems related to climate change as well.Mostly, low and middle income countries will be the worst affected since they are excessively exposed, and in addition because of their weaker adaptive abilities as health systems and other infrastructure (5) .Climate change is triggering increased transmission of infectious disease, elevating sea levels, water and food insecurity and individuals and governments financial inadequacy; all of the above damage person's physical, mental, and social health (6) .By the year 2030-2050, approximately 250,000 additional deaths per year are expected as a consequence of climate change from heat stress, malnutrition, and malaria.By the late twenty-first century, climate change is likely to increase intensity and frequency of drought at global scale.The increase of temperature and variable precipitation decrease food production and increase the prevalence of under nutrition and malnutrition (7) .Climate change is a problem that affects all human beings, but it will affect the most vulnerable population groups to a greater extent, including the elderly.Especially, since elderly, which can be viewed as a vulnerable group, are usually more sensitive to any change in surrounding environment, their health are more likely to be negatively affected by climatic factors rather than younger.Understanding which health outcomes are likely to be affected by external climatic factors is significant for enhancing elderly"s overall health status (8) .Additionally, elderly are more likely to experience detrimental physical impacts like dehydration and symptoms worsening of existing health problems as heart and respiratory diseases during a heat wave which make the process of temperature regulation less efficient because of biophysical differences between elderly and others, something which is important in terms of people"s ability to cope with extremes of cold as well as heat (9) .Coping difficulties in heat waves can be particularly marked when older people have other health problems which also affect thermoregulation, such as diabetes, chronic cardiovascular and respiratory illness (10) .Basic prerequisites for wellbeing can be threatened by Climate change, including clean air and water, food supply and security of shelter.Its effects on elderly are particularly deleterious.Elderly yield much more readily to climate adversities with high incidence of mental and physical health conditions resulting in significant mortality from exposure to extreme conditions such as heat or hurricanes (11) .Therefore, Education is an essential element of the global response to climate change.Climate change education helps elderly comprehend and address the impact of global warming especially on health.Furthermore, it encourages change in their attitudes and practices that help them adapt to climate change (12) .Moreover, adaptive elderly practices towards climate change are any actions that lessen the risk of climate change impacts.Health-related adaptive practices are focus on practices that related to health and disease prevention such as wearing a hat when going outside on hot days (13) .Climate change knowledge, attitudes and practices are unevenly varying all over the world.The awareness level in respect to climate change is reported to be better in developed countries than in developing countries.Moreover, educational attainment is the strongest predictor of climate change awareness in developed countries, while the perception of local temperature change is the strongest one in developing countries.On the other hand, those in developing countries perceive climate change as a more serious threat than those in developed countries (14) .Vol. 31.No. 4 (Suppl 1) ,November 2023 To increase public awareness of climate change issues, there is a need to increase public sensitivity to the environment as well as to increase public motivation and commitment to sustainable development.Education is a critical agent in addressing the issue of climate change through public participation in programs.Education can change attitudes and behaviors of people including helping them to make informed decisions; people can be taught the impacts of global warming and how to adapt to climate change.Education also can empower all people especially motivates the young to act.Knowing the facts helps eliminate the fear of an issue that is frequently catastrophized in the public arena (15) .Based on the above and to meet Egypt 2030 Sustainable Development Goals specifically Goal thirteen, Target three: "Improving environmental education and awareness", Gerontological nurse must provide elderly with the knowledge about the health risks posed by climate change and how to prevent these problems via awareness program to improve elderly knowledge, attitudes and self-reported practices within primary preventive strategies for vulnerable groups (16) .Therefore the study aimed to evaluate the effect of awareness program on knowledge, attitudes and practices of community dwelling elderly regarding climate change and health.

Significance of the study
According to World Health Organization, (2021) (17) climate change is responsible for a minimum of 150,000 deaths every year worldwide, a number that is expected to double by 2030.In Egypt, the heat wave of 2018 has killed about 65 people within 3 days when the temperature reached about 47°c (18) .

Climate
change increases the temperature, affects air quality, drinking water, food, and increases vector-borne diseases, and these affect elderly's health.Elderly are more vulnerable to climate change due to normal changes in the body associated with aging and the presence of chronic health conditions, such as diabetes (19) .In Egypt, the number of older adults is about 6.8 million, representing 6.7% of the total population, and this percentage is expected to rise to 17.9% in 2052 (20) .To address these risks, Egypt has made a public commitment in the Sustainable Development Strategy and some sectoral plans to integrate climate change into national development policies (21) .Egypt"s National Climate Change Strategy 2050 asserts the importance of integrating climate issues into the educational process, scientific research, technology transfer, and awarenessraising.Climate change has similarly received attention from Egyptian universities and research centers, which have issued publications, conducted scientific research and studies, and organized various events to raise awareness about climate change among the wider community (22) .Education is crucial to promote climate action that helps people understand and address the impacts of the climate crisis, empowering them with the knowledge, skills, values and attitudes needed to act as agents of change (23) .Nevertheless, a review of government efforts to spread climate change education in Egypt shows that they are still in their infancy, and some of them lack coordination and integration (22) .Operational Definition Climate change is defined as change in climate attributed directly or indirectly to human activities that alter the composition of the global atmosphere, in addition to natural climate variability observed over comparable time.

Aim of the study:
The aim of the present study was to evaluate the effect of awareness program on knowledge, attitudes and practices of community dwelling elderly regarding climate change and health.

Research hypothesis:
knowledge, attitudes and practices of community dwelling elderly regarding climate change and health will be improved after implementation of awareness program.

Sample size calculation:
The sample size was estimated using G* Power software for Windows (version3.1.9.2) based on the results of a similar previous study (24) that demonstrated a difference in attitude toward climate change among study subjects.-Part 3: Elderly's previous information about climate change and its effect on health and source of information if present.Tool II: Climate change knowledge questionnaire: This tool was developed by the researcher after reviewing the relevant literatures (28)(29)(30)(31)(32) to assess baseline knowledge of elderly about climate change and related health impact.It included 32  ).Each expert valued each item according to the relevance using a fourpoint Likert scale (1 = not relevant, 2 = somewhat relevant, 3 = quiet relevant and 4 = very relevant).The CVI was applied, and the accepted value was ≥0.80 (46) . As a result, the suggested modifications necessary were made as simplifying certain words to be more understood, restating and removing of some statements.CVI for tool -Fifth session (Practices to reduce human causes of climate change): It included possible practices that may lessen the human causes of climate change as practices to saving energy in our homes, practices related to green procurement, practices related to reuse of the materials and dealing with wastes practices.

Tools: Five tools were used in this study
-Throughout the program sessions, the researchers used PowerPoint presentation through their lap top.Also, the prepared booklet was assumed to all the studied elderly to refresh their knowledge.Moreover, at the end of each sessions, the researchers were given concise summary about most important items.-Before starting the next session, the researcher was inquire questions related go the previous the topic.-The researcher used to meet the studied elderly in groups (5-7 elderly person) in the El Amal elderly clubs" hall.-The researchers were in contact with the studied elderly periodically by telephone call or through whatsApp massages if possible for any questions.
-The researchers visited the elderly club three days per week for four months according to time available for elderly.-The field work was carried over a period of 6 months from the first of April, 2023 to the end of September, 2023.D. Evaluation phase: Evaluation phase was done firstly before the program implementation (pre/test) using all study tools, then after 3 months from the program implementation (post/test) (37) to evaluate the effect of awareness program on knowledge, attitudes and practices of community dwelling elderly regarding climate change and its effect on health using tools; II, III, IV and V. Statistical analysis: The Statistical Package for Social Sciences (SPSS) version 22 was used to organize, categorize, tabulate and analyze the collected data.Descriptive statistics in the form of Means and standard deviations were used for continuous variables and frequencies and percentages were used for categorical variables.Normality of the study variables was tested by using Kolmogrov Smironov test.A paired (t) test was used to compare the mean score between both studied variables and to compare the non-parametric qualitative ordinal variables Wilcoxon signed-rank paired t-test (Z) was used.In addition, Pearson correlation coefficient (r) was used for measuring the correlation between numerical variables.The p-value ≤0.05 was considered significant, and less than 0.001 as highly significant.

Results
Table (1) revealed that 88.9 % of the study participants aged from 60 to 75 years old with the mean age 66.86± 4.86 years, 55.6 % of them were female, 62.5% were married, 55.6% had secondary education , 52.8% have enough income monthly.Also, 90.3% lived in urban areas and 70.8 % lived with their family.The table also illustrated that 90.3% of the studied elderly suffered from chronic diseases.Diabetes mellitus was prevailing among 43.1% followed by hypertension (36.1%).Table (2) showed that 41.7 % of the studied elderly reported they had previous information about climate change; 56.7% of them reported that social media was the primary source of information followed by friends & relatives and finally radio &TV by 46.7%.Table (3) indicated that there was statistically improvement of the studied elderly responses to knowledge questions about climate and climate change and its effect on human health items after implementation of the awareness program.Figure 1 showed that only 13.9 % the studied elderly had good knowledge about climate change and its effect on health before implementation of awareness program, which improved to 41.7% after the program implementation (p=0.000*).showed that a statistically significant strong positive correlation was found between the total knowledge score of the studied elderly and all of total practices scores, total attitudes scores and total awareness score after implementation of the program.As, the total practices, attitudes and awareness scores were higher among participants who had high level of knowledge.     .As a result, Gerontological Nurses should apprehend the effects of climate change and promote practices that will lessen the climate change and dangerous effect on health (49) .Consequently, increase elderly awareness about climate change have essential circumstantial to deal with climate change and health related effects (32) .Therefore, the aim of this study was to evaluate the effect At the present time, Social media can play a vigorous role in the broadcasting of climate change related information (50) ..The present study stated that about two third of the studied elderly had unsatisfactory level of practices before implementation of the awareness program, while there was an improvement in practices score after the program implementation.In the same line, study conducted in Northern Malaysia by Tiong et al., (2021) (63) who observed that to more than half of studied subjects" practices were improved after teaching program than before.In the same direction, another studies done in USA by Lavey, (2018) (64) , in Brazil by Tibola da Rocha et al., (2020) (57) and in United Kingdom by Kurup et al., (2021) (65) who confirmed that educational interventions had a significant effects in improving selfreported practices related to climate change and its effect on health of the study subjects than before.In addition, a study done in Egypt by Abdallah & Farag, (2022) (66) showed that self-reported behaviors regarding climate change of the study respondents' significantly increased after the teaching program implication.Furthermore, climate change awareness is a chief step in attaining adaptation and alleviation approaches as increasing awareness would change behavior towards strengthening the environment and help to face climate change adverse impacts (55) .Meanwhile our study results confirmed there was a statistical significant increase in awareness level of the studied elderly after implementation of awareness program than before.In similarity, studies done in the United Arab Emirates by Abuelgasim & Daiban., (2017) (67) and in Nigeria by Onuoha et al., (2021) (68) reported that climate change play an effective role in increasing awareness levels of the studied subjects .This result in the same line with a study done in Saudi Arabia by Almulhim ,(2021) (69) who stated that more than one quarter of the studied subjects had good awareness level about climate change at posttest.Also, Ghazy & Fathy, (2023) (37) in Egypt reported that significant improvement in most aspects of studied sample' awareness about climate change after the program application.Additionally another studies conducted in Italy by Mebane et al., (2023) (70) and in Philippines by Adlit et al., (2023) (71) who stated that climate change education intervention improve the studied sample awareness level.In addition, the current study presented that statistically significant strong positive correlation was found between the total knowledge score and all of total practices scores, total attitudes scores and total awareness score of the studied elderly after awareness program implementation.This result was accordance with studies conducted by Karami et al., (2017) (23) in Iran; Kolenatý et al., (2022) (72) in Czech by Sambath et al., (2022) (40) in India who displayed that significantly positive correlation between climate change knowledge, attitude and practices were found among the studied sample.The same opinion was found in another study performed in Turkey by Tuna et al., (2022) (73) who stated that there was strong positive correlation between knowledge, practices and attitude of the studied participant .The previous results also were supported by a study done by Abdel Nabi et al., (2023) (31) in Egypt by who indicated that, there was a highly statistically significant positive correlation between total knowledge, reported practices and attitudes related to climate change among studied subjects.Also, the same result was reinforced by Amin et al., (2023) (74) in Egypt who revealed that study subjects with satisfactory knowledge were four times more likely to perceive danger as higher than participants with insufficient knowledge (P = 0.000*).Last but not least, A study conducted by Ghazy, and Fathy, (2023) (37) in Egypt who revealed that there was a highly positive correlation between total participants' knowledge score level &attitudes and total daily life practices (at p < 0.001).This result can be justified by that the greater the knowledge regarding climate change , the more the elderly demonstrate satisfactory practices and having positive attitude toward adaptation with climate change and its effects on their health.

Conclusion:
The awareness program has a significant positive effect on improving elderly's knowledge, attitudes, practices and awareness about climate change and health.Furthermore, There was strong positive correlation was found between the knowledge , attitudes , practices and awareness level of community dwelling elderly regarding climate change and health after implementation of the awareness program.
Design: A Quasi-Experimental research design (one group pre/post design) was used in this study.Setting: The study was carried out El-Amal elderly club in Mansoura city affiliated To Ministry of Social Solidarity.Subjects: A convenience sample of 72 community dwelling elderly visiting the above mentioned setting and fulfilling the following criteria; Able to communicate, willing to participate in the study and available at the time of data collection.

Tool I :
Demographic and Health profile structured interview sheet: This tool was developed by the researchers after reviewing the relevant literatures (25-27) and it was divided into three parts: -Part 1: Demographic characteristics of the elderly: as age, sex, marital status, level of education, residence and income.-Part 2: Health profile of the elderly: as presence of chronic diseases, type of chronic disease.Vol. 31.No. 4 (Suppl 1) ,November 2023

Figure ( 1
Figure (1): Percentages of total climate change knowledge pre and post awareness program

Figure ( 2
Figure (2): Percentages of attitudes about climate change and its effect on health pre and post awareness program

Figure ( 3 ):
Figure (3): Percentages of total practices of climate change and its effect on health pre and post awareness program

Part 2: Elderly's self-reported preventive practices: it
(37)e, score 1 if answer was uncertain and score zero if answer was disagree.Total awareness score of elderly was summed up and converted into a percent.Total responses were classified into three categories(37): (42)(43)(44)(45)s awareness level about climate change and its effect of health:This tool was developed by the researchers after reviewing the relevant literatures(42)(43)(44)(45).It included 10 questions to assess elderly's level of awareness toward climate change and its effect on health.Using a 3-point Likert-type scale with such category as agree, uncertain, disagree to competently provoke the exact responses from the elderly.Scoring responses to each statement by score 2 if answer was  Two language experts translated the study tools into Arabic and then back translated them into English by another two language experts in English language from Faculty of Education, English Department, Mansoura University  Content validity: the content validity index (CVI) was used to calculate the degree of agreement among the experts to analyze the study tools and the entire set of items.Content validity was determined by seven experts (three Gerontological nursing professionals, and two Community health nursing professors from the Faculty of Nursing, Mansoura University and two

The awareness program was conducted through four phases: A. Assessment phase: It
II, III, IV, & V was 94, 92, 95, 93, & 92 respectively. A pilot study was performed on ten percent of the studied sample equal 8 elderly who visiting El Amal elderly club at Mansoura city before data collection to determine the study tools applicability and clarity and the suggested modifications  were done and they were excluded from the study sample.
 Ethical considerations: An ethical approval from the Faculty of Nursing, Mansoura University Research Ethics Committee on the study proposal (Ref.No.p.0430) was obtained.After being informed of the study's objectives, each studied elderly provided written consent to participate in the study.The privacy of the studied elderly and the confidentiality of the obtained data's was conserved.The elderly participated in the study were informed that they had right to leave the study any time without penalty.-Second session (Introduction about climate change): It included the following outlines; climate change definition, elements, difference from Vol. 31.No. 4 (Suppl 1) ,November 2023

Table ( 1): Distribution of the study participants according to their demographic characteristics and health data
# More than one response

Table ( 2): Distribution of the study participants according to their previous information about climate change and the information source
# More

than one response Table (3): Distribution of the study participants according to their knowledge about climate change pre and post awareness program (n=72) First: Elderly's knowledge about climate and climate change#
Q1: Climate is the average measure of temperature and rain place over a long period of time up to 30 years.Vol. 31.No. 4 (Suppl 1) ,November 2023 Cont.

Table (3): Distribution of the study participants according to their knowledge about climate change pre and post awareness program (n=72) Second : Elderly's knowledge about effect of climate change on human health#
Z= Wilcoxon Signed Ranks Test, # Only true answers were presented, * p≤0.05, ** p≤0.001Vol. 31.No. 4 (Suppl 1) ,November 2023

Table ( 4): Distribution of the study participants according to their attitudes about climate change pre and post awareness program Items Pre Program Post Program Test of Significance
Q10: I am preparing myself for the effects of climate change 22 (30.6)50 (69.4)47 (65.3) (34.7) 3.904 (0.000**) Z= Wilcoxon Signed Ranks Test, * p≤0.05, ** p≤0.001

Table ( 6): Distribution of the study participants according to their self-reported preventive practices about climate change pre and post awareness program (n=72)
: Paying attention to enough hours of sleep at night to strengthen the immune * Vol. 31.No. 4 (Suppl 1) ,November 2023 Q11