Due to climate change, there is an expected increase in heatwaves in Western Europe, both in frequency and intensity. The severe heatwave that hit Europe in 2003 resulted in more than 70,000 deaths in Europe, prompting many countries to implement heatwave early warning systems with response plans. These national heatwave plans are aimed at reducing the avoidable human health consequences due to heatwaves by providing warnings as well as improving communication between relevant stakeholders. They usually feature timely, accurate warnings, tailored communications and notifications of adaptation actions to the most vulnerable populations, and heat avoidance advice to general populations.
The objective of this study* was to assess the perceptions of key stakeholders within plans in Belgium and The Netherlands of their responsibilities, the partnerships, and the effectiveness of the local implementation in Brussels and Amsterdam. Key informant interviews were held with stakeholders that had an important role in development of the heatwave plan in these countries, or its implementation in Brussels or Amsterdam.
The study found that care organisations—including hospitals and elderly care organisations—had a lack of familiarity with the national heatwave plan in both cities, and prioritised heat the lowest. Some groups of individuals, specifically socially isolated individuals, are not sufficiently addressed by the current national heatwave plans and most local plans. Stakeholders reported that responsibilities were not clearly described and that the national plan does not describe tasks on a local level. The findings of the study relevant for Brussels are provided in more detail below.
This study was originally published in the International Journal of Environmental Research and Public Health in November 2016.
*The full study can be downloaded from the right-hand column.
Materials and Methods (abridged)
Desk Evaluation of National Heatwave Plans
A desk evaluation was performed on the national heatwave plans in Belgium and The Netherlands in December 2014. We evaluated whether the plans have described (i) main collaborating partners, (ii) different levels of alert, and (iii) stakeholders and responsibilities. For the topics that were included in the plans, we described the level of detail.
Key Informant Interviews
Brussels and Amsterdam were selected as major metropoles of Belgium and The Netherlands respectively, as the effects of heatwaves are stronger here due to the urban heat island effect. In both countries representatives at the following stakeholder organisations were contacted: national institutes of public health, regional health and environment agencies, municipalities, the Red Cross, elderly and homecare organisations, hospitals, overarching childcare centre networks, and circles of general practitioners.
Key informants were identified through networks of the researchers, snowballing and internet searches. The aim was to interview stakeholders from each of three categories in each country, representing the hierarchical and communication organisation, which we defined as: (i) Activators, or those stakeholders who were (co-)responsible for developing and setting up the national heatwave plan in their country; (ii) Intermediaries, as those responsible for rolling out information from the activators to a (large) group of care providers and end users; and (iii) Care providers, those organisations or professionals directly responsible for health of risk groups with respect to heat.
An interview format was designed, containing the topics and questions for the key informant interviews (see Appendix A of the full text). In Belgium, interviews were conducted in Dutch or French, depending on the stakeholder’s language proficiency or preference, between March 2015 and May 2016.
The National Heatwave Plan
National heatwave plan for Belgium was found on the website of the national government. It was developed by the Federal Public Service for Health and Food Chain Safety and Environment (FOD), and is available in French as well as Dutch. The main collaborating partners that are described in the plan are the National Meteorological Institute (KMI), the Belgian Interregional Environment Agency (IRCELINE) and the Belgian regional governments (Flanders, Wallonia and Brussels).
The plan contains information on heat-related health effects and their treatment, risk groups and aggravating factors. Risk groups for heat that are mentioned in the plan are young children, elderly, socially isolated individuals and persons who perform heavy physical exercise. In addition, different upscaling phases are described, as well as actions that will be taken during those phases (see Table 1 of the full text).
Key Informant Interviews
Interviews with several activators of the national heatwave plan were carried out, namely the FOD public health, food safety and environment, Public Service Wallonia (PSW), and Leefmilieu Brussels (LB). Intermediary stakeholders whom we interviewed were from Red Cross Brussels (RCB) and two municipalities within the Brussels Capital Region, namely Etterbeek (MoE) and Saint-Gilles (MoS-G). A big homecare organisation in Brussels, Familiehulp, did not want to participate in an interview but answered some of our questions by email. The total number of positive responses was seven. It is noteworthy that most non-responding organisations belonged to the category of care providers (e.g., general practitioners, childcare centres).
The three care organisations that participated in our study were not familiar with the existence of the national heatwave plan, both in Brussels and Amsterdam. All other organisations were aware of the plan, although not always of the exact content.
Involvement in National Heatwave Plan Development
From the data collected, it was detected that the national heatwave plans were developed without involvement of local organisations, including government, health and social care.
Heat as a Public Health Priority
The perception that heat was a priority for public health varied significantly between stakeholders. Heatwaves were considered by some stakeholders to: be a lower priority than other public health risks, such as air pollution and infectious diseases; have a seasonal pattern of presentation and a low probability of occurrence; and that sufficient measures to cope with heatwaves were already in place.
On the other hand, reasons for placing heat as a high priority were that: measures against heat are cost-effective and require a low investment; the likelihood of more frequent and severe heatwaves will increase due to trends in climate change and urbanisation; a direct increase in mortality can be observed during heatwaves; and heatwaves are perceived as more important than other public health issues, such as ozone. Overall, care organisations did not give high priority to heat as a public health issue.
Involvement in Warning At-Risk Populations
One observation was that some of the organisations directly involved in caring for heat-risk groups (Cordaan, Familiehulp) reported few or no activities aimed at warning these groups on the risks of heat. It was also observed that, although a detailed description on all risk groups is available within national heatwave plans, some municipalities do not focus on all of them.
Success in Reaching the At-Risk Populations
Perceived reasons were varied. Some stakeholders found the plan reached the at-risk population adequately due to a high level of media attention (RIVM) and others concurred that televised information adequately reaches targeted groups (FOD, RCB). Moreover, some stakeholders received positive feedback from regional public health organisations (RIVM) and citizens (MoS-G). In contrast, others felt that there is limited awareness from informants and risk groups on the topic of heat (DRC, MoE), and that the list of stakeholders involved in the care of risk groups was incomplete (LB). Homeless people did not fall under the responsibility of the municipality and were therefore excluded in municipal actions (FOD). The effectiveness of warning at-risk populations was not evaluated, according to a stakeholder interview (MHSA).
Responsibilities Described in National Heatwave Plan
Dutch stakeholders reported overall that responsibilities were not clearly described and that the plan is non-committal. However, an updated version of the plan would be implemented in 2015, which would put more emphasis on describing tasks of different stakeholders. Similar results were found for Belgium, where most stakeholders felt that the national plan does not describe tasks on a local level.
Collaboration Between Stakeholders
We observed a clear trend in our results, suggesting that stakeholders on a higher level (i.e., activators) had a much more positive perception towards the quality of collaborations compared to intermediaries, which in turn were more positive than care organisations, the more local level of stakeholders considered in our study. This pattern was consistent across both study countries. One stakeholder pointed out that the quality of collaborations may suffer from the lack of sufficient budgets (MoE).
Strengths and Weaknesses of the National Heatwave Plan
One strength consistently reported about the Dutch National Heatwave Plan was the inclusion of a description on relevant stakeholders. Both national heatwave plans were considered to offer a good evidence base on the links between heat and health. Especially for Belgium, stakeholders felt that the description of roles and responsibilities in the plan was not optimal. All care organisations reported lack of awareness with the plan as an issue.
Low awareness of the impact of heat on health among stakeholders working in care organisations should be urgently addressed.
A detailed quantifiable survey among a large sample of representative of general practitioners should be carried out, to obtain clarity in their perception of the messages and potential barriers and should be address.
There should be more emphasis on the variety of risk groups for heat, such as socially isolated individuals, and the organisation structure responsible for their care.
More clarity should be given to the roles and responsibilities of the different stakeholders within the plans, which can be ensured by involving them in the development of updates of the plan.
Best practices and lessons learnt about implementation of the heatwave plans should be shared at a local level.