Assessing Psychosocial Health Impacts of Climate Adaptation: A Critical Review

Abstract

The urgency of dealing with risks associated with climate change and the need for effective response measures to their impacts are increasing daily the world over. Literature abounds regarding the impacts of climate change on physical, psychosocial, and other health outcomes. In contrast, little research exists on the health impacts of response measures to climate change. This critical review seeks to contribute towards closing this gap through a synthesis of current literature on the psychosocial health outcomes of climate adaptation actions. Our results found both positive and negative outcomes associated with psychosocial health that may result from climate adaptation actions. We propose the utilization of well-developed conceptual frameworks and evaluation tools in assessment and analysis of these outcomes. Ultimately, there is need to expand similar and related areas of research more broadly and on psychosocial effects, specifically.

Keywords

psychosocial health climate change adaptation impact assessment

Introduction

There is growing evidence that climate change affects both the distribution and urgency of health risks globally.^1,2 Climate change impacts on health can be direct, for example, through various ways in which extreme weather events such as floods, droughts and storms affect individuals or communities. Indirect effects may occur through changes in air, food, and water quality, which in turn, affect health.³ Vulnerability to climate change-related health impacts is determined by, among other factors, poverty, geographic location, exposure to hazards (i.e., location of the population exposed to drought or flooding), individual and community sensitivity to such hazards, and the capacity to adapt to the consequences of these changes.⁴ While the focus now is mostly on responses to the effects of climate change, a variety of studies have assessed different aspects of climate mitigation and adaptation. For the most part, these studies have not focused on understanding the health impacts of these responses in different countries and communities. Yet the health impacts of climate responses are directly linked to the physical, social, and economic wellbeing of a society as well as livelihood resilience and sustained household and community adaptive capacity. In addition, although climate policy instruments in most countries acknowledge the need for strengthening the surveillance of human health under climatic variability and change, many do not proffer strategies for doing that, nor do they discuss how to track and evaluate direct health impacts of mitigation and adaptation in different contexts.

In an endeavor to address this gap, this article focuses specifically on reviewing the state of knowledge on the links between climate adaptation and psychosocial health. We focus on psychosocial health because this emphasis has not received as much attention in climate change and climate response discussions as other elements of public health (e.g., physical and nutritional health). Yet, this aspect of health is as important as other elements of public health. Although there is a growing body of knowledge on the direct health impacts of climate change, there is still relatively limited focus on the ways in which responses to climate change impinge upon mental health specifically, and other dimensions of psychosocial health more broadly.

Psychosocial characteristics describe the influences of social and cultural factors on an individual's mental health, well-being, and behavior. These characteristics mediate between health outcomes and environmental factors.⁵ Psychosocial health is a construct that encompasses multiple dimensions of wellbeing, including mental, emotional, social, and spiritual.⁶ Those who are psychosocially healthy are not without problems, but generally have a balanced outlook about themselves and are able to cope with their lives.⁷

Mitigation and adaptation are interconnected concepts aimed at reducing climate change and its impacts, and to improve community capabilities and resilience in response. Climate change mitigation refers to efforts to reduce or prevent emission of greenhouse gases using new technologies and renewable sources of energy; or by making older equipment more energy efficient, for instance. Climate change adaptation has been defined by the IPCC as “adjustments in natural or human systems in response to actual or expected climatic stimuli or their effects, which moderates harm or exploits beneficial opportunities” (p 982).⁸

Climate change is not a linear event. It is the result of complex systems which are multi-dimensional in nature; both immediate and longer term. For these reasons, it is difficult to identify the key pyschosocial outcomes to measure. Predictions regarding ecological and physical impacts are typically uncertain, making research on the variety of potential impacts more difficult.⁹ Climate change impacts can affect one or more of the dimensions of psychosocial health at individual and/or community levels.¹⁰ For example, at community level, following a human or livelihood loss due to the impacts of climate change, acts of altruism, compassion and optimism (which are social and emotional dimensions of psychosocial health) may be triggered as people come together to share ideas and material resources, and to console each other following the loss. In the same vein, climate impacts may lead people to become individualistic and focus more on their family/household survival and/or interests as environmental and common-pool resources become depleted (due to the impacts). As a result of these possible mixed effects of and reactions to climate impacts, attempts to discover and define the underlying goals of specific adaptive actions and then establishing direct cause-effect relationships with psychosocial health outcomes are all challenging tasks.¹¹ However it is still critical to make efforts to relate the two since the generally agreed observation in literature is that climate change, its effects and associated psychosocial health outcomes are on the rise.⁹

Multiple adaptation strategies need to be in place simultaneously to be successful (i.e., in the case of this analysis, to have a positive impact towards reducing and/or addressing individual and community psychosocial health effects), otherwise, the burden on psychosocial health may be too great for either individuals or communities at large.¹² Resilience is essential for adaptive actions to be accepted, carried out, and ultimately successful, however, individual citizens may be reluctant to make necessary changes. Due to the complexity of climate change adaptation strategies, it is important that governments and policymakers apply basic adaptation principles to navigate and tailor interventions to the specific needs and priorities of the affected communities.¹³ Basic adaptation principles as advanced by the Intergovernmental Panel on Climate Change (IPCC) and widely accepted in adaptation discourse are that adaptation should: a) enhance resilience and reduce vulnerability to observed or expected changes in climate, via such broad socio-economic interventions as investments in basic social services, infrastructure, and social protection; b) include not only reactive interventions but also proactive anticipatory actions; c) take into consideration the (sometimes limited) abilities of environmental and socio-ecological systems within which they are being implemented to account for continuous alterations in baseline conditions; d) take an equity-informed approach and consider different intersecting vulnerability factors with respect to how individuals and communities are impacted by climate change including race, gender, age, income level, employment status, among many others.^8,14–16

Reactions to weather-related events can be latent or delayed. Post-traumatic stress is a possible response that can be passed along to later generations.¹¹ Post-disaster adjustment problems may lead to emotions such as fear, anger, helplessness, and resignation. These emotions may contribute to such outcomes as poor sleep, exhaustion, psychosomatic disorders, and increased domestic violence, among others. On a community level, effects may prompt violence and conflicts over scarce resources, displacement, and migration. Depending on the nature of the climate event(s), the reactions may be mild to severe.¹⁷

In our critical review and synthesis of the state of knowledge about the psychosocial health impacts of adaptation to climate change, we draw on existing literature to discuss theoretical and practical frameworks that can be used to explain the relationship between adaptation and psychosocial health. Moreover, this paper highlights the need to account for change over time in assessing the psychosocial health outcomes of climate change adaptation. This is important because immediate or short-term benefits of adaptation may be outweighed over time by negative long-term health effects or ongoing climate impacts.

This critical review is part of a larger project to study the psychosocial health impacts of agricultural adaptations to climate changes in a rural community in northern Zimbabwe. Although Zimbabwe is a low-income country, this review does not address national or regional income as a factor affecting the psychosocial impact of climate adaptation. However, it stands to reason, that locations with fewer resources will be less able to implement mitigation strategies and adaptation efforts or cope with their impacts.

Methods

This critical review and synthesis differs from normative systematic reviews in that it does not strictly evaluate the quality of the evidence found in the literature and is also more exploratory towards uncovering knowledge gaps.^18,19 An exploratory approach seeks to interrogate research questions and/or areas that have not been previously studied in-depth, that have been under-investigated, or are otherwise poorly understood.²⁰ In conducting the review, we formulated and utilized three key questions which helped to guide our analysis. These key questions are as follows:

How can the climate change adaptation-psychosocial health link be understood?

What frameworks and evaluation tools can be used to assess the impacts of climate adaptation on psychosocial health?

Where are the gaps vis-à-vis current psychosocial health and climate change adaptation analyses?

The Search, Appraisal, Synthesis, and Analysis (SALSA) framework was used to conduct a thorough search and review of the current body of literature on climate change adaptation as it pertains to psychosocial health and psychosocial health outcomes.²¹ The comprehensive search process and critical review emanating from the adoption of the SALSA framework results in an evidence-based synthesis. The various steps of the SALSA framework (Figure 1) enabled a systematic, yet robust analysis of literature and documents while minimizing the potential for bias.²²

Figure 1.

Flow diagram of the SALSA framework (adapted from Gunnarsdottir et al., 2020)²².

The following databases were used in the literature search: PubMed, Google Scholar, Scopus, PsycInfo and ProQuest, using the following keywords (as well as synonyms and related words): “psychosocial health” or “psychosocial health outcomes” and “climate change adaptation,” and “response” or “response strategies” or “resilience.” We selected peer-reviewed publications, including journal articles, book chapters, books, and miscellaneous editorial material. We also included working papers and academic reports. Psychosocial health was conceptualized as encompassing mental, emotional, and spiritual elements of what it means to be “healthy” in a broad sense.

Inclusion criteria were the following:

Text documented in English

Focus on psychosocial health

Address the impacts of climate adaptation actions

The text contains sufficient relevant detail for the review

Over 800 articles were retrieved. After removing duplicates and scanning the title and abstract of all articles for relevancy, a total of 250 remained. After reviewing the full articles, removing irrelevant ones, and then searching the reference list of applicable articles, 96 relevant articles were retained for inclusion. The basis of inclusion for the remaining 96 articles was that they had information which sufficiently addressed at least one of our key guiding questions.

Results

The three key questions outlined in the methodology section provide the structure of the results from this review. We critically engaged with the arguments, viewpoints, and perspectives emerging from the 96 articles selected using thematic analysis, before methodically identifying the primary points and common perspectives that emerged from the majority of articles vis-à-vis the guiding questions.

Understanding the Link Between Climate Change Adaptation and Psychosocial Health

As described in the introduction, psychosocial health is a construct of health that encompasses mental, emotional, social, and spiritual dimensions of well-being. Establishing the link between climate change adaptation and psychosocial health outcomes (whether negative or positive) can be difficult because other social, ecological, and economic factors contribute to psychosocial health outcomes as well. It is so difficult and challenging to discover and define the underlying goals of specific adaptive actions and to establish direct cause-effect relationships between those actions and psychosocial health that some scholars have suggested that a new discipline of “eco-psychiatry” is needed to do so.¹¹

Climate change adaptation is intrinsically meant to assist individuals, households, and communities to adjust to actual and/or expected climate stimuli, hence, ideally, to lead to positive psychosocial (and other forms of) health outcomes. The goal of climate change adaptation is to reduce vulnerability and increase resilience to the harmful effects of climate change and the resulting environmental impact. Adjusting or adapting to climate change effects through various means (e.g., migration from areas affected by climate disruptions; diversification of crops, planting times, and livelihood; use of drought-resistant varieties; and improved soil and water conservation techniques, etc.) may reduce harmful effects such as loss of occupation and income, food, and other resources, which can, in turn, help individuals have some sense of control and manage the negative feelings and thoughts that can arise. Such changes may assist people to face up to and come to terms with climate-related threats and consequences. Hence, climate adaptation may activate hope and move people from passive helplessness to active responses to climate impacts.²³

Adaptive actions, especially at the community level, may inspire altruism, compassion, and optimism as people come together to share ideas and material resources, and to console each other following loss. Climate adaptive actions such as migration may, sometimes, lead to positive psychosocial health outcomes by fostering hope and belonging for immigrants in new communities or countries where and when they feel welcomed, safe, and experience better living conditions.²⁴ In addition, research suggests that climate adaptation strategies that involve environmental preservation, such as water and soil conservation, may lead people to develop a sense of stewardship and investment in their environmental resources at both the personal and the communal level. Having a sense of stewardship and investment can help overcome feelings of helplessness, anxiety, and eco-paralysis.²⁵

Conversely, climate change adaptation may, at times, produce negative psychosocial health outcomes. In essence, negative psychosocial health outcomes due to climate adaptation represent a form of maladaptation. The concept of maladaptation pertains to the formation of undesirable and negative consequences of adaptive responses, which may even increase risks.²⁶ Health outcomes emanating from maladaptive climate actions may include increased stress and distress symptoms, and clinical disorders ranging from anxiety and sleep disturbances to depression, post-traumatic stress disorder, and in extreme cases, even suicidal thoughts. Studies have found that failure to respond adequately or successfully to climate change may create a sense of powerlessness, unresolved loss, grief, frustration, and depression, leading to such psychopathological reactions as loss of appetite, sleeplessness, and panic attacks.^27,28

Migration in the context of this discussion is involuntary relocation either because of climate-related conditions or to avoid further attempts to adapt. Migration may be considered a severe form of adaptation to climate events. Climate migrants may experience a range of negative psychosocial health outcomes such as further stress, anxiety and trauma compounding the impact of the precipitating event(s). However, in some instances, migration may result in positive psychosocial health outcomes if there is an opportunity to relocate to a more convenient or beneficial area. The reviewed papers show that migration may challenge the identity, sovereignty, and heritage of people who must leave their homelands and community connections, leading to heightened levels of anxiety, fear, and even fatalism.²³ It is, therefore, possible for adaptive actions to have impacts that are salutary in one context but turn out to be maladaptive in others.

There are barriers to making adaptive changes that are influenced by individual and/or community/societal perception and knowledge of the problem and options for change. Barriers to climate adaptation refer to obstacles that hinder the planning and implementation of climate change adaptation.^29,30 Such barriers result in ineffective adaptive actions. Limits, on the other hand, refer to the point at which adaptation fails to alleviate climate impacts or creates more vulnerabilities than it solves, leading to maladaptive responses.³¹ Over time, even across many centuries, adaptation by humans has either been limited or strengthened by biological, cultural, or technological resources.¹⁷

While technological, institutional, and financial factors are the main sources of barriers and limits articulated in adaptation literature,^32–35 there is a growing recognition that psychosocial factors can also represent formidable constraints to effective adaptation.^12,29 Limits are typically viewed as absolute, referring not just the point at which adaptation becomes inefficient, but also ineffective in reducing vulnerability.^29,36,37 Limits may result when: a) the effort involved in pursuing an adaptation strategy exceeds the benefits of the outcome, b) a specific strategy does not address an actual source of vulnerability, and/or c) potential benefits are undermined by other factors unrelated to the proposed adaptation. Identifying limits to climate adaptive actions will enable the prioritization of adaptation efforts and the avoidance of potentially ineffective or even harmful adaptive strategies.²⁹

In climate adaptation, strategies are needed to address the macro level (i.e., available societal resources and inherent strength of the species involved), the meso level (i.e., cultural and ethnic group capabilities), and the micro level (i.e., family and individual physical, emotional, and psychological abilities).¹⁷ Psychological distancing regarding adaptation to climate change may be hindered by such factors as media coverage and incomplete information. Hindered psychological distancing can lead to helplessness, anxiety, or depression, resulting in inability to act (or react) or even outright rejection of the problem. Responses to climate crises require some level of crisis communication and education for adaptation. If governments fail to provide resources for communities this will only further increase stress, anxiety, depression, and a sense of helplessness about the future. Communities will need financial support for management of severe weather events and recovery efforts, improved telecommunications technology, and strengthened health systems, for instance. In particular, attention to improved mental health care resources will be critical to help individuals and communities cope with the consequences of climate-related events and improve their resilience for the future.^38,39

Figure 2 provides a graphic of the intersection of components of physical and mental health (i.e., one dimension of psychosocial health) for individuals and the impacts on community health.⁴⁰ Exposures from climate change exist within the context of the range of individual and community factors that positively or negatively influence health outcomes. Further, individual vulnerability is a combination of social determinants of health and behavioral choices; societal factors, such as natural and built environments, governance and management, and institutions also mitigate the capacity and resilience in response to crises. It is also important to note that there are and will be disparities among different groups of people who are compromised for one reason or another and less capable of handling the extremes of climate change events and the ability to adapt to them.⁴¹

Figure 2.

The interconnected relationship between physical and mental health, and community well-being. Source: Clayton et al (2021), pg. 17.⁴⁰

Establishing Frameworks to Assess the Link Between Climate Change Adaptation and Psychosocial Health

The frameworks included in this review describe, with varying degrees of complexity and success, the link between a key environmental stressor and associated health outcomes. They can, therefore, be viewed as potentially useful for development of health impact assessments (HIA) to establish and conceptualize the relationship between climate adaptation and psychosocial health. An HIA is a useful theoretical construct that can help in analyzing the complex relationships among climate-caused phenomena (such as wildfires, drought, flooding, and other disasters), climate impacts, adaptation efforts, and health outcomes. According to the World Health Organization, an HIA is “a combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population”.⁴² ^{(p 4)} This process can, therefore, be used to evaluate the positive and negative health impacts of climate adaptation.

As emphasized in the reviewed papers, a conceptual framework for climate adaptation in public health must describe, among other things, the causal chain linking climate and health indicators, the dynamics of wider social systems, and the structure of the adaptation process. Such a conceptual framework should clearly spell out the direct impacts of climate change, the adaptation responses that these changes trigger, and, in this case, the positive and negative psychosocial health impacts that the adaptation activities trigger.^43,44 The reviewed literature shows that most of the existing frameworks for understanding the climate-health relationship focus on the linkages between climate change and human health, with little focus on the relationship between climate change response strategies, such as adaptation, and human health outcomes. In many frameworks, the incorporation of climate adaptation is secondary. Moreover, conceptual frameworks which directly articulate the impacts of climate adaptation on psychosocial health are non-existent to the best of our knowledge.

We summarize some of the climate change-health frameworks in Table 1. Below, we make the case for seeing them as models for a health impact assessment framework. With appropriate modification, such a framework can provide meaningful insights into the impacts of climate adaptation on psychosocial health.^45–48

Table 1.

Summary of Select Frameworks for Assessing the Relationship Between Climate Change Adaptation and Health.

Framework	Purpose	Shortcomings
Driving force, Pressure, State, Exposure, Effect, and Action (DPSEEA)⁴⁵	Links measurable indicators to diseases caused by environmental factors, displaying levels of actions that can be undertaken to mitigate environmental health impacts	Poorly captures issues like the complexity of disease aetiology Interactions between climatic and non-climatic risk factors involved in climate-sensitive disease causation not well articulated
Causal Webs and the Hierarchy of Causes (CWHC)⁴⁶	Can be used to capture the aetiology of any health issue Captures hierarchical cause-to-effect relationships among risk factors (distal, proximal, and direct causes), and between risk factors and diseases Important for capturing complexities of multiple interacting disease factors	Current causal web literature fails to clarify the elements of such a web Does not distinguish between determinants of disease in individuals as against populations
Burden of Disease Assessment⁴⁷	Useful in ascertaining attributable and avoidable burden of disease	Difficulty in disease attribution
U.S. National Health Impact Assessment⁴⁸	Important in the assessment of current and future climate-related health risks	Lack of a careful definition of important relationships between causative factors and their effects in the articulation of some health impact assessment frameworks

Source: Adapted from Fussel & Klein (2004).⁴⁴

The Driving force, Pressure, State, Exposure, Effect, and Action (DPSEEA) framework links measurable indicators to diseases caused by environmental factors, displaying levels of action that can be undertaken to mitigate environmental health impacts.^45–53 While this framework captures the direct effect of environmental hazards on health, it does not adequately cover the complexity of disease etiology and the interactions between climatic and non-climatic risk factors involved in the causation of climate-sensitive diseases.⁵⁰

The Causal Webs and the Hierarchy of Causes (CWHC) framework captures hierarchical cause-to-effect relationships among risk factors and between risk factors and disease outcomes.⁴⁶ The hierarchy of causes distinguishes between distal causes (i.e., socioeconomic driving forces at national/regional levels); proximal causes (i.e., the level of a health hazard at the local milieu); and direct causes (i.e., individual exposure to the hazard).⁵⁴ The reviewed papers show that this framework appears better suited for capturing the complexities of multiple interacting disease factors than the DPSEEA framework.^45,51

The Burden of Disease assessment is used to ascertain the magnitude of a particular health problem.⁴⁷ In our analysis, we find that this framework appears to be more applicable to mitigation rather than adaptation. However, even in the case of mitigation, its use requires care even in specific circumstances because attributing any specific health issue to climate change events is generally difficult – a challenge that plagues other frameworks too.⁵⁵

The U.S. National Health Impact Assessment framework looks at the potential impact of climate change on health with a key focus on the assessment of current and future risks, risk management options, and the identification of limiting research gaps.⁴⁸ This framework addressed questions to assess the status of and stresses on the nation's health; the climate change impacts on the population's health; the country's capacity to adapt to climate change; and knowledge gaps to understand these impacts.^48,56–58 However, our analysis identified some deficiencies in the use of the framework, such as failure by some scholars using the framework to define important relationships between causative factors and their effects.⁵⁹

The highlighted frameworks can provide a model for a systematic HIA to evaluate the impacts of climate adaptation and links to psychosocial health. The relationship between climate change adaptation and health is complex and poses many challenges which include, among other issues:

- ascertaining the most effective adaptive actions,

- identifying uncertainty about the outcome of those actions, and

- dealing with the dearth of data as well as evaluation tools.

In the face of these challenges, it is important to utilize tools that can improve the performance of an HIA in explaining the climate-health relationship. One such tool is the Causal Loop Diagram (CLD) used in studying complex systems.^60,61 CLDs are often constructed with the help of multiple stakeholders to capture the complexity of a system under consideration. Indeed, frameworks discussed in this section have been represented by their authors using diagrams that can be characterized as CLDs. For the purposes of analysis and discussions in this paper, an example of a useful CLD will highlight, among other things, dominant climate adaptive actions, their intended and unintended psychosocial health effects, as well as synergies and barriers to successful psychosocial health outcomes.⁶¹ Figure 3 depicts a typical climate-health CLD and the impact of green initiatives on health in an urban context.

Figure 3.

A causal loop diagram (CDL) showing multiple consequences of climate adaptation measures for human health (Source: Brown et al. 2011).⁶¹

The heavy arrows in R1 indicate that rising temperatures increase community exposure to thermal stress. This results in an increase in air conditioning (an adaptation action) shown via B, which increases the load on thermal stations, contributing to the rise in greenhouse gas (GHG) emissions, which leads to rising temperatures. Moreover, temperature increases due to GHG emissions lead to increased clamor for “green” initiatives. This may lead to another adaptation action, tree planting, which may result in an increase in community participation in outdoor activities, resulting in an improvement in community health and well-being (R2). Better community health may reduce suffering from thermal stress (R3). All components of a complex system interact to produce both intended and unintended consequences. As captured in Figure 3, a possible unintended effect of tree planting may be an increase in the proportion of community members suffering from allergies and asthma due to pollens from the trees.

Although the examples in this CLD highlight the impact of climate adaptation on physical health, it is possible to conceptualize and accommodate the psychosocial impacts of adaptation in this CLD. For instance, thermal stress due to rising temperatures can result in psychological distress and sleep disruption. On the other hand, the increase in outdoor activities due to tree planting can enhance mental health by fostering a greater sense of community and improved physical health. In the context of an agricultural setting, one can think of the occurrence of drought due to climate-induced irregular rainfall patterns in a CLD. This may lead to poor harvest, and the adaptive introduction of new seed varieties. The poor harvest and uncertainty regarding the performance of the new crop varieties can result in psychosocial distress especially in poor communities already facing huge socioeconomic challenges. At the same time, successful adaptation outcomes may imbue people with a greater sense of agency and confidence in tackling challenges and, thereby, boost their psychosocial health.^62,63 The foregoing example illustrates the complexity of the relationships that can be depicted using a CLD, which is summarized in the following statement:

“The use of CLDs within HIA can improve understanding of the behaviour of the system in which climate change adaptation measures will be introduced and provide an improved understanding of relationships between climate and health; determinants of vulnerability; the range of potential health impacts of adaptation and mitigation strategies; barriers to these strategies; and interactions between different sectors or stakeholders in the system.”⁶¹ ^{(p S51)}

CLDs can be useful to identify the appropriate stakeholders and actions associated with risk factors, as well as mitigation and adaptation efforts. The combination of HIA and CLDs can

- provide a better understanding of the impacts of adaptive actions, either autonomous – which refers to spontaneous livelihood diversification and fund mutualization strategies undertaken by communities in the face of climate shocks, or anticipatory, such as deepening institutional capacity to respond to future climate shocks on health⁶⁴;

- identify the determinants of vulnerability and barriers to implementation of adaptation strategies; and

- explain the interactions among stakeholders and different sectors within a community.

Ultimately, improved integration of HIA and CLDs within the context of increased communication and collaboration between relevant stakeholders when understanding adaptive actions will be required to promote individual and community health and well-being. This is important since both a well-designed HIA and CLD rely on the input of relevant stakeholders to speak to each other in clarifying important relationships between health and adaptive actions even in the face of complex relationships between both phenomena.⁶¹

Evaluation Tools to Assess Impacts of Climate Adaptation on Psychosocial Health

The lack of validated psychosocial research tools specifically addressing climate change adaptations poses many challenges in conducting an evaluation of the impact of climate adaptation on psychosocial health. This is likely due, in part, to the lack of importance and attention this issue has raised; the complex nature of such research; and the need for researchers to work increasingly across disciplines. Our review found that much of the literature focuses on the surface relationship between climate change impacts and mental health rather than the larger constellation of psychosocial health outcomes.^{11,23,65–67} In addition, much of the literature places specific focus on extreme weather events rather than broader climatic system dynamics that are constantly in flux, evolving, and hence unpredictable.^68–73 In general, the discussion of the mental health outcomes of extreme weather events focuses on three phases: the (climate) emergency and crisis phase, the post-impact phase, and the rehabilitation and recovery phase.⁷⁴ As a result, important mental health issues that emerge in the pre-crisis period receive less attention although responses during this time frame can ultimately affect outcomes during the subsequent phases surrounding a serious crisis event.^9,23 Impacts such as anxiety, depression, restlessness, and sleep deprivation may occur, for example, due to warnings of droughts and possible future crop failures.

Evaluation tools to assess the impacts of climate adaptation on psychosocial health must integrate, not only mental health as much currently published work has done, but broader psychosocial health indicators. Criteria for those tools include elements such as relevance, effectiveness, efficiency, impact, sustainability, and generalizability. In a scoping review of the literature, Hayes and Poland (2018) found few survey instruments that evaluate individual psychological/mental health issues, e.g., post-traumatic stress disorder (PTSD), anxiety, and depression, in response to climate change events.⁹ There is even less literature that assesses psychosocial resilience, positive mental health responses, or chronic climate change-related effects at the community level.

Attribution of psychosocial health outcomes to climate change factors is difficult for several reasons. Firstly, there is need to avoid casually classifying normal reactions to abnormal events as psychosocial challenges or underdiagnosing serious long-term psychosocial health effects of climate-related disasters. Secondly, attribution is difficult, due to the vast array of possible climate change effects and psychosocial health outcomes as well as the potentially long timeframe for attributing psychosocial health outcomes to climate change. In addition, the complex relationship between psychosocial health and non-climate social determinants of health further complicates the drawing of a causal link to climate.²³

Various tools have been applied to the study of the relationship between climate-related disasters and psychosocial-related distress. For instance, several were used to evaluate mental health outcomes among cohorts that experienced flooding in England⁷⁵; Brisbane⁷⁶; and select developing countries.^77,78 The empirical application, as well as limitations of selected tools, are summarized in Table 2.^{27,76,79–88}

Table 2.

Select Tools in Studies for Evaluating the Climate Psychosocial Health Relationship and Limitations to Assess the Adaptation Psychosocial Health Relationship.

Instrument	Empirical application	Limitations
Patient Health Questionnaire (PHQ)^79,80	Used for criteria-based depressive and other mental disorder diagnosis Administered either as a two or nine-question instrument Can be self-administered	Cannot detect depression in some settings Inadequate for capturing non-mental health components of psychosocial health Not yet validated for climate adaptation settings
Generalized Anxiety Disorder (GAD)⁸¹	Designed for diagnosis of generalized anxiety disorder Two and seven-item versions have been validated in clinical settings Congruence between self-reported and individual administered versions has been found	May not be appropriate for capturing non-anxiety aspects of psychosocial health outcomes Not yet validated for climate adaptation settings
PTSD Checklist (PCL)⁸²	Standardized self-report scale for PTSD Various versions of the instrument: PCL-M (military), PCL-C (civilian), and PCL-S (specific) PCL-M applies to military experiences; PCL-C applies generally to traumatic events Instrument can be self-administered	Instrument not designed to capture the array of non-PTSD psychosocial health outcomes Instrument is not validated for climate adaptation settings
Groningen Sleep Quality Scale⁷⁶	It is a tool used to understand patterns in overall sleep quality	Tool may not be helpful in capturing non-sleep quality related psychosocial health conditions Sleep disturbance may not be the result of psychosocial health problems Instrument is not validated for climate adaptation settings
Trauma Screening Questionnaire⁸³	Used to screen for PTSD To be administered at least three weeks after trauma to allow for natural recovery processes	Not comprehensive enough to account for all psychosocial health conditions Not validated to deal with climate change adaptation settings
Kessler Psychological Distress Scale^84,85	A tool for measuring psychological distress through questions about emotional states It can be either self-administered or read out by a practitioner Scores indicate a continuum of psychological distress ranging from “likely to be well” to “likely to have a severe disorder”	It lacks the comprehensiveness of a psychosocial assessment tool Though widely used, relevance in a climate adaptation context has not been validated
Mental Wellbeing Impact Assessment (UK)^86,87	A tool for understanding how an organization, policy, service, etc. affects mental wellbeing Great emphasis is placed on mitigating health inequalities and social injustice	Its equity focus notwithstanding, it cannot be used to ascertain progress towards health equity for non-mental health problems Applicability to climate crisis and adaptation settings is not validated
Environmental Distress Scale (EDS)⁸⁸	Used to assess the bio-psychosocial cost of environmental disturbance It can be adapted to a general tool assessing people's distress to changing environments emanating from lived experiences Also known as “Solastalgia”	Validation in a climate adaptation setting is not known
Disaster Psychosocial Assessment and Surveillance Toolkit (PAST)²⁷	Designed for community mental health and psychosocial functioning surveillance post-disaster Aimed at informing distribution of services and engendering better understanding of need in recovering communities	Validation in a climate adaptation setting is not known

A general limitation of these tools is the lack of their validation to address climate change adaptation scenarios. Where the tools are validated, a major challenge is that they tend to validate the conceptualization of psychosocial health principally as mental illness and mental health problems. However, in addition to emotional, spiritual and social dimensions, psychosocial health includes mental wellbeing in addition to mental health problems and disorders.⁸ Therefore, tools to be employed in evaluating the psychosocial impacts of climate adaptation, must be aimed at broadly eliciting and measuring well-being, not just problems, and disorders.

To further clarify, wellbeing is a subjective sense of satisfaction with one's life, and includes positive emotions such as contentment or happiness, and an absence of feelings of depression or anxiety.⁸⁹ A sense of wellbeing allows one to perceive, manage and express emotions in an appropriate way. Mental health is a broader condition that encompasses emotional, psychological, and social well-being. Mental illness refers to diagnosable conditions that interfere with one's functioning in relationships and daily activities.⁹⁰

A few tools attempt to assess the psychosocial dimensions of environmental shocks (positive and negative). Some evaluate both positive and negative emotions in relation to climate-related disasters, particularly for cases that challenge identity and sense of belonging in the home environment. One such tool is the Environmental Distress Scale (EDS), which assesses wellbeing in changing environmental conditions, known as “Solastalgia.”^91–93 Others, like the Disaster Psychosocial Assessment and Surveillance Toolkit (PAST) focus on negative mental health experiences.²³ Although we found that tools evaluating the psychosocial impact of climate change are generally scant in the literature, tools evaluating specific psychosocial effects of climate change adaptation are virtually non-existent. To create such tools, it is, therefore, important to be careful in adapting existing tools to relevant contexts.

Gaps of Current Climate Change Adaptation Analyses

Key gaps were identified in our review vis-à-vis current psychosocial health and climate change adaptation analyses. First, we note that there is a need to expand research and analysis assessing the impact of climate adaptation on health outcomes more broadly and on psychosocial health, specifically. The available work focused on these areas is extremely limited and, in some cases, non-existent. Furthermore, more research is required to understand both positive and negative psychosocial health outcomes of climate adaptation in different contexts and at both the individual and community levels. Second, there is need for developing tools that purposefully include critical evaluation elements such as relevance, effectiveness, efficiency, impact, and sustainability in assessing the effects of adaptive actions on psychosocial health outcomes. Last, an implication of this study is that the promotion of effective adaptation to climate change must include measures to tackle concomitant adverse psychosocial health outcomes.

Thus, at the heart of climate adaptation policies must be health promotion and public health strategies to improve attendant psychosocial health disruptions. For example, climate migrants must be supported to overcome the mental and psychological health effects of being uprooted from one's indigenous cultural context. To be effective, such support must account for the dynamic nature of climate change and adaptive actions.

Conclusions and Implications for Policy and Research

This review sought to make a case for a focused assessment of the impacts of climate adaptation on psychosocial health outcomes, using a critical synthesis of current literature.

The climate crisis is the greatest threat of our time to society in general, and public health, in particular. Adaptive responses to climate change are typically accompanied by other stressors that affect physical and psychosocial health. Other events exacerbated by the climate crisis and devastating many parts of the world include:

- infectious disease, such as the COVID-19 pandemic;

- devastating earthquakes and other natural disasters;

- refugee migration away from areas under siege in ongoing conflicts and war; and

- migration already occurring in many parts of the world due to climate events, poverty, and famine.

This review did not attempt to address the psychosocial health impacts of these additional stressors, but all will require some type of adaptative actions as they occur. More attention to impacts from these events is needed.

We acknowledge the difficulties in evaluating the psychosocial and other health impacts of adaptive actions in response to the climate crisis. We summarize the limited available information on the immediate, latent and long-term consequences of climate change adaptation which mainly focus on the occurrence of extreme events. Knowledge is even more limited regarding broader climate change dynamics that are often gradual, insidious and/or cumulative, unlike catastrophic events whose impacts are sudden.

There are multiple simultaneous stressors on the psychosocial health of individuals and communities. It is important to improve preparation of baseline physical and mental health services, access to food resources, and other community supporting efforts as soon as possible. Time is of the essence in building resilience of communities to respond to impacts that are already underway. Local and national government agencies must plan and prepare national adaptation programs. They should develop and implement education programs to prepare communities for the decision-making that will be needed. More research is needed to identify and promote not only local grass roots solutions to climate-related events, but also mechanisms for better program planning and implementation to reduce harmful impacts and enhance positive responses.^94,95

It is hoped this critical review helps to advance a clear case for undertaking assessments and evaluation of the psychosocial consequences of climate adaptation. It is anticipated that a research project focused on an evaluation of the impacts of climate adaptation on psychosocial health outcomes in specific rural Southern African contexts, currently being implemented by the authors and which is the basis of this review, will contribute further empirical insights to these important issues. Specific strategies focused on low- to middle-income countries are urgently needed.⁹⁶

Limitations

This review has some crucial limitations. A key shortcoming is the dearth of empirical literature on the range of psychosocial health outcomes caused by adaptation to climate change as stated in our discussion. As earlier mentioned, this review had to draw largely from the climate change-mental health literature in framing the relationship between climate adaptation and psychosocial health. Consequently, it lacks the richness provided by a discussion of specific case studies highlighting how particular adaptive actions have resulted in specific psychosocial health outcomes in a given setting. There is a paucity of frameworks that can be used to evaluate the psychosocial health impact of climate adaptation. In contrast, there is a more developed set of tools and instruments to measure the mental health impact of climate change. We hope that this review will help spur debates and widen views on the psychosocial health impacts of various climate adaptive actions.

Footnotes

Acknowledgments

The authors gratefully acknowledge funding from the Wellcome Trust for the project, ‘Climate adaptation and sustainable rural health outcomes in Southern Africa’, under which this review was undertaken. We are also grateful for the thoughtful comments by Dr Cliff Zinyemba, PhD, University of Zimbabwe, Harare, Zimbabwe; and Dr Nancy Nelson, PhD, Consultant, Ann Arbor Michigan, USA.

Author Contributions

Mary E. Miller, Chijioke Nwosu and Admire Nyamwanza contributed equally to the writing of the manuscript. Peter Jacobs contributed to the technical revision of the manuscript.

Consent for Publication

All authors read and approved the final manuscript and consent to publication.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding provided from the Wellcome Trust grant #216034/Z/19/Z.

ORCID iD

Mary E Miller

Supplemental Material

Supplemental material for this article is available online.

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