Public Health Climate Change Adaptation Planning Using Stakeholder Feedback Millicent Eidson, MA, DVM; Kathleen A. Clancy, MPH; Guthrie S. Birkhead, MD, MPH rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Context: Public health climate change adaptation planning is an urgent priority requiring stakeholder feedback. The 10 Essential Public Health Services can be applied to adaptation activities. Objective: To develop a state health department climate and health adaptation plan as informed by stakeholder feedback. Design: With Centers for Disease Control and Prevention (CDC) funding, the New York State Department of Health (NYSDOH) implemented a 2010-2013 climate and health planning process, including 7 surveys on perceptions and adaptation priorities. Participants: New York State Department of Health program managers participated in initial (n = 41, denominator unknown) and follow-up (72.2%) needs assessments. Surveillance system information was collected from 98.1% of surveillance system managers. For adaptation prioritization surveys, participants included 75.4% of NYSDOH leaders; 60.3% of local health departments (LHDs); and 53.7% of other stakeholders representing environmental, governmental, health, community, policy, academic, and business organizations. Interviews were also completed with 38.9% of other stakeholders. Results: In 2011 surveys, 34.1% of state health program directors believed that climate change would impact their program priorities. However, 84.6% of state health surveillance system managers provided ideas for using databases for climate and health monitoring/surveillance. In 2012 surveys, 46.5% of state health leaders agreed they had sufficient information about climate and health compared to 17.1% of LHDs (P = .0046) and 40.9% of other stakeholders (nonsignificant difference). Significantly fewer (P < .0001) LHDs (22.9%) were incorporating or considering incorporating climate and health into planning compared to state health leaders (55.8%) and other stakeholders (68.2%). Stakeholder groups agreed on the 4 highest priority adaptation
J Public Health Management Practice, 2016, 22(1), E11–E19 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
categories including core public health activities such as surveillance, coordination/collaboration, education, and policy development. Conclusions: Feedback from diverse stakeholders was utilized by NYSDOH to develop its Climate and Health Strategic Map in 2013. The CDC Building Resilience Against Climate Effects (BRACE) framework and funding provides a collaborative model for state climate and health adaptation planning. KEY WORDS: climate change, public health, state health
planning, surveys Climate change, including variation in long-term averages of atmospheric conditions, poses a risk to public health.1-3 The Centers for Disease Control and Author Affiliations: Office of Public Health, New York State Department of Health, Albany, New York (Drs Eidson and Birkhead and Ms Clancy); and Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, New York (Drs Eidson and Birkhead). The 2010-2013 Centers for Disease Control and Prevention (CDC) Cooperative Agreement Number 5UE1EH000737 and the CDC/CSTE Applied Epidemiology Fellowship program Cooperative Agreement Number 5U38HM000414 supported this project. This publication is solely the responsibility of the authors and its contents do not necessarily represent the official views of CDC. CDC had no role in study design, collection, analysis, and interpretation of data; writing the report; or decision to submit the report for publication. No other funding supported the project. The authors thank the following members of our Project Coordinating Team in alphabetical order: Marie Desrosiers, Kevin Gleason, Dr Nathan Graber, Claudia Hutton, Dr Syni-An Hwang, Dr Shao Lin, Dr Daniel Luttinger, Dr Faith Schottenfeld, and Dr Jan Storm, New York State Department of Health. The authors acknowledge the contributions to methods and analysis of Danielle Abraham, Eva Pradhan, and Dr Shelley Zansky, New York State Department of Health, and interns Stephanie Mack, Daniel Malashock, Natasha Karim, Asma Madad, and Sakib Bin Aziz, University at Albany. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (http://www.JPHMP.com). Correspondence: Millicent Eidson, MA, DVM, Office of Public Health Practice, New York State Department of Health, 923 Corning Tower, Empire State Plaza, Albany, NY 12237 ([email protected]). DOI: 10.1097/PHH.0000000000000243
E11 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
E12 ❘ Journal of Public Health Management and Practice Prevention (CDC) Climate-Ready States and Cities Initiative (CRSCI) funds policy making and health planning in the United States to prepare for climate change.4 This report summarizes a CRSCI model for state health department climate change adaptation plan development. Climate change adaptation is defined as the “strategies, policies, and measures . . . undertaken now and in the future to reduce the burden of climate-sensitive health determinants and outcomes.”5 The 10 Essential Public Health Services were released by the Institute of Medicine to “provide the foundation for the Nation’s public health strategy,”6 and Frumkin et al developed specific climate change examples.7 In developing its climate change adaptation plan, the New York State Department of Health (NYSDOH) was informed by these frameworks in developing categories for public health activities recommended in the 2010 New York State (NYS) Climate Action Council (CAC) Interim Report8 and other climate and health literature. New York State, the Nation’s third most populous,9 is the largest of 10 states which warmed by at least 2◦ F in the past 30 years.10 The St Lawrence Valley in northern NYS is 1 of 5 US regions which warmed by more than 2.5◦ F over the same time period. Between 1958 and 2010, very heavy precipitation events increased by more than 70% in the Northeast, a greater increase than any other US region.11 Extreme heat events, intense precipitation events, and coastal flooding are projected to increase in NYS.3,12 With the impetus of a changing climate and with CDC support, NYSDOH undertook a 3-year process between late 2010 and 2013 to prioritize adaptation activities and develop a NYSDOH Climate and Health Strategic Map (as a summary of the adaptation plan). The final plan will foster implementation of the CDC Building Resilience Against Climate Effects (BRACE) framework, which has 5 steps: (1) forecasting climate impacts and assessing vulnerabilities; (2) projecting the disease burden; (3) assessing public health interventions; (4) developing and implementing a climate and health adaptation plan; and (5) evaluating impact and improving quality of activities.4,13 The NYSDOH adaptation planning process provides a foundation for a replicable method particularly for BRACE step 4 in other geographic areas.
● Methods In early 2011, NYSDOH formed teams and workgroups specifically to collect feedback and guide its climate and health planning process. A Project Coordinating Team (PCT), which met regularly to oversee planning activities related to climate change,
included the Principal Investigator, 2 co-Principal Investigators, Project Coordinator, Health Administrator, and 7 NYSDOH Center for Environmental Health leaders addressing climate change. A larger Guidance Team included an additional 14 representatives of potentially climate-impacted NYSDOH programs and provided input into surveys and planning by e-mail. Represented programs included surveillance, laboratory, emergency preparedness, injuries, health care, long-term care, and prevention/control programs for infectious diseases and chronic diseases associated with climate change. Three staff workgroups addressed needs assessments, potential surveillance systems for climate and health outcomes, and risk communication. The NYS Association of County Health Officials was consulted for advice on the inclusion of local health departments (LHDs) in the planning process; LHDs consist of 57 county health departments and the New York City Department of Health and Mental Hygiene. Local health departments are a key stakeholder group with responsibility for provision of public health services at the local level. Although federal and state statutes and regulations guide delivery of local public health services, LHDs operate under the authority of local governments. The PCT and Guidance Team also assisted in developing a list of other stakeholder organizations with potential interest in NYS climate and health planning. The 3-year planning process included feedback through meetings, telephone calls, e-mails, webinars, presentations, reports, and surveys. Thus, the information collected was not anonymous, but participants were assured that summaries would not identify names or programs. The NYSDOH institutional review board process was not utilized because the activities did not meet the federal research definition.14
Samples and surveys Over the 3-year planning process, NYSDOH conducted 7 surveys to inform the development of the NYSDOH Climate and Health Adaptation Plan (Table 1). All surveys were pretested for clarity and time for survey completion, followed by necessary revisions. All surveys were electronic and sent by e-mail, except for the interviews. Recipients received at least 3 weeks to complete the surveys. Reminders were sent during and at the close of initial response periods, and time extensions were granted to maximize response rates.
Initial NYSDOH needs assessment The NYSDOH program directors’ perceptions of climate change were captured through distribution of an
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Public Health Climate Change Adaptation Planning
❘ E13
TABLE 1 ● Survey Summary
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Survey
Dates
Participants
DOH initial needs assessment
1/28/11-3/1/11
Program directors
DOH follow-up needs assessment
7/5/11-8/26/11
Program directors
DOH surveillance assessment
7/5/11-9/7/11
Database managers
DOH priorities
2/10/12-2/24/12
LHD priorities/needs
5/4/12-6/15/12
Other stakeholder priorities/needs
8/10/12-10/2/12
Leaders with priority authority Directors or Commissioners Organization leaders
Nongovernmental organization needs
8/17/12-11/2/12
Organization leaders
How Administered
Response Rate
Emailed down chain of command Emailed using department program list In-person interviews using department list Emailed using list from Guidance Team Emailed to list of 57 counties plus NYC Emailed using list from Guidance Team Individual phone interviews
41 (denominator unknown) 72.2% (78/108) 98.1% (52/53) 75.4% (43/57) 60.3% (35/58) 53.7% (22/41) 38.9% (14/36)
Abbreviations: DOH, New York State Department of Health; LHD, local health department; NYC, New York City.
electronic survey. To introduce the planning process and recommend staff participation, the Principal Investigator e-mailed the brief 4-page survey down the chain of command; thus, the number of recipients was unknown. Questions focused on previous involvement with climate change and perceptions of potential impact on programs.
Follow-up NYSDOH needs assessment The NYSDOH organizational chart was reviewed and 108 directors of programs deemed relevant to climate change were asked to participate in a follow-up needs assessment to collect new information about program needs and expertise in adaptation planning. The 15page survey was estimated to take 15 to 30 minutes.
Surveillance system assessment The NYSDOH previously generated an inventory of 309 surveillance system databases, which was used as a starting point to identify 53 that addressed environmental exposures or health outcomes associated with climate change in the literature. Two staff members used an 11-question, 20-page form to individually conduct database manager interviews, which lasted up to 1 hour, and consulted with each other to assure similar interviewing and coding procedures. Questions addressed data quality, accessibility, tracking, timeliness, and geolocation to look for clustering of potential climate and health indicators in time and space, as well as use of climate data. The surveillance system attributes were subsequently evaluated using the CDC guidelines for evaluating public health surveillance systems.15
NYSDOH adaptation prioritization Frumkin et al7 developed climate change examples for 9 of the 10 Essential Public Health Services6 with the exception of “enforce laws and regulations” because there was “little role for public health.”7 For the 3 adaptation prioritization surveys with NYSDOH, LHDs, and other stakeholders, NYSDOH developed 9 categories of adaptation services informed by the descriptions of the 10 Essential Public Health Services and the Frumkin et al examples. Next, a list of 77 adaptation activities was developed on the basis of the CAC adaptation priorities8 (26 New York-specific activities), lists of adaptation activities developed previously by New Hampshire16 and the Environmental Defense Fund,17 and other climate and health references provided by the PCT and Guidance Team. Each activity was included under 1 of the 9 adaptation categories and the number of activities within each category ranged from 4 to 13. (Categories and activities used by NYSDOH are included with the results tables.) Invited NYSDOH adaptation survey participants were the center, office, division, and bureau directors identified as departmental leaders with authority to set priorities. The cover letter, instructions, and 5 survey pages (estimated to take 15 minutes) introduced the survey as an opportunity for the participants to provide feedback on possible NYSDOH priorities for implementation of adaptation activities. Survey participants were first asked to rank the top 3 activities within each category, with (1) assigned to the highest priority activity for NYSDOH. Participants were instructed to leave unranked activities blank, and ties were not permitted. This instruction was designed to reduce survey completion time and
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E14 ❘ Journal of Public Health Management and Practice increase participation by simplifying the amount of ranking required. Next, participants were asked to indicate their top 3 priority categories. The survey also included questions for additional information about climate and health knowledge, attitudes, and access to information.
and policy organizations (2 each), and academia (1). No significant differences were found between participating LHDs and those not participating on county population size (≤75 000 or >75 000) and public health capacity (full service vs partial service with no environmental health services).18
LHD adaptation prioritization All LHDs received a similar survey instrument but one page of additional climate and health perception questions was added because a prior needs assessment had not been conducted.
Other stakeholder adaptation prioritization A July 2011 meeting with the PCT, Guidance Team, and LHD volunteers included 5 state government stakeholders—the NYS Department of Environmental Conservation, the NYS Department of State, the NYS Department of Agriculture and Markets, the NYS Climate Office, and the NYS Energy Research and Development Authority. The meeting reviewed current work on climate change, and discussed recommendations for NYSDOH. These 5 state governmental organizations plus 36 other stakeholder organizations were invited for the adaptation prioritization survey. Populations served by these groups include migrant farmworkers, city planners, racial/ethnic minorities, those with asthma or other respiratory diseases, children, farmers, physicians, and public health workers. The stakeholder organizations not included in the meeting were invited to discuss potential partnerships in individual phone interviews, which included climate and health perception questions.
Statistical analysis The top 3 adaptation activities and categories were coded as 1, 2, or 3 (unranked activities and categories were coded as “4”). SAS version 9.2 (SAS Institute, Inc, Cary NC) was used for data analysis. The KruskalWallis test option was used to identify ranking differences among the 3 key groups (P < .05). Chi-square tests were used to identify differences in proportions.
● Results Response rates for all 7 surveys are presented in Table 1. For the written survey with other stakeholder organizations, response rates by group were as follows: governmental 87.5% (7/8), policy 75% (6/8), community 60% (3/5), academic and business each 50% (1/2), health 33.3% (2/6), and environmental 20% (2/10). Interviews were conducted with government, community, and health organizations (3 each), environment
NYSDOH needs assessments Only 17.1% of NYSDOH program directors (7/41) had previously received questions from outside the program related to climate and health. Internal discussions were more frequent, at 31.7% (13/41). Perceived impact on program priorities, using a scale from 1 (to a large degree) to 5 (not at all), averaged 2.85 (to a small degree), with 34.1% (14/41) indicating some impact (to a large, medium, or small degree), and 22% (9/41) indicating uncertainty. Perceived impact on populations averaged 2.41, with 26.8% (11/41) indicating uncertainty. Program directors most often (17.1%, 7/41) reported “everyone” as an at-risk population, followed by older adults and young children (each reported by 10%, 4/41). Program directors recommended reaching vulnerable populations through public outreach, advisories, and training. In the follow-up needs assessment, 86 climate and health program needs were reported by the 78 participants, with “additional staff” representing the largest proportion of the responses at 26.7% (23/86). Others included “staff training” at 18.6% (16/86), “budget/ money/funding” at 16.3% (14/86), “information” at 14% (12/86), “equipment/technology” at 11.6% (10/86), and “communication” at 9.3% (8/86). More programs (37.2%, 29/78) reported ample expertise to create an adaptation plan at the NYSDOH level than at the health care delivery level (16.7%, 13/78) or program level (14.1%, 11/78).
Surveillance systems To use data for climate and health surveillance, 51.1% (24/47) of the systems required special requests for data with personal identifiers. Data sharing agreements were in place for 52% (26/50), with CDC as the partner mentioned most often. Most (69.2%, 36/52) had data representing all NYS. About half (51.9%, 27/52) had data reported daily. Sensitivity was assessed for monitoring impacts over time and in different geographic areas. Health event date was available for 88% (44/50) of the systems, and 71.2% (37/52) had tracking to detect changes for investigation or action. Only 25.5% (13/51) of the systems geocoded all data, but 70% (21/30) of the remaining systems reported the possibility of full geocoding.
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Public Health Climate Change Adaptation Planning
For acceptability of using the system to address climate and health, only 13.5% (7/52) of the system managers were using climate data, but 84.6% (44/52) mentioned ideas on how their system could be useful as part of a climate change adaptation plan.
Perceptions and adaptation prioritizations Although DOH leaders and other stakeholders were neutral about having sufficient climate and health information (Table 2), 46.5% of DOH leaders (20/43) agreed or strongly agreed they have sufficient information compared to 17.1% of LHDs (6/35) (P = .0046), with other stakeholders in between at 40.9% (9/22) (nonsignificant difference). A significantly higher proportion (90.9%) of other stakeholders (20/22) agreed that climate change should be an important NYSDOH focus than DOH leaders at 60.5% (26/43) and LHDs at 62.9% (22/35) (P < .001). Regarding incorporating or considering incorporating climate and health into organizational plans, 55.8% (24/43) of DOH leaders and 68.2% (15/22) of other stakeholders said yes, compared to 22.9% (8/35) of LHDs (P < .001). In open-ended explanations, participants reported incorporating it to “increase their knowledge of the impact of climate change on health” and as part of “adaptation planning and/or implementation.” Those not incorporating it cited “no capacity” or “strategic plan developed by someone else.” Sixty percent of the LHDs were unsure, with “strategic plan in development” as one explanation. “Climate change not a priority” was listed by those unsure or not incorporating it into planning. Local health departments reported 68 climaterelated health concerns and other stakeholders reported 38. Local health departments most frequently reported vector-borne diseases at 26.5% (18/68), severe weather/storms at 22.1% (15/68), and water qual-
❘ E15
ity at 10.3% (7/68). For other stakeholders, the top 3 were extreme heat events at 21.1% (8/38) and severe weather/storms and respiratory illness, each at 15.8% (6/38). To address these issues, LHDs reported 36 and other stakeholders reported 48 actions. Local health departments most frequently reported emergency preparedness at 16.7% (6/36) and tick/lymerelated and education/communication activities, each at 13.9% (5/36). For other stakeholders, the top 3 actions were education/information/communication at 16.7% (8/48) and vulnerability assessment and partnership with state agencies, each at 10.4% (5/48). Local health departments reported 62 and other stakeholders reported 38 barriers to addressing issues of concern. Local health departments most frequently reported lack of funding at 27.4% (17/62), lack of staff at 19.4% (12/62), and lack of education/training at 14.5% (9/62). For other stakeholders, the top 3 barriers were lack of public awareness/preparedness at 31.6% (12/38), lack of funding at 26.3% (10/38), and mixed messages/poor communication at 13.2% (5/38). For the 3 stakeholder groups, Table 3 presents prioritization results for the adaptation categories in order of DOH leader highest priority (lowest ranking average on a 4-point scale). All 3 groups gave higher priority to the same 4 adaptation categories of “Monitoring, Surveillance,” “Capacity Building: Coordination, Collaboration,” “Education, Awareness,” and “Policy Development, Planning.” The highest priority category for DOH leaders and other stakeholders was “Monitoring, Surveillance” (mean rankings 2.28 and 2.59, respectively), whereas “Education, Awareness” was the highest priority category for LHDs (mean ranking 2.26). For all 3 groups, “Quality Assurance, Program Evaluation” was the lowest priority category. Table 4 presents the prioritization of the 77 adaptation activities for which significant differences were found between the 3 groups. The highest priority
TABLE 2 ● Mean Agreement on Climate Change and Health Perceptions
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq Participant Group
Climate Change and Health Perception (5-Point Scale: 1 = Strongly Agree to 5 = Strongly Disagree) Agree they have access to sufficient information on climate change and health impacts Agree that climate change should be an important focus of NYSDOH
DOH Leaders (n = 43) a
LHDs (n = 35) a
Other Stakeholders (n = 22)
P
2.75
3.46
3.00
.02
2.33b
2.34c
1.73b,c
.03
Abbreviations: NYSDOH, New York State Department of Health; LHDs, local health departments. a P = .005. b P = .02. c P = .02.
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E16 ❘ Journal of Public Health Management and Practice TABLE 3 ● Mean Prioritization of Climate Change and Health Adaptation Categories
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq Participant Group c
Adaptation Category (In Order of DOH Leaders Highest Prioritization) Monitoring, surveillance Capacity building: coordination, collaboration Education, awareness Policy development, planning Community screening, diagnostic, investigative Research, innovation Workforce development Access to services Quality assurance, program evaluation
DOH Leaders (n = 43)
LHDs (n = 35)
a
a
2.28 2.88 3.26a 3.26 3.40 3.51 3.70 3.74 3.93
3.26 3.37 2.26a,b 3.11 3.60 3.77 3.53 3.74 4.00
Other Stakeholders (n = 22)
P
2.59 3.05 3.00b 2.95 3.86 3.50 3.82 3.45 3.91
.004 .21 .002 .58 .18 .36 .007 .49 .15
Abbreviations: DOH, New York State Department of Health; LHDs, local health departments. a,b Statistically significant pair-wise differences using t test, P < .05. c Rankings were 1 (top) to 3, with unranked categories coded as 4; categories were developed from the 10 Essential Public Health Services6 informed by 9 examples from Frumkin et al.7
adaptation activity for DOH and LHDs, with mean rankings 1.77 and 1.91, respectively, was “Provide assistance to local governments for surveillance and response to vector-, food-, water-borne and diseasecausing agents,” and it was prioritized significantly lower by other stakeholders (mean ranking 2.82, P = .004). The other stakeholders had 2 highest priority activities, with mean ranking 2.32: “Partnership building with stakeholders” and “Research agenda” (not included in table because of no significant differences).
Climate and health strategic map Written summaries of survey results and slide presentations were provided in early 2013 to participants, as well as others from each group attending the presentations. The NYSDOH reviewed PCT, Guidance Team, and workgroup membership to identify key leaders for all NYSDOH areas with potential impact from climate change, and 21 were available to meet for a daylong, in-person meeting in July 2013 with a contracted facilitator. Survey and interview findings were reviewed, including the prioritizations of the
TABLE 4 ● Mean Prioritization of Adaptation Activities with Statistically Significant Differences (P < .05) across
Participant Groups qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq Participant Group c
Adaptation Activity (In Order of DOH Leaders’ Highest Prioritization) Provide assistance to local governments for surveillance and response to vector-, food-, water-borne and disease-causing agents Raise awareness on CC and health significance Partnership building with stakeholders Early warning and evacuation systems Provide local intervention/control resources Participate in risk, prevention research studies Technical assistance for needs assessment Provide resources for local education capacity Provide funding for partnerships Housing displaced/relocated persons
DOH Leaders (n = 43) a
LHDs (n = 35) b
Other Stakeholders (n = 22) a,b
P
1.77
1.91
2.82
.004
2.14a 2.33a 3.02a 3.16 3.19a 3.37 3.58a 3.70a,b 3.95a
2.60 2.91a,b 2.34a 2.69a 3.66a 3.09a 2.97a 2.74a 3.77a,b
3.23a 2.32b 2.59 3.41a 3.36 3.77a 3.23 2.95b 3.95b
.007 .02 .03 .03 .049 .03 .01
Context: Public health climate change adaptation planning is an urgent priority requiring stakeholder feedback. The 10 Essential Public Health Services can be applied to adaptation activities. Objective: To develop a state health department climate and health adaptation plan as informed by stakeholder feedback. Design: With Centers for Disease Control and Prevention (CDC) funding, the New York State Department of Health (NYSDOH) implemented a 2010-2013 climate and health planning process, including 7 surveys on perceptions and adaptation priorities. Participants: New York State Department of Health program managers participated in initial (n = 41, denominator unknown) and follow-up (72.2%) needs assessments. Surveillance system information was collected from 98.1% of surveillance system managers. For adaptation prioritization surveys, participants included 75.4% of NYSDOH leaders; 60.3% of local health departments (LHDs); and 53.7% of other stakeholders representing environmental, governmental, health, community, policy, academic, and business organizations. Interviews were also completed with 38.9% of other stakeholders. Results: In 2011 surveys, 34.1% of state health program directors believed that climate change would impact their program priorities. However, 84.6% of state health surveillance system managers provided ideas for using databases for climate and health monitoring/surveillance. In 2012 surveys, 46.5% of state health leaders agreed they had sufficient information about climate and health compared to 17.1% of LHDs (P = .0046) and 40.9% of other stakeholders (nonsignificant difference). Significantly fewer (P < .0001) LHDs (22.9%) were incorporating or considering incorporating climate and health into planning compared to state health leaders (55.8%) and other stakeholders (68.2%). Stakeholder groups agreed on the 4 highest priority adaptation
J Public Health Management Practice, 2016, 22(1), E11–E19 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
categories including core public health activities such as surveillance, coordination/collaboration, education, and policy development. Conclusions: Feedback from diverse stakeholders was utilized by NYSDOH to develop its Climate and Health Strategic Map in 2013. The CDC Building Resilience Against Climate Effects (BRACE) framework and funding provides a collaborative model for state climate and health adaptation planning. KEY WORDS: climate change, public health, state health
planning, surveys Climate change, including variation in long-term averages of atmospheric conditions, poses a risk to public health.1-3 The Centers for Disease Control and Author Affiliations: Office of Public Health, New York State Department of Health, Albany, New York (Drs Eidson and Birkhead and Ms Clancy); and Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, New York (Drs Eidson and Birkhead). The 2010-2013 Centers for Disease Control and Prevention (CDC) Cooperative Agreement Number 5UE1EH000737 and the CDC/CSTE Applied Epidemiology Fellowship program Cooperative Agreement Number 5U38HM000414 supported this project. This publication is solely the responsibility of the authors and its contents do not necessarily represent the official views of CDC. CDC had no role in study design, collection, analysis, and interpretation of data; writing the report; or decision to submit the report for publication. No other funding supported the project. The authors thank the following members of our Project Coordinating Team in alphabetical order: Marie Desrosiers, Kevin Gleason, Dr Nathan Graber, Claudia Hutton, Dr Syni-An Hwang, Dr Shao Lin, Dr Daniel Luttinger, Dr Faith Schottenfeld, and Dr Jan Storm, New York State Department of Health. The authors acknowledge the contributions to methods and analysis of Danielle Abraham, Eva Pradhan, and Dr Shelley Zansky, New York State Department of Health, and interns Stephanie Mack, Daniel Malashock, Natasha Karim, Asma Madad, and Sakib Bin Aziz, University at Albany. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (http://www.JPHMP.com). Correspondence: Millicent Eidson, MA, DVM, Office of Public Health Practice, New York State Department of Health, 923 Corning Tower, Empire State Plaza, Albany, NY 12237 ([email protected]). DOI: 10.1097/PHH.0000000000000243
E11 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
E12 ❘ Journal of Public Health Management and Practice Prevention (CDC) Climate-Ready States and Cities Initiative (CRSCI) funds policy making and health planning in the United States to prepare for climate change.4 This report summarizes a CRSCI model for state health department climate change adaptation plan development. Climate change adaptation is defined as the “strategies, policies, and measures . . . undertaken now and in the future to reduce the burden of climate-sensitive health determinants and outcomes.”5 The 10 Essential Public Health Services were released by the Institute of Medicine to “provide the foundation for the Nation’s public health strategy,”6 and Frumkin et al developed specific climate change examples.7 In developing its climate change adaptation plan, the New York State Department of Health (NYSDOH) was informed by these frameworks in developing categories for public health activities recommended in the 2010 New York State (NYS) Climate Action Council (CAC) Interim Report8 and other climate and health literature. New York State, the Nation’s third most populous,9 is the largest of 10 states which warmed by at least 2◦ F in the past 30 years.10 The St Lawrence Valley in northern NYS is 1 of 5 US regions which warmed by more than 2.5◦ F over the same time period. Between 1958 and 2010, very heavy precipitation events increased by more than 70% in the Northeast, a greater increase than any other US region.11 Extreme heat events, intense precipitation events, and coastal flooding are projected to increase in NYS.3,12 With the impetus of a changing climate and with CDC support, NYSDOH undertook a 3-year process between late 2010 and 2013 to prioritize adaptation activities and develop a NYSDOH Climate and Health Strategic Map (as a summary of the adaptation plan). The final plan will foster implementation of the CDC Building Resilience Against Climate Effects (BRACE) framework, which has 5 steps: (1) forecasting climate impacts and assessing vulnerabilities; (2) projecting the disease burden; (3) assessing public health interventions; (4) developing and implementing a climate and health adaptation plan; and (5) evaluating impact and improving quality of activities.4,13 The NYSDOH adaptation planning process provides a foundation for a replicable method particularly for BRACE step 4 in other geographic areas.
● Methods In early 2011, NYSDOH formed teams and workgroups specifically to collect feedback and guide its climate and health planning process. A Project Coordinating Team (PCT), which met regularly to oversee planning activities related to climate change,
included the Principal Investigator, 2 co-Principal Investigators, Project Coordinator, Health Administrator, and 7 NYSDOH Center for Environmental Health leaders addressing climate change. A larger Guidance Team included an additional 14 representatives of potentially climate-impacted NYSDOH programs and provided input into surveys and planning by e-mail. Represented programs included surveillance, laboratory, emergency preparedness, injuries, health care, long-term care, and prevention/control programs for infectious diseases and chronic diseases associated with climate change. Three staff workgroups addressed needs assessments, potential surveillance systems for climate and health outcomes, and risk communication. The NYS Association of County Health Officials was consulted for advice on the inclusion of local health departments (LHDs) in the planning process; LHDs consist of 57 county health departments and the New York City Department of Health and Mental Hygiene. Local health departments are a key stakeholder group with responsibility for provision of public health services at the local level. Although federal and state statutes and regulations guide delivery of local public health services, LHDs operate under the authority of local governments. The PCT and Guidance Team also assisted in developing a list of other stakeholder organizations with potential interest in NYS climate and health planning. The 3-year planning process included feedback through meetings, telephone calls, e-mails, webinars, presentations, reports, and surveys. Thus, the information collected was not anonymous, but participants were assured that summaries would not identify names or programs. The NYSDOH institutional review board process was not utilized because the activities did not meet the federal research definition.14
Samples and surveys Over the 3-year planning process, NYSDOH conducted 7 surveys to inform the development of the NYSDOH Climate and Health Adaptation Plan (Table 1). All surveys were pretested for clarity and time for survey completion, followed by necessary revisions. All surveys were electronic and sent by e-mail, except for the interviews. Recipients received at least 3 weeks to complete the surveys. Reminders were sent during and at the close of initial response periods, and time extensions were granted to maximize response rates.
Initial NYSDOH needs assessment The NYSDOH program directors’ perceptions of climate change were captured through distribution of an
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Public Health Climate Change Adaptation Planning
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TABLE 1 ● Survey Summary
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Survey
Dates
Participants
DOH initial needs assessment
1/28/11-3/1/11
Program directors
DOH follow-up needs assessment
7/5/11-8/26/11
Program directors
DOH surveillance assessment
7/5/11-9/7/11
Database managers
DOH priorities
2/10/12-2/24/12
LHD priorities/needs
5/4/12-6/15/12
Other stakeholder priorities/needs
8/10/12-10/2/12
Leaders with priority authority Directors or Commissioners Organization leaders
Nongovernmental organization needs
8/17/12-11/2/12
Organization leaders
How Administered
Response Rate
Emailed down chain of command Emailed using department program list In-person interviews using department list Emailed using list from Guidance Team Emailed to list of 57 counties plus NYC Emailed using list from Guidance Team Individual phone interviews
41 (denominator unknown) 72.2% (78/108) 98.1% (52/53) 75.4% (43/57) 60.3% (35/58) 53.7% (22/41) 38.9% (14/36)
Abbreviations: DOH, New York State Department of Health; LHD, local health department; NYC, New York City.
electronic survey. To introduce the planning process and recommend staff participation, the Principal Investigator e-mailed the brief 4-page survey down the chain of command; thus, the number of recipients was unknown. Questions focused on previous involvement with climate change and perceptions of potential impact on programs.
Follow-up NYSDOH needs assessment The NYSDOH organizational chart was reviewed and 108 directors of programs deemed relevant to climate change were asked to participate in a follow-up needs assessment to collect new information about program needs and expertise in adaptation planning. The 15page survey was estimated to take 15 to 30 minutes.
Surveillance system assessment The NYSDOH previously generated an inventory of 309 surveillance system databases, which was used as a starting point to identify 53 that addressed environmental exposures or health outcomes associated with climate change in the literature. Two staff members used an 11-question, 20-page form to individually conduct database manager interviews, which lasted up to 1 hour, and consulted with each other to assure similar interviewing and coding procedures. Questions addressed data quality, accessibility, tracking, timeliness, and geolocation to look for clustering of potential climate and health indicators in time and space, as well as use of climate data. The surveillance system attributes were subsequently evaluated using the CDC guidelines for evaluating public health surveillance systems.15
NYSDOH adaptation prioritization Frumkin et al7 developed climate change examples for 9 of the 10 Essential Public Health Services6 with the exception of “enforce laws and regulations” because there was “little role for public health.”7 For the 3 adaptation prioritization surveys with NYSDOH, LHDs, and other stakeholders, NYSDOH developed 9 categories of adaptation services informed by the descriptions of the 10 Essential Public Health Services and the Frumkin et al examples. Next, a list of 77 adaptation activities was developed on the basis of the CAC adaptation priorities8 (26 New York-specific activities), lists of adaptation activities developed previously by New Hampshire16 and the Environmental Defense Fund,17 and other climate and health references provided by the PCT and Guidance Team. Each activity was included under 1 of the 9 adaptation categories and the number of activities within each category ranged from 4 to 13. (Categories and activities used by NYSDOH are included with the results tables.) Invited NYSDOH adaptation survey participants were the center, office, division, and bureau directors identified as departmental leaders with authority to set priorities. The cover letter, instructions, and 5 survey pages (estimated to take 15 minutes) introduced the survey as an opportunity for the participants to provide feedback on possible NYSDOH priorities for implementation of adaptation activities. Survey participants were first asked to rank the top 3 activities within each category, with (1) assigned to the highest priority activity for NYSDOH. Participants were instructed to leave unranked activities blank, and ties were not permitted. This instruction was designed to reduce survey completion time and
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E14 ❘ Journal of Public Health Management and Practice increase participation by simplifying the amount of ranking required. Next, participants were asked to indicate their top 3 priority categories. The survey also included questions for additional information about climate and health knowledge, attitudes, and access to information.
and policy organizations (2 each), and academia (1). No significant differences were found between participating LHDs and those not participating on county population size (≤75 000 or >75 000) and public health capacity (full service vs partial service with no environmental health services).18
LHD adaptation prioritization All LHDs received a similar survey instrument but one page of additional climate and health perception questions was added because a prior needs assessment had not been conducted.
Other stakeholder adaptation prioritization A July 2011 meeting with the PCT, Guidance Team, and LHD volunteers included 5 state government stakeholders—the NYS Department of Environmental Conservation, the NYS Department of State, the NYS Department of Agriculture and Markets, the NYS Climate Office, and the NYS Energy Research and Development Authority. The meeting reviewed current work on climate change, and discussed recommendations for NYSDOH. These 5 state governmental organizations plus 36 other stakeholder organizations were invited for the adaptation prioritization survey. Populations served by these groups include migrant farmworkers, city planners, racial/ethnic minorities, those with asthma or other respiratory diseases, children, farmers, physicians, and public health workers. The stakeholder organizations not included in the meeting were invited to discuss potential partnerships in individual phone interviews, which included climate and health perception questions.
Statistical analysis The top 3 adaptation activities and categories were coded as 1, 2, or 3 (unranked activities and categories were coded as “4”). SAS version 9.2 (SAS Institute, Inc, Cary NC) was used for data analysis. The KruskalWallis test option was used to identify ranking differences among the 3 key groups (P < .05). Chi-square tests were used to identify differences in proportions.
● Results Response rates for all 7 surveys are presented in Table 1. For the written survey with other stakeholder organizations, response rates by group were as follows: governmental 87.5% (7/8), policy 75% (6/8), community 60% (3/5), academic and business each 50% (1/2), health 33.3% (2/6), and environmental 20% (2/10). Interviews were conducted with government, community, and health organizations (3 each), environment
NYSDOH needs assessments Only 17.1% of NYSDOH program directors (7/41) had previously received questions from outside the program related to climate and health. Internal discussions were more frequent, at 31.7% (13/41). Perceived impact on program priorities, using a scale from 1 (to a large degree) to 5 (not at all), averaged 2.85 (to a small degree), with 34.1% (14/41) indicating some impact (to a large, medium, or small degree), and 22% (9/41) indicating uncertainty. Perceived impact on populations averaged 2.41, with 26.8% (11/41) indicating uncertainty. Program directors most often (17.1%, 7/41) reported “everyone” as an at-risk population, followed by older adults and young children (each reported by 10%, 4/41). Program directors recommended reaching vulnerable populations through public outreach, advisories, and training. In the follow-up needs assessment, 86 climate and health program needs were reported by the 78 participants, with “additional staff” representing the largest proportion of the responses at 26.7% (23/86). Others included “staff training” at 18.6% (16/86), “budget/ money/funding” at 16.3% (14/86), “information” at 14% (12/86), “equipment/technology” at 11.6% (10/86), and “communication” at 9.3% (8/86). More programs (37.2%, 29/78) reported ample expertise to create an adaptation plan at the NYSDOH level than at the health care delivery level (16.7%, 13/78) or program level (14.1%, 11/78).
Surveillance systems To use data for climate and health surveillance, 51.1% (24/47) of the systems required special requests for data with personal identifiers. Data sharing agreements were in place for 52% (26/50), with CDC as the partner mentioned most often. Most (69.2%, 36/52) had data representing all NYS. About half (51.9%, 27/52) had data reported daily. Sensitivity was assessed for monitoring impacts over time and in different geographic areas. Health event date was available for 88% (44/50) of the systems, and 71.2% (37/52) had tracking to detect changes for investigation or action. Only 25.5% (13/51) of the systems geocoded all data, but 70% (21/30) of the remaining systems reported the possibility of full geocoding.
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Public Health Climate Change Adaptation Planning
For acceptability of using the system to address climate and health, only 13.5% (7/52) of the system managers were using climate data, but 84.6% (44/52) mentioned ideas on how their system could be useful as part of a climate change adaptation plan.
Perceptions and adaptation prioritizations Although DOH leaders and other stakeholders were neutral about having sufficient climate and health information (Table 2), 46.5% of DOH leaders (20/43) agreed or strongly agreed they have sufficient information compared to 17.1% of LHDs (6/35) (P = .0046), with other stakeholders in between at 40.9% (9/22) (nonsignificant difference). A significantly higher proportion (90.9%) of other stakeholders (20/22) agreed that climate change should be an important NYSDOH focus than DOH leaders at 60.5% (26/43) and LHDs at 62.9% (22/35) (P < .001). Regarding incorporating or considering incorporating climate and health into organizational plans, 55.8% (24/43) of DOH leaders and 68.2% (15/22) of other stakeholders said yes, compared to 22.9% (8/35) of LHDs (P < .001). In open-ended explanations, participants reported incorporating it to “increase their knowledge of the impact of climate change on health” and as part of “adaptation planning and/or implementation.” Those not incorporating it cited “no capacity” or “strategic plan developed by someone else.” Sixty percent of the LHDs were unsure, with “strategic plan in development” as one explanation. “Climate change not a priority” was listed by those unsure or not incorporating it into planning. Local health departments reported 68 climaterelated health concerns and other stakeholders reported 38. Local health departments most frequently reported vector-borne diseases at 26.5% (18/68), severe weather/storms at 22.1% (15/68), and water qual-
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ity at 10.3% (7/68). For other stakeholders, the top 3 were extreme heat events at 21.1% (8/38) and severe weather/storms and respiratory illness, each at 15.8% (6/38). To address these issues, LHDs reported 36 and other stakeholders reported 48 actions. Local health departments most frequently reported emergency preparedness at 16.7% (6/36) and tick/lymerelated and education/communication activities, each at 13.9% (5/36). For other stakeholders, the top 3 actions were education/information/communication at 16.7% (8/48) and vulnerability assessment and partnership with state agencies, each at 10.4% (5/48). Local health departments reported 62 and other stakeholders reported 38 barriers to addressing issues of concern. Local health departments most frequently reported lack of funding at 27.4% (17/62), lack of staff at 19.4% (12/62), and lack of education/training at 14.5% (9/62). For other stakeholders, the top 3 barriers were lack of public awareness/preparedness at 31.6% (12/38), lack of funding at 26.3% (10/38), and mixed messages/poor communication at 13.2% (5/38). For the 3 stakeholder groups, Table 3 presents prioritization results for the adaptation categories in order of DOH leader highest priority (lowest ranking average on a 4-point scale). All 3 groups gave higher priority to the same 4 adaptation categories of “Monitoring, Surveillance,” “Capacity Building: Coordination, Collaboration,” “Education, Awareness,” and “Policy Development, Planning.” The highest priority category for DOH leaders and other stakeholders was “Monitoring, Surveillance” (mean rankings 2.28 and 2.59, respectively), whereas “Education, Awareness” was the highest priority category for LHDs (mean ranking 2.26). For all 3 groups, “Quality Assurance, Program Evaluation” was the lowest priority category. Table 4 presents the prioritization of the 77 adaptation activities for which significant differences were found between the 3 groups. The highest priority
TABLE 2 ● Mean Agreement on Climate Change and Health Perceptions
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Climate Change and Health Perception (5-Point Scale: 1 = Strongly Agree to 5 = Strongly Disagree) Agree they have access to sufficient information on climate change and health impacts Agree that climate change should be an important focus of NYSDOH
DOH Leaders (n = 43) a
LHDs (n = 35) a
Other Stakeholders (n = 22)
P
2.75
3.46
3.00
.02
2.33b
2.34c
1.73b,c
.03
Abbreviations: NYSDOH, New York State Department of Health; LHDs, local health departments. a P = .005. b P = .02. c P = .02.
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E16 ❘ Journal of Public Health Management and Practice TABLE 3 ● Mean Prioritization of Climate Change and Health Adaptation Categories
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq Participant Group c
Adaptation Category (In Order of DOH Leaders Highest Prioritization) Monitoring, surveillance Capacity building: coordination, collaboration Education, awareness Policy development, planning Community screening, diagnostic, investigative Research, innovation Workforce development Access to services Quality assurance, program evaluation
DOH Leaders (n = 43)
LHDs (n = 35)
a
a
2.28 2.88 3.26a 3.26 3.40 3.51 3.70 3.74 3.93
3.26 3.37 2.26a,b 3.11 3.60 3.77 3.53 3.74 4.00
Other Stakeholders (n = 22)
P
2.59 3.05 3.00b 2.95 3.86 3.50 3.82 3.45 3.91
.004 .21 .002 .58 .18 .36 .007 .49 .15
Abbreviations: DOH, New York State Department of Health; LHDs, local health departments. a,b Statistically significant pair-wise differences using t test, P < .05. c Rankings were 1 (top) to 3, with unranked categories coded as 4; categories were developed from the 10 Essential Public Health Services6 informed by 9 examples from Frumkin et al.7
adaptation activity for DOH and LHDs, with mean rankings 1.77 and 1.91, respectively, was “Provide assistance to local governments for surveillance and response to vector-, food-, water-borne and diseasecausing agents,” and it was prioritized significantly lower by other stakeholders (mean ranking 2.82, P = .004). The other stakeholders had 2 highest priority activities, with mean ranking 2.32: “Partnership building with stakeholders” and “Research agenda” (not included in table because of no significant differences).
Climate and health strategic map Written summaries of survey results and slide presentations were provided in early 2013 to participants, as well as others from each group attending the presentations. The NYSDOH reviewed PCT, Guidance Team, and workgroup membership to identify key leaders for all NYSDOH areas with potential impact from climate change, and 21 were available to meet for a daylong, in-person meeting in July 2013 with a contracted facilitator. Survey and interview findings were reviewed, including the prioritizations of the
TABLE 4 ● Mean Prioritization of Adaptation Activities with Statistically Significant Differences (P < .05) across
Participant Groups qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq Participant Group c
Adaptation Activity (In Order of DOH Leaders’ Highest Prioritization) Provide assistance to local governments for surveillance and response to vector-, food-, water-borne and disease-causing agents Raise awareness on CC and health significance Partnership building with stakeholders Early warning and evacuation systems Provide local intervention/control resources Participate in risk, prevention research studies Technical assistance for needs assessment Provide resources for local education capacity Provide funding for partnerships Housing displaced/relocated persons
DOH Leaders (n = 43) a
LHDs (n = 35) b
Other Stakeholders (n = 22) a,b
P
1.77
1.91
2.82
.004
2.14a 2.33a 3.02a 3.16 3.19a 3.37 3.58a 3.70a,b 3.95a
2.60 2.91a,b 2.34a 2.69a 3.66a 3.09a 2.97a 2.74a 3.77a,b
3.23a 2.32b 2.59 3.41a 3.36 3.77a 3.23 2.95b 3.95b
.007 .02 .03 .03 .049 .03 .01
