https://orcid.org/0000-0001-5353-9526
Abstract
Rural populations are at risk of climate-related impacts due to ecological and geographical determinants, potentially leading to greater morbidity and health utilization. They are often highly dependent on primary care services. However, no rural- or primary care specific synthesis of these issues has ever been conducted. This review aimed to identify, characterize, and summarize existing research on the effects of climate-related events on utilization and health outcomes of primary care in rural and remote areas and identify related adaptation strategies used in primary care to climate-related events.
A scoping review following PRISMA-ScR guidelines was conducted, examining peer-reviewed English-language articles published up to 31 October 2022. Eligible papers were empirical studies conducted in primary care settings that involved climate-related events as exposures, and health outcomes or utilization as study outcomes. Two reviewers independently screened and extracted relevant information from selected papers. Data were analysed using content analysis and presented using a narrative approach.
We screened 693 non-duplicate papers, of those, 60 papers were analysed. Climate-related events were categorized by type, with outcomes described in terms of primary, secondary, and tertiary effects. Disruption of primary care often resulted from shortages in health resources. Primary care may be ill-prepared for climate-related events but has an important role in supporting the development of community.
Findings suggest various effects of climate-related events on primary care utilization and health outcomes in rural and remote areas. There is a need to prepare rural and remote primary care service before and after climate-related events.
Climate-related events impact health outcomes and health utilization, and these effects may be exacerbated in rural populations.
Rural primary care providers are crucial during immediate responses to extreme events, and in managing climate-related risks.
Primary care mitigation and adaptation strategies are essential, though many providers and services maybe under-prepared.
Disaster management planning and risk mitigation strategies should incorporate community perspective and vulnerabilities.
Primary care providers in rural areas have an important role in supporting community resilience development.
Background
Climate change, largely attributable to human emissions, poses a great threat to human health. It affects social and environmental determinants of health, e.g. clean air, safe drinking water, food systems, and secure shelter.1 Climate change is predicted to cause 250,000 extra deaths annually, with total estimated direct health costs of USD$ 2–4 billion per year by 2030.1
The changing climate has led to increases in climate-related risks and extreme events that can directly or indirectly affect human health.2 For example, through reduced water availability and agricultural production, changes to human settlements and distributions of disease vectors, environmental disasters, and loss of ecosystem resources.1,3,4 Floods can cause fatalities in place and bodily trauma,5 but also can lead to disruption of food and clean water supply posing greater risk for gastrointestinal infections and malnutrition among children.3,6,7 Increasing ambient temperature along with bushfire events may lead to heat-related illnesses, cardiovascular and respiratory hospitalization,8,9 mental health issues10 or can increase transmission of vector-borne diseases.11,12 Extreme events associated with changing climate can also institute social and economic disruptions,3,6,7,13 food insecurity,3 and disruption of access to health care.14–16
Climate-related risks and extreme events are often more visible in low- and middle-income countries (LMICs), where adaptation capacities are limited, further exacerbating health inequities between rich and poor countries.1,4 The existing social, environmental, and economic pressures experiencing by LMICs, such as increasing poverty levels and food insecurity, land degradation, deforestation, rapid urbanization, water shortages, and limited public health and primary care capacity, all contribute to increased vulnerability to climate-related risks and extreme events.1,4
Similarly, some social and environmental characteristics of rural and remote communities can increase vulnerability to climate-related risks and extreme events. Many rural and remote areas are heavily reliant on climate-sensitive resources, particularly water and food.17 They are also at higher risk of exposure to effects of multiple extreme events such as prolonged drought or floods,18 and resultant reductions in agricultural production. In turn, these events may increase the burden of chronic illness, infectious disease, unintentional injury and death, and poor mental health.19,20 Rural and remote populations in various countries face ongoing issues associated with access to quality health care and higher burden of disease,20–26 meaning residents have limited capacity to mitigate health-related outcomes. Given that rural and remote populations already experience disadvantages associated with geographical isolation and reduced access to health services, they may also be at greater risk of adverse outcomes from climate-related risks and extreme events than urban settings. Such hazards further exacerbate many of the social, economic, health, and environmental inequities already experienced by rural population.18
The backbone of rural and remote health service delivery is ambulatory primary care providers (PCPs), with essential personnel ranging from medical doctors, nurses, and technicians to community health workers and allied health professionals.17 Some areas are also supported by rural and regional hospitals with variable access to specialist services, but with limited scale and capacity relative to their metropolitan counterparts.27,28 Rural and remote populations commonly rely on PCPs to mitigate and address health impacts of climate-related risks, including preparing for and responding to disasters and extreme weather events, providing care for health-related sequelae, and dealing with indirect and long-term consequences.29 Additionally, primary care may also play a significant role in mitigating climate-related risks by promoting environmentally sustainable health care services.30
The increasing number of publications examining health effects of climate change31 suggest it may timely to review the available literature to identify the effects of climate-related risks and extreme events on health outcomes and health care utilization among rural and remote populations, in light of potential differences. There is also a case for considering these issues with specific reference to primary care settings, and their role in response and adaptation to climate-related effects on health. Previous reviews have focussed on mental health20 or examined impacts on health which are not specific either to primary care or to rural areas.1,3,6,19 This paper presents findings from a scoping review, which aimed to (i) identify, characterize, and summarize existing research on the effects of climate-related events on health outcomes and health utilization of primary care in rural and remote areas globally and (ii) identify adaptation strategies used in primary care in response to climate-related events in rural and remote areas. Findings from this review can be used to identify research gaps and inform policy formulation related to primary care preparedness in disaster management in rural and remote areas.
Methods
This scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR).32,33 It also forms part of a broader living systematic review of ecological determinants of health care outcomes in rural and remote settings registered in the Open Science Framework (doi:10.17605/OSF.IO/GEPSJ).
Concepts and contexts
Definitions of rurality and remoteness differ internationally but generally encompass regions with relatively smaller populations outside major cities.21,27 In this review, the classification of rurality was based on a simple, inclusive categorization of not urban.
According to the World Health Organisation, primary care constitutes any health services that facilitates entry-level access to the health system and is primarily the first encounter of a person with a given health concern.34 The primary care covers a broad range of health care; including health promotion, prevention, early intervention, treatment, and management of acute and chronic conditions; but is generally not related to hospital visits.
Climate-related risks and extreme events are defined as long-term alteration of temperatures and weather patterns observed across the globe.11 In this review, these included bushfires, floods, storms/hurricanes, drought, and extreme heat. The effects on health are considered using 3 ‘pathways’: primary effects as the direct result of climate-related risks; secondary, as indirect effects in which changes to the physical environments subsequently impact health, and tertiary effects in which environmental changes disrupt social determinants of health and eventually impact health.2
Searching
The following databases were searched, without date restriction, for eligible studies on the 1 April 2022: PubMed, Web of Science Core Collection, Scopus, the Cochrane Library, ProQuest Dissertations and Theses, and WHO IRIS. In addition, hand searches of cited articles within eligible studies were also conducted. A follow-up search was conducted on the 31 October 2022.
Search terms included words associated with health outcomes, primary care service utilization, climate change, and rural and remote settings. An initial search strategy was developed in PubMed, combining Medical Subject Headings terms and specific terms, which were then adapted for the remaining databases. Pilot searches demonstrated that title and abstract searches were satisfactory, returning sufficient relevant articles without retrieving excessive irrelevant results. Table 1 displays employed search terms using a population, exposure, comparison, and outcome (PECO) approach.
PECO search strategy.
| Patients/setting | Exposures | Outcomes |
|---|---|---|
| Subject terms (MESH): Rural population (includes community, rural, rural populations) | Subject terms (MESH): Ecological and environmental phenomena Ecology Environmental pollution Environmental pollutants Natural disasters | Subject terms (MESH): Delivery of health care Primary health care Hospitals General practice Health services (includes rural health services and rural hospitals) Health facilities (includes hospitals) |
| Specific terms: Rural, provincial, periurban | Specific terms: Ecology, ecological Climate change Global warming Biodiversity Greenhouse gases Surface temperature, air temperature, heatwave Sea level rise, freshwater, groundwater Storms, hurricane, flood, drought, weather event, desertification, rain Bushfire, wildfire Pollution/pollutants Ecotoxicity, industrial waste, heavy metals, nanoparticles, microplastics Fossil fuel Disaster management, disaster response | Specific terms: Health care/health care primary care, general practice, family medicine, family practice, health service, community health centre, allied health practice |
| Patients/setting | Exposures | Outcomes |
|---|---|---|
| Subject terms (MESH): Rural population (includes community, rural, rural populations) | Subject terms (MESH): Ecological and environmental phenomena Ecology Environmental pollution Environmental pollutants Natural disasters | Subject terms (MESH): Delivery of health care Primary health care Hospitals General practice Health services (includes rural health services and rural hospitals) Health facilities (includes hospitals) |
| Specific terms: Rural, provincial, periurban | Specific terms: Ecology, ecological Climate change Global warming Biodiversity Greenhouse gases Surface temperature, air temperature, heatwave Sea level rise, freshwater, groundwater Storms, hurricane, flood, drought, weather event, desertification, rain Bushfire, wildfire Pollution/pollutants Ecotoxicity, industrial waste, heavy metals, nanoparticles, microplastics Fossil fuel Disaster management, disaster response | Specific terms: Health care/health care primary care, general practice, family medicine, family practice, health service, community health centre, allied health practice |
PECO search strategy.
| Patients/setting | Exposures | Outcomes |
|---|---|---|
| Subject terms (MESH): Rural population (includes community, rural, rural populations) | Subject terms (MESH): Ecological and environmental phenomena Ecology Environmental pollution Environmental pollutants Natural disasters | Subject terms (MESH): Delivery of health care Primary health care Hospitals General practice Health services (includes rural health services and rural hospitals) Health facilities (includes hospitals) |
| Specific terms: Rural, provincial, periurban | Specific terms: Ecology, ecological Climate change Global warming Biodiversity Greenhouse gases Surface temperature, air temperature, heatwave Sea level rise, freshwater, groundwater Storms, hurricane, flood, drought, weather event, desertification, rain Bushfire, wildfire Pollution/pollutants Ecotoxicity, industrial waste, heavy metals, nanoparticles, microplastics Fossil fuel Disaster management, disaster response | Specific terms: Health care/health care primary care, general practice, family medicine, family practice, health service, community health centre, allied health practice |
| Patients/setting | Exposures | Outcomes |
|---|---|---|
| Subject terms (MESH): Rural population (includes community, rural, rural populations) | Subject terms (MESH): Ecological and environmental phenomena Ecology Environmental pollution Environmental pollutants Natural disasters | Subject terms (MESH): Delivery of health care Primary health care Hospitals General practice Health services (includes rural health services and rural hospitals) Health facilities (includes hospitals) |
| Specific terms: Rural, provincial, periurban | Specific terms: Ecology, ecological Climate change Global warming Biodiversity Greenhouse gases Surface temperature, air temperature, heatwave Sea level rise, freshwater, groundwater Storms, hurricane, flood, drought, weather event, desertification, rain Bushfire, wildfire Pollution/pollutants Ecotoxicity, industrial waste, heavy metals, nanoparticles, microplastics Fossil fuel Disaster management, disaster response | Specific terms: Health care/health care primary care, general practice, family medicine, family practice, health service, community health centre, allied health practice |
Search results were exported to Endnote,35 and duplicates were removed before importing to Covidence (Veritas Health Innovation, Melbourne, VIC, Australia) for screening. Titles and abstracts were screened, and studies outside the scope of the review were removed. Full-text screening of articles was undertaken against inclusion and exclusion criteria by 2 reviewers independently (SD and RK), and any disagreements were resolved by inviting a third reviewer (SHD and INS).
Inclusion criteria
The review included English-language, original research articles published in peer-reviewed journals that described the effects of climate-related risks and extreme events in geographically rural or remote areas. Eligible studies were conducted in primary care settings and identified at least 1 climate-related event as exposure and at least 1 outcome concerning health outcomes or health service utilization. Studies that used quantitative, qualitative, and mixed methods approaches were included, though we excluded study protocols, reviews, letters, editorials, and commentaries. Studies that did not directly address the effect of climate-related events on health outcomes or utilization were also excluded. This review also excluded studies that examined the impacts of health care utilization on ecological factors (e.g. the effect of telemedicine on greenhouse gas reduction).
Data extraction and analysing
A data charting form, aligned with review objectives, was used to extract information from included studies. The form was developed a priori and piloted on 5 randomly selected studies to ensure all relevant results were extracted and then iteratively updated. Critical information included authors, year of publication, country and region, study setting and population, study design and aims, exposure, outcomes, and key findings.
Included studies were classified according to exposure (climate-related risks and extreme events) and outcome type (patient health outcomes, health care utilization). Study concepts, characteristics, and results were coded and analysed using summary statistics and qualitative descriptions where appropriate. Given the inclusion of both quantitative and qualitative findings and heterogeneous study designs, a narrative synthesis of the evidence was performed.36 Results are presented both numerically and narratively as appropriate to map the evidence and identify gaps for future research.
Results
A total of 693 non-duplicate articles were identified through the search strategy; after screening, 60 articles from 49 individual studies were included in the analysis (Fig. 1). Studies were conducted from 2003 to 2022. Using the World Bank country classification,37 26 of the studies were undertaken in high-income countries (Australia, Canada, China, and the United States) and 23 studies were conducted in LMICs (Bangladesh, Guatemala, India, Iran, Namibia, Pakistan, Peru, Sri Lanka, Tanzania, Vietnam, Zimbabwe). All articles were observational designs, including quantitative (n = 24), qualitative (n = 23), and mixed methods (n = 13) approaches (see Table 2) (Supplementary Material).
Summary of characteristics of included studies.
| Study type | Publication (n = 60) |
|---|---|
| Qualitative methods | 23 |
| Quantitative methods | 24 |
| Mixed methods | 13 |
| Primary care setting | |
| Community health centre | 48 |
| General practice clinic | 9 |
| Allied health practice | 1 |
| Family medicine practice | 2 |
| Location | |
| Remote | 1 |
| Remote and rural | 6 |
| Rural | 43 |
| Mixed: rural, regional and urban | 10 |
| Study setting/country | |
| Australia | 17 |
| Bangladesh | 11 |
| Canada | 5 |
| China | 3 |
| Guatemala | 1 |
| India | 2 |
| Iran | 3 |
| Namibia | 1 |
| Pakistan | 2 |
| Peru | 1 |
| Sri Lanka | 3 |
| Tanzania | 1 |
| United States | 7 |
| Vietnam | 2 |
| Zimbabwe | 1 |
| Study type | Publication (n = 60) |
|---|---|
| Qualitative methods | 23 |
| Quantitative methods | 24 |
| Mixed methods | 13 |
| Primary care setting | |
| Community health centre | 48 |
| General practice clinic | 9 |
| Allied health practice | 1 |
| Family medicine practice | 2 |
| Location | |
| Remote | 1 |
| Remote and rural | 6 |
| Rural | 43 |
| Mixed: rural, regional and urban | 10 |
| Study setting/country | |
| Australia | 17 |
| Bangladesh | 11 |
| Canada | 5 |
| China | 3 |
| Guatemala | 1 |
| India | 2 |
| Iran | 3 |
| Namibia | 1 |
| Pakistan | 2 |
| Peru | 1 |
| Sri Lanka | 3 |
| Tanzania | 1 |
| United States | 7 |
| Vietnam | 2 |
| Zimbabwe | 1 |
Summary of characteristics of included studies.
| Study type | Publication (n = 60) |
|---|---|
| Qualitative methods | 23 |
| Quantitative methods | 24 |
| Mixed methods | 13 |
| Primary care setting | |
| Community health centre | 48 |
| General practice clinic | 9 |
| Allied health practice | 1 |
| Family medicine practice | 2 |
| Location | |
| Remote | 1 |
| Remote and rural | 6 |
| Rural | 43 |
| Mixed: rural, regional and urban | 10 |
| Study setting/country | |
| Australia | 17 |
| Bangladesh | 11 |
| Canada | 5 |
| China | 3 |
| Guatemala | 1 |
| India | 2 |
| Iran | 3 |
| Namibia | 1 |
| Pakistan | 2 |
| Peru | 1 |
| Sri Lanka | 3 |
| Tanzania | 1 |
| United States | 7 |
| Vietnam | 2 |
| Zimbabwe | 1 |
| Study type | Publication (n = 60) |
|---|---|
| Qualitative methods | 23 |
| Quantitative methods | 24 |
| Mixed methods | 13 |
| Primary care setting | |
| Community health centre | 48 |
| General practice clinic | 9 |
| Allied health practice | 1 |
| Family medicine practice | 2 |
| Location | |
| Remote | 1 |
| Remote and rural | 6 |
| Rural | 43 |
| Mixed: rural, regional and urban | 10 |
| Study setting/country | |
| Australia | 17 |
| Bangladesh | 11 |
| Canada | 5 |
| China | 3 |
| Guatemala | 1 |
| India | 2 |
| Iran | 3 |
| Namibia | 1 |
| Pakistan | 2 |
| Peru | 1 |
| Sri Lanka | 3 |
| Tanzania | 1 |
| United States | 7 |
| Vietnam | 2 |
| Zimbabwe | 1 |
PRISMA flow diagram. PHC, primary health care.
Specific climate-related risks and extreme events reported in the included studies were floods (n = 15), storms (n = 9), drought (n = 8), extreme heat (n = 7), and bushfires (n = 3), while mixed extreme weather events were reported in 7 studies. Findings are presented in 3 categories: effects of climate-related risks and extreme events on health outcomes of rural populations, effects of climate-related risks on primary care utilization, and adaptation strategies adopted by primary care in response to climate-related risks and extreme events. These results are summarized in Table 3 and Fig. 2, with outcomes also considered in terms of effect pathways.
Effects of climate-related risks and extreme events on health outcomes and health utilization of primary care in rural and remote areas.
| No. | Climate-related risks and extreme events | Effects on health outcomes | ||
|---|---|---|---|---|
| Primary | Secondary | Tertiary | ||
| 1 | Bushfires | Increased unintentional injury38 | Mental health38,39 Eye irritation40 Increased respiratory diseases40 | |
| 2 | Droughts | Increased respiratory diseases41 Increased heat-related illness42,43 | Increased vector-borne diseases44 Increased infectious diseases45 Increased water-borne diseases44,46,47 Increased respiratory diseases47–49 Food and water insecurity44,50 Increased cardiovascular diseases49 Mental health44,50–57 Skin disease47 | Malnutrition47 |
| 3 | Floods | Increased unintentional injury58 Death59,60 Increased snakebites59–61 | Increased infectious diseases44,48,49,59,61–63 Increased water-borne diseases49,61,63–67 Increased vector-borne diseases61 Mental health issues54,55,62,63,68 Food insecurity44,60,63,65,67,69,70 Increased hypertension60 Skin diseases54,61 | Increased risk of HIV and other sexually transmitted diseases63 Maternal mortality71 Malnutrition59,63,64 Increase poverty49,64 Increase domestic violence63,70 |
| 4 | Extreme heat | Increased heat-related illness40,44,46,54,55,72–75 | Mental health issues41,55,75 Increased vector-borne disease40 | |
| 5 | Storms | Unintentional injury40,76 | Mental health issues76,77 Increased infectious diseases76 Increased water-borne diseases76 | Higher risks of low birth weight, SGA, and spontaneous preterm birth78 |
| No. | Climate-related risks and extreme events | Effects on health services utilization of primary care in rural and remote areas | Adaptation strategies of PCPs | |
| 1 | Bushfires | Damage of health care access and facilities40 Decrease visits to PCPs in emergency period79 Increase visits to PCPs38,80 Inconsistency service delivery38 | Training for PCPs to identify mental health risks38 Community training and preparation39,81 | |
| 2 | Droughts | Decreased visits to PCPs53,82,83 Shortages in the medical and health resources48,51,53,83 Patient self-knowledge of medication53 Increased visits to PCPs82 Increased out-of-pocket payment49,82 Reduced health expenditure84 | Training for PCPs to identify mental health risks53 Community training and preparation52,81 Partnership and collaboration with different agencies52,81 Improve health promotion54,55,81 | |
| 3 | Floods | Damage of health care access and facilities58,63,67,85 Shortages in the medical and health resources42,48,58,60,63,64,67,71 Decreased visit to primary care63,65 Increased visit to unqualified health workers42,60,71 Patient self-knowledge of medication42 Increased visits to PCPs after flood decreased49,58,63 Disruption of maternal and childcare70,71,85,86 Disruption of HIV treatment63 Rely on community62 Increased out-of-pocket payment49,60,72 No disaster preparedness69 | Referred patient to other health facilities71 Implement water ambulance71 Relocate to a safer place71 Training for PCPs to identify mental health risks68 Non-clinical staff performed minor procedures and dispense medication87,88 Strengthening health promotion54,55,81 Modify health service delivery programmes61,85,89 Contingency plan to provide the need of HIV patient, reduce procedure to collect medicine63 Community training and preparation10,40,69,90,91 Develop tools to evaluate community vulnerabilities44 | |
| 4 | Extreme heat | Decreased visits to primary care41,75 Increased visits to PCPs after heatwave41,72,75 | Community training and preparation40 Partnership and collaboration with different agencies92 Modify health service delivery programmes75 | |
| 5 | Storms | Damage of health care access and facilities40,76 Rely on community93 Shortages in the medical and health resources67,78 Rely on community, clergy76,91,93,94 Disruption of maternal and childcare78 Increased visits to PCPs after emergency period91,94 | Referred patient to other health facilities78,95 Community training for emergency and mental health issues77,94 Special team was developed for health service delivery96 Setting up mobile clinic76 Modify local clinic as resources centre76 | |
| No. | Climate-related risks and extreme events | Effects on health outcomes | ||
|---|---|---|---|---|
| Primary | Secondary | Tertiary | ||
| 1 | Bushfires | Increased unintentional injury38 | Mental health38,39 Eye irritation40 Increased respiratory diseases40 | |
| 2 | Droughts | Increased respiratory diseases41 Increased heat-related illness42,43 | Increased vector-borne diseases44 Increased infectious diseases45 Increased water-borne diseases44,46,47 Increased respiratory diseases47–49 Food and water insecurity44,50 Increased cardiovascular diseases49 Mental health44,50–57 Skin disease47 | Malnutrition47 |
| 3 | Floods | Increased unintentional injury58 Death59,60 Increased snakebites59–61 | Increased infectious diseases44,48,49,59,61–63 Increased water-borne diseases49,61,63–67 Increased vector-borne diseases61 Mental health issues54,55,62,63,68 Food insecurity44,60,63,65,67,69,70 Increased hypertension60 Skin diseases54,61 | Increased risk of HIV and other sexually transmitted diseases63 Maternal mortality71 Malnutrition59,63,64 Increase poverty49,64 Increase domestic violence63,70 |
| 4 | Extreme heat | Increased heat-related illness40,44,46,54,55,72–75 | Mental health issues41,55,75 Increased vector-borne disease40 | |
| 5 | Storms | Unintentional injury40,76 | Mental health issues76,77 Increased infectious diseases76 Increased water-borne diseases76 | Higher risks of low birth weight, SGA, and spontaneous preterm birth78 |
| No. | Climate-related risks and extreme events | Effects on health services utilization of primary care in rural and remote areas | Adaptation strategies of PCPs | |
| 1 | Bushfires | Damage of health care access and facilities40 Decrease visits to PCPs in emergency period79 Increase visits to PCPs38,80 Inconsistency service delivery38 | Training for PCPs to identify mental health risks38 Community training and preparation39,81 | |
| 2 | Droughts | Decreased visits to PCPs53,82,83 Shortages in the medical and health resources48,51,53,83 Patient self-knowledge of medication53 Increased visits to PCPs82 Increased out-of-pocket payment49,82 Reduced health expenditure84 | Training for PCPs to identify mental health risks53 Community training and preparation52,81 Partnership and collaboration with different agencies52,81 Improve health promotion54,55,81 | |
| 3 | Floods | Damage of health care access and facilities58,63,67,85 Shortages in the medical and health resources42,48,58,60,63,64,67,71 Decreased visit to primary care63,65 Increased visit to unqualified health workers42,60,71 Patient self-knowledge of medication42 Increased visits to PCPs after flood decreased49,58,63 Disruption of maternal and childcare70,71,85,86 Disruption of HIV treatment63 Rely on community62 Increased out-of-pocket payment49,60,72 No disaster preparedness69 | Referred patient to other health facilities71 Implement water ambulance71 Relocate to a safer place71 Training for PCPs to identify mental health risks68 Non-clinical staff performed minor procedures and dispense medication87,88 Strengthening health promotion54,55,81 Modify health service delivery programmes61,85,89 Contingency plan to provide the need of HIV patient, reduce procedure to collect medicine63 Community training and preparation10,40,69,90,91 Develop tools to evaluate community vulnerabilities44 | |
| 4 | Extreme heat | Decreased visits to primary care41,75 Increased visits to PCPs after heatwave41,72,75 | Community training and preparation40 Partnership and collaboration with different agencies92 Modify health service delivery programmes75 | |
| 5 | Storms | Damage of health care access and facilities40,76 Rely on community93 Shortages in the medical and health resources67,78 Rely on community, clergy76,91,93,94 Disruption of maternal and childcare78 Increased visits to PCPs after emergency period91,94 | Referred patient to other health facilities78,95 Community training for emergency and mental health issues77,94 Special team was developed for health service delivery96 Setting up mobile clinic76 Modify local clinic as resources centre76 | |
Effects of climate-related risks and extreme events on health outcomes and health utilization of primary care in rural and remote areas.
| No. | Climate-related risks and extreme events | Effects on health outcomes | ||
|---|---|---|---|---|
| Primary | Secondary | Tertiary | ||
| 1 | Bushfires | Increased unintentional injury38 | Mental health38,39 Eye irritation40 Increased respiratory diseases40 | |
| 2 | Droughts | Increased respiratory diseases41 Increased heat-related illness42,43 | Increased vector-borne diseases44 Increased infectious diseases45 Increased water-borne diseases44,46,47 Increased respiratory diseases47–49 Food and water insecurity44,50 Increased cardiovascular diseases49 Mental health44,50–57 Skin disease47 | Malnutrition47 |
| 3 | Floods | Increased unintentional injury58 Death59,60 Increased snakebites59–61 | Increased infectious diseases44,48,49,59,61–63 Increased water-borne diseases49,61,63–67 Increased vector-borne diseases61 Mental health issues54,55,62,63,68 Food insecurity44,60,63,65,67,69,70 Increased hypertension60 Skin diseases54,61 | Increased risk of HIV and other sexually transmitted diseases63 Maternal mortality71 Malnutrition59,63,64 Increase poverty49,64 Increase domestic violence63,70 |
| 4 | Extreme heat | Increased heat-related illness40,44,46,54,55,72–75 | Mental health issues41,55,75 Increased vector-borne disease40 | |
| 5 | Storms | Unintentional injury40,76 | Mental health issues76,77 Increased infectious diseases76 Increased water-borne diseases76 | Higher risks of low birth weight, SGA, and spontaneous preterm birth78 |
| No. | Climate-related risks and extreme events | Effects on health services utilization of primary care in rural and remote areas | Adaptation strategies of PCPs | |
| 1 | Bushfires | Damage of health care access and facilities40 Decrease visits to PCPs in emergency period79 Increase visits to PCPs38,80 Inconsistency service delivery38 | Training for PCPs to identify mental health risks38 Community training and preparation39,81 | |
| 2 | Droughts | Decreased visits to PCPs53,82,83 Shortages in the medical and health resources48,51,53,83 Patient self-knowledge of medication53 Increased visits to PCPs82 Increased out-of-pocket payment49,82 Reduced health expenditure84 | Training for PCPs to identify mental health risks53 Community training and preparation52,81 Partnership and collaboration with different agencies52,81 Improve health promotion54,55,81 | |
| 3 | Floods | Damage of health care access and facilities58,63,67,85 Shortages in the medical and health resources42,48,58,60,63,64,67,71 Decreased visit to primary care63,65 Increased visit to unqualified health workers42,60,71 Patient self-knowledge of medication42 Increased visits to PCPs after flood decreased49,58,63 Disruption of maternal and childcare70,71,85,86 Disruption of HIV treatment63 Rely on community62 Increased out-of-pocket payment49,60,72 No disaster preparedness69 | Referred patient to other health facilities71 Implement water ambulance71 Relocate to a safer place71 Training for PCPs to identify mental health risks68 Non-clinical staff performed minor procedures and dispense medication87,88 Strengthening health promotion54,55,81 Modify health service delivery programmes61,85,89 Contingency plan to provide the need of HIV patient, reduce procedure to collect medicine63 Community training and preparation10,40,69,90,91 Develop tools to evaluate community vulnerabilities44 | |
| 4 | Extreme heat | Decreased visits to primary care41,75 Increased visits to PCPs after heatwave41,72,75 | Community training and preparation40 Partnership and collaboration with different agencies92 Modify health service delivery programmes75 | |
| 5 | Storms | Damage of health care access and facilities40,76 Rely on community93 Shortages in the medical and health resources67,78 Rely on community, clergy76,91,93,94 Disruption of maternal and childcare78 Increased visits to PCPs after emergency period91,94 | Referred patient to other health facilities78,95 Community training for emergency and mental health issues77,94 Special team was developed for health service delivery96 Setting up mobile clinic76 Modify local clinic as resources centre76 | |
| No. | Climate-related risks and extreme events | Effects on health outcomes | ||
|---|---|---|---|---|
| Primary | Secondary | Tertiary | ||
| 1 | Bushfires | Increased unintentional injury38 | Mental health38,39 Eye irritation40 Increased respiratory diseases40 | |
| 2 | Droughts | Increased respiratory diseases41 Increased heat-related illness42,43 | Increased vector-borne diseases44 Increased infectious diseases45 Increased water-borne diseases44,46,47 Increased respiratory diseases47–49 Food and water insecurity44,50 Increased cardiovascular diseases49 Mental health44,50–57 Skin disease47 | Malnutrition47 |
| 3 | Floods | Increased unintentional injury58 Death59,60 Increased snakebites59–61 | Increased infectious diseases44,48,49,59,61–63 Increased water-borne diseases49,61,63–67 Increased vector-borne diseases61 Mental health issues54,55,62,63,68 Food insecurity44,60,63,65,67,69,70 Increased hypertension60 Skin diseases54,61 | Increased risk of HIV and other sexually transmitted diseases63 Maternal mortality71 Malnutrition59,63,64 Increase poverty49,64 Increase domestic violence63,70 |
| 4 | Extreme heat | Increased heat-related illness40,44,46,54,55,72–75 | Mental health issues41,55,75 Increased vector-borne disease40 | |
| 5 | Storms | Unintentional injury40,76 | Mental health issues76,77 Increased infectious diseases76 Increased water-borne diseases76 | Higher risks of low birth weight, SGA, and spontaneous preterm birth78 |
| No. | Climate-related risks and extreme events | Effects on health services utilization of primary care in rural and remote areas | Adaptation strategies of PCPs | |
| 1 | Bushfires | Damage of health care access and facilities40 Decrease visits to PCPs in emergency period79 Increase visits to PCPs38,80 Inconsistency service delivery38 | Training for PCPs to identify mental health risks38 Community training and preparation39,81 | |
| 2 | Droughts | Decreased visits to PCPs53,82,83 Shortages in the medical and health resources48,51,53,83 Patient self-knowledge of medication53 Increased visits to PCPs82 Increased out-of-pocket payment49,82 Reduced health expenditure84 | Training for PCPs to identify mental health risks53 Community training and preparation52,81 Partnership and collaboration with different agencies52,81 Improve health promotion54,55,81 | |
| 3 | Floods | Damage of health care access and facilities58,63,67,85 Shortages in the medical and health resources42,48,58,60,63,64,67,71 Decreased visit to primary care63,65 Increased visit to unqualified health workers42,60,71 Patient self-knowledge of medication42 Increased visits to PCPs after flood decreased49,58,63 Disruption of maternal and childcare70,71,85,86 Disruption of HIV treatment63 Rely on community62 Increased out-of-pocket payment49,60,72 No disaster preparedness69 | Referred patient to other health facilities71 Implement water ambulance71 Relocate to a safer place71 Training for PCPs to identify mental health risks68 Non-clinical staff performed minor procedures and dispense medication87,88 Strengthening health promotion54,55,81 Modify health service delivery programmes61,85,89 Contingency plan to provide the need of HIV patient, reduce procedure to collect medicine63 Community training and preparation10,40,69,90,91 Develop tools to evaluate community vulnerabilities44 | |
| 4 | Extreme heat | Decreased visits to primary care41,75 Increased visits to PCPs after heatwave41,72,75 | Community training and preparation40 Partnership and collaboration with different agencies92 Modify health service delivery programmes75 | |
| 5 | Storms | Damage of health care access and facilities40,76 Rely on community93 Shortages in the medical and health resources67,78 Rely on community, clergy76,91,93,94 Disruption of maternal and childcare78 Increased visits to PCPs after emergency period91,94 | Referred patient to other health facilities78,95 Community training for emergency and mental health issues77,94 Special team was developed for health service delivery96 Setting up mobile clinic76 Modify local clinic as resources centre76 | |
Effects of climate-related events on health outcomes and health utilization of primary care in rural and remote areas. HIV, human immunodeficiency virus.
Effects of climate-related risks and extreme events on health outcomes in primary care
Of the 60 included articles, 42 articles examined the effects of climate-related risks and extreme events on the health of rural populations.38–78,82,86
Primary effects were evident in the direct impact of these events on health outcomes in real time, such as asthma and chronic obstructive pulmonary diseases in those with chronic conditions due to dust storms caused by prolonged drought82 and bushfires.40 Floods and storms caused increased snakebites,60,61 accidental injuries and deaths of those living in affected areas.58,60 Extreme heat led to heatwaves and initiated heat-related illnesses, such as heat stroke and heat cramps.46,72–75
Climate-related events also triggered environmental changes, producing secondary effects. For example, drought and floods disrupted safe drinking water, sanitation and hygiene, leading to increased water-borne diseases such as diarrhoea.60,66,85 In addition, drought and bushfires reduced air quality, leading to respiratory and cardiovascular diseases.38,40,47,56 Drought also affected mental health, particularly in the elderly, adolescents and indigenous peoples.51–53,57 Extreme weather events also modified the natural environment of disease pathogens, leading to an increase in vector-borne diseases, such as Malaria, Lyme disease, Dengue fever, Ross River40,43,60 and zoonotic diseases, such as Q fever.45 Floods and drought also negatively affected agricultural production, as a primary source of food that could create food insecurity.44,48,59,63–65,67,70
Tertiary effects regenerated as climate-related events institute changes in social, behavioural, and political dimensions that affect the health of rural populations. In this review, disruption of health facilities in flood-affected areas caused medicinal shortages, including antiretroviral therapies for HIV/AIDS, leading to disruption of HIV/AIDS treatment and increased risk of transmission.63 Three maternal deaths were reported during flooding in Bangladesh due to disruption of access that delayed medical help during difficult deliveries.71 Two studies reported increased domestic violence against women during flooding in Zimbabwe70 and Namibia.63 Those who experienced climate-related events such as floods and prolonged drought often decided to displace to a safer location or migrate to a major city.53,60 These migrants consequently had a lacked social support, which contributed to poor mental health.
Floods, storms, and droughts affected agricultural crops, exacerbating the vulnerability of rural populations to poverty.40,42,47,49,50,58,70 In some circumstances, this poverty led to the inability to meet energy requirements, causing protein-energy malnutrition, especially in children47 or reducing health care expenditure and resultant worsening of chronic conditions.49
Effects of climate-related risks and extreme events on primary care utilization
Thirty-five articles reported changes in the utilization of primary care in rural and remote areas.38,40–42,48,49,51,53,58–60,62–65,67,69–72,75–80,82,83,85,86,91,93–95 Increased health care visits were reported during the emergency or acute event (commonly the first 2 weeks), especially for those subjected to primary effects, such as unintentional injuries.42,76,89 Once the emergency period was over, there was increased health service utilization (commonly the first 6 months), especially for those experiencing chronic conditions,58,72,80,82,94 including mental health.41,79,95
Extreme weather events such as floods and storms caused the destruction of health facilities, power outages, and disruption access to primary care.40,53,60–65,67,76,85 While demand for health services increased, PCPs experienced medicinal and health workforce shortages.48,61,63,70,77 In this situation, some communities visited unqualified local health providers for their health issues.42,60,71,85 Some survivors found their communities and families were more helpful in assisting their health problems,62,76,91,93–95 and the use of self-knowledge of medications and previous healing experiences was also noted.42,53 Other studies suggested that decreased utilization for non-urgent services during extreme heat was related to patient adaptation to limit their outdoor activities to prevent heat-related illness.40,41,43,75 Once the ambient temperature decreased, the number of services returned to normal. Some studies also suggested that displacement during extreme weather events might contribute to decreased health care utilization in displaced areas.43,80,86,97
Studies reported that maternal care had been seriously disrupted during extreme weather events. There was a decreased number of deliveries attended by trained health workers.71,78,86 One study reported that mothers from displaced households had lower prenatal care compared with non-displaced mothers,86 while another found that pregnant mothers received inadequate prenatal care that might induce risk of preterm birth and small gestational age.78 Similar disruptions also existed in family planning care70 and treatment for HIV infection.63 These findings showed that women were more susceptible than men to the impacts of climate-related events.
The exacerbation of poverty in rural populations in response to climate-related events resulted in decreased health expenditure.49 In addition, those living in rural or remote areas in LMICs, had out-of-pocket payments generated by unattainable universal health coverage.49,59,84 This further reduced health expenditure of personal or family resources on preventive health care or to manage existing chronic conditions.64,65
Adaptation of primary care to climate-related risks and extreme events
Twenty-eight articles discussed strategies used by primary care to adapt health care provision.10,38–40,44,52–55,61,63,68–71,75–77,81,85,87–92,94,96 As the first contact for health care, rural populations are relying on PCPs for assistance in managing their health issues.
Emergency task forces were formed within a brief period after events and provided initial responses focussed on managing health concerns.38,61,76 PCPs commonly adjusted their operating hours during floods61,85 or extreme heat.40,75 Additionally, some relocated their health services to other facilities such as schools85 or established mobile clinics.76 Occasionally, non-clinical staffs were tasked to undertake minor procedures and dispense medications.71,85,87,88 Patients were sometimes referred to other health facilities.71,85 However, these conditions often did not last long due to limited medical and financial resources as well as access to referrals that could provide more extensive care.71,85 Special programmes or health teams were sometimes set up to cover health services that were not readily available. For example, Zika virus screening health brigades were formed after Hurricanes Irma and Maria to provide care for mothers and children in the US Virgin Islands.96
Eight articles evaluated the preparedness of primary care for climate-related risks,61,76,85,87–90,92 concluding that PCPs in rural areas were unprepared for climate-related impacts, in various ways. Service delivery was focussed mainly on treatment, meaning health promotion and prevention programmes, such as disease surveillance, were not well implemented.61,76,89 The absence of local disaster management guidelines and lack of primary care involvement in decision-making leadership were also reported.61,76,89 Health resources, including financial, workforces, clinical, and information systems, were inadequate for responding to extreme weather events and rarely involved disaster prevention and mitigation strategies at the community level.61,76,89 These conditions were predominant for primary care in LMICs.54,55,58,61,76,87–89,93
Conversely, a series of studies described strategies to develop community resilience. One Australian study reported that 5 PCPs in Australia adapted their health promotions practices to address climate-related risks.81 The key strategies for their health promotion practices were oriented toward active and sustainable transport; healthy and sustainable food supply; mental health and community resilience; engaging vulnerable population groups such as women; and organizational development.
Four articles from a single study explained the development of mental health programmes for those impacted by drought in Australia.10,51,52,83 The difficulties of rural populations in accessing mental health support initiated a state programme collaborating between primary care, community, and government. They conducted programmes to train local health workforces, share information on climate-related risks, identify mental health issues, and allocate resources. The programmes collaborated with communities and local PCPs, to identify risk factors. Local providers, then continued running programmes and modified them to local needs. Similar studies in other countries also supported collaboration and networking with the community to help with mental health issues.53,68 These findings highlighted the importance of working with the community to ensure sustainability. These programmes can strengthen community resilience, as reported in the included studies.
The role of rural communities in providing aid to their population was crucial. In this review, community members helped each other by sharing knowledge of protection and conservation measures during extreme weather events, and sharing medicine and resources, as well as offering comfort.77,91,94 One study reported the development of tools to support community-level assessment of health risks and adaptation response to climate change.44 One study also reported that social workers were involved in addressing challenges after a disaster.70 These findings highlighted the crucial role of PCPs in developing community resilience before natural disasters as well as adaptation strategies post-extreme weather events appropriate to community cultural beliefs and needs.
Discussion
Our findings indicate that people living in rural and remote areas are at risk for a range of climate-related health effects, including on mental health, consistent with previous research.20,98 While these studies in this review vary widely in their outcomes, they identified primary, secondary, and tertiary effects of climate-related risks and extreme events on a range of health outcomes and health utilization. Various clinical conditions, including unintentional injuries, respiratory diseases, gastrointestinal diseases, cardiovascular diseases, mental health, heat-related illness, skin diseases, and infectious diseases among people living in rural and remote areas were reported. In addition, food insecurity and increased vulnerability to poverty were identified as indirect impacts. Our findings also show that women were more vulnerable than men to the indirect impacts of climate-related events, similar to other review.99 In addition, women also experienced domestic violence related to their role as caring for the family.70
Utilization of primary care utilization was affected by reduced availability and disruption to service supply, by changes in behavioural responses among patients, and by tertiary effects of social determinants of health. PCPs adaptation strategies are crucial in maintaining health service delivery and ensuring disaster preparedness and management in rural and remote areas.100 In this review, people living in rural and remote areas in LMICs were more affected by their socioeconomic determinants than those in high-income countries. The vulnerabilities to climate-related risks and extreme events of rural populations in LMICs are possibly worsening, particularly with the existing social, environmental, and economic conditions.18 Our results suggest that LMICs still face challenges in implementing their health programmes, thus often focussing on responding to emergency procedures rather than mitigating community risk and building resilience.17,18
Our findings show that PCPs in rural and remote areas have a crucial role in immediate clinical response by adapting their health programmes to meet the needs of rural populations, as discussed in previous literature.101,102 While climate-related risks and extreme events have substantial impacts on both the health outcomes of rural populations and their health utilization of primary health care services, adaptation strategies are often limited to immediate responses under emergency conditions rather than ongoing adaptation or mitigation strategies.
A range of primary health care adaptation strategies in response to climate-related risks have been identified, including (i) community education and awareness about the risks; (ii) developing and strengthening implementation of early alert systems such as impending weather extremes or disease outbreaks; (iii) disaster preparedness including designing better surge capacity to respond to emergencies; (iv) enhancing infectious disease control programme and surveillance of risks and health outcomes; and (v) appropriate health workforce training on climatic influences on health and public health strategies.100 These approaches focus on disaster preparedness, as well as disease prevention and surveillance, and support for identifying and responding to secondary or tertiary effects, such as psychosocial and nutritional interventions100; they are specifically relevant to rural and remote populations, and have international applicability. Furthermore, the lack of disaster management plans as reported in the included studies, emphasize the needs for PCPs be engaged in coordination across different agencies and communities for strengthening health system resilience.103 At the country level, health policy should support the development of flexible, resilient health care system that can adapt to climate-related risks and extreme weather events and be suitable to local needs. Our findings also highlight essential factors to identify of health risks and vulnerabilities of rural populations and environment. The information can be used to develop public education and awareness to climate-related risks and weather events that suited to community cultural beliefs.101 As community resilience is crucial for mitigation process, PCPs have a crucial role in supporting this development.
Strengths and limitations
As far as we are aware, this scoping review is the first to describe how primary care utilization in rural and remote areas is impacted by and responds to climate-related risks and extreme events. However, many of the included studies are from Australia, similar to findings from previous umbrella reviews of climate change effects on health.31 This may reflect an unidentified bias in our search structure or language, or an underlying predominance in the relevant literature.
No studies evaluated long-term effects, focussing instead on the immediate periods following a disaster. The heterogeneity of study designs and objectives meant that direct comparisons and clustering of results was also challenging. Although this review is limited by its English-language focus, the included studies provided an international overview of various countries. Further studies using longitudinal methods are needed to explain the association of climate-related risks more fully with the health outcomes and health utilization in rural and remote areas to inform the adaptation strategies of PCPs post-extreme weather events as well as health policy for mitigation strategies of rural populations.
Conclusions
This scoping review synthesizes published studies assessing the impact on climate-related risks and extreme events on health outcomes and health utilization of primary care in rural and remote areas. Changes in the clinical presentation of certain diseases, and associated health outcomes, are reported. These conditions worsen health status of rural populations in general with disrupted access to primary care services and shortages in medical and health resources. PCPs and services in rural areas may be ill-prepared, especially during initial responses, but have an essential role in supporting the development of community resilience and influencing health policy for disaster preparedness in response to such events. PCPs in rural areas may require support, particularly in LMICs, to mitigate risk and help develop community resilience.
Funding
The study was funded by The Rural Clinical School ANU.
Ethical approval
This type of review does not require ethical clearance.
Conflict of interest
None declared.
Data availability
The data underlying this article are available in the article and in its online supplementary material.
