Views of Health Professionals About Climate and Health in Sierra Leone: A Cross-Sectional Study

Abstract

Climate change presents one of the biggest global threats to society, while the impact of its manifestations on human health has been poorly characterized and quantified, especially in middle- and low-income countries. The perceptual views of health professionals about the climate and health nexus are critical for the effective implementation of climate policies. The Sierra Leone health professionals are no exception to this, and no such data exist for their country. To this extent, we distributed a cross-sectional survey to understand the perceptual views and beliefs of health professionals in Sierra Leone about the climate and health nexus. A validated international questionnaire on the topic was electronically administered to 265 participants. A descriptive analysis of the survey responses was conducted. Results showed that almost all of the respondents (97%) felt that climate change is an important issue; more than half (68%) of them were very worried about climate change, and 28% were somewhat worried. About half of respondents believed that human activities mostly caused climate change, while 40% of health professionals felt this was equally caused by human activities and natural changes in the environment. The need to engage health professionals with the public and policymakers to bring the health effects of climate change to their attention was particularly highlighted; however, most respondents (81%) stated that numerous barriers impede them from doing so. The most widely reported barriers and needs were the need for training to communicate effectively about climate change and health (96%) and guidance on creating sustainable workplaces (94%), followed by the need for lifelong training and education programs on climate and health, and the lack of time (73%). These survey findings would be valuable to policymakers in Sierra Leone and the broader African regions towards mitigating and adapting to climate change threats to human health.

1. Introduction

Sierra Leone is a country in West Africa with a population of ~7.65 million [1]. The country’s climate is tropical with two distinct seasons—the rainy season (May to November) and the dry season (December to April). Average temperatures range between 25 and 27 °C and between 22 and 25 °C during the dry and rainy seasons, respectively [2]. In the World Risk Index 2021, Sierra Leone is ranked 47 among 181 countries with high scores for vulnerability to, susceptibility to, and absence of coping capacities for climate change [3]. Furthermore, the country is among the most vulnerable African countries in terms of the increasing frequency of climate change impacts; the Intergovernmental Panel on Climate Change (IPCC) ranked Sierra Leone the third most vulnerable to climate change in the world, after Bangladesh and Guinea Bissau [3].

Climate manifestations heavily impact Sierra Leone and its people. In August 2017, a 6-kilometer mudslide and flooding occurred in the country’s capital city, Freetown, and its outskirts—the worst natural disaster in modern history; over 1000 people were reported dead or missing, over 11,000 were displaced, and over 300 buildings were submerged [3,4]. In 2018, ~2.2 million people were adversely impacted by destructive cyclones, resulting in severe flooding, high death tolls, and forced migration out of their countries (Malawi, Mozambique, and Zimbabwe) [5].

Evidence suggests that the current climate change crisis could undermine public health gains made during the past 2–3 decades in tackling major causes of mortality and morbidity burden of disease. The changing weather and abnormal environmental patterns affect proximal agents of disease, such as the transmission patterns of various pathogens in the environment. The number of months with environmentally suitable conditions for malaria (Plasmodium falciparum) transmission has increased by 39% from the 1950s to 2019 in highland areas of low human development index countries [6]. Similar increases in Vibrio cholerae transmission rates were observed in coastal areas between 2003 and 2019 with 98% of these coastal areas located in low human development index countries [6]. Studies suggest that climate change directly influences the etiology of vector-borne diseases, particularly malaria and dengue fever [7]. Prediction models for the period 2020–2040 suggest that increased air temperatures are anticipated to adversely affect Africa’s malaria burden [8]. Approximately 34% of the global disability-adjusted life years (DALYs) presented by the adverse effects of climate change are in sub-Saharan Africa [9].

Climate change may be associated with non-communicable diseases and their risk factors as well. According to Charlson et al. [10], climate change manifestations were associated with psychological distress and deteriorating mental health, i.e., anxiety, post-traumatic stress, and depression [11,12]. A systematic review found that exposures to heat and air pollution were linked with severe birth effects such as pre-term birth and low birth weight [13]. Climate change stressors bring about hostile pregnancy results, influencing the development of offspring [14]. Additionally, climate change is associated with respiratory difficulties, deteriorating asthma, and other lung diseases [15]. Studies have shown that climate change can significantly increase chronic malnutrition among under-five children and stunting cases, especially in the most vulnerable countries [16,17].

Climate change presents considerable difficulties for global food security. This affects farming routines, agricultural productivity, and the dietary quality of food produced. Emerging and classic plant pests are affected by climate change manifestations, becoming increasingly important in food production [18,19]. Heatwaves, humidity, droughts, uncontrollable wildfires, and torrential flooding [10] would potentially affect food security. The Intergovernmental Panel on Climate Change (IPCC) reports predicted declining agricultural productivity in sub-Saharan Africa from 21% to 9% by 2080 because of climate change. The increasing high temperature will reduce the production of food eaten by many up to 50%. Approximately two-thirds of the continent’s agricultural productive lands are expected to be lost by 2025 due to a lack of rainfall and drought [20]. Globally, around 700 million and 832 million people were food insecure in 2019 and 2020, respectively, and this number is projected to reach over a billion by 2050 due to climate change [19].

It is well appreciated that health professionals hold major responsibility in assessing and managing the human health risks associated with climatic manifestations. The health of patients, families, communities, and the population at large is already impacted as a result of changing weather patterns [21]. The public looks up to health professionals for information regarding their health, including information about climate change impacts on individual health [22]. However, evidence supporting health professionals’ preparedness and literacy regarding their effective engagement with climate change remains unclear across many parts of the world [23,24].

In Sierra Leone, to the best of our knowledge, no study has been published about the perceptual views of health professionals on climate change and the human health nexus. Sierra Leoneans trust health professionals for information regarding their health and other related issues. The planetary health theoretical framework and its practical applications throughout the globe were underpinned here to describe linkages and systems jointly operating between proximate environmental agents of human disease, global ecological drivers such as climate change, and human health outcomes [25]. Hence, this is the first-ever survey on the perceptual views of health professionals in Sierra Leone about the climate and health nexus, which serves as a crucial baseline assessment to design and implement climate policies. Thus, this study’s objectives were to (i) document the perceptual views of Sierra Leone health professionals about the climate and health nexus and (ii) document the extent to which they support action to address the climate crisis.

2. Materials and Methods

The study population was a random cross-section of health professionals in Sierra Leone, including medical doctors, nurses, public health professionals (individuals with public health qualifications), midwives, and other allied health professionals. The validated international health survey on health professionals’ views about climate change and health was used here [26], with written permission from Prof. J. Kotcher. The survey was administered in English (as this is the official language in the country) and online, using REDCap from July to November 2023. To facilitate cultural adaptation, the questionnaire was pre-tested with twenty selected health professionals in Sierra Leone. A total of 265 volunteers responded partially to the survey and 215 (81%) complete responses were recorded. Data were managed using the REDCap electronic data capture tools. The questionnaire used a Likert scale which can be found in Supplementary Materials. The Sierra Leone Ethics and Scientific Review Committee granted ethical approval (SLESRC #019/04/2023) to the study.

The survey was distributed via emails and via select professional WhatsApp platforms (Health Promotion Network, Malaria Fighters, and One Health Comms Team) of the Ministry of Health and Sanitation (MoHS) in Sierra Leone. The inclusion criteria were (i) >18 years of age and (ii) actively working in Sierra Leone as a health professional. A synopsis of the research was provided to a representative of the MoHS who distributed the survey link to the various WhatsApp groups of the Ministry of Health. Those who responded positively received the survey electronic link with instructions. Follow-up messages on WhatsApp and emails were sent as a reminder within two weeks of the initial email/WhatsApp dispatch.

The survey dataset was divided and analyzed by sub-sections with unweighted data: understanding key facts on the issue and engagement; risk perceptions of the changing climate as a threat to health; engagement with the public and policymaker on the issue; professional bodies’ policies related to the issue; and barriers to engagement and helpful resources in addressing the issue [26]. The incomplete questionnaires (19%) were not included in the main analysis [27]. Descriptive statistics included means and standard deviations (SDs) for continuous variables or sample sizes and percentages for categorical variables. Statistical analysis was carried out using the R app version 4.2.2 for Windows.

3. Results

About 65% of survey participants were men, while 54% of participants were aged between 30 and 44 years old, 30% were between 45 and 59 years old, 10% were between 18 and 29, and 6% were >60 years of age (

Table 1. Study population characteristics.

n%
Category of Health Professionals	Medical Doctors	53	25
	Nurses	34	16
	Midwives	10	5
	Public Health Practitioners	99	46
	Others (e.g., Pharmacist, District Social Mobilization Coordinator, Lab Technician)	19	9
Age (in Years)	18–29	22	10
	30–44	116	54
	45–59	64	30
	60+	13	6.0
Gender	Male	140	65
	Female	75	35

). Almost half (46%) of participants described their primary occupation as public health professionals, whereas 25% were medical doctors, with nurses comprising 16%, midwives 5%, and other allied health professionals 9%.

3.1. Understanding Human-Caused Climate Crisis and Its Importance

The vast majority (98%) of participating health professionals in Sierra Leone responded that climate change is happening (Figures S2 and S3). A total of 92% of respondents felt sure that climate change is happening (38% were extremely sure; 54% were very sure). Responding to the causes of the climate crisis, 46% of respondents believed that human activities mostly caused climate change, while a considerable portion of respondents (39%) felt that climate change was equally caused by human activities and natural changes in the environment; only 8% reported climate crisis is entirely caused by human activities (Figure 1).

The majority (60.5%) reported that the climate crisis is very important to them personally, 23.3% reported it is extremely important, and 13.5% indicated it is somewhat important (Figure 2). About 68% were very worried about climate change, 28.4% were somewhat worried, and 3.7% were not too worried (Figure S7).

3.2. Risk Perceptions and the Impact of the Climate Crisis on Human Health

About 72% of respondents reported the climate change crisis would cause harm to them personally, their patients (54%), people in their community (84%), people in Sierra Leone (88%), and future generations (87%) at a moderate amount or a great deal (Figure S8). When asked about specific health effects, most of the survey respondents stated that the climatic crisis has already negatively affected the health of people in Sierra Leone, either in a moderate amount or a great deal (Figure 3). Approximately 52% of participants reported heat-related illnesses, 71% reported physical or mental harm from storms and floods, 58% reported physical or mental harm from forest fires or bushfires, 72% reported vector-borne infectious diseases, 75% reported water-borne and food-borne diseases, 51% reported housing loss for people displaced by extreme weather events, 75% reported hunger and malnutrition as a result of rising food prices, and 75% reported higher poverty risk due to economic hardship and resulting health problems.

About half of the survey respondents acknowledged other adverse health consequences due to the changing weather patterns, including anxiety, depression, or other mental health conditions (40%), illness due to reduced outdoor air quality (e.g., air pollution or pollen) (44%), physical or mental harm from droughts (37%), disruptions to health care services for people with chronic conditions during extreme weather events (41%), and violence, conflict, and resulting dislocation (38%).

Participants indicated that climate change will greatly influence human health outcomes more frequently or severely in Sierra Leone for the next decade with the most common being vector-borne infectious diseases (68%), water- and food-borne diseases (68%), increased poverty due to economic hardship and resulting health problems (68%), hunger and malnutrition due to rising food prices (67%), physical or mental harm from storms and floods (58%), physical or mental harm from forest fires or bush fires (53%), and health-related illnesses (46%) (Figure 3).

3.3. Engagement with the Public and Policymakers

The vast majority of study participants (88% strongly or somewhat agreed) felt a responsibility to bring the health effects of the changing climate to the attention of the public (Figure S16) and policymakers (Figure S17). Half of them strongly agreed (46.5%) and 41.4% somewhat agreed with actively encouraging national leaders to strengthen national commitment towards lowering emissions to achieve the Paris Climate Agreement. Similarly, 44.7% of respondents strongly agreed and 43.3% somewhat agreed with actively encouraging all world leaders to strengthen national commitment towards lowering emissions (Figure S21). Almost all participants (96%) believed that health organizations should advocate for increased investments in the health sector (Figure S1). Responding on their willingness to participate in a global advocacy campaign to encourage world leaders to prioritize their commitments, 56% said they are personally willing to participate, 36% are possibly willing to participate, but they need more information on the issue, 7% of participants think they would support such a campaign, but they might not personally participate, and 0.5% of respondents felt that they would not participate, nor support such a campaign (Figure 4).

3.4. Policies of Health Professional Society/Association

Responses from survey participants on the question about policies of their professional society/association indicated that 13% of survey participants strongly agreed, 37% somewhat agreed, and 36% neither agreed nor disagreed that the organizations they belong to should cut any ties that they may have with companies producing fossil fuel (Figure S18). This includes divestment of any fossil fuel reserves or bonds. Furthermore, of the total survey participants, 21% strongly agreed, 38% somewhat agreed, and 31% neither agreed nor disagreed that their professional entities or associations should offer opportunities for members to partake in online sessions like seminars and conferences held by their society or association to decrease emissions (Figure S19).

3.5. Barriers to Public Engagement and Useful Resources

A total of 73% and 50% indicated insufficient time and lack of knowledge, respectively, influencing their willingness (from a moderate amount or a great deal) to engage and communicate with the public about the climate crisis (Figure 5); other reasons included beliefs that such efforts would be futile (47%), controversy of the topic (33%), no support from peers (26%), and too risky for them professionally or personally (13%). Most survey respondents (83%) stated having little formal education on climate change and health (Figure S23).

Participants expressed different views on the resources to address climate change and health (Figure 6): training for communicating the science of climate and health (70% very helpful, 26% moderately helpful), direction or guidance on how to ensure a sustainable workplace (67% very helpful, 27% moderately helpful), continuous professional education on climate and health (58% very helpful, 31% moderately helpful), early notification mechanism (action alerts) to engage and advocate with policymakers (53% very helpful), the issuing of relevant policy statements by the MoHS or the Sierra Leone Medical and Dental Association (47% very helpful), and patient education materials (41% very helpful).

4. Discussion

To the best of our knowledge, this is the first survey in Sierra Leone on the views of health professionals about the changing climate and its effects on human health. Health professionals reported that a median of 75% (range of 39–100%) of climate scientists would think that human-caused climate change is happening. Interestingly, about half of participating health professionals in Sierra Leone believed that human activities mostly caused climate change, while about 40% felt this was equally caused by human activities and natural changes in the environment. This result highlights the mixed views of health professionals in Sierra Leone about the causes of climate change.

A large number (96%) of Sierra Leone’s healthcare workers were worried that the effects of climate change would impact them personally, their patients, people in their community, people in Sierra Leone, and future generations. This possibly echoes concerns about the country’s high vulnerability to climate change and low readiness to mitigate and adapt to climate change. Records of numerous weather events, like extreme heat, rising sea levels, recurring storms, floods, bushfires, coastal erosion, mudslides, etc., threaten Sierra Leone’s food security, health and infrastructure [28,29]. The country’s economy is dependent on natural resources and fragile ecosystems, which present with low agricultural productivity indices, while they have repeatedly suffered from environmental disasters, leaving many communities vulnerable to hunger and malnutrition [30,31].

Furthermore, communicable and non-communicable diseases (NCDs) have a strong grip on the country. In 2019 alone, 34% of all-cause mortality was attributed to NCD [32,33]. The country’s vulnerability to climatic, environmental, and energy-related changes has been associated with increasing rates of asthma and other respiratory diseases [2]. Studies have revealed that increasing climatic conditions are associated with heightened episodes of diarrheal diseases, water-borne diseases, seafood poisoning, dangerous pollutants, and a rise in malaria infections [30]. Malaria is one of the major health challenges in the country responsible for most of the out-patient visits and in-patient admissions, especially among children under five [34]. Consistent with previous studies [25,35], health professionals in Sierra Leone agreed that climate change has already negatively impacted the country and its population in numerous ways, such as affecting food security, hunger, and malnutrition due to rising food prices. Survey participants felt that the climate crisis would increase the incidence of NCDs over the next decade in Sierra Leone [2].

Health professionals in Sierra Leone strongly felt the responsibility to bring climate and health issues to the attention of policymakers and the public/patients, similar to surveys conducted among healthcare professionals in the Caribbean [25,35]. This would include health education/promotion activities, with 56% of the respondents willing to participate in advocacy campaigns, both at the national and global levels [36]. The need to communicate with the public about the climate and health nexus was also brought forward. However, several barriers and needs were recorded among the health professionals that would prevent them from doing so, such as lack of time or knowledge on the topic. Interestingly, about half of them (48%) reported that such efforts would not make a difference. Similarly, health professionals in the Caribbean (53%) mentioned a lack of time, 45% mentioned a lack of knowledge, and 36% said it will not make a difference if they do [25,35]. In April 2024, MoHS launched the country’s climate health unit as a continuing commitment to adapting and mitigating the adverse effects of the changing climate on human health and survival [37]. This is a positive move as it will provide interested health professionals with opportunities to collaborate with the unit, engage in advocacy, and educate the public on the issue. The climate health unit in collaboration with health professional associations in the country should lead in the production of resources mentioned by the survey participants to support health professionals in implementing sustainable practices.

5. Conclusions

The views of health professionals highlighted in this research represent a cross-section of health workers in Sierra Leone. Health professionals in the country are worried about the climate crisis and its impact on human health. Regarding health professionals’ involvement, provision of resources, and addressing of the barriers that prevent health professionals from being more actively involved with the climate and health nexus, a call for action is needed by regulatory agencies and policymakers. The recently formed unit on climate and health within the Ministry of Health and Sanitation in Sierra Leone should closely collaborate with health professionals to accelerate the implementation of climate and environment strategies for the country and the broader African region.

It is suggested that health professional societies or organizations, non-governmental organizations, and the Government of Sierra Leone should work together to empower health professionals through structured professional training programs in climate and health, while strengthening ties with stakeholders, such as NGOs, international organizations, and the public in terms of enhanced adaptation and mitigation to climate change.

6. Limitations and Future Directions

This study took place during the country’s presidential and parliamentary general elections; however, a large proportion of the study sample participated in the study (81%), and responses by health professionals originated from different parts of the country. The online data collection method was a challenge for many participants to complete the survey due to poor or no access to internet data. This made it difficult to obtain data from remote areas of the country, which is a limitation. The data presented in this study were a representation of survey participants from cities and towns across the country where internet access is less problematic.

This baseline assessment of health professionals’ views on climate and health should act as the guide for the design and implementation of future health education and health promotion programs for health professionals and also for the general public.