Co-developing climate services for public health: stakeholder needs and perceptions for the prevention and control of Aedes-transmitted diseases in the Caribbean

Background Small island developing states (SIDS) in the Caribbean region are challenged with managing the health outcomes of a changing climate. Health and climate sectors have partnered to co-develop climate services to improve the management of these diseases, for example, through the development of climate-driven early warning systems. The objective of this study was to identify health and climate stakeholder perceptions and needs in the Caribbean, with respect to the development of climate services for arboviruses (e.g. dengue, chikungunya, and Zika). Methods Stakeholders included public decision makers and practitioners from the climate and health sectors at the regional (Caribbean) level and from the countries of Dominica and Barbados. From April to June 2017, we conducted interviews (n=41), surveys (n=32), and national workshops with stakeholders. Survey responses were tabulated and audio recordings were transcribed and analyzed using qualitative coding to identify responses by research topic, country/region, and sector. Results Health practitioners indicated that their jurisdiction is currently experiencing an increased risk of diseases transmitted by Ae. aegypti due to climate variability, and most anticipated that this risk will increase in the future. National health sectors reported financial limitations and a lack of technical expertise in geographic information systems (GIS), statistics, and modeling, which constrained their ability to implement climate services for arboviruses. National climate sectors were constrained by a lack of personnel. Stakeholders highlighted the need to strengthen partnerships with the private sector, academia, and civil society. They identified a gap in local research on climate-arbovirus linkages, which constrained the ability of the health sector to make informed decisions. Strategies to strengthen the climate-health partnership included a top-down approach by engaging senior leadership, multi-lateral collaboration agreements, national committees on climate and health, and shared spaces of dialogue. Mechanisms for mainstreaming climate services for health operations to control arboviruses included climate-health bulletins and an online GIS platform that would allow for regional data sharing and the generation of spatiotemporal epidemic forecasts. Conclusions These findings support the creation of interdisciplinary and intersectoral communities of practices and the co-design of climate services for the Caribbean public health sector. By fostering the effective use of climate information within health policy, research and practice, nations will have greater capacity to adapt to a changing climate.


Introduction 8 1
Small island developing states (SIDS) in the Caribbean region are highly interventions to prevent and control disease outbreaks through insecticide application,  Despite these efforts, the annual number of dengue cases in the region increased from an 1 0 2 estimated 136,000 to 811,000 cases between 1990 and 2013, with case estimates adjusted Climate services for arboviral diseases in the Caribbean 6 to account for underreporting [8]. Novel tools and management strategies are urgently 1 0 4 needed to increase the capacity of the public health sector to prevent and respond to 1 0 5 arboviral disease outbreaks. capacity, which may be constrained by resources, information, prior experiences, and 1 3 7 other actors or institutions [30]. To guide this process, the Global Framework for Climate Services (GFCS) was developed as the policy mechanism to support the development of

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In Dominica, interviewees highlighted the need for vector control specialists in the MoH, better data collection and storage practices in the health sector in order to create high-4 9 5 quality, long-term datasets. Climate services for arboviral diseases in the Caribbean Dominica indicated the need for additional personnel, as well as a better understanding of 4 9 9 health sector end-user needs Interviewees from the Dominica NMHS indicated that they and improved security to prevent vandalism the meteorological stations. They stated, 5 0 5 "We use our personal vehicles, but some of the areas are a bit challenging, and we 5 0 6 are two females, so sometimes …depending on where we are going, we need 5 0 7 somebody else to go with us, for security" (Climate Stakeholder, Dominica).

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Health sector interviewees from Dominica suggested that their technicians could be 5 0 9 trained to download data from meteorological stations to support the local NMHS. their current use of climate information (S6 Table). Two thirds of respondents indicated and half of the respondents confirmed that climate information was used for some level Climate services for arboviral diseases in the Caribbean 3 1 an EWS for arboviruses existed in their jurisdiction, but most indicated that climate 5 2 0 information was not part of existing epidemiological warning systems.

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Interviewees confirmed that the arbovirus alert systems in Dominica and 5 2 2 Barbados were based solely on epidemiological surveillance. The health sector and al.
[11] for details). Interviewees indicated that the current system did not provide 5 2 6 sufficient lead-time to effectively reduce the threat of an epidemic.

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Interviewees described the current use of climate information for arbovirus process. Overall, climate information was reported to play a minor role in decision-5 3 5 making, which was instead driven by policies, regulations, and specific competencies of  stakeholders were asked to identify the interventions they would implement if they were provided with short (2 week), medium (3 month) and long-term (1 year) forecasts of 5 4 0 vector abundance and dengue incidence (S3 Text). They unanimously stated that disease 5 4 1 incidence forecasts would be more effective than vector forecasts in garnering the interventions. With a short-term forecast, the health sector would increase education, 5 4 4 community mobilization, and larval source reduction, especially in known hotspots. With 5 4 5 a medium-term forecast, the health sector would be better able to plan with stakeholders, 5 4 6 mobilize the field team, look at trends, and create bulletins for community mobilization.

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With a long-term forecast the health sector could better lobby with health sector more effective budgeting. They would be able to monitor and evaluate interventions and conduct a needs assessment to inform planning. They would also be able to procure 5 5 1 diagnostic reagents and supplies for the national reference laboratory, a process that can interventions at each timescale, they preferred the medium-term (3-month) forecast as resources" (Health Stakeholder, Barbados).

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Added value of climate services. Health sector interviewees highlighted the ways in which climate services would improve their planning for arbovirus interventions. By processes, they felt they could be proactive and more effective at preventing outbreaks, as  activities would be at a higher cost, but you can be more specific… It will be 5 7 5 easier for us to respond to an impending threat, instead of running around" 5 7 6 (Health Stakeholder, Dominica).

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Interviewees indicated that forecasts of disease risk could be used to inform hospitals how the data that they collect was being used to inform decision-making.

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Climate services for arboviral diseases in the Caribbean

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Interviewees were also asked to identify climate services that would improve their 5 8 9 day-to-day work related to arboviruses. Health sector interviewees confirmed that they reiterated that a GIS platform would allow them to integrate and analyze real-time disease risk in relation to rainfall, temperature, and other climate information. They suggested that these forecasts be converted into spatiotemporal alerts using a color- Stakeholder, Dominica). administrators, they are politicians, and we need to help them. We need to feed Global research on climate services has identified characteristics or conditions to 6 2 6 develop a usable science that can be mainstreamed for public health operations. The first 6 2 7 phase is to establish an enabling environment for partnership with different stakeholders.

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This is done by identifying the common priorities, needs for research, and by building sectors. This partnership is critical to ensure commitment and ownership by different  Climate services for arboviral diseases in the Caribbean

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In this study, climate services for health, specifically for Ae. aegypti-transmitted 6 3 5 arboviral diseases, were considered because high policy level organizations of these initiatives will require the political will to establish climate services for health as Ministry of Tourism, as well as regional universities, research centers, and sustainable We found that the national climate sectors (NMHSs), in particular, identified 6 5 2 capacity challenges when asked about engaging in work on climate and health. We also 6 5 3 found that the regional climate stakeholders were more experienced with climate services 6 5 4 for health than local NMHS stakeholders. Prior assessments of the NMHSs in the Caribbean also noted that there is limited technical capacity of local level staff, especially 2016. The study found that drought periods followed by a combination of warm and wet Hydrology could be incorporated in the model framework as an early warning tool. This could help the health sector to plan interventions that mitigate the impact of mosquito- borne disease epidemics in the region up to three months in advance. Climate services for arboviral diseases in the Caribbean

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The results of this study highlight the need for local research on climate-health protocols between the climate and health sectors is a priority given the sensitivity of 6 8 9 sharing health information.
Health sector stakeholders demonstrated concern, awareness and a high-level 6 9 1 understanding of the impacts of climate variability on arboviruses and health in general.

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Prior research in the Caribbean [42] found that there was limited knowledge about 6 9 3 climate and health linkages amongst nurses and doctors in private and public sectors. However, this study focused on health sector practitioners and decision makers engaged 6 9 5 in environmental health and vector borne diseases, which may account for their greater 6 9 6 awareness and concern. More recent studies in the Caribbean confirm a relatively high 6 9 7 level of awareness and concern amongst health-care providers [41], similar to studies in 6 9 8 the U.S. [36,38]. Several capacity building initiatives undertaken by regional institutions With respect to expertise, we identified a demand for basic training to increase in this area, thus providing long-term sustainability for a program on climate and health. Interviewees proposed that joint training activities across the climate and health sectors Our findings suggest that technical skills are most needed in the health sector, institutional Consortium, is increasing expertise and awareness of users and providers. CIMH plans to strengthen their RCC platform for engaging stakeholders to share lessons 8 0 5 and promote awareness of climate services based on user-needs for all sectors. When comparing the results of this study to prior studies on health sector 8 0 9 perceptions of climate, one key difference is that our study focused on people working involved with overall management of the public health sector, epidemiological programs, environment, climate change and health. Although we did consider a regional 8 1 6 perspective, the results of this study may not be generalizable to all of the Caribbean. Climate services for arboviral diseases in the Caribbean

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Country-level studies should be conducted to capture the nuances of local governance 8 1 8 structures, disease epidemiology, and climate.

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Our results were skewed towards the health sector perspective rather than the 8 2 0 climate sector, given that more health sector stakeholders were interviewed, and only 8 2 1 health sector stakeholders were surveyed. In part, this reflected that there were many 8 2 2 more people working in the national health sectors than in the national climate sectors. On the climate side, our results were skewed towards the regional perspective, given that 8 2 4 regional stakeholders had more experience with climate services for health. The results of this study provide recommendations to enhance an interdisciplinary and scientists [31,80]. This study contributes to a broader effort to work collaboratively One of the key conclusions of this assessment is the need to strengthen the 8 3 4 provider-user interface, as currently there is only limited consideration of the products with the will and support of the climate and health sector institutions. At the same time, it is necessary to create appropriate 'communities of practices' and to emphasize the co- Climate services for arboviral diseases in the Caribbean to create Health National Adaptation Plans, may be an opportunity to include a and other sectors. focused on climate services and capacity building tailored to the health sector. This could build on existing regional climate meetings like the bi-annual 8 5 6 Caribbean Climate Outlook Forum convened by the CIMH. and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Climate services for arboviral diseases in the Caribbean describes the mandates and competencies of regional (Caribbean) and national (Barbados and Dominica) climate and health sectors with respect to arbovirus and vector Climate services for arboviral diseases in the Caribbean   5  5   3  5  .  G  o  u  l  d  S  ,  R  u  d  o  l  p  h  L  .  C  h  a  l  l  e  n  g  e  s  a  n  d  O  p  p  o  r  t  u  n  i  t  i  e  s  f  o  r  A  d  v  a  n  c  i  n  g  W  o  r  k  o  n  1  0  2  5   C  l  i  m  a  t  e  C  h  a  n  g  e  a  n  d  P  u  b  l  i  c  H  e  a  l  t  h  .  I  n  t  e  r  n  a  t  i  o  n  a  l  j  o  u  r  n  a  l  o  f  e  n  v  i  r  o  n  m  e  n  t  a  l  1  0  2  6   r  e  s  e  a  r  c  h  a  n  d  p  u  b  l  i  c  h  e  a  l  t  h  .  2  0  1  5  ;  1  2  :  1  5  6  4  9  -1  5  6  7  2  .  1  0  2  7   3  6 .  a  c  p  h  e  r  s  o  n  C  C  ,  A  k  p  i  n  a  r  -E  l  c  i  M  .  C  a  r  i  b  b  e  a  n  h  e  a  t  t  h  r  e  a  t  e  n  s  h  e  a  l  t  h  ,  w  e  l  l  -b  e  i  n  g  1  0  4  6   a  n  d  t  h  e  f  u  t  u  r  e  o  f  h  u  m  a  n  i  t  y  .  P  u  b  l  i  c  h  e  a  l  t  h  e  t  h  i  c  s  .  2  0  1  5  ;  p  h  v  0  0  Climate services for arboviral diseases in the Caribbean   6  0   b  y  r  e  a  l  -t  i  m  e  s  e  a  s  o  n  a  l  c  l  i  m  a  t  e  f  o  r  e  c  a  s  t  s  .  T  h  e  L  a  n  c  e  t  I  n  f  e  c  t  i  o  u  s  D  i  s  e  a  s  e