Climate change has been identified as the biggest global health threat of the 21st century [1
]. In Canada, climate change is expected to pose greater health risks to Canadians from increases in the frequency and magnitude of extreme weather events (e.g., more heat events of longer duration [2
], floods, droughts, wildfires andstorm surges), poor air quality, impacts on drinking and recreational water quality, food-borne diseases and vector-borne and zoonotic diseases [2
]. Health care facilities play a critical role in reducing health impacts from climate change by treating illnesses and injuries attributable, at least in part, to climate-related hazards, caring for patients during and after disasters [4
] and actively participating in community efforts to adapt to and mitigate climate change [5
]. Health care pressures in communities will increase with climate change and are expected to occur coincident with important socio-economic changes (e.g., ageing population, increased urbanization) and environmental degradation that can further increase health risks in populations and demands on health care facilities [6
A changing climate threatens the quality and continuity of care provided at health care facilities due to more frequent and severe extreme weather events and increased health risks from a range of other climate hazards including food-, water-, vector-borne and zoonotic diseases and poor air quality. Health care facilities will become increasingly vulnerable to impacts from climate change without adaptation [2
]. For example, extreme weather events can lead to public health emergencies which can overwhelm health care facility capacity, disrupt services, and damage facility infrastructure which can subsequently pose health risks to patients and staff [4
]. In many regions, more extreme heat events and generally warmer summers are expected to increase heat-related illnesses and exacerbate chronic diseases [1
]. Studies have linked extreme heat events with increased health care facility visits [9
] and similar correlations have been made with poor air quality days [11
]. Health care facilities are highly dependent on critical community services (e.g., electricity, clean drinking water, food service delivery, waste disposal and treatment) that are vulnerable to power disruptions as evidenced by recent events in Canada [13
] and internationally [14
]. Health care facility officials may have a false sense of security that critical services will be available in emergencies which may not be the case with changing weather patterns due to climate change [14
]. Risks of critical infrastructure loss from flooding events are expected to rise with climate change and health care facilities will need to adapt systems accordingly. Health professionals will need to be better trained and equipped to diagnose and treat new and emerging diseases and to respond to a wider range of climate-related public health emergencies. Costs and unforeseen expenses associated with climate change impacts may exacerbate existing financial challenges and strain functional capacity of health care systems at the community level [17
Health care facilities in developed nations, like Canada, are not immune to climate change impacts. Recent climate-related disasters in Canada, the United States, Australia and Europe have highlighted challenges in disaster preparedness associated with climate hazards. The Alberta floods (2013), Hurricane Sandy (2013), Hurricane Juan in Nova Scotia (2003), Hurricane Katrina (2002), and the ice storm in Eastern Canada (1998) created unexpected challenges for health care facilities that exceeded coping capacity in some cases. Challenges included damage to infrastructures, limited access to essential services, increased patient loads, and issues with maintaining supply chains, such as essential drugs. The 1998 ice storm led to widespread power outages and surges of patients at hospitals with a wide range of injuries and acute illnesses such as fractures, hemorrhages, hypothermia, and carbon monoxide poisoning. Many health facilities were called upon to provide shelter for persons without power at home and critical supplies to other hospitals [18
]. Some studies have highlighted the need to bolster health care facility emergency preparedness in Canada [19
], further highlighting the need to improve disaster resiliency to prepare for a changing climate. Knowledge of the impacts of climate change on the health care sector is increasing [1
]; however, guidance for developing comprehensive adaptation strategies for health systems is needed [4
Information exists to support efforts by health care facilities to prepare for climate change but guidance is piecemeal. For example, Blashki provides examples of adaptations to climate change hazards for health systems that are included in Australia’s National Adaptation Research Plan [24
]. Hiete et al
. provide strategies to reduce a health care facility’s vulnerability to power outages and VanVactor outlines recommendations for ensuring supply chain management processes are resilient in emergencies [16
]. Health care facilities contribute significantly to greenhouse gas emissions through the energy intensive 24 h operation of services and to environmental degradation through the high demand of health care services and operations on natural resources (energy, water, and food procurement) [26
]. As such, tools are available to help health care facilities reduce their environmental footprint [5
]. A lack of a coherent and integrated approach to adaptation results in preparedness gaps that can leave some health care facilities and surrounding communities vulnerable. Furthermore, no climate change resiliency tool has been developed and tested in Canada and tailored to the needs of facilities in the country.
Health care facilities need a comprehensive tool to support climate change resiliency. This paper describes the methods undertaken to produce a climate change resiliency assessment toolkit for use by health care facility officials. The toolkit consists of: (1) a checklist for officials who work in areas of emergency management, facilities management and health care services and supply chain management; (2) a facilitator’s guide for administering the checklist; and (3) a resource guidebook to inform adaptation. The facilitator’s guide provides an overview of climate change impacts on health and on health care facilities, information for officials on how to complete the assessment checklist and suggestions on how to adapt using the assessment results and information from the resource guidebook. A project lead within the health care facility can use the facilitator’s guide to aid officials in completing the checklist and in identification of needed adaptation strategies. The methodology used to develop the toolkit, a description of the resiliency indicators used to develop the checklist and recommendations for operationalization of the toolkit in Canada and internationally are discussed below.
A mixed methods approach was used to develop the climate change resiliency assessment toolkit for health care facilities. Methods included a literature review to identify indicators of health care facility resiliency, development and pilot testing of an assessment checklist, and a workshop of key stakeholders to validate the toolkit and identify optimal strategies for its dissemination and uptake in health care facilities.
2.1. Literature Review of Health Care Resiliency Indicators
A literature review to identify indicators of health care facility resiliency to climate change was conducted in September and October 2012 and used to inform development of the assessment checklist. Peer-reviewed and grey literature published between 1 January 2003 and October 2012 was retrieved using a standard search strategy based on keywords related to:
Community and health care facility resilience to health impacts from climate change
Climate change and health hazard mitigation and prevention
Management of climate-related disasters or emergencies
Sustainable health care practices that reduce climate-related health burdens
Communication of heat-health and other climate-related health risks to patients and to the public
Separate searches were conducted to identify relevant articles describing resiliency in terms of emergency management and environmental sustainability. Keywords were used in the literature searches to capture the climate-related stimulus (e.g., climate change, global warming, extreme weather, heat, cold, air pollution, ultraviolet radiation, wildfires, flooding, storms, drought, water-, food-, vector-, rodent-borne disease), entity impacted or impact type (e.g., hospital, health care facility, food service, supply chain, health care, morbidity, mortality, disease, infrastructure damage), emergency management (e.g. plan, evacuation, prevention, recovery, response) and/or environmental sustainability (e.g., greening, green, recycle, reduce, reuse, waste management). The following databases were searched: EMBASE, Global Health and Ovid Medline. A total of 2,342 peer-reviewed journal articles were identified and titles and abstracts were scanned for relevance. Articles were retrieved and further included for analysis if they were written in English and had information pertinent to the Canadian context (developed countries). Articles that did not directly address indicators of health care resiliency to climate change were excluded, with 34 peer reviewed articles remaining. In addition, a total of 30 grey literature reports were included, which were retrieved from various government (e.g., World Health Organization, Department of Health in the United Kingdom, Health Canada) and non-government websites (e.g., Health Care Without Harm, Centre for Excellence in Emergency Preparedness). The sixty-four references included in this study that informed development of the assessment checklist can be found in the Supplementary Materials
2.3. Pilot Testing and Expert Review of the Assessment Checklist
The checklist was reviewed and revised based on input from the expert advisory committee before being further tested at health care facilities. To ensure that the checklist would meet the needs of facilities in Canada in terms of relevance, understandability, and ease of use, it was piloted in six health care facilities representing three provinces—Nova Scotia, Ontario and Manitoba. The pilots were chosen based on the following criteria: facilities representing different provincial health care systems in Canada; facilities of different sizes (indicated by the number of beds); and facilities faced with a wide variety of climate change hazards (e.g., sea level rise, drought, flooding, hurricanes and infectious disease outbreaks). Pilot testing of the checklist was conducted from 4–8 February 2013 through expert interviews to inform revisions. For each facility, one facility official was responsible for consulting with relevant officials to complete the checklist prior to interviews. Interviewees for each facility included all individuals who contributed to answering the checklist questions. On the dates of the interviews, group discussions were held among a member of the research team and health care facility officials. The interview questions posed are presented in Table 2
. Interviews were recorded and responses were analyzed to identify needed revisions.
Interview questions to pilot health care facility officials.
Interview questions to pilot health care facility officials.
After revisions were made based upon interview results, a stakeholder workshop was held on 20 March 2013 to present and validate the final toolkit.