Climate Change and Health Equity

In the context of climate change, vulnerability refers to the “degree to which a system is susceptible to, or unable to cope with, adverse effects of climate change, including climate variability and extremes” (IPCC, 2007). The vulnerability of individuals or groups to the health impacts of climate change is determined by the exposure to climate change hazards, the sensitivity to possible impacts, and the capacity to respond or cope with them (Berry et al., 2008; Gamble et al., 2016).

Understanding the concept of vulnerability, and its primary components, is important for public health actors and decision makers, and can aid in understanding health outcomes related to climate change, as well as in identifying where resources and adaptation measures are most needed. However, it is recognized that the term “vulnerability” can be highly stigmatizing when applied to individuals or population groups and has frequently perpetuated a narrative of victimization (see Box 9.1). The intent of the discussion in this section is not to label vulnerable populations, but, rather, to explore how health equity intersects with exposure, sensitivity, and adaptive capacity, to shape vulnerability to climate change. While this discussion focuses on determinants of health and health equity in the context of climate change vulnerability, it is important to recognize the systemic nature of health inequities that construct the conditions that ultimately shape vulnerability.

All individuals display some vulnerability factors to the health impacts of climate change; however, this vulnerability is not uniform. Disproportionate impacts and various experiences of adaptation and resilience have been observed across Canada (Wandel et al., 2010; Berry et al., 2014a; Sellers, 2018; Gouvernement du Québec, 2019). In many cases, the status of determinants of health plays an important role in influencing vulnerability (Kumar, 2018), can increase the risk of exposure or sensitivity to climate-related health risks, and can create barriers that limit adaptive capacity (see Figure 9.2). For example, while physiological processes (e.g., chronic diseases, decreased sense of thirst, reduced ability to sweat) can increase the vulnerability of seniors to heat-related health risks, the entire senior population does not experience the same degree of vulnerability. Some people may have greater access to air conditioning and cooling spaces, which have been found to mitigate health risks during extreme temperatures, whereas such adaptations may be less available to some seniors because of economic or mobility challenges (Health Canada, 2012).

Exposure refers to the degree to which individuals or populations may come into contact with climate-related health hazards (McMichael et al., 2003). Inequitable exposure to particular climate hazards can result in parts of the population experiencing heightened vulnerability and negative health outcomes. For example, urban heat islands experience warmer temperatures compared to surrounding regions and can magnify health impacts during heat waves (Health Canada, 2020). A study of the 175 largest urbanized areas in the continental United States found that in 97% of cities racialized populations are disproportionately exposed to high surface urban heat island intensity (SUHI), compared to White residents. Black residents, followed by Hispanic residents, have the highest average SUHI exposure. In terms of income, in 70% of cities, people living below the poverty line had significantly higher exposure compared to those living at twice the poverty line (Hsu et al., 2021). Another study in the United States found that of 108 urban areas analyzed, 94% displayed consistent city-scale patterns of elevated land surface temperatures in formerly redlined² neighbourhoods compared to non-redlined neighbourhoods by as much as 7°C (Hoffman et al., 2020).

In Canada, during a heat wave in Montréal, Quebec, in 2018, 66% of people who died were located in urban heat islands. Low-income and social isolation were also determined to be important risk factors (Gouvernement du Quebéc, 2019). In Toronto, Ontario, low-income and racialized communities have less access to tree canopy cover and public green spaces, which can mitigate the urban heat island effect and provide other health co-benefits (Greene et al., 2018; Conway & Scott, 2020).

Sensitivity refers to the degree to which individuals are affected by a climate-related health risk (Adger et al., 2004). Sensitivity to climate change health impacts can be shaped by biological traits, such as age, genetics, and chronic health conditions (Gamble et al., 2016) and influenced by determinants of health, such as socio-economic status and availability of and access to health services (Berry et al., 2008). Climate change impacts may affect the status of such determinants and increase sensitivity to health risks related to climate change for some individuals. For example, food security is a key determinant of health and contributes to positive health outcomes. In Canada, a higher prevalence of household food insecurity has been reported among households with children under the age of 18, with households headed by single women being most negatively affected (Statistics Canada, 2012). There is also a higher prevalence of food insecurity in the Canadian North compared to the rest of the country. Climate change may challenge the availability, accessibility, and/or use of food for individuals (see Chapter 8: Food Safety and Security). Such effects can increase the prevalence of food insecurity and contribute to adverse health impacts. Compromised health status, due to food insecurity, could increase sensitivity to other health risks related to climate change, particularly among population groups that already disproportionately experience negative health outcomes from a warming climate.

Adaptive capacity refers to the ability of a system to adjust and manage climate change effectively, moderating or coping with adverse impacts (IPCC, 2007). Factors that contribute to adaptive capacity include access to economic resources, technology, information and skills, public health infrastructure, institutional arrangements, and the existing burden of disease (Grambsch & Menne, 2003; Berry et al., 2008). Existing social and health inequities contribute to the variation of adaptive capacity across individuals and communities in Canada. For example, it is well documented that those with limited access to and use of resources (e.g., financial, information, social networks) will experience the most difficulty adapting to climate change (UNEP, 2018; WHO, 2018; Friel, 2019). For example, low-income households located in flood zones may not have the ability to relocate, which increases risk of exposure to flood hazards. In the absence of flood insurance, uninsured losses to property and belongings cannot be recovered, compounding economic disadvantage and further limiting individual adaptive capacity for future events (Islam & Winkel, 2017; Paavola, 2017).

Climate change impacts on determinants of health can further compound barriers to adaptive capacity of individuals and communities, which could result in increased vulnerability to poor health outcomes from a warming climate. The availability, accessibility, and acceptability³ of public health and emergency management services and infrastructure is not only a determinant of health but can also support community resilience to climate change impacts on health (Séguin, 2008) and varies across communities in Canada. For example, experiences of inequitable availability, accessibility, and acceptability of health care services have been noted among First Nations, Inuit, and Métis peoples as a result of complex intersecting factors, including colonialism, geography, health systems, human resources, jurisdictional issues, cultural safety, communications, and the importance and use of traditional medicines (NCCIH, 2019). Thus, existing inequities related to health care services may limit adaptive capacity for some individuals, which could enhance vulnerability to climate change impacts on health.

In an effort to inform the development of adaptation measures to prepare for climate change, past Canadian climate change and health assessments have identified broad categorizations of “vulnerable populations” such as seniors and children, pregnant people, Indigenous Peoples, low-income individuals, and immunocompromised or chronically ill people. Generalizations are often made regarding these populations’ characteristics, conditions, and/or circumstances that increase vulnerability to particular health risks of climate change. However, such generalizations often fail to recognize the important heterogeneity of these population groups and may not adequately reflect how an individual or group understands themselves (Dhamoon & Hankivsky, 2011, p. 38). They also often overlook how differences among and within populations may change over time in the face of climate change (Kaijser & Kronsell, 2014). This “universalizing” of various population groups disregards the multidimensional nature of vulnerability and may result in the unique needs of individuals being overlooked, creating barriers to effective adaptation. Further, it is common for climate change vulnerability research to focus on a single or limited number of discrete variables, such as economic status or sex (Kaijser & Kronsell, 2014; Bunce & Ford, 2015). As the understanding of climate change vulnerability evolves, there is increasing evidence that the characterization of vulnerability to the health impacts of climate change must include considerations of how multiple existing inequities can interact, shaping and compounding experiences and responses to climate change (Gamble et al., 2016). Employing an intersectional lens can contribute to this analysis and enhance understanding of climate change vulnerability.

Intersectionality is understood as the complex and interdependent interaction between various individual identity factors (e.g., sex, gender, age, language, ability) (Figure 9.3), social norms and cultural practices, institutional processes and systems of power and oppression (Dhamoon & Hankivsky, 2011; Kaijser & Kronsell, 2014; Hankivsky & Mussell, 2018). It can help to understand and identify existing power dynamics in society (Kaijser & Kronsell, 2014) and “encourages a contextual analysis that probes beneath single identities, experiences and social locations to consider a range of axes of difference to better understand any situation of disadvantage” (Dhamoon & Hankivsky, 2011, p.38). The relevance of applying an intersectional approach to public health action to improve health equity has been established, although practical uptake appears low in Canada (NCCDH & NCCHPP, 2016).

Applying an intersectional approach to V&As, and to other climate change and health activities, can enhance understanding of the patterns of power, social conditions, and individual characteristics that contribute to health inequities and influence climate change vulnerability. Broadening this perspective of vulnerability also helps inform effective responses to climate change that can simultaneously address underlying drivers of inequity and broader social issues (Buse & Patrick, 2020). The application of intersectionality frameworks and the demonstrated effectiveness of practical application in the context of climate change has been limited. Nonetheless, tools informed by an intersectional approach, meant to be applied to policy, research, and programs across all sectors, are emerging in Canada (Box 9.2). An exploration of tools and resources that can enhance integration of health equity considerations into assessments of climate change and health vulnerability, and application of an intersectional approach, is provided in section 9.4.5 Integrating Health Equity into Climate Change and Health Actions.

As previously discussed, upstream drivers of health inequities, including social, cultural, economic, and political structures, as well as structural racism, ongoing colonialism, and climate change, result in the unequal distribution of power and resources. This influences the conditions in which individuals live and work, shaping determinants of health and giving rise to health inequities. Increasingly, determinants of health are recognized as major drivers of climate change vulnerability (Watts et al., 2015; Gamble et al., 2016; Commission of the Pan American Health Organization on Equity and Health Inequities in the Americas, 2019). The determinants of health related to climate change can be grouped into six broad categories (Table 9.1). While not an exhaustive list, these determinants are commonly found in the climate change and public health literature. Although typically discussed as discrete factors, determinants of health interact with and influence each other. For example, income can determine the status of many other determinants of health, including stable and safe housing and economic access to nutritious food (Mikkonen & Raphael, 2010; CIHI, 2018). 

At an individual level, vulnerability to health risks related to climate change likely increases as the number of determinants of poor health (e.g., low income, poor housing quality, food insecurity) increases. Importantly, individuals and populations that experience health inequities and determinants of poor health are not homogeneous, and much variation exists in terms of the experience of health impacts and degree of vulnerability, across and among population groups (see Box 9.3). These combinations vary for each individual and for each specific health risk. Improving determinants of health and redressing health inequities can, therefore, aid in reducing vulnerability to the health impacts of climate change. A selection of key determinants of health are analyzed below, establishing the linkages to climate change vulnerability.

9.4.3.1 Natural and Built Environments

Human health depends on conditions constructed within social systems, but also the natural environment and ecosystems (Hancock, 2015). The state of ecosystems we live within, and their ability to provide the ecosystem services upon which we rely — known as the ecological determinants of health — are fundamental to human health. Changes in the environment that compromise the ability of ecosystems to function optimally and provide important life-sustaining resources and supplies (e.g., food, water, and oxygen) — for example, those associated with climate change — can negatively affect human health and well-being (CPHA, 2015). Recognizing the important interactions between ecological determinants of health and social determinants of health, the Canadian Public Health Association (CPHA) suggested that an eco-social approach in population health promotion is needed. Such an approach provides health and other co-benefits of a more just and sustainable society (CPHA, 2015).

The design and condition of the built environment is a significant determinant of health and encapsulates the external built environment where individuals live, work, play, and study. This includes roads, public transit systems, buildings, parks, and other infrastructure (MOHLTC, 2012; PHAC, 2017). Working conditions may be a source of physical risks and psychosocial stress, both of which have implications for health and well-being (Mikkonen & Raphael, 2010). Certain occupations can increase exposure to natural hazards that are worsened by climate change. For example, outdoor workers (e.g., agriculture, landscape, and construction workers) may be at increased risk to the health impacts of extreme heat, while emergency responders have increased exposure to extreme weather events such as wildfires, flooding, and hurricanes (Berry et al., 2014a; Gamble et al., 2016).

Safe, adequate housing, and well-planned neighbourhoods and cities can promote healthy behaviours and contribute to positive health outcomes (Mikkonen & Raphael, 2010), even as the climate warms. Communities with aging infrastructure may have more difficulty coping with climate impacts; for example, aging water and sewage infrastructure may contribute to increased risk of flooding and water contamination (Rudolph et al., 2018). In contrast, robust and durable housing may reduce exposure to extreme weather events.

9.4.3.2 Economic Stability

Economic stability and, specifically, income and income distribution have been identified as among the most influential determinants of health (Commission of the Pan American Health Organization on Equity and Health Inequities in the Americas, 2019). Economic stability has close linkages with, and operates alongside, other determinants of health (CIHI, 2018). Income can determine the quality of other determinants of health, shaping an individual’s overall living conditions (Mikkonen & Raphael, 2010; CIHI, 2018). For example, steady and adequate income can ensure stable and safe housing and access to food, which have important influences on human health.

In Canada, on average, low-income individuals experience higher rates of chronic disease, heart attack, stroke, self-injury, and perceived poorer physical and mental health (CIHI, 2018). Low-income individuals and families may face increased challenges with accessing health care services, for example, prohibitive transportation costs, prohibitive costs of medication or medical treatments, and an inability to take time off work to go to appointments (CMA, n.d.). Inability to pay for out-of-pocket fees associated with health care can be a major barrier to accessing health care services (Whitehead & Dahlgren, 2007). The bottom 33% of Canadians, in terms of income earned, are 50% less likely to see a specialist when necessary, 50% more likely to have difficulty accessing health care services on weekends or evenings, and 40% more likely to wait five or more days to see a physician (Mikkonen & Raphael, 2010). Evidence suggests that quality of care is also lower for those with low socio-economic status, and discrimination by health care workers associated with low socio-economic status has been recorded (CIHI, 2018).

Low-income status is commonly associated with material and social deprivation (Mikkonen & Raphael, 2010). This is especially important in the context of climate change. Evidence suggests that those with fewer resources are less able to protect themselves and adapt to climate change (WHO, 2003; IPCC, 2014; Gamble et al., 2016; Friel, 2019). The impacts of climate-driven natural hazards can trigger household financial distress (Bank of Canada, 2021) and push people into poverty (Hallegatte et al., 2016). It was estimated that, in the absence of natural disasters for the year 2018, 26 million fewer people would have been in extreme poverty (World Bank, 2017). Globally, it is estimated that between 3 million and 16 million people could be forced into extreme poverty, primarily through climate change impacts on agriculture and food prices (Hallegatte, 2016; Hallegatte & Rozenberg, 2017).

9.4.3.3 Health Care Services and Accessibility

Accessibility, acceptability, and availability of health care are also important determinants of health. Access to health care varies across the population as a result of various socio-economic, geographic, and cultural factors (WHO, 2008). In Canada, geographic access to health care facilities and services differs across regions. For example, those living in rural and remote areas may have difficulty accessing health care due to geographic remoteness, long travel distances to facilities, long wait times, and limited access to specialty and emergency services (CIHI, 2018).

Individuals and populations that experience discrimination and stigmatization often face difficulties obtaining resources necessary for good health and encounter barriers accessing health services (PHAC, 2019). Discrimination based on race, religion, ethnic origin, gender, or sexual orientation is common, with over one in four people in Canada reportedly experiencing at least one form of discrimination in their lifetime (Godley, 2018; PHAC, 2019). 2SLGBTQQIA+, African, Caribbean, and Black people, as well as Indigenous Peoples, were more likely to report being unfairly treated while accessing health services than the general population in Canada (PHAC, 2019).

As noted above, cultural acceptability of health care can also present challenges to accessibility. Language barriers and cultural practices may create challenges for some, such as newcomers to Canada and Indigenous Peoples, in accessing and accepting health care (Whitehead & Dahlgren, 2007). First Nations, Inuit, and Métis peoples across Canada experience inequitable access to health care, which contributes to the reinforcement of existing health disparities. For many rural and remote Indigenous communities, accessing health care involves travelling long distances, and extended periods of separation from family and social networks, which can lead to emotional stress and discourage Indigenous Peoples from seeking care (NCCIH, 2019). Experiences of anti-Indigenous racism and discrimination also represent a significant barrier to health care, leading to unsafe care, mistrust, and ultimately poorer health outcomes (Goodman, 2017; NCCIH, 2019).

Access to health care can also be more challenging for those with disabilities. A study of Canadian women with disabilities found multiple barriers to accessing health care services, including negative attitudes and discriminatory practices from some health care providers (Gibson & Mykitiuk, 2012). Timely access to quality health care services can play an important role in reducing morbidity and mortality associated with climate-related health risks.

Climate change impacts on health systems in Canada are already being observed (see Chapter 10: Adaptation and Health System Resilience). For example, melting permafrost in the North can damage health and transportation infrastructure important for supply routes and access to health services (Séguin, 2008). Given that First Nations, Inuit, and Métis peoples face unique challenges in accessing health care services, climate change impacts on health systems are of particular concern (see Chapter 2: Climate Change and Indigenous Peoples’ Health in Canada).

9.4.3.4 Social and Community Context

Social exclusion refers to individuals and groups that are excluded from fully participating in society. This commonly arises from the marginalization of populations, such as racialized groups, to effectively limit access to economic, social, and cultural resources (Mikkonen & Raphael, 2010; PHAC, 2019). People who experience social exclusion are more likely to be unemployed and low-income, have difficulty accessing health care services, and have limited opportunities to advance their education (Mikkonen & Raphael, 2010).

At an individual level, social support networks, that is, strong relationships with and support from family, friends, and the community, have been associated with positive health outcomes (PHAC, 2008). The broader social environment context can also influence human health. A supportive society, which includes social stability, recognition of diversity, safety, good working relationships, and cohesive communities, can aid in reducing potential risks and adverse impacts on health (MOHLTC, 2012), including mental health (see Chapter 4 Mental Health and Well-Being). Such networks can be very important for coping with and adapting to climate change impacts. For example, while Indigenous communities in the North are disproportionately impacted by climate change, strong social capital has contributed to adaptive capacity and climate change resilience (Ratelle & Paquette, 2019). Actions such as cutting wood for Elders and sharing meat from hunting with community members strengthen social capital (Ratelle & Paquette, 2019) and contribute to positive health outcomes.

9.4.3.5 Education and Childhood Development

Education is an important determinant of health and can increase opportunities for employment and income security (PHAC, 2008; MOHLTC, 2012), thus influencing other important determinants of health (CIHI, 2008; WHO, 2008; Mikkonen & Raphael, 2010). Lower levels of education are associated with difficulty accessing health care services, decreased ability to interpret and understand health messaging and labels, greater use of emergency care, and unhealthy behaviours, such as smoking (CIHI, 2018).

Evidence suggests that early childhood development and experiences have significant biological, psychological, and social effects on health; the quality of early childhood development is strongly associated with social and economic gradients of advantage and disadvantage (PHAC, 2008; Mikkonen & Raphael, 2010; MOHLTC, 2012; Bennett & Friel, 2014). Existing inequities in child health outcomes can be exacerbated by climate change, which can limit adaptive capacity. For example, the ability of families to safely relocate when necessary, protect themselves from climate-related health risks, and recover from climate change impacts is enhanced as resources, power, and socio-economic status increase (Bennett & Friel, 2014).

Direct and indirect effects of climate change can affect the health of children (Helldén et al., 2021). For example, a study conducted in Southwestern Ontario found an association between extreme heat and increased emergency department visits among children (Wilk et al., 2020). Climate change impacts can also affect maternal, fetal, and infant health (Kuehn & McCormick, 2017; Bekkar et al., 2020). Canadian research has identified a positive association between heat exposure and gestational diabetes, sudden infant death syndrome, placental abruption, and early delivery (Auger et al., 2014; Auger et al., 2015; Booth et al., 2017; He et al., 2018). Existing inequities, variation in geographic region, and broader socio-economic conditions influence the impact of climate change on the health of children (Helldén et al., 2021).

Health authorities across Canada and the world are increasingly using V&As as a tool to help individuals, communities, and health systems prepare for climate change (Berry et al., 2018). In Canada, 35% of public health authorities already have, or are in the process of conducting, a V&A (University of Waterloo Research Centre, 2019). They can be conducted at the local, regional, or national levels.

The primary objectives of a V&A are to understand the association between climate and health outcomes, identify current and future impacts on health, understand current conditions of vulnerability to climate-related health impacts, explore adaptation options that effectively reduce the current and future adverse health implications of climate change, and contribute to capacity-building within health organizations to respond to climate change (WHO, 2013; Ebi et al., 2016; Berry et al., 2018).

Results of V&As, supported by findings from academic literature, help public health authorities identify individuals and communities that experience disproportionate impacts on health associated with specific, discrete, individual and contextual characteristics (e.g., sex, gender, age, geographic isolation, low income) (Benmarhnia et al., 2017; Buse, 2018). When a health equity lens is applied in V&As, they can elucidate conditions that contribute to vulnerability specific to the geographic region assessed and determine how existing health inequities may be exacerbated with climate change. In the public health field, understanding which individuals and groups may face disproportionate impacts from climate change can be useful for prioritizing health adaptation measures and resources (Benmarhnia et al., 2017; Berry et al., 2018). Additionally, identifying existing health inequities and other local conditions that drive vulnerability in a V&A can promote the allocation of resources to address upstream drivers of negative health outcomes to strengthen health equity in a community (Buse, 2018).

According to a survey of Ontario health units in 2016, only 42% of respondents applied a health equity lens when identifying, prioritizing, and addressing climate change and health risks in their region (Doyle, 2017). Results of a 2019 survey of Canadian health units indicate that 85.1% of respondents consider implications for populations deemed to be at higher risk of climate change impacts in their climate change and health adaptation actions; however, only 37.3% consider implications for Indigenous Peoples, and 17.9% consider sex- and gender-based implications (University of Waterloo Survey Research Centre, 2019).

An intersectional approach can provide information on interacting variables, at an individual and structural level, that shape individual lives and health status (Dhamoon & Hankivsky, 2011) and that influence health inequities. When applied to a V&A process, this can be helpful in identifying which populations may be at higher risk of health impacts related to climate change. New V&A guidance from WHO (WHO, 2021) and from Health Canada (Health Canada, 2022) includes explicit consideration of health equity. Existing tools may complement V&A activities and adaptation actions. For example, the Ontario Ministry of Health and Long-Term Care’s Health Equity Impact Assessment (HEIA) tool can be used to identify unintended — negative or positive — health impacts of a planned policy, program, or initiative on marginalized populations (MOHLTC, 2012). The HEIA workbook and templates allow users to identify unintended health impacts and develop recommendations for adjustments to mitigate adverse effects and maximize positive impacts among marginalized populations. They can also be used to increase the capacity of organizations to integrate health equity into decision making models and service design and delivery (MOHLTC, 2012). While the HEIA tool does not explicitly include climate change, the tool could be useful in assessing the outcomes of climate change and health adaptation measures and policies, as part of a V&A process.

Climate change and health is an area of increasing interest and work for local and regional public health units (see Chapter 10: Adaptation and Health System Resilience). While the concept and promotion of health equity is not new for public health actors, challenges remain about how to most effectively integrate this into climate change and health activities. Building on the four primary roles identified in the Public Health Roles for Health Equity Action Framework (Region of Waterloo Public Health, 2009; NCCDH, 2013), Table 9.2 identifies a range of public health actions to address climate change and improve health equity. These actions should be accompanied by a recognition and understanding of how historic and ongoing colonialism and racism are central to the creation of inequities.

For many local and regional health units, conducting a V&A is often the first step to protecting their communities from health impacts and adapting to future climate change. Such units can conduct practical activities and exercises to better understand the social context of their respective jurisdiction and identify drivers of climate change and health vulnerability. They can make the V&A more robust and support the development of tailored adaptation options for populations at higher risk of impacts. Examples of activities, described below, include resilience and asset mapping, vulnerability mapping, climate change and health projections, inclusive public engagement, and communications.

9.4.5.1 Resilience and Asset Mapping

Communities have many existing resources that play an important role in building climate resilience (e.g., social networks and cohesion). However, such assets and resources can be difficult to identify in common sources of data. Community surveys and community-based participatory asset mapping are exercises and tools that can identify people, organizations, spaces, and other “intangible factors” that contribute to community resilience (Rudolph et al., 2018; UCLA, n.d.). Such information is valuable for informing V&As and developing adaptive responses (Buse & Patrick, 2020).

Local initiatives that build an assets-based approach to mapping resilience to climate change and other hazards at the community level are increasing in Canada; many of these follow guidance outlined by Colussi (2000). For example, the Building Resilient Neighbourhoods (BRN) project (BRN, n.d.) has run applied projects across the Capital Regional District of British Columbia, in which local community members participate in assessing the resilience of their own neighbourhood to various shocks. The BRN project supplies a suite of online resources to support communities in undertaking such an assessment, including checklists for resilient neighbourhoods, workshop planning materials, and associated tools (e.g., scenario planning, asset mapping, resilience assessment). The BRN initiatives guide communities through exercises that consider a range of issues often overlooked in traditional planning, such as consideration for determinants of health and well-being (Wipond et al., 2017).

The City of Vancouver’s Resilient Neighbourhood Toolkit is employed in a similar initiative and includes a series of modules for neighbourhood climate resilience assessment activities, including asset mapping and development of resilience action plans (City of Vancouver, n.d.). These activities provide opportunities to strengthen relationships among people in different neighbourhoods and increase understanding of where risks may exist that would affect certain households or streets. They also examine the community’s capacity to plan and respond to climate change impacts. Another innovative example includes a role-playing game called Resilientville Canada (CREW, n.d.), in which players take on the role of a community stakeholder facing a scenario of either a flood, windstorm, or earthquake. The game gets players to think about their social relationships within a neighbourhood and what assets will assist them in strengthening their ability to respond to climate-related shocks or stresses.

These examples of resilience and asset mapping focus more broadly on understanding the assets available in communities that contribute to, and enhance resilience to, a broad range of shocks and stressors, including extreme weather events and climate change impacts. Assets that contribute to resilience in the health sector and mitigate human health impacts are generally included in these exercises. While these activities can be modified to focus specifically on health system resilience, there is also benefit in focusing on resilience-building activities and asset mapping from a broader perspective. This facilitates multisectoral collaboration on climate change activities that include appropriate linkages to human health and the health system.

9.4.5.2 Vulnerability Mapping

Vulnerability mapping provides information on patterns of social conditions and climate change vulnerability in a particular region (Gamble et al., 2016; Foster et al., 2019), and can inform V&As. Mapping can be accomplished, for example, by developing a social vulnerability index, which uses social vulnerability indicators (e.g., socio-economic status, housing tenure, education, age, race, access to medical services, etc.) to elucidate the social conditions that drive vulnerability to health impacts or hazards related to climate change (Rudolph et al., 2018; Foster et al., 2019). Commonly, social vulnerability maps are combined with maps that display exposure to biophysical hazards related to climate change (e.g., wildfires, flooding, sea level rise, urban heat islands). The resulting maps aid in understanding the intersection of social and biophysical vulnerabilities and in identifying neighbourhoods and regions that experience disproportionate risk. Vulnerability maps can inform the V&A process by identifying populations and neighbourhoods that may be disproportionately affected by climate change hazards, such as extreme heat events or flooding, and help inform public health interventions (Rinner et al., 2010; Gamble et al., 2016; Foster et al., 2019).

Developing vulnerability indexes and frameworks are typically the first step in developing vulnerability maps. There are a variety of approaches to developing vulnerability indicators and indexes related to climate change impacts, and various Canadian examples exist (Rinner et al., 2010; Chakraborty et al., 2020; Yu et al., 2021). Raval et al. (2019) conducted a review of more than 40 existing climate change vulnerability frameworks that analyze community vulnerability to climate impacts in California. The review found a lack of frameworks that adequately reflect the intersectional nature of climate vulnerability. Four frameworks were highlighted in the report, recognized for excelling in their ability to comprehensively integrate multiple exposures, population sensitivity, and adaptive capacity, as well as their breadth in terms of the number of indicators incorporated across exposures and other vulnerability factors and in terms of taking data accessibility into account (Raval et al., 2019). These frameworks included:

• Public Health Alliance of Southern California’s California Healthy Places Index (PHASC, 2018)
• California Department of Public Health’s California Building Resilience Against Climate Effects: Climate Change and Health Vulnerability Indicators (CalBRACE, 2018)
• California Energy Commission’s Social Vulnerability to Climate Change (Mazur et al., 2010)
• Climate Change Vulnerability Screening Index (English et al., 2013)

These frameworks and indexes may be adapted by public health authorities to increase understanding of characteristics and conditions in their regions that may increase or decrease vulnerability to various climate change health risks. Such knowledge can be used to inform and enhance V&As.

Tools based on geographic information systems (GIS) and vulnerability mapping exercises can also be helpful in developing and implementing adaptation measures. For example, urban forests provide a number of environmental, social, and economic benefits that support health equity, including mitigating air pollution; mitigating urban heat island effects; contributing to the management of surface water quantity and quality; maintaining and enhancing natural heritage; enhancing economic value; providing direct cost savings; supporting improved physical health and emotional well-being; and strengthening communities and enhancing social equity (Morrison, 2017). Recognizing these benefits, the Region of Peel, Ontario, developed the Peel Tree Planting Prioritization Tool, which aids decision makers in determining where tree planting is most beneficial to the community (Richardson, n.d.). Accounting for 12 target benefits, which include supporting improved physical health and emotional well-being, strengthening communities, and enhancing social equity, the GIS-based tool generates maps at various geographic scales that identify areas in Peel Region for tree planting where benefits will be maximized (Richardson, n.d.).

9.4.5.3 Climate Change and Health Projections

Climate change projections can provide useful information on how mortality, morbidity, and/or other health outcomes related to climate warming may change in the future. This information can help inform adaptation and response plans and aid policy makers in understanding long-term impacts of climate change and needed resources (Sellers & Ebi, 2017; Rudolph et al., 2018).

Changes in demographic and socio-economic conditions, urbanization, land use, investments in new technologies, governance, the extent to which equity issues are addressed, and other factors can influence vulnerability to future health impacts of climate change (Ebi et al., 2016). For example, knowledge of how populations exposed to various climate hazards may change (e.g., aging, health status, migration) can assist decision makers to plan adaptation measures to protect populations from health risks (Rudolph et al., 2018). Further, considering how health care service and delivery is expected to evolve over the coming decades and how they may need to be altered to adapt to climate change is important for health sector decision makers to include in iterative planning processes to plan for climate change (Sellers & Ebi, 2017).

9.4.5.4 Inclusive Community Engagement

Health equity cannot be realized without transparent and accountable inclusion and meaningful engagement that provides individuals and groups with agency to represent their interests and experiences (USDN, 2017; Rudolph et al., 2018; Friel, 2019). An effective way of including diverse groups and perspectives is through broad community engagement when undertaking a V&A. Residents and community-based organizations (CBOs) can provide valuable information related to the history and social context of a neighbourhood, past experiences with climate events, existing assets and resources that contribute to adaptive capacity, and the success and/or challenges of previous public health adaptations (Rudolph et al., 2018). Community residents, particularly through CBOs, can provide assistance with data collection and support communication and outreach activities with individuals and populations in their respective networks (USDN, 2017). There are a number of public engagement strategies and frameworks, and each have their own strengths and benefits (NCCDH, 2013; Oickle, 2020). Public health authorities may establish various engagement strategies throughout a V&A process, choosing specific activities that align with the objectives of each step in the process.

Adaptation actions should provide benefits to those most in need; however, outcomes from these measures are not experienced in the same way across populations and communities. In the absence of careful planning and implementation, adaptation measures may have unintended outcomes that adversely impact some population groups or exacerbate existing inequities (Levy & Patz, 2015; Boeckmann & Zeeb, 2016). For example, while air conditioning units can be effective adaptation measures for extreme heat, prohibitive energy bills may keep some households from using air conditioning, which may increase their risk of health impacts related to heat (EPA, 2008). In addition, air conditioning can generate a significant amount of waste energy, further increasing outdoor air temperatures (Salamanca et al., 2014), exacerbating the urban heat island effect, and increasing cooling demands, which can increase heat-related health risks for those who do not have access to air conditioners.

Increasing green spaces in an urban centre can reduce health risks associated with urban heat islands and has a number of associated health co-benefits (Friel, 2019; Health Canada, 2020). However, an increase in green spaces could also result in unintended consequences. For example, new green spaces could perpetuate gentrification and increase property values in the neighbourhood, which may lead to the displacement of low-income residents and small local businesses (USDN, 2017; Kreslake, 2019; Cleveland et al., 2020). A literature review on the creation of green spaces in urban centres concluded that these spaces generally benefited communities that are predominantly high-income and White (Wolch et al., 2014). To address these concerns, adaptation plans may involve instituting rent-control policies and other strategies to maintain housing affordability when creating green spaces (USDN, 2017).

When adaptation programs are put in place, individuals and population groups may face barriers to accessing and using the measures effectively. In efforts to reduce risks from extreme heat, cooling centres are often established for residents to get relief. However, an individual who has challenges with mobility (e.g., due to low income, disability, and/or social isolation) may have difficulty gaining access to a centre unless appropriate supportive measures are put in place (Health Canada, 2012). The City of Greater Sudbury partnered with Greater Sudbury Transit to make all transit trips free of charge during extreme heat events to ensure equitable access to cooling centres (Evergreen, 2020). Such considerations are needed to ensure that adaptation measures can be accessed and used by all, particularly those who face disproportionate risk of health impacts related to climate change. Considerations of equity should guide intervention strategies, and strategies will be most effective when they are developed in partnership with the community and decision makers from across a variety of sectors.

Public health officials can leverage adaptation actions and climate change resilience-building efforts to improve health equity and strengthen determinants of health (Boeckmann & Zeeb, 2014; Gould & Rudolph, 2015; Deas et al., 2017; Rudolph et al., 2018). This is important given that, in Canada, some health disparities continue to increase (PHAC, 2018), as does income inequality, particularly in urban centres (Hankivsky, 2014; CPA, 2017).

An example of a collaborative project for climate change adaptation that simultaneously strengthened determinants of health is the InosiKatigeKagiamik Illumi: Healthy Homes in Nunatsiavut initiative in Nain, Nunatsiavut, Newfoundland and Labrador. It is estimated that 38% of children in Nunatsiavut live in a home that is in need of major repairs, and 86% of homes show signs of damage from permafrost melt and ground subsidence (ISC, 2019). Homelessness, overcrowding, and difficulties with keeping homes warm due to poor quality of structures and/or a lack of economic resources for heating needs were identified as undermining health and well-being in the community (Bennett, 2015). Additionally, a lack of land suitable for building, the high cost of development, and a frequent need to repair or replace existing homes created a number of difficulties meeting housing needs in rapidly expanding communities. The aim of the project was to develop climate-resilient housing infrastructure that was also culturally relevant, affordable, energy efficient, and reduced the health impacts from overcrowded dwellings and mould. Upon a thorough assessment of existing homes in Nain and the surrounding region, residents were engaged in a community-driven process for housing design in which they shared existing housing challenges and design preferences, which allowed for important cultural values to inform the design of a prototype multi-unit, climate-adapted housing development (ISC, 2019). Space to store hunting equipment, a large steel sink for cleaning fish and preparing sealskins, and large open-concept living spaces to allow for gathering were all features proposed by residents that were incorporated into the final design (Bennett, 2015).

Another example is the Nunamin Illihakvia Learning from the Land (phase 1) and TUMIVUT: Tracks of Our Ancestors Towards a Healthy Future (phase 2) project implemented in Ulukhaktok, Inuvialuit Settlement Region, Northwest Territories. This two-phase project focused on strengthening community health and food security through increased transmission of Inuit traditional knowledge and promotion of the Inuinnaqtun language (ISC, 2019). The program brought together Inuit youth, experienced hunters and sewers, and Elders; through a series of activities, knowledge was shared and skills were built around caribou hunting, traditional sewing skills, and language. These skill sets and values are important to Inuit in Ulukhaktok, contributing to a healthy lifestyle, physically, mentally, and culturally (ISC, 2019). Many benefits were observed as a result of the program. Inuit youth gained practical skills that have economic and social value, which was particularly beneficial for those who did not have family members who could teach them these traditional skills, or who lacked equipment or economic resources to participate in such activities. Participants also noted an increased sense of well-being, reduced stress, and strengthened cultural identity (ISC, 2019). The project supported values and skills that are important for individual and community health, while also strengthening determinants of health (e.g., food security) and building capacity to adapt to increasing climate and societal change.

BlueLA Carshare program is an example of an initiative that combines climate change action with health-equity objectives. To reduce air pollution and mitigate GHG emissions associated with personal vehicles, the City of Los Angeles, California, collaborated with partners to develop an electric vehicle (EV) carsharing pilot project — BlueLA — which was funded through a grant from the California Air Resources Board. Launched in 2018, BlueLA prioritized service to disadvantaged communities, accounting for low-income residents in areas with high exposure to air pollution to redress existing health and social inequities. Carshare memberships were provided to low-income residents at a discounted cost. The EV fleet simultaneously reduced local air pollution from gas-fuelled vehicles and mitigated GHG emissions (SUMC, 2019a).

In the first year of the project, 80 EVs were introduced to the community, 130 charging points and 26 charging stations were installed, nearly 2000 residents registered as BlueLA members, and more than 12,000 trips were made. Approximately 260 t of CO₂ were avoided as a result (SUMC, 2019b). Given the success of the program, BlueLA was awarded a grant of $3 million dollars from California Air Resources Board to initiate phase 2, which will involve scaling up the project to expand into three additional regions: South Los Angeles, East Los Angeles, and East Hollywood (SUMC, 2019b).

Adaptation measures that result in equitable outcomes emerge from equitable adaptation processes. Ensuring equitable participation and the inclusion of diverse voices at all stages of the adaptation process results in better planning and policy making (Race Forward, 2018). While common engagement practices and strategies involve many community members, important voices may be missed. Deliberate efforts must be made to ensure participation by those who are most at risk of health impacts related to climate change. Meaningful engagement can provide valuable information concerning the unique context and social conditions of the target community, including current power dynamics and existing inequities. This information is required to develop transformative, effective, and equitable adaptation measures that reflect the expertise and perspectives of those most affected (Drolet & Sampson, 2017; Schlosberg et al., 2017; Race Forward, 2018).

There are significant challenges with meaningful public engagement in the adaptation process. For example, engagement opportunities may be reactive and conducted only after a planning process has been initiated and/or after major decisions have already been made. Budget and timeline constraints can also limit the effectiveness of engagement processes (USDN, 2017; Foster et al., 2019; Evergreen, 2020). Decision makers can ensure more comprehensive participation by ensuring that an appropriate timeline and budget for engagement is included in the plan from the outset, engaging community members from the beginning of the development and design process, and incorporating input from community members into the adaptation strategy to more effectively reflect the needs and unique vulnerabilities of the community (Foster et al., 2019). This would ensure that interventions address the specific conditions, health risks, and challenges in the community (Ebi, 2009). Other benefits of broad community engagement include increased “buy-in” of the final adaptation actions, enhanced reach of information dissemination activities, and greater capacity to participate in future decision making and planning activities in neighbourhoods (USDN, 2017).

In Canada, there are examples of effective, broad community and stakeholder engagement during adaptation design processes. For example, as part of Middlesex-London Health Unit’s V&A process, a workshop was conducted with more than 100 people from various community groups, government agencies, and the health sector. In addition to validating preliminary findings from the vulnerability assessment, participants were also provided the opportunity to discuss concerns about climate change impacts on health already observed in the community, and identify collaborative efforts needed for effective adaptation. Additionally, workshop participants provided their views on (Berry et al., 2014b):

• options for reducing current and future risks to health through adaptation;
• challenges for current and future adaptation efforts to protect health;
• willingness of organizations to participate in strategies for climate change and health adaptation; and
• effective avenues for communicating the results of the V&A.

Perceptions of needed or appropriate climate interventions may differ between the public and decision makers. For example, Schlosberg et al. (2017) reviewed local council climate adaptation plans in Australia and compared them to concerns related to climate change and proposed adaptation efforts posted on local environmental groups’ websites and social media accounts. The analysis found that there was often little correlation between the climate adaptation plans and the concerns expressed by public and environmental groups regarding impacts and their suggested adaptation measures. Local government plans largely followed a risk- or resilience-based approach, while public interest groups were much more focused on climate change impacts on “basic needs and capabilities of everyday life” (e.g., health, food security, housing, etc.), which are required to achieve social justice (Nussbaum, 2011; Schlosberg et al., 2017) and support health equity. Participatory and community engagement approaches are an opportunity to reduce this disconnect between decision makers and public needs and perceptions, and thereby develop effective adaptations that support health equity.

A 2018 U.S. study highlighted the importance of engaging with and understanding the views and perceptions of community members to support the development of climate change measures (Kreslake, 2019). To gain insight into the perceived importance of adaptation and GHG mitigation measures, residents from three regions in the United States (Southern California, Florida, and Arizona) recently affected by extreme weather events were surveyed. Participants were categorized using individual-level indicators of vulnerability to the health impacts of climate change. The study revealed that perceptions varied across population groups, with differences in the types of adaptation and GHG mitigation interventions considered most important. For example, there was greater perceived importance of enhanced emergency alert systems among individuals with chronic illness (Kreslake, 2019). In addition, racialized groups prioritized communication activities from local government regarding climate change impacts and GHG mitigation efforts. Low-income residents were among those who indicated the greatest support for actions that would strengthen social services during extreme weather events (Kreslake, 2019).

The differences in perceptions across these groups illustrate the important role public engagement can play in developing climate change and health actions. Working with community members and stakeholders ensures that adaptation interventions reach those who are disproportionately affected, provide information in an accessible way, and motivate and empower individuals to make appropriate choices (Ebi & Semenza, 2008). Participatory approaches to developing adaptation measures can create the space and opportunity for front-line and disadvantaged communities to actively participate in decision making processes that result in policies and programs that will directly affect their lives (Ebi & Semenza, 2008; MSC, 2015; USDN, 2017, The Greenlining Institute, 2019).

Engaging with community members who are at higher risk of climate change impacts on health can also enhance existing strategies for climate change adaptation. In a project to better address equity in its climate change adaptation work, the City of Vancouver partnered with a non-profit organization, Evergreen, to conduct engagement activities among populations whose “voices are not often heard in public decision making on climate change” (FCM, 2021). In total, more than 500 community members participated in the engagement process, and 21 key stakeholders from community service organizations were interviewed. Engagement activities were tailored to meet specific socio-cultural needs and interests of particular population groups (e.g., activities were offered in five different languages), designed to reflect the populations’ interests and activities (e.g., a senior walking group was engaged in an urban forest walk, where their observations of climate change and coping behaviours during extreme heat were collected) and held at familiar, safe locations (Evergreen, 2020; FCM, 2021). By sharing their lived experiences, community members provided significant information on the current climate change and health challenges they face, specifically in relation to extreme heat and air quality. Feedback on the effectiveness of existing adaptation measures and strategies was collected, along with particular needs related to cooling centres, climate change education and awareness, transportation, and access to water. As a result, recommendations for enhanced and additional adaptation measures were developed, and will be incorporated into the city’s adaptation strategy (Evergreen, 2020).

A number of frameworks provide guidance and promising practices for inclusive and equitable community engagement for planning for climate change resilience and adaptation, including:

• Community-Based Adaptation to Climate-Related Health Impacts Framework (Ebi & Semenza, 2008)
• Making Equity Real in Climate Adaptation and Community Resilience Policies and Programs: A Guidebook (The Greenlining Institute, 2019)
• Equitable, Community-Driven Climate Preparedness Planning Framework (USDN, 2017)
• Community-Driven Climate Resilience Planning Framework (Movement Strategy Centre, 2015)
• Working Better Together: Collaborating with Inuit on Climate Actions in Inuit Nunangat: A Framework for Governmental and Non-Governmental Bodies (ITK, 2019)

To appropriately increase the representation and participation of groups that have often been excluded from developing and shaping climate change and health adaptation measures, it is important for decision making organizations and actors to recognize, acknowledge, and remove barriers to participation (such as financial burdens, travel requirements, language, child care, etc.), as well as to demonstrate sensitivity to the context in which engagement is taking place (Dhamoon & Hankivsky, 2011). Prioritizing time and resources to invest in relationship-building and cultivating trust is key to this process, as is creating spaces and engagement processes that are culturally relevant, inclusive, and safe for marginalized populations.

Key considerations and actions that can guide decision makers as they seek to address climate change and health risks through community engagement and community-based approaches include the following:

• Engage communities and residents at the beginning of and throughout the process of climate change assessment and adaptation (Moser et al., 2017).
• Recognize the power dynamics between decision-making actors and community members, specifically with groups that experience discrimination (Dhamoon & Hankivsky, 2011; Hankivsky, 2014).
• Address and replace patterns of behaviours that perpetuate inequities, for example, dominance of Western science versus Indigenous knowledge(s) and uneven patterns of participation in decision-making processes.
• Work with the community to identify current priorities, concerns, challenges, and existing inequities (Dhamoon & Hankivsky, 2011).
• Identify the level of literacy about climate change and health in the community, and tailor engagement activities appropriately.
• Acknowledge communities and marginalized members as active agents of change and determine community strengths and assets — avoiding victimization narratives.
• Listen to community members and incorporate their local knowledge and assets.
• Meet partners where they are and where they are coming from (Shi et al., 2016; Moser et al., 2017); for example, conduct engagement activities and speak with residents where they are most comfortable, such as traditional community gathering places.

Recognizing the importance of community input into the development of climate change action plans and adaptation strategies, local and regional decision makers are developing innovative, community-based approaches to collect input. In 2012, the City of Portland, Oregon, began the process of updating its climate action plan. Aware that considerations for social equity were absent in prior climate change strategies, the City administration took intentional action to integrate equity in every stage of the process and ensured that the plan featured an equity lens (Williams-Rajee & Evans, 2016). An Equity Working Group was created, made up of six CBOs that represented low-income populations and racialized communities. Funding was provided to these CBOs to support participation in the working group. The Equity Working Group collaborated with the Climate Action Plan Steering Committee to finalize an equity considerations framework, which staff used to assess every action proposed in the draft climate action plan. The Equity Working Group then reviewed the updated plan to ensure its input had been incorporated effectively. An Equity Implementation Guide was also developed by the Equity Working Group as a companion piece to the final 2015 Climate Action Plan, and the guide included an implementation approach and further recommendations for incorporating equity into climate change actions (Williams-Rajee & Evans, 2016).

The outcomes of adaptation measures are borne by individuals and organizations at the local level, which may foster the perception that adaptation actions are the sole responsibility of local decision makers (Pelling & Garschagen, 2019). However, it is important that health equity aspects of adaptation are considered at all scales of decision making, given that national, provincial, and territorial policies, standards, and regulations, such as land-use planning, building codes, taxation, financial incentives, environmental regulation, and related measures influence local conditions and livelihoods and affect many important determinants of health  (Pelling & Garschagen, 2019).

In addition to working with a broad range of community members and organizations, stakeholders in and outside of the health sector should be engaged in planning for climate change and health adaptation. Climate change impacts and conditions that affect determinants of health cross multiple sectors and do not fall neatly into defined jurisdictions and mandates, making it difficult to allocate responsibility to one particular sector (Friel, 2019). To maximize the opportunity adaptation measures offer to strengthen determinants of health and address drivers of health inequity, collaboration, across a range of disciplines (science, social sciences, humanities, etc.) and sectors is key (CSDH, 2008; Friel, 2019).

The complex interactions among determinants of health, current and projected health inequities, and climate change adaptation measures makes it challenging to assess the immediate and long-term effects of climate change interventions on human health and health equity (Boeckmann & Zeeb, 2016). Given the urgency of climate change, particularly in relation to effects on the severity and frequency of extreme weather events, decision makers must often design and implement adaptation actions in the absence of this information. Evaluating adaptation measures for their effectiveness in protecting health, including the promotion of health equity, can provide important information about their benefits and identify where modifications may be necessary.

Frameworks that specifically evaluate the impact of climate change adaptation actions on health equity are limited, and few have been evaluated or implemented in practice. Nevertheless, they may be useful in guiding public health authorities in their efforts to prepare for climate change impacts. For example, Boeckmann and Zeeb’s (2016) framework assesses the effectiveness of an adaptation measure by evaluating its effect on seven domains of health determinants (e.g., infrastructure, social, economic, community, environmental) (Figure 9.4). Indicators and guiding questions related to access to information, cultural values, health services, and civic engagement, are provided to assist users in conceptualizing the positive and negative implications of their adaptation measures.

Recognizing the difficulties associated with attributing health outcomes with specific adaptation measures in many cases, this framework highlights the linkages between adaptation and the broader social domains associated with determinants of health (Boeckmann & Zeeb, 2016). This provides a much broader conceptualization of how adaptation measures fit into various social contexts and can advance understanding of possible short- and long-term impacts of adaptation measures on health equity as well as related concepts of environmental justice. The framework indicators and guiding questions could be applied in V&As conducted by health authorities to evaluate health adaptation strategies as well as measures implemented in other sectors that may have direct and/or indirect impacts on human health. Given that a variety of actors are involved in each of the seven domains, the framework also promotes a multisectoral approach to adaptation development and evaluation. The practical use of the framework depends on the data available (Boeckmann & Zeeb, 2016); however, collaboration among practitioners, academia, and other stakeholders can facilitate acquisition of needed research and data.

As noted previously, the HEIA tool (MOHLTC, 2012), and GBA+ tool (Government of Canada, 2019b), although not designed specifically in the context of climate change, could be useful for considering health equity in climate change actions when applied to V&A processes and adaptation actions. The Equity Assessment Tool (Race Forward, 2018) can also be applied to climate change and health activities; it proved to be effective in identifying opportunities to enhance racial equity in planning and community-engagement activities in a pilot project in Seattle, Washington, based on an extreme heat scenario (Equity Matters, 2015).