Climate Change, Heat-Related Health Risks, and Stroke: Perceptions and Adaptations Among Older Israeli Adults

Abstract

Extreme heat, a leading cause of weather-related morbidity and mortality, particularly affects vulnerable populations such as older people, increasing their risk of stroke. There is a gap between scientific knowledge and policy implementation, particularly regarding climatic risk factors for stroke. This study aims to identify knowledge barriers and enablers and formulate recommendations. We held eight focus groups of participants aged ≥ 60 years (N = 56), a workshop with 36 public health policy experts and stakeholders, and six in-depth interviews with experts. Three main themes emerged: (1) risk perception and responsibility attribution, revealing varying awareness of climate change risk for stroke and complex personal, cultural, and institutional responsibilities; (2) barriers to climate change adaptation, including knowledge gaps, environmental maladaptation, and insufficient governmental resources; and (3) enabling factors and adaptive solutions, highlighting individual coping strategies, education, and collaborative policy interventions. Focus group participants demonstrated diverse adaptive behaviors, while policymakers emphasized interagency collaboration and targeted knowledge dissemination. Older individuals demonstrated limited knowledge about climate change and its health risks. National policies lack effective communication. There is a critical need for knowledge dissemination, coping tools, and solutions for healthcare providers and at-risk groups, particularly regarding the health implications of climate change.

1. Introduction

The climate crisis, classified by the World Health Organization (WHO) as the greatest threat to humanity in the 21st century, is reshaping global health landscapes [1]. The health implications of climate change are both direct and indirect and are intricately linked to socio-economic and demographic factors. These implications range from increased morbidity and mortality due to extreme weather events (such as heat waves or floods) to shifts in the geographic distribution of vector-borne diseases [2,3]. Recent studies have emphasized the urgent need for action, highlighting the escalating health risks associated with the impacts of climate change [4,5]. Extreme heat, in particular, has emerged as a leading cause of weather-related health issues [6]. Over the past two decades, heat-related mortality among adults aged 65 years and above has surged by 53.7%, resulting in 296,000 deaths in 2018 alone [7]. Future projections are equally concerning, with estimates suggesting that by 2100, approximately 3 billion people will be vulnerable to heat waves [3]. The physiological consequences of heat exposure are severe and varied, including heat stroke, acute kidney injury, and exacerbation of cardiovascular conditions. Particularly vulnerable are older individuals, those with chronic illnesses, and outdoor workers [8,9,10].

Importantly, ambient temperature has been linked to an increased risk of stroke, the second leading cause of death globally [11]. Studies have shown correlations between temperature variation and stroke incidence. For instance, both extreme cold and heat have been associated with higher stroke risk [12,13,14]. A study in Israel found a significant relationship between high temperatures during summer and the risk of stroke or transient ischemic attack [15]. Moreover, the diurnal temperature range has been found to have a significant interactive effect on ischemic stroke risk [16]. These findings underscore the interplay between climate change and cerebrovascular health.

In response to these multifaceted challenges, global and national initiatives have been launched. The WHO [1] has published comprehensive guidelines for climate change preparedness, while various countries have adopted national strategies. However, significant gaps persist as many regions still lack climate adaptation plans altogether, while in regions where such plans exist, implementation often remains partial due to multiple barriers, including resource constraints, institutional challenges, and coordination gaps, leaving them inadequately prepared for the climate crisis [17,18]. Addressing these issues necessitates an evidence-based approach to policymaking. This approach, known as evidence-based public health, aims to bridge the gap between research and practical implementation, encompassing new guidelines, interventions, and behavior change strategies at all levels [19,20]. Recent work has further emphasized the importance of integrating health considerations into climate change policies and decision-making processes [21,22]. The involvement of public health officials and decision makers in climate change policy discussions is crucial for effective action and societal discourse on this critical issue [23]. A recent study showed that health professionals increasingly recognize their role in climate change advocacy and policy development, although significant barriers to engagement remain, including a lack of resources [24]. As climate change continues to evolve as a global health crisis, understanding its multifaceted impacts, including its effects on stroke risk, and developing effective, evidence-based responses remains a critical challenge for researchers, policymakers, and healthcare professionals worldwide.

Located in the eastern Mediterranean Basin, Israel is experiencing a significant warming trend, significantly higher than the global average, with longer and warmer summers, increased frequency and severity of heat waves, and changes in precipitation patterns [25,26]. In Israel, 96.8% of households have air conditioning [27]. Although the population of the Mediterranean countries is acclimatized to high temperatures and the use of air conditioning is common, the health of the region’s population has been significantly impacted [28]. Research examining heat wave response strategies has identified significant gaps in preventive measures among older populations. A review study found that older adults do not implement all recommended preventive measures during heat waves, while healthcare professionals and support staff are insufficiently active in preventing the negative impacts of heat waves. Although governments have begun implementing policy changes, other recommended support measures outlined in the Ottawa Charter for Health Promotion remain lacking and require additional action [29].

Knowledge about stroke varies significantly across regions and countries. Studies in India and Spain found limited knowledge among older adults regarding risk factors, warning signs, and early treatment approaches for stroke [30,31]. A recent review examining stroke knowledge and prevention concluded that awareness and preventive measures were inadequate [32]. In contrast, research in Saudi Arabia demonstrated high public awareness of stroke symptoms, risk factors, and treatment facilities, although people still struggled to identify appropriate actions when confronted with a stroke [33].

Various qualitative studies have examined the attitudes, perceptions, and knowledge of older adults regarding climate change. A study in Canada investigating the knowledge, attitudes, and experiences of older adults identified three main narrative themes: making sense of climate change, a lack of leadership in crisis management, and personal actions and responsibility [34]. Another study conducted in Israel found that fatalism significantly influences active climate behavior among older adults [35].

In conclusion, Israel is experiencing a significant warming trend, characterized by increasingly frequent, severe heat waves, which have already been linked to higher stroke incidence and other adverse health outcomes, especially among older adults [15]. Despite this, significant gaps in preventive measures persist, as current governmental responses remain inadequate and the implementation of comprehensive adaptation strategies is still lacking. For instance, systems such as Heat Health Warning Systems have yet to be developed and implemented. These critical gaps highlight the scientific and policy relevance of the present study, aiming to identify effective protective behaviors and provide evidence-based recommendations to strengthen public health preparedness and reduce heat-related health risks among vulnerable populations in Israel.

2. Materials and Methods

A qualitative research design was conducted with a phenomenological approach, comprising two main components: (1) focus groups with individuals aged 60 years and above and (2) a workshop with policy experts and stakeholders in public health in Israel, both followed by in-depth interviews with selected participants (see Appendix A).

For the focus groups, we recruited 56 participants aged 60 years and above. This age group was specifically selected as age is a primary risk factor for stroke, with risk doubling each decade after the age of 55 [36]. Recruitment was conducted through managers and coordinators at senior day centers across Israel, using a purposive sampling method to ensure representation from various regions and sectors. Eight focus groups were integrated into the participants’ regular attendance at the day centers, all of which were air-conditioned. Prior to each session, participants were provided with an information sheet and consent form, as well as an anonymous demographic questionnaire. Each focus group session, lasting 40 to 60 min, was audio-recorded and subsequently transcribed. At the conclusion of each session, participants received an information sheet containing recommendations for coping with hot weather from the Ministry of Health.

Six semi-structured interviews were conducted in July 2023 with participants who attended a science-policy workshop, organized jointly by the research team and the Ministry of Health. The workshop brought together public health policymakers and stakeholders to discuss research findings on climate change and stroke risk perceptions. The interviews followed a six-question protocol; they were conducted by telephone and audio-recorded with participants’ consent, except in one case where key points were documented in writing. Semi-structured interviews were chosen to ensure a balance between guided questioning and flexibility, allowing interviewers to explore participants’ perspectives in depth while maintaining consistency across responses [37]. This method involves a predefined set of questions while permitting open-ended discussion, enabling interviewers to adapt to participants’ answers and obtain richer qualitative insights. The study received ethical approval 240/22 from the ethics committee of the Faculty of Social Welfare Health and Sciences, University of Haifa, Israel.

Data Analysis

The analysis of both focus groups and follow-up interviews was conducted using the grounded theory approach [38], allowing for the development of theories and models based on emergent findings from the field. The analytical process comprised four stages: (1) transcription and initial reading of all focus groups and interviews, (2) initial coding using ATLAS.ti 22 software, (3) grouping of primary codes from the focus groups (N = 56) and interviews (N = 9) into 50 primary codes, using ATLAS.ti 22 software, and (4) theme identification and refinement. During the final stage, a meticulous re-reading of the codes was conducted, resulting in a selection of 40 codes for thematic analysis, grouped into three recurring themes (see Appendix B): (1) risk perception regarding extreme heat, health, and responsibility attribution (11 codes); (2) barriers to climate change adaptation (16 codes); and (3) enabling factors and adaptive solutions to climate change (13 codes). Relevant quotations were selected to illustrate and explain each theme and are presented in the Results chapter.

This mixed-method approach provides a comprehensive exploration of the phenomenon under study, allowing for a nuanced understanding of both individual experiences and policy perspectives related to the research question.

3. Results

The study included eight focus groups from different regions in Israel according to the Ministry of Health districts, and from various sectors in Israeli society, including both Jewish and Arab (i.e., Christian, Muslim, and Druze) populations. Detailed demographic characteristics of the participants are presented in

Table 1. Demographic characteristics of focus group participants (N = 56).

Category	Sub-Category	N	%
Gender	Women	20	35.7
	Men	36	64.3
Religion	Jewish	34	60.7
	Druze	6	10.7
	Muslim	11	19.6
	Christian	5	9.0
Education	None	4	7.1
	Elementary	18	32.1
	High School	13	23.2
	Vocational	11	19.6
	Bachelor’s degree	6	10.7
	Master’s degree	2	3.6
	PhD	2	3.6

. The groups were conducted in eight cities representing different climatic zones and geographic regions across Israel (

Table 2. Climatic characteristics of the study sites in Israel.

City	Geographic Region	Climate Zone	Mean Summer Temperature (°C)	Thresholds for Extreme Heat (°C) *	Mean Annual Difference in Summer Daily Maximum Temperature (°C) for Each Region Between 1964–1979 and 2006–2020 **
Be’er Sheva	Southern District	Semi-arid	33.5	>35 °C	+1.6
Rahat	Southern District	Semi-arid to Arid	33.8	>35 °C	+1.6
Tel Aviv	Tel Aviv District	Mediterranean coastal	30.2	>32 °C	+1.7
Haifa	Haifa District	Mediterranean	29.1	>32 °C	+1.7
Yoqneam Illit	Northern District	Mediterranean	30.5	>32 °C	+1.7
Daliyat al-Carmel	Haifa District	Mediterranean mountain	28.3	>32 °C	+1.7
Shfar’am (Shefa-Amr)	Northern District	Mediterranean	29.8	>32 °C	+1.6
Acre	Northern District	Mediterranean coastal	29.3	>32 °C	+1.7

Notes: * The thresholds for extreme heat, 32 and 36 °C in the Mediterranean zone and the desert zone, respectively, are based on [39,40]. ** According to a comparison among three atlases published by the Israel Meteorological Service for the periods 1964–1979, 1995–2009, and 2006–2020, a significant, statistically robust warming trend in temperature was detected between the earlier two periods and the most recent one, on both annual and seasonal scales. The average warming rate between 1964–1979 and 2006–2020 is approximately 1.5 °C, with the three most recent decades (1991–2020) exhibiting a pronounced general warming trend in Israel of approximately 0.6 °C per decade. Seasonal analysis reveals that all seasons in all regions demonstrate a clear warming trend, with summer characterized by the most substantial warming, averaging approximately 1.6 °C in maximum temperatures and 1.9 °C in minimum temperatures [41].

and Figure 1). A total of 56 participants took part in the study, comprising 30 women and 26 men, with a mean age of 77 years.

The analysis of the focus group discussions and the interviews revealed an interplay of knowledge, perceptions, and adaptive strategies related to climate change and its health impacts, particularly among the older population and the policymakers. Three main themes emerged from the findings: (1) risk perception regarding extreme heat and health and responsibility attribution, (2) barriers to climate change adaptation, and (3) enabling factors and adaptive solutions to climate change (see Figure 2). These themes provide insight into how individuals and policymakers understand and respond to climate-related health risks, the obstacles they face in implementing adaptive measures, and potential pathways for enhancing resilience to climate change impacts. Each theme incorporates perspectives from both the focus group participants and the policymakers, offering a comprehensive view of the current landscape of climate change adaptation in Israel, with a particular focus on heat-related health risks.

3.1. Risk Perception Regarding Extreme Heat and Health and Responsibility Attribution

The theme of risk perception and responsibility attribution emerged as a complex interplay of personal beliefs, cultural factors, and societal expectations. Participants in the focus groups demonstrated varied levels of awareness and concern regarding the health risks associated with climate change, particularly regarding extreme heat. Many participants readily identified specific health risks associated with hot weather. For example, a woman from Be’er Sheva, a city in the Negev desert, associated hot weather with “High blood pressure, dizziness,” while another from the same city added, “Headaches, heat rashes, itching, mosquitoes.” A man from Yoqneam (Mediterranean climate zone) emphasized the systemic impact: “The heat dehydrates me and, of course, affects my health, and breathing is difficult.” These responses indicate a general awareness of the immediate physiological effects of extreme heat.

However, the perception of personal risk varied significantly among participants. Some viewed climate change, particularly global warming, as a direct threat to their personal health and well-being. A woman from Tel Aviv encapsulated this perspective: “I think it’s a personal issue for everyone. It’s not a matter of political parties, it’s a national issue…” This view aligns with the expert consensus on the urgency of addressing climate change as a public health concern. Conversely, others distanced themselves from the perceived threat. Some participants, particularly older ones, viewed climate change as a long-term, global issue that would not significantly impact them personally. As a woman from Yoqneam stated, “It’s not a priority for me, not at our age.” This sentiment was echoed by a man from Haifa: “The way I see the situation, there’s no need to panic, it’s not happening tomorrow—it’s not a catastrophe.” The disconnect between scientific projections and personal risk perception presents a challenge for public health communicators and policymakers.

A subset of participants, particularly those with strong religious affiliations, expressed a fatalistic view of climate change. They perceived these environmental shifts as divine decrees beyond human control. For instance, a Druze woman from Daliyat al-Carmel simply stated, “Everything is from God”, while a Jewish woman from Yoqneam remarked, “Look, some things are in God’s hands. I can’t change the weather outside….” This fatalistic perspective sometimes extended to the belief that personal intervention could only come through prayer, as exemplified by a woman from Yoqneam who said, “We have prayers, the Torah; all our worship of God protects the world.”

Contrasting with this fatalistic view, many participants expressed a strong sense of personal responsibility. They believed that individual actions could significantly impact climate change. A woman from Tel Aviv emphatically stated, “It actually is in our hands—definitely.” This sense of personal responsibility often extended beyond self-care to include influencing one’s immediate environment and community. As a Muslim man from Rahat noted, “It starts with us, the residents, with human beings,” suggesting a grassroots approach to climate action.

The third perspective placed the onus of responsibility on governmental and municipal authorities as well as international entities. Proponents of this view argued that these institutions have the power and resources to implement large-scale changes and policies. A woman from Tel Aviv articulated this sentiment: “This challenge should be in the hands of politicians and governments. They must work together and think of steps to build the future.”

The expert interviews largely aligned with the latter two perspectives, emphasizing the importance of both individual action and institutional responsibility. “I think what is missing is an explanatory mechanism for both the general public and the stakeholders. The medical, therapeutic teams need to know more and be more updated about the consequences of this change (climate change). It’s a very fundamental issue.” They stressed the need for a multi-faceted approach, combining personal behavior changes with robust policy implementations.

This diverse range of perspectives highlights the complexity of addressing climate change. It suggests that effective strategies must consider and engage with these varied viewpoints, potentially combining elements of personal responsibility, community action, and institutional policy to create comprehensive, widely accepted climate change mitigation and adaptation strategies.

3.2. Barriers to Climate Change Adaptation

The analysis of the focus group discussions and expert interviews revealed significant barriers to climate change adaptation efforts. These barriers manifest in three primary areas: a lack of knowledge and information, inappropriate urban planning, and insufficient resources and collaboration at the governmental level.

The first barrier identified, particularly among the focus group participants, was the perceived lack of knowledge about the climate crisis and its implications. On one hand, participants reported perceiving significant changes in heat levels, describing increased warming as unprecedented in their experience. As a Druze woman from Daliyat al-Carmel noted, “each year it gets worse.” They were also acutely aware of the impact of heat on their well-being, reporting increased irritability and reduced physical capability. A man from Tel Aviv explained: “I become slower, heavier, irritable, more fatigued,” while a woman from Yoqneam noted: “When it’s terribly hot at home, I’m more irritable than on a regular day, I get more annoyed in the heat.”

On the other hand, despite this experiential awareness, participants expressed significant uncertainty about how to respond to these changes, leaving many feelings powerless to protect themselves effectively. As a Bedouin man from Rahat emphasized, “Explain to people, increase awareness.” Participants consistently highlighted the need for clear guidelines on coping with extreme heat. A Jewish woman from Tel Aviv pointedly noted, “They don’t inform the public or the general population on how to behave during extreme heat… I think when I talk about life here in Israel, we have no instructions.”

Besides the lack of knowledge about the climate crisis, a lack of knowledge about stroke emerged. When specifically asked about stroke risk and symptoms, most participants demonstrated limited or inaccurate knowledge, which significantly influenced their risk perception. This knowledge gap appeared to reduce their sense of personal vulnerability to stroke, despite belonging to a high-risk group. Some participants provided partial descriptions of stroke symptoms, such as “I think it’s related to memory,” “Their mouth and eye become a bit crooked,” or “Paralysis of part of the body.” Many participants were unable to answer questions about stroke symptoms or appropriate responses to stroke events, suggesting a disconnect between their objective risk status and their perceived risk. Others provided incorrect information, as illustrated by a woman from Be’er Sheva: “I felt like I had headaches and weakness and I was sweating. It was really mild, nothing special. That was my luck. I treated it and today, thank God, I’m past it.” This minimization of symptoms demonstrates how limited knowledge can lead to underestimation of the health risks.

Furthermore, the lack of formal health education appeared to contribute to reduced risk awareness. When asked about receiving information about stroke from their family physician, healthcare provider, or other sources, most participants reported receiving no formal guidance or education on the topic. A woman from Daliyat al-Carmel emphasized this gap in healthcare communication: “At the health clinic they don’t give us such things, they just give us pills and that’s it, they don’t tell us anything. I’m not satisfied with the attitude of the clinic staff.” This lack of professional guidance may have contributed to participants’ limited understanding of their vulnerability to stroke, particularly during extreme heat events.

This widespread lack of accurate knowledge about stroke symptoms and appropriate responses not only represents a significant public health concern but also appears to create a dangerous disconnect between actual and perceived risk. When participants are unaware of their vulnerability to stroke, particularly during extreme heat events, they may be less likely to take appropriate preventive measures or seek timely medical attention.

The second barrier is current urban planning, which is not suited to the changing climate. When asked about their natural environment and its adaptability to current climate conditions, participants highlighted significant infrastructural inadequacies. Issues such as insufficient shading and systematic tree removal for urban development were frequently mentioned. A man from the Arab town Shfar’am (Shefa-Amr) observed: “You can’t find trees everywhere, not inside the city; there are some on the outskirts, in public places.” This urban vegetation deficit was particularly concerning in rapidly developing areas, as noted by a woman from Tel Aviv: “I see trees being cut down in Tel Aviv to build more towers. And that’s very, very negative.”

Participants suggested several environmental adaptations to address these challenges. These included strategic tree planting, both natural and artificial shading solutions, and the installation of electrical ventilation in public spaces. A man from Tel Aviv compared local conditions with other countries: “Creating options on streets, in different neighborhoods. When I look abroad, I see street ventilation in many places, but we don’t have that here.”

These observations reflect participants’ recognition of the need to adapt their immediate environment to changing climatic conditions. They expressed a clear understanding that their urban surroundings require substantial modifications to provide adequate protection against extreme heat.

Third, at the governmental level, interviews with senior officials revealed a lack of approved, structured action plans addressing climate change impacts. While the Ministries of Health and Environmental Protection have begun drafting initial plans, comprehensive, budgeted strategies remain absent. A senior official from the Ministry of Health described the nascent process: “We have developed and built a plan (draft) based on several principles… We have consulted within the health system with different people in different subfields.”

Resource scarcity and insufficient collaboration constitute additional barriers. Most interviewees reported a need for various resources to advance climate change adaptation in their respective areas of responsibility. A Ministry of Health department head highlighted, “There is a significant lack of human resources within the health system… What’s missing within the system is a dedicated team to deal with this.” She also noted a positive shift in the past two years regarding attention to climate change: “We are being listened to, not that there’s too much understanding of how urgent it is right now, not tomorrow. But they are already talking to us.”

Financial constraints were emphasized by several interviewees as a significant obstacle to funding relevant research, dedicated teams, and community development plans. As one Ministry of Health department head stated, “Of course, for the sake of emergency preparedness, there will be a need to allocate a budget for this at some stage. Right now, I don’t see it in the 2023 work plan.”

These findings underscore the complex interplay between public awareness, environmental adaptation, and institutional readiness with regard to climate change impacts. They suggest that effective climate change adaptation strategies must simultaneously address knowledge gaps, environmental modifications, and resource allocation at both community and governmental levels.

3.3. Enabling Factors and Adaptive Solutions to Climate Change

The analysis revealed adaptive behaviors and proposed solutions to climate change impacts, particularly extreme heat, from the perspectives of both the older population and policymakers, including everyday adaptations, community-driven solutions, and policy-level interventions.

Focus group discussions revealed that older citizens have perceived a significant increase in heat levels in recent years, with one woman from Daliyat el-Carmel succinctly noting, “every year it gets worse.” This perception has led to substantial changes in their daily routines and habits. The most prevalent adaptive behavior was the increased use of air conditioning, with a man from Rahat emphasizing its necessity: “I can’t sit outside. Kids can’t sleep without air conditioning in the summer.” While some participants used air conditioning without financial concerns, others acknowledged its economic burden. Beyond air conditioning, participants reported adopting various other strategies, which are considered everyday adaptations [42]. These included adjusting the timing of their activities, preferring air-conditioned environments for errands and social activities, increasing their flexibility in scheduling, and adopting alternative solutions such as online shopping to avoid heat exposure. A woman from Yoqneam highlighted the challenges of moving between air-conditioned and non-air-conditioned spaces, illustrating the complex nature of adapting to extreme heat in her daily life.

When they were asked about potential solutions, participants emphasized several key areas. Health promotion and education emerged as a primary concern, with participants expressing a strong desire for increased knowledge about climate change and its health impacts. As a woman from Be’er Sheva noted: “We would be happy to receive more information such as lectures. It’s general knowledge for us.” Many viewed such knowledge as a personal gain at their stage of life. Some participants expressed optimism about technological solutions, drawing parallels between past innovations and potential future advancements. A woman from Tel Aviv reflected this perspective: “I think there’s always progress. Once we didn’t have air conditioners, and the next generation will take care of themselves and find solutions, that’s what I hope.” This optimistic note was particularly strong with respect to Israel’s capabilities, as expressed by a woman from Acre: “Everyone has problems, but we will cope because our technology is advanced.”

Many participants emphasized the importance of educating younger generations about climate change, viewing this as crucial for long-term adaptation and mitigation. They identified education and guidance as key drivers of change, particularly given that future generations will face the long-term consequences of climate change. A woman from Haifa emphasized this point: “We need to activate the education system, which we often forget about. Children need to know from a young age exactly how to behave, what to do, how to do it, and how to act in with respect to this issue.” This sentiment was echoed by a woman from Be’er Sheva, who stressed the importance of intergenerational knowledge transfer: “People should be aware of what to do and what not to do, and explain to their children and grandchildren so everyone knows.” From their perspective, young people need to understand ongoing environmental processes, as they represent a crucial link in creating meaningful change.

Interviews with health policymakers and stakeholders revealed complementary perspectives on addressing climate change challenges. Most interviewees emphasized the importance of inter-departmental collaboration and partnerships with academia. As a Ministry of Health department head explained: “The connection with academia is very important. Continued research is crucial, not only for increasing scientific knowledge but also as a foundation for regulatory decision making… it’s very important for us to stay updated and participate in the conclusion-drawing process, progressing together.” Additionally, interviewees emphasized the critical importance of inter-departmental collaboration, recognizing the scale and significance of the climate challenge and the need to provide customized guidelines for specific populations. A Geriatrics Division department head at the Ministry of Health expressed this urgency: “I must say I feel strongly that this struggle is not just a national issue; national efforts alone aren’t enough. The fight needs to be more integrated, with everyone cooperating because this is the present need. It’s upon us, it’s here, and we need to address it together.”

Policymakers also emphasized the need to equip service providers, citizens, and at-risk populations with knowledge and tools. A Ministry of Health department head highlighted this gap: “What I feel is missing is an explanatory mechanism for both the general public and the stakeholders. The medical teams, the therapeutic teams, and the entire caregiving environment—support for them needs to be more informed and updated about the consequences of this change. It’s very significant.” This aligns closely with the expressed desire of the population for more information and guidance. Particular emphasis was placed on medical team awareness and the role of family physicians in disseminating knowledge about the implications of extreme heat exposure. A Geriatrics Department manager at the Ministry of Health suggested a specific intervention: “I thought to myself that it should be mandatory. In primary [healthcare] clinics, family doctors must inform patients immediately in the event of a stroke. Suppose [a person] was hospitalized, rehabilitated, or something, and returned to the community, no matter what stage of the year; to say, to add it as another recommendation for heat and blood pressure.”

4. Discussion

This study explored the perceptions, barriers, and adaptive solutions related to climate change impacts on health among older adults and policymakers in Israel. The findings reveal an interplay of individual, societal, and institutional factors that influence climate change adaptation and health risk awareness.

4.1. Risk Perception and Knowledge Gaps

Our findings highlight the interplay between climate change risk perception and health awareness among older individuals. While participants demonstrated awareness of the immediate physiological effects of heat exposure, there was a significant disconnect between this experiential knowledge and the understanding of broader health implications, particularly regarding stroke risk. This finding aligns with recent research suggesting that personal experience of climate impacts does not automatically translate into comprehensive risk awareness [43].

The study revealed that risk perceptions were influenced by socio-demographic, cognitive, experiential, and socio-cultural factors, as researched by Van der Linden [44,45]. In our study, these influences were particularly evident in the educational background of participants, where only ten out of 56 participants had higher education, potentially affecting their understanding and interpretation of climate-related health information. Cultural influences were notably manifested through climate fatalism, where participants, particularly those from religious backgrounds, viewed climate change as predetermined or divine will rather than a phenomenon requiring human intervention. This finding aligns with another qualitative study conducted in Israel, which found that fatalism also influences climate change activism [35]. These influences manifested in two critical ways: first, in the participants’ understanding of climate change health risks, and second, in their awareness of stroke symptoms and prevention. Of particular concern was the participants’ limited ability to recognize stroke symptoms or understand their connection to heat exposure, despite being in a high-risk group. When asked about stroke symptoms, many participants provided incomplete or incorrect information, suggesting a significant gap in health literacy that could impact their ability to respond to heat-related health risks. These findings align with other studies demonstrating that knowledge and awareness levels significantly influence preventive behaviors and healthcare-seeking patterns [46,47].

While the lack of awareness regarding stroke symptoms was evident in all focus groups, awareness of the health impacts of heat was higher among residents of hot and dry regions, as can be expected. However, this heightened awareness of the immediate effects of heat was not necessarily associated with a better understanding of associated health risks. This finding aligns with theoretical frameworks suggesting that recognition of environmental risks does not automatically translate into engagement with adaptation behaviors, particularly when people perceive the consequences as temporally or spatially distant from their immediate experience [48,49].

4.2. Role of Knowledge and Education

Our analysis revealed that participants with knowledge regarding climate change also expressed higher climate risk perceptions, consistent with recent studies [50,51]. Most participants expressed a willingness to learn more about both climate change and its health implications, suggesting potential for educational interventions. This openness to learning aligns with Xie et al. [52], who found that increased knowledge can influence both risk perception and behavioral change. Moreover, Salma et al. [34] suggested that expanding opportunities for adults to learn about climate change and engage in climate initiatives would bring significant benefits to both this population and the climate change movement.

The importance of education emerged as particularly significant in two contexts: immediate health protection and intergenerational knowledge transfer. Regarding immediate health protection, participants expressed a need for practical information about recognizing and responding to heat-related health risks, including stroke symptoms. The effectiveness of such targeted education has been demonstrated in recent intervention studies, with Lou et al. [53] and Ibrahim et al. [54] reporting reduced heat exposure and improved risk awareness among older populations following educational programs. Additionally, a systematic review by Monroe et al. [55] identified six strategies that might result in effective educational interventions regarding climate change.

Addressing religion-based fatalistic views poses unique challenges for climate change education and awareness campaigns. Some participants with strong religious affiliations expressed beliefs that climate events are divinely controlled, making them less receptive to scientific explanations or proactive climate initiatives. To overcome these barriers, educational strategies must respect and integrate religious perspectives, emphasizing stewardship and responsibility toward creation, a viewpoint supported by multiple religious teachings. Studies suggest that involving religious leaders as climate educators can significantly enhance the receptivity to and effectiveness of educational interventions [56]. Furthermore, tailored communication campaigns that align scientific information with religious values can bridge the gap between fatalism and action-oriented responses to climate risks [57]. Policy development should also reflect this integrative approach by including religious communities in policy dialogues, thus fostering trust and collaborative climate action [56].

4.3. Policy Formulation and Implementation

Analysis of responses from both older participants and policymakers revealed critical insights for developing effective climate change adaptation strategies. A key finding was the alignment between population needs and policy priorities, particularly regarding education and awareness programs. However, this alignment has not yet translated into comprehensive implementation, highlighting a gap between the recognition of needs and actual service delivery.

Our focus groups revealed that while participants viewed the government as primarily responsible for policy formulation, there was limited understanding of personal adaptation strategies. This finding highlights the need to bridge the gap between institutional responsibility and individual agency through a more collaborative approach to policy development. Research has shown that co-creation and citizen engagement in policymaking not only enables better understanding of participation and involvement but also enhances community empowerment [58].

The effectiveness of such participatory approaches is well-documented. A 2019 systematic review demonstrated that participatory co-design approaches lead to improved health outcomes, including enhanced physical and mental health, increased adoption of health-promoting behaviors, greater self-efficacy, and more effective use of health services [59]. The involvement of relevant stakeholders in policy implementation and ongoing monitoring creates public value, insight, and cooperation, leading to greater transparency and accountability [58].

The challenge lies in effectively balancing institutional leadership with community engagement. Our findings suggest that while strong governmental guidance remains essential, a participatory approach to policy development could significantly increase public engagement and improve health outcomes [60].

A significant finding was the gap between Israel’s policy commitments and program implementation. Despite Government Decision No. 4079 in 2018 and international commitments, Israel lacks a comprehensive national program comparable to those implemented in other developed countries. Interviews with policymakers revealed that while initial steps have been taken, particularly in the Ministry of Health, the transition from policy to practice faces multiple barriers, including resource constraints and coordination challenges. The effectiveness of comprehensive national programs in reducing heat-related mortality has been well-documented in other countries [8,61,62], and evidence shows that urban climate policy can have multiple health co-benefits, even in hot and dry regions [63,64], suggesting potential health benefits from implementation in Israel.

5. Conclusions and Future Directions

This study highlights several critical gaps in climate change adaptation and health risk awareness among older adults in Israel, while also identifying opportunities for improvement. The findings suggest that effective climate change adaptation requires both knowledge deficits and structural barriers to implementation to be addressed.

Our research reveals three main conclusions. First, while older individuals recognize immediate physiological responses to heat, there is limited understanding of the connection between climate change and serious health risks, particularly stroke. This gap in knowledge presents both a challenge and an opportunity for targeted health education programs. Second, the willingness of participants to engage with health information suggests the potential for successful educational interventions, particularly when these are culturally sensitive and practically oriented. Third, while policy frameworks do exist, there is a need for better integration between institutional initiatives and community-level implementation.

These findings suggest several key future research directions. Building on the identified knowledge gaps regarding heat-related health risks, future studies should focus on developing and evaluating targeted educational programs for older populations, particularly addressing the critical connection between extreme heat and stroke risk, which was found lacking in our focus groups. Given our findings about the challenges in healthcare communication revealed through both focus groups and expert interviews, there is a clear need to examine how healthcare providers can more effectively communicate climate-related health risks to older patients. Additionally, considering the institutional barriers identified in our study, future research should evaluate the implementation and effectiveness of heat-health action plans in various healthcare settings serving older populations, ensuring that vulnerable populations receive the targeted support they need to bridge the gap between awareness and adaptation to increasing climate-related health risks.

Policy Recommendations

Integrating the bottom-up suggestions from focus group participants with the top-down perspectives from policymaker interviews, we propose the following policy recommendations:

• Expedite the development and implementation of a comprehensive national climate change adaptation program, building upon and finalizing the initiatives currently in progress at the Ministry of Health. This program should have a specific focus on heat-related health risks, particularly stroke for vulnerable populations, including older individuals.
• Establish targeted education and awareness campaigns to increase public knowledge about climate change impacts, particularly emphasizing the immediate, personal nature of these risks. These campaigns should also include information about stroke, its symptoms, and its connection to extreme heat, addressing the knowledge gap identified in the focus groups.
• Implement a multi-faceted approach incorporating a collaborative framework that involves government ministries, academic institutions, and community organizations. This integrated strategy should combine insights from public health, social sciences, environmental studies, and policy making to develop interdisciplinary programs that directly impact the elderly population. By addressing climate change adaptation through education, healthcare planning, and community-based initiatives, these programs will enhance resilience and improve risk awareness among older adults.
• Invest in climate-resilient urban planning, including increased shading in public spaces and the integration of cooling technologies in community centers frequented by older individuals.
• Implement a national heat warning system, coupled with clear, actionable guidelines for the public, particularly tailored for at-risk groups such as older individuals. This system should include specific guidance on stroke prevention and recognition of early symptoms during extreme heat events.
• Allocate dedicated funding and resources for climate change adaptation research, focusing on Israel-specific challenges and solutions, particularly in relation to stroke prevention and management in the context of rising temperatures.