Developing a Healthy Environment Assessment Tool (HEAT) to Address Heat-Health Vulnerability in South African Towns in a Warming World

Prolonged exposure to high temperatures can cause heat-related illnesses and accelerate death, especially in the elderly. We developed a locally-appropriate Healthy Environment Assessment Tool, or 'HEAT' tool, to assess heat-health risks among communities. HEAT was co-developed with stakeholders and practitioners/professionals from the Rustenburg Local Municipality (RLM), a setting in which heat was identified as a risk in an earlier study. Feedback was used to identify vulnerable groups and settings in RLM, consider opportunities and barriers for interventions, and conceptualize a heat-health vulnerability assessment tool for a heat-resilient town. Using information provided by the RLM Integrated Development Plan, the HEAT tool was applied in the form of eight indicators relating to heat-health vulnerability and resilience and areas were evaluated at the ward level. Indicators included population, poverty, education, access to medical facilities, sanitation and basic services, public transport, recreation/community centres, and green spaces. Out of 45 wards situated in the municipality, three were identified as critical risk (red), twenty-eight as medium-high risk (yellow), and six as low risk (green) in relation to heat-health vulnerability. Short-term actions to improve heat health resilience in the community were proposed and partnerships between local government and the community to build heat health resilience were identified.

Respiratory health among adolescents living in the Highveld Air Pollution Priority Area in South Africa

BACKGROUND

Air pollution is a global, public health emergency. The effect of living in areas with very poor air quality on adolescents' physical health is largely unknown. The aim of this study was to investigate the prevalence of adverse respiratory health outcomes among adolescents living in a known air pollution hotspot in South Africa.

METHODS

Ambient air quality data from 2005 to 2019 for the two areas, Secunda and eMbalenhle, in the Highveld Air Pollution Priority Area in Mpumalanga province, South Africa were gathered and compared against national ambient air pollution standards and the World Health Organization Air Quality Guidelines. In 2019, adolescents attending schools in the areas completed a self-administered questionnaire investigating individual demographics, socio-economic status, health, medical history, and fuel type used in homes. Respiratory health illnesses assessed were doctor-diagnosed hay fever, allergies, frequent cough, wheezing, bronchitis, pneumonia and asthma. The relationship between presence (at least one) or absence (none) of self-reported respiratory illness and risk factors, e.g., fuel use at home, was explored. Logistic regression was used to estimate the odds ratio and 95% confidence interval (CI) of risk factors associated with respiratory illness adjusted for body mass index (measured by field assistants), gender, education level of both parents / guardians and socio-economic status.

RESULTS

Particulate matter and ozone were the two pollutants most frequently exceeding national annual air quality standards in the study area. All 233 adolescent participants were between 13 and 17 years of age. Prevalence of self-reported respiratory symptoms among the participants ranged from 2% for 'ever' doctor-diagnosed bronchitis and pneumonia to 42% ever experiencing allergies; wheezing chest was the second most reported symptom (39%). Half (52%) of the adolescents who had respiratory illness were exposed to environmental tobacco smoke in the dwelling. There was a statistically significant difference between the presence or absence of self-reported respiratory illness based on the number of years lived in Secunda or eMbalenhle (p = 0.02). For a one-unit change in the number of years lived in an area, the odds of reporting a respiratory illness increased by a factor of 1.08 (p = 0.025, 95% CI = 1.01-1.16). This association was still statistically significant when the model was adjusted for confounders (p = 0.037).

CONCLUSIONS

Adolescents living in air polluted areas experience adverse health impacts Future research should interrogate long-term exposure and health outcomes among adolescents living in the air polluted environment.

Perceptions of thermal comfort and coping mechanisms related to indoor and outdoor temperatures among participants living in rural villages in Limpopo province, South Africa

Global heating is considered one of the greatest threats to human health and well-being. Supporting human resilience to heating threats is imperative, but under-investigated. In response, this article reports a study that drew together results from quantitative data on perceptions of thermal comfort and mechanisms for coping with thermal discomfort among 406 households in a study in Giyani, Limpopo province. Indoor dwelling and outdoor temperatures were also analysed. Most participants perceived their dwellings to be too hot when it was hot outdoors. People relied on recommended heat health actions such as sitting outdoors in the shade or opening windows. While this agency is meaningful, resilience to climate change requires more than personal action. In light of the climate threats and climate-related disaster risks facing South Africa, an all-encompassing approach, including education campaigns, climate-proofed housing, access to basic services, and financial considerations that will help support resilient coping among South Africans, is urgently required.

Applying a WASH Risk Assessment Tool in a Rural South African Setting to Identify Risks and Opportunities for Climate Resilient Communities

Climate change threatens the health and well-being of populations. We conducted a risk assessment of two climate-related variables (i.e., temperature and rainfall) and associated water, sanitation and hygiene (WASH)-related exposures and vulnerabilities for people living in Mopani District, Limpopo province, South Africa. Primary and secondary data were applied in a qualitative and quantitative assessment to generate classifications of risk (i.e., low, medium, or high) for components of hazard/threat, human exposure, and human vulnerability. Climate-related threats were likely to impact human health due to the relatively high risk of waterborne diseases and WASH-associated pathogens. Vulnerabilities that increased the susceptibility of the population to these adverse outcomes included environmental, human, physical infrastructure, and political and institutional elements. People of low socio-economic status were found to be least likely to cope with changes in these hazards. By identifying and assessing the risk to sanitation services and water supply, evidence exists to inform actions of government and WASH sector partners. This evidence should also be used to guide disaster risk reduction, and climate change and human health adaptation planning.

Classroom Temperature and Learner Absenteeism in Public Primary Schools in the Eastern Cape, South Africa

Children spend a significant proportion of their time at school and in school buildings. A healthy learning environment that supports children should be thermally conducive for learning and working. Here, we aimed to study the relations between indoor classroom temperatures and learner absenteeism as a proxy for children’s health and well-being. This one-year prospective study that spanned two calendar years (from June 2017 to May 2018) entailed measurement of indoor classroom temperature and relative humidity, calculated as apparent temperature (Tapp) and collection of daily absenteeism records for each classroom in schools in and around King Williams Town, Eastern Cape province, South Africa. Classroom characteristics were collected using a standardized observation checklist. Mean indoor classroom temperature ranged from 11 to 30 °C, while mean outdoor temperature ranged from 6 °C to 31 °C during the sample period. Indoor classroom temperatures typically exceeded outdoor temperatures by 5 °C for 90% of the study period. While multiple factors may influence absenteeism, we found absenteeism was highest at low indoor classroom Tapp (i.e., below 15 °C). Absenteeism decreased as indoor Tapp increased to about 25 °C before showing another increase in absenteeism. Classroom characteristics differed among schools. Analyses of indoor classroom temperature and absenteeism in relation to classroom characteristics showed few statistically significant relations—although not exceptionally strong ones—likely because of the multiple factors that influence absenteeism. However, given the possible relationship between indoor temperature and absenteeism, there is a learning imperative to consider thermal comfort as a fundamental element of school planning and design. Furthermore, additional research on factors besides temperature that affect learner absenteeism is needed, especially in rural areas.

Major climate change-induced risks to human health in South Africa

There are many climatic changes facing South Africa which already have, or are projected to have, a detrimental impact on human health. Here the risks to health due to several alterations in the climate of South Africa are considered in turn. These include an increase in ambient temperature, causing, for example, a significant rise in morbidity and mortality; heavy rainfall leading to changes in the prevalence and occurrence of vector-borne diseases; drought-associated malnutrition; and exposure to dust storms and air pollution leading to the potential exacerbation of respiratory diseases. Existing initiatives and strategies to prevent or reduce these adverse health impacts are outlined, together with suggestions of what might be required in the future to safeguard the health of the nation. Potential roles for the health and non-health sectors as well as preparedness and capacity development with respect to climate change and health adaptation are considered.

Associations between high temperatures in pregnancy and risk of preterm birth, low birth weight, and stillbirths: systematic review and meta-analysis

OBJECTIVE

To assess whether exposure to high temperatures in pregnancy is associated with increased risk for preterm birth, low birth weight, and stillbirth.

DESIGN

Systematic review and random effects meta-analysis.

DATA SOURCES

Medline and Web of Science searched up to September 2018, updated in August 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical studies on associations between high environmental temperatures, and preterm birth, birth weight, and stillbirths.

RESULTS

14 880 records and 175 full text articles were screened. 70 studies were included, set in 27 countries, seven of which were countries with low or middle income. In 40 of 47 studies, preterm births were more common at higher than lower temperatures. Exposures were classified as heatwaves, 1°C increments, and temperature threshold cutoff points. In random effects meta-analysis, odds of a preterm birth rose 1.05-fold (95% confidence interval 1.03 to 1.07) per 1°C increase in temperature and 1.16-fold (1.10 to 1.23) during heatwaves. Higher temperature was associated with reduced birth weight in 18 of 28 studies, with considerable statistical heterogeneity. Eight studies on stillbirths all showed associations between temperature and stillbirth, with stillbirths increasing 1.05-fold (1.01 to 1.08) per 1°C rise in temperature. Associations between temperature and outcomes were largest among women in lower socioeconomic groups and at age extremes. The multiple temperature metrics and lag analyses limited comparison between studies and settings.

CONCLUSIONS

Although summary effect sizes are relatively small, heat exposures are common and the outcomes are important determinants of population health. Linkages between socioeconomic status and study outcomes suggest that risks might be largest in low and middle income countries. Temperature rises with global warming could have major implications for child health.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD 42019140136 and CRD 42018118113.

Extreme heat exposure in pregnancy and risk for preterm birth, low birth weight and stillbirths

Background

Exposure to high ambient temperatures during pregnancy may increase the risk of adverse pregnancy outcomes due to physiological and anatomical changes in pregnancy compromising the ability to thermoregulate.

Methods

A systematic review and meta-analysis of studies that assessed associations between ambient heat, and preterm birth, birth weight and stillbirths. Articles were identified through a search of Medline (PubMed) and Web of Science. Titles and abstracts were screened, eligible studies extracted and risk of bias assessed using the Joanna Briggs Institute appraisal tools.

Results

14,880 records were screened and a total of 70 studies included. In 40 of 47 studies, preterm births were more frequent at higher than lower temperatures. In random effects meta-analysis, the odds of a preterm birth rose 1.05-fold per 1 °C increase in temperature (95%CI=1.03, 1.07), and 1.16 fold during heat waves (95%CI=1.10, 1.23). Reduced birth weight associated with higher temperature was found in in 18 of 28 studies, with considerable heterogeneity. Studies on stillbirths (n = 8) all showed temperature-stillbirth associations, with stillbirths increasing 1.05-fold per 1 °C rise in temperature (95%CI=1.01, 1.08). Associations between temperature and outcomes were largest among women in lower socioeconomic groups and at age extremes. The multiple temperature metrics and lag analyses limited comparison between studies and settings.

Conclusions

As frequency of heat exposures is increasing, prevention for pregnant women during heat waves should become a standard aspect of heat adaptation.

Key messages

Increase in extreme temperature events may have major implications for child health unless much more is done to provide heat adaptation services for pregnant women. Links between socio-economic status and study outcomes suggest higher vulnerability for already disadvantaged groups.

A Comparison of Solar Ultraviolet Radiation Exposure in Urban Canyons in Venice, Italy and Johannesburg, South Africa

Urban environments can have high-risk spaces that can provide excess personal sun exposure, such as urban or street canyons, and the spaces between buildings, among others. In these urban spaces, sun exposure can be high or low depending on several factors. Polysulphone film (PSF) was used to assess possible daily solar ultraviolet radiation (UVR) exposure in urban canyons in Venice, Italy and, for the first time in Africa, in Johannesburg, South Africa. The photodegradation of PSF upon solar exposure was monitored at a wavelength of 330 nm by ultraviolet-visible spectrophotometry, and the resultant change was converted to standard erythemal dose (SED) units (1 SED = 100 J m^-2 ). Mean daily ambient solar UVR exposure measured for Venice and Johannesburg ranged between 20-28 SED and 33-43 SED, respectively. Canyon-located PSF exposures were lower in Venice (1-9 SED) than those in Johannesburg (9-39 SED), depending mainly on the sky view factor and orientation to the sun. There was large variation in solar UVR exposure levels in different urban canyons. These preliminary results should be bolstered with additional studies for a better understanding of excess personal exposure risk in urban areas, especially in Africa.

Drivers for Sun Protection in Black South Africans

Sun protection behavior studies are almost exclusively carried out in populations with fair skin for the obvious reason that people with unpigmented skin are more susceptible to the health impacts of excess solar ultraviolet radiation exposure. In a dataset of 1271 Black South Africans, we analyzed factors related to sun protection applied when spending time outdoors including awareness of skin cancer, gender, age and Living Standards Measure (LSM) where 1-4 equate to the lowest, 5-7 intermediate and 8-10 the highest LSM status. The most important driver for Black South Africans to use sun protection was whether they were aware of skin cancer (OR: 2.6 for those who were aware versus those who were not, P < 0.0001). Sunscreen was preferred by respondents in LSM 8-10 whereas people in the lowest group (LSM 1-4) favored shade, umbrellas and hats. One in two respondents claimed to use some form of sun protection, which appears to be higher than deeply pigmented populations in other countries.

Skin Cancer Awareness Among 1 271 Black Africans in South Africa

Little is known about levels of awareness and perceptions of skin cancer among Africans living in Africa. This study assessed skin cancer awareness among 1271 deeply pigmented South Africans. Participants (n = 642 males vs n = 629 females) were aware of skin cancer (79%) with more females than males being aware of skin cancer (P = 0.02). Majority of all participants had never checked their skin for signs or symptoms of skin cancer (90%). Palms of hands and soles of feet were the least recognized anatomic sites for skin cancer development, despite these sites being the common sites for acral lentiginous melanoma in individuals with deeply pigmented skin. Results suggest a need for targeted skin cancer awareness among population groups with dark skin on identification, screening, and early detection, professional training for healthcare personnel and content on skin cancer in deeply pigmented skin in medical curricula.