Characteristics of the focus groups
A total of 59 individuals participated in the focus group discussions (FGDs) (see Table 1). The majority (89.9%) of the participants were female and ranged in age from 27 to 62 years, with a mean age of 40.34 +/- 8.9 years. Nurses and Community Health Aides were the largest group represented (see Table 2)
Table 1: FGD location (Health Districts)
Table 2 Demographic Information for Participant of FGDs
|
|
Number
|
Percentage
|
|
Sex
|
|
|
|
Female
|
53
|
89.9
|
|
Male
|
6
|
10.1
|
|
Level of Education
|
|
|
|
Graduate university diploma
|
11
|
18.6
|
|
Undergraduate University Diploma
|
14
|
23.7
|
|
Non-university post secondary diploma
|
23
|
39.0
|
|
Secondary School
|
9
|
15.3
|
|
Primary
|
2
|
3.4
|
|
Category of Staff
|
|
|
|
Cleaner
|
1
|
1.7
|
|
Community Health Aide
|
13
|
22.0
|
|
Community Health Nurse
|
3
|
5.1
|
|
Driver
|
1
|
1.7
|
|
Environmental Health Officer
|
4
|
6.8
|
|
Family Nurse Practitioner
|
2
|
3.4
|
|
Medical Doctor
|
5
|
8.5
|
|
Pharmacist
|
3
|
5.1
|
|
Primary care nurse
|
1
|
1.7
|
|
Registered Nurse
|
21
|
35.6
|
|
Staff Nurse Midwife
|
5
|
8.5
|
*N=59
Findings
The four themes presented below are organized around the four categories and subcategories of the Essential Public Health Functions (Figure 1). It is important to note that, in theory, these areas of activity are interrelated. However, as we will see, this is not the case in practice.
Health assessment: knowledge, monitoring and surveillance
In Dominica’s PHC in Dominica, data collection on routine visits is ostensibly done manually on morbidity sheets or other ledgers at each point of care in the health districts. Medical records are in the form of notebooks kept by the patient. Data collection is fragmented with each program area having its own data collection system. Quarterly reports are sent to the Health Information Unit which operates at the central level.
In terms of knowledge about climate change, some participants shared their observations about the local impact of climate change and how it relates to the health of the population. A few participants linked climate change to global warming but the most common themes were ‘climate disasters’ and changes in seasonality. In general, the discussion focused on hurricanes and floods. Issues such as droughts, heat waves and sea level rise were rarely discussed, and it was clear that these aspects of climate change were underestimated. The following categories emerged from the discussions and are the result of the participants’ perspectives.
A change in seasonality
Dominica’s climate is thought to have two seasons – the rainy season which runs from June to the end of November and the dry (or “Kawem” season in Creole), which runs from early December to the end of May. Participants observed that this pattern has changed, and that this distinction is no longer apparent. One participant noted “ Now we no longer have a “kawem” or dry season and rainy season. it’s like we don’t see that pattern no more”. Another stated: “I think it’s more in a change in the weather pattern … During the rainy season it was dry and during the dry season you had a lot of rain” (FGD7).
Intensification of extreme weather events: hurricanes, heat, rainfall, floods, landslides
Some participants explained that there has been an increase in the intensity of hurricanes in Dominica: « well the hurricanes have intensified. Look at Maria, that was the worst we have ever experienced. » (FGD7). Regarding heat waves: « yes, we've been having some serious uprise in heat.» (FGD 4). According to the participants, the frequency of floods and landslides has increased, especially in areas that are not usually flooded “I think we are having more frequent floods. Because when I was younger you would never think of Dominica having floods..” (FGD2). Respondents explained that even with very little rainfall, flooding and landslides occur, causing extensive damage to property and disrupting of livelihoods. “Because we have never seen in our lifetime our river overflowing its bank so heavily and that caused a lot of the houses the buildings were torn apart, washed away. Villagers were relocated, some had to rebuild” (FGD1). In addition, some participants reported that there were tropical storms outside of the normal hurricane season including during the month of December which was considered unexpected. In at least 4 of the FGDs, participants indicated an increased frequency and intensity of rainfall during the Christmas season which seemed abnormal: “take December for example for the past Christmases, we have had tropical storm weather on Christmas days. Usually we might have light drizzle during the Christmas season but not that magnitude where you can barely walk through Roseau and you have flooding” (FGD4); “we have rain so often in this month of December which is not normal.” (FGD6)
Warming Temperatures
One participant described the warming over the last 10 years: “10 years ago it didn’t really used to be so hot and as the years go by it’s getting hotter and hotter every day” (FGD2). It was noted that the increase in heat has led to a reduction in physical activity among people accessing the primary healthcare system. In contrast, in some FGDs, particularly in the rural areas, heat waves were not seen as a problem at all “Our heat waves, here in Dominica we do not have heat waves like other countries where... We do get it but it’s not that bad...” (FGD3). It was also not clear what was meant by heat waves.
Intensification of Saharan dust
Some participants mentioned Saharan dust, indicating that there was a perceived increase in the frequency and amount of Saharan dust and that this was perceived to be linked to climate change. Others mentioned the increase in seaweed washing ashore, particularly in the Atlantic Ocean and the appearance of black flies along the coastal areas as being related to climate change. They suggested that these vectors cause skin lesions that require treatment with antibiotics.
A lack of feedback communication mechanism regarding surveillance data
There appears to be a focus on infectious disease surveillance as these types of diseases are reported from the primary care level through the completion of weekly surveillance reports. These reports are sent to the Health Information unit and provide information regarding any infectious disease outbreak. Regarding the recording of weather related events, (heatwaves, floods, fire, drought, etc.) these events are not monitored by the PHC in Dominica.
Participants indicated that the feedback mechanism does not work adequately: “ the only thing I want to put it on record is that we send the information up but we don’t get feedback. And the information is there… And somebody gets it but it never filters down…well report comes but we get it like everybody else, like general public, on the radio or on social media but it doesn’t come back to us. This can represent a barrier to effective disease prevention.
Participants discussed health problems that were seen as directly or indirectly related to climate change. Physical injuries and infections which can occur in the immediate aftermath of an extreme climate event such as a hurricane were reported as direct health problems related to climate change. These include health issues such as wounds and fractures, wound infections, gastroenteritis, dengue, and other vector borne diseases. As a result, PHC staff are alert to these conditions, especially after hurricanes and storms.
Non-communicable diseases
Participants linked climate change to an increase in the burden of non-communicable diseases (NCDs), particularly hypertension and diabetes. “I think all of us can attest that there has been a rise in new conditions post Hurricane Maria, especially high blood pressure and diabetes and stroke in younger persons, so maybe there is some relation, we did not conduct a survey or research to prove that but ....ˮ (FGD6). In other words, these observations from the field do not seem to be validated by systematic surveillance activities of chronic diseases, a situation that may impede systematic prevention and health promotion activities that should be conducted in primary care at the national level.
In addition, it was suggested that there is a change in diet following extreme weather events such as storms, with increased consumption of processed foods contributing to an increase in cases of hypertension and diabetes and also affecting on the blood pressure and/or glycemic control of clients who are already diagnosed. Some participants suggested that climate change threatens food security particularly with the destruction of agricultural products due to climate related events.
Mental health issues
Mental health problems were also identified as an indirect effect of climate change. Participants perceived that mental health problems such as anxiety and depression are related to fear during events, loss of property and loved ones, loss of livelihoods and other social problems that may arise after an extreme climate event.
Participants noted that mental health problems are often undiagnosed and untreated. For clients with other NCDs, these mental health challenges sometimes contribute to non-adherence to care and lack of disease control.
Participants reported that the social and physical challenges faced in the aftermath of extreme climatic events have psychological effects that last beyond the emergency period. “Even some people develop mental disorders, psycho-social problems, they no longer can interact with others socially. And there are people, if you do take a look around, mental illness is on a rise in our country. Yes, it is on a rise and there is no statistics necessary to show you the evidence of that because you can see it, and the younger people are becoming more mentally ill” (FGD 1). Participants explained that the psychological effects of extreme climate events are long-lasting. People have become traumatized to the point where a small amount of rainfall causes extreme anxiety: “what I have noticed is that people have become affected psychologically where based on their experience during the event of a disaster that they are unable to sleep at night they complain about being fearful, they are traumatized so to speak, based on what it is that they experienced during a storm” (FGD 4).
Staff also indicated that they too face mental health challenges. They face the same stressors as the rest of the population and they perceived that their needs are rarely addressed: “I mean they (the PHC Staff) suffered. They suffered during the storms and hurricanes. Some of them were displaced some of them lost family members or their Property. So it impacted very heavily on them. Some of those health care providers were not able to provide healthcare services because they themselves were affected” (FGD3).
Risks and vulnerabilities: demographic, socioeconomic, medical and land exposition
It was said that ‘our disaster plan is reviewed every year before the hurricane season at least we try to update it and to identify the vulnerable population and areas too and usually our disaster committee collaborates with us’ (FGD 2). In case of an event like a storm or a flooding, people identified as ‘vulnerable’ or ‘at risk’ could be evacuated. However, it was unclear how risk assessment was carried out and how risk and vulnerability were assessed and interpreted. There is a pre-existing list of « vulnerable populations » based on age and medical conditions. Participants identified the elderly, older people living alone, pregnant women, children under 5, shut-in (home bound) and people with disabilities as vulnerable. Some mentioned of the housing status as an indicator of vulnerability and pointed out the lack of attention to social conditions that contribute to vulnerability. One participant said: « sometimes we forget the social aspects of how people live » FGD 2.
In relation to land issues, the following participant said that: ‘I consider people vulnerable when they live in areas prone to landslides, floods’ (FGD 2). Thus, vulnerability is also linked to land conditions: « we have some areas that are severely compromised. Every time it rains heavily and we don't know how possible it is to have river walls to prevent water from flowing into the community and into people’s homes because we are way in the center of the community, so it happens all the time. If we do not correct these situations it is going to happen all the time.» (FGD 1). Thus, land planning appears to be a concern but it is unclear whether such an observation leads to action.
Participants reported that there are manual records of community statistics that helps to identify “at-risk” individuals. These records are segmented based on the program areas and used to create the community profile which is a snapshot of the community’s needs based on indicators such as age, medical conditions and income status. It was unclear how often the community profile is updated and how it is used by the PHC for planning purposes.
Provision of and access to health care services
Health care services driven by field observations
Participants were asked to describe how they ensure access to healthcare services in the context of climate change. Staff seemed to respond to health issues based on their observations and not necessarily based on empirical data and systematic information based on surveillance systems (nutritional status, mental health, etc.).
Communication challenges
Participants reported that communication challenges were a significant barrier to accessing to care. Some individuals and families are inaccessible due to their location and particularly in the context of climate related disasters, communication challenges may prevent them from receiving the health care they need. When telecommunications services are down, individuals must rely on the goodwill of neighbors and their access to help is not always timely: “If someone fall sick, they cannot access, they cannot call the ambulance or anyone for that matter to come and pick them up. So, they may have to rely on maybe a close neighbor or maybe their child or someone to run and call somebody else…” (FGD 2). They noted that some people only receive needed health services if they are identified by the staff during home or household visits:
“So, we have to just sit and hope that they show up. Sometimes we would go to the homes and the homes would be badly destroyed and we not even sure that they moved to a neighbor or if they moved out of the district or out of state. We don't know. So, it made that part of primary health care difficult.’’ (FGD 3)
Increase of health care needs during emergencies
In addition, participants indicated that the increased volume of patients at health centers limits the amount of time that can be spent treating patients. Staff reported having to select the most urgent cases to treat and this decision is generally related to the level of physical injury. “after a hurricane or a disaster you might have a large amount of people coming here, let’s say you would stay 15, 20 minutes with somebody it’s going to be a rush on that day. So, you might spend about 2 minutes, 3 minutes trying to deal with each person, …. everything is going to be limited….’’ (FGD 2). Participants suggested that the disruption of services that typically follows a climate related disaster limits access to care for many vulnerable groups. They noted that there is an increase in workload following the impact of storms or hurricanes which necessitates a reduction in services provided to the public and therefore people face challenges with medication stock-outs and inconsistencies in follow-up clinics.
Occasional limited access to medical supplies and health centers
Access to medical supplies at health facilities is also a challenge affecting access to health services. Participants indicated that there are not enough supplies for community health centers to be self-sufficient after a climatic event. In many cases, medication and other resources are stretched beyond their limits and this affects people who are faced with medication stock outs. Staff noted that the resources provided to the PHC are so limited that patients with chronic diseases cannot be receive additional supplies due to limitations of the PHC pharmacies. One participant noted “I think access to medication was another problem, all what was going on so you find that some of the persons in the village that didn’t have a stock up on medication didn’t have medication for that month.” (FGD 5)
With regard to health centers, some participants noted that some individuals have limited access to some health facilities due to the location of the health facility. Some felt that not enough attention was being paid to ensuring access for groups such as the elderly.
Focus on the biomedical …
Based on the discussions, it was understood that PHC practices mainly follow a biomedical approach to health care, focusing on the management of physical health problems. Priority is given to the treatment of “life-threatening” physical injuries and some participants indicated that some clinics for other problems such as routine care for chronic diseases are rescheduled. In addition, mental health problems are seen as less important than physical injuries and, therefore receive less attention from health workers. When asked how care is prioritized in the PHC, one participant replied: “You do your assessment and then you decide. Most times on the physical aspects you would see it. So, I’m saying yes somebody might be depressed but somebody come with - lets say a broken bone, you have to decide …. After all it is quite obvious…” (FGD 2).
….but less on the social aspects of health
Primary health care staff said that because they routinely make home and household visits, they have intimate interaction with the community and are therefore are able to identify the needs of the population: “that’s the beauty of having district nurses because everybody knows everybody. So, the persons are aware of their nurses so they will find a way to pass the message to you. Or they have your number, most persons have our numbers or they have the numbers for the health center and if they cannot call, they will send a message thru somebody so it will get to us” (FGD 3). In some communities, staff conduct a walkthrough in the community in the immediate emergency period following extreme climate events. There are no guidelines as to how often this is done or what the assessment entails more precisely. It was understood that there was no systematic way for ensuring universal access to health services in the context of weather events. According to participants PHC teams in Dominica know the location of the people who have been identified as vulnerable in the community: “ because (it)is a small community. All the nurses know the(ir) people. So I know (that) if you(are) living in a block house, (with a )concrete roof you may not need the primary initial care as opposed to someone who was in a wooden structure, who was displaced without treatment and without food” (FGD 3). It appeared that staff had different interpretations of what needed to be “known” about the community. However, some expressed concern about barriers to accessing health care such as when someone lives alone and is seriously ill or living with a disability. The (in-) ability to monitor is therefore strongly linked to (lack of) access to care and support.
Some were particularly concerned about the issue of internal displacement which they noted has led to an increase in social challenges related to extreme poverty, physical and psychological abuse and lack of access to adequate health services. One participant lamented: “We also see to that the displacement of certain families, where they have to separate from each other due to accommodation and all that, we see children and the elderly, vulnerable groups where they can be affected, where children may be exposed to abuse” (FGD3). On the other hand, some participants felt that they were not a priority group because they would somehow find their way home: “... They make their way home, they pass by the sea. A lot of persons got trapped in places where they would not have been for Hurricane Maria and even TS Erica but they made their way home” (FGD 3).
Participants also explained that the PHC system treats everyone who attends the clinic and therefore it is likely that displaced individuals have access to care wherever they are. However, some saw this as a challenge. One participant stated that: “If you have persons that are severely affected, maybe their house was broken and they have to move to another area the nurse might not even know they are there and the services, even the clinics, appointments, their children. Follow-up will be a problem.’’ (FGD 6)
Resource allocation
Participants described severe resource constraints within PHC that hindered their ability to provide quality health care services. Limitations in human resources for health, financial resources and physical equipment pose challenges to the type and quality of services that the PHC is able to provide and these challenges are said to be chronic in the PHC.
In all the FGDs, participants lamented over the lack of supplies and limited human resources for health. This general perception of lack of resources seems to be exacerbated during extreme climate events. Participants perceived that they are expected to function with limited physical and human resources and this has not changed despite the previous experiences with climate related disasters. Resources are insufficient for the normal day-to-day functioning of the primary health care system: “The resources were not there at the time to deal with the patient” (FGD 7). Some participants felt that even the effort and time required to provide the necessary level of physical and psychological support was often beyond the capacity of staff.
Resource allocation was linked to access to care. Staff reported being overwhelmed especially after extreme climatic events due to the large influx of patients seeking care for acute problems: “if access to one health center is compromised, the population served by that health center have (or need) to be redirected (to another facility) causing overwhelm at other health centers” (FGD 4). In addition, staff shortages mean that staff work long hours with limited breaks and little relief. “We can always offer the services but staffing is one of our major issues. If we do not have sufficient staff there is going to be a burden or the services will be less because is one nurse to (serves) one hundred or one nurse to 600 people in a community. The one-on-one care is still an issue because of staffing (FGD6). Staff did not feel adequately supported during past climate disasters. The sense of being overwhelmed was compounded by the personal stressors that faced by the staff and the feeling of being alone: “In the district there was not enough backup to help. I was severely impacted personally and there was no backup for me from no area that I could take a day off so I could take care of my personal business because I had to come in tears and still had to operate..[…] That was hard” (FGD 3)
Working conditions for primary health care staff in the field, especially during climate related disasters were not ideal. Staff reported having to improvise in order to provide services, which increased their level of psychological stress. They cited several instances of working without the necessary resources: “During Hurricane Maria I remember we had to use the counter to do dressings, there was no water (FGD1); “Without electricity many people were still able to their pap smears. You use a flashlight; you use your phone but we could still do pap smears” (FGD5). Participants perceived that the difficulties faced by staff both personally and in the execution of their work, precipitated an increase in out migration of health workers. The country then has to rely on foreign nurses from Cuba, which poses another challenge in terms of language barriers and effective communication.
Some participants also emphasized the need for specialized training for PHC staff to function effectively. They stated that staff are transferred from the secondary care without adequate orientation to PHC, which affects their ability to perform the required tasks specific to PHC.
Policy Development
Participants were not aware of any policies within the primary health care system related to climate change. Staff are guided by the primary health care directives (2011) and the primary healthcare manual (1982). Each health district is required to develop a disaster plan to guide staff response in the event of a disaster. Staff are engaged in the development of the disaster plan, but questions can be raised about its focus and systematic operationalization.
The limited use of monitoring and surveillance data for policy purposes
The previous themes on surveillance and monitoring and access to health care tend to show that vulnerability is seen as consisting of demographic, social and medical components, and that the related information will somehow guide local field practice. However, they are not necessarily and systematically treated at a central level as important knowledge for planning and systematic practice purposes. These potential geographic differentials could lead to issues of inequity.
Participants felt that there needs to be more policies to address issues related to climate change and this needs to take into account the advice of the staff “our policy holders need to take our advice, because advice are given, they don’t listen and we find ourselves in problem” (FGD 4). Regarding vulnerability, some participants raised the issue of lack of proper land use planning, which can potentially expose people and territories to climate hazards. This includes issues of communication and collaboration for cross-sectoral action to prevent or reduce vulnerability to climate events.
Community engagement in health districts
It appears that communities are somehow informally engaged with the primary health care systems and because of the closeness of the communities, some participants expected community members to inform staff when there are any new individuals (strangers) in the community. They relied on the goodwill of the community members to keep track of people who might need assistance. Information was passed on informally through family members or neighbors. This calls into question the level of access to primary health care and points to a lack of policy guidance on community engagement in the context of climate change.
Limited consideration for PHC at the central level
Participants also expressed their dissatisfaction with the level of input that they have in policy and infrastructure matters. They cited examples of facilities which were being built with little input from PHC staff. One participant stated: I think the policy makers should, when they (are) making new facilities they should involve their staff because it’s the staff that knows what essential part that they use in the facilities. For instance we are there right now and that health center is build and there is no area that we can do dressings for persons and that health center was recently built (FGD 6).
Some participants were concerned that PHC was not a priority in Dominica. “I think they should give primary health care a little more priority, …we are there serving the public and there are no special preparations made, and you know during these times the road is bad, no vehicles have access to get to the health center and you have no priority. You need to get to work,…and there are no special vehicles to come pick you up or even with everywhere lacking electricity and we are not getting no security. We should get more priority because we are serving the public” (FGD 5)
They felt that staff were treated poorly after the last two climate related disasters and staff who could no longer endure the hardship left the country: “disaster and climate change have affected the migration of our nurses because of the way the system treated us …. some persons they reached a peak.ˮ (FGD 3)
Other issues were raised and discussed that appear important in this context.
Some raised concerns about collaboration with other departments: « you don’t want to encroach on other departments jobs because if anything you can refer them to social welfare to assist with housing » (FGD 2).