FINNISH REGISTERED NURSES’ OBSERVATIONS OF HEALTH EFFECTS RELATED TO CLIMATE CHANGE
Iira Tiitta Master’s thesis Nursing Science
Preventive Nursing Science University of Eastern Finland Faculty of Health Sciences Department of Nursing Science May 2019
ABSTRACT
1 INTRODUCTION ... 2
2 CLIMATE CHANGES HEALTH EFFECTS IN EUROPE ... 5
2.1 Literature review ... 5
2.2 Health problems related to climate change ... 9
2.2.1 Extreme temperatures ... 10
2.2.2 Air quality ... 11
2.2.3 Infectious diseases ... 12
2.2.4 Cultural effects ... 13
2.2.5 Mitigation and adaptation to climate change ... 13
2.3 Summary about basis for study ... 14
3 AIMS OF STUDY AND STUDY QUESTIONS ... 16
4 DATA COLLECTION AND ANALYSIS ... 17
4.1 Research Design ... 17
4.2 Data Collection ... 18
4.3 Data analysis ... 19
5 RESULTS ... 21
5.1 Background information of the participants ... 23
5.2 Main groups vulnerable to climate changes health effects ... 24
5.2.1 Elderly ... 25
5.2.2 Children ... 27
5.2.3 Immigrants and refugees ... 28
5.2.4 Health care professionals ... 29
5.3 Health problems associated to climate change ... 31
5.3.1 Respiratory problems ... 32
5.3.2 Infections ... 33
5.3.3 Injuries ... 36
5.3.4 Mental health problems ... 37
5.4 Registered nurses’ preparedness to address climate changes health effects ... 38
5.4.1 Need for nursing education ... 39
5.4.2 Clearer policies ... Error! Bookmark not defined. 5.4.3 Climate Adaptation interventions ... 41
5.4.4 Global perspective ... 43
5.5 Summary of the main findings ... 45
6 DISCUSSION ... 47
6.1 Review of the main findings ... 47
6.2 Trustworthiness of the study... 50
6.2.1 Preparation of analysis ... 50
6.2.2 Organization of the materials ... 52
6.2.3 Reporting of the findings ... 53
6.3 Ethical considerations and data protection ... 54
6.4 Conclusion, Implications for nursing practice, education, and suggestions for future research ... 56
REFERENCES ... 58
Appendix 1. Research tablet Appendix 2. Recruitment flyer Appendix 3. Interview questions Appendix 4. Fact sheet
Appendix 5. Informed Consent
Appendix 6. Content analysis example Appendix 7. Demographic data
TABLES
Table 1. Database searches 6
Table 2. Inclusion criteria for studies 7
FIGURES
Figure 1. Literature search process: including and excluding studies 8 Figure 2. Finnish RNs’ observations of climate change 22 Figure 3. Main groups vulnerable to climate change 24 Figure 4. Health problems related to climate change 31
Figure 5. RN’s preparedness to climate change 38
Figure 6. Main themes from interviews 45
ABBREVIATIONS
RN Registered Nurse
ICN International Council of Nurses
IPCC International Panel for Climate Change
Hoitotieteen laitos Hoitotiede
Preventiivinen hoitotiede
Tiitta, Iira SUOMALAISTEN SAIRAANHOITAJIEN
HUOMIOITA ILMASTONMUUTOKSEN
TERVEYSVAIKUTUSISTA
Pro gradu -tutkielma, 63 sivua, 7 liitettä (16 sivua) Ohjaajat: Professori Lauri Kuosmanen, TtT, Professori Hannele
Turunen, TtT, Apulaisprofessori Ruth McDermott- Levy PhD
Toukokuu 2019
Ilmastonmuutos vaikuttaa ihmisten terveyteen suoraan ja välillisesti. Ilmastonmuutoksesta johtuvat lämpötilan ja ilmanlaadun muutokset ovat ympäristötekijöitä, jotka vaikuttavat suoraan ihmisiin. Lämpötilan noustessa näemme muutoksia ilmastossa. Nämä voivat tarkoittaa eri alueilla eri asioita, toisaalla kesätä voivat lämmetä ja toisaalla talvet kylmenevät. Muutosten myötä sään ääri-ilmiöt yleistyvät, kuten kesäiset helleaallot.
Hellepäivien ja helleaaltojen lisääntyessä, lisääntyvät kuumuuteen liittyvät sairaudet ja kuolemat. Sairaanhoitajien tulisi olla tietoisia paikallisista sääolosuhteista ja potilasryhmistä, jotka ovat erityisen alttiita ilmastonmuutoksen terveysvaikutuksille ja huomioida työssään asianmukaiset sopeutumiskäytännöt, kuten äärimmäisiin sääolosuhteisiin varautuminen ja tarvittaessa käydä näitä läpi potilaidensa kanssa.
Tämän tutkimuksen tarkoituksena oli tunnistaa terveyshaitat, joita suomalaiset sairaanhoitajat yhdistävät ilmastonmuutokseen. Tarkoituksena oli myös selvittää, kuinka valmistautuneita sairaanhoitajat ovat käsittelemään ilmastonmuutoksen terveysvaikutuksia.
Kirjallisuuskatsaus tehtiin selvittämään, onko tutkimustiedossa aukko. Katsauksen lisäksi tehtiin kuvaileva laadullinen tutkimus. Tutkimusaineisto kerättiin sairaanhoitajilta (n=6) kahdessa puolistrukturoidussa ryhmähaastattelussa syksyllä 2018. Haastattelu aineisto analysoitiin induktiivisella sisällön analyysillä.
Tulosten mukaan sairaanhoitajat kokivat olevansa tietämättömiä ilmastonmuutoksen terveysvaikutuksista. Haastatteluissa kävi ilmi, että sairaanhoitajat ovat havainneet paljon ilmastonmuutoksen aiheuttamia terveyshaittoja potilaissaan. He eivät kuitenkaan olleet liittäneet havaitsemiaan potilaiden terveydentilassa tapahtuneita muutoksia ilmastonmuutokseen. Lisäksi sairaanhoitajat kokivat että ilmastonmuutosta ei huomioida riittävästi sairaanhoitaja peruskoulutuksessa eikä työpaikkakoulutuksessa. Tämä vahvisti tarvetta kehittää sairaanhoitajien koulutuksesta ilmastonmuutoksesta ja sen aiheuttamista terveysvaikutuksista.
Tutkimuksen tuloksia voidaan käyttää koulutuksen suunnitteluun, jotta esiintulleet terveysongelmat ja koulutustarpeet voitaisiin liittää hoitatyön opetukseen, niin työpaikoilla kuin oppilaitoksissa. Tutkimuksen tulokset myös voidaan lisätä kirjallisuuteen ilmastonmuutoksen terveysvaikutuksista Suomessa.
Asiasanat: Ilmastonmuutos, Terveysvaikutus, Hoitotyö, Sairaanhoitaja, Ympäristöterveys
Department of Nursing Science Nursing Science
Preventive Nursing
Tiitta, Iira: FINNISH REGISTERED NURSES’
OBSERVATION OF HEALTH
EFFECTS RELATED TO CLIMATE CHANGE Master’s Thesis, 63 pages, 7 appendices (16 pages) Supervisors: Professor, Lauri Kuosmanen PhD, Professor Hannele
Turunen PhD, Assoc.Professor Ruth McDermott- Levy PhD
May 2019
Climate change affects our health directly and indirectly. Changes in temperature and air quality because of climate change are essential environmental factors that affect people directly.
As the climate changes we see temperatures rising in some areas and deceases in temperature in other areas. These changes can mean different things in different regions, elsewhere the summer may be much warmer, in other regions winters can be colder. With the changes in our climate, extreme weather phenomena become more common, such as summer heat waves.
As hot days and heat waves increase, heat-related illnesses and mortality increase. Nurses should be aware of the local weather conditions and patient groups that are particularly vulnerable to the health effects of climate change and take appropriate actions to support adaptation practices in their work.
The aim of this study was to identify the health effects that Finnish registered nurses associate with climate change. The aim was also to find out how prepared registered nurses are to address the health effects of climate change.
The literature review was conducted to determine whether there is a gap in research. In addition to the review, a descriptive qualitative study was conducted. The research material was collected through semi-structured focus group interviews. Study participants were graduate nursing students at the University of Eastern Finland (n = 6) in the autumn of 2018. The verbatim focus group transcripts were analyzed by inductive content analysis.
According to the results, the RNs felt that they were unaware of the health effects of climate change. The interviews revealed that RNs have observed a lot of climate change health effects in their patients. However, they had not linked the changes in the patients' health to climate change. The nurse participants shared that nursing studies and workplace education did not address the impact of climate change upon human health. This confirmed the need to develop nurses' education regarding climate change and health effects.
Findings from this study can be used to identify areas for educational preparation to integrate the identified health impacts and learning needs into nursing curricula and professional development. Results will also add to the body of literature about climate change health impacts in Finland.
Keywords: Climate change, Health effect, Nursing, Nurse, Environmental Health
1 INTRODUCTION
The term climate change has become synonymous with human-induced global warming. In scientific texts, global warming refers to an increase in surface temperature, whereas climate change includes global warming and all other impacts of rising atmospheric greenhouse gases.
(UN 2019, WHO 2018.) In early 1990’s there was little evidence or knowledge about the impact climate changes on human health and this reflected as a general lack of understanding. In 1991 the first report that associated climate change with heath risk was released from Intergovernmental Panel on Climate Change. (IPCC 2019, UN 2019, WHO 2019.)
In 2015 Committee of the Parties (COP) of United Nations Framework Convention on Climate Change (UNFCCC) made an agreement with participating nations to combat climate change.
This agreement is better known as the Paris Agreement. For the first time, the Paris Agreement brought all signatory nations together to make ambitious efforts to combat climate change and adapt to its effects. Thus, it charted a new course in global climate work.22 April 2016, 175 world leaders signed the Paris Agreement at United Nations Headquarters in New York (Paris agreement 2015, WHO 2019.) In the Finnish Climate Act (609/2015) states as one of its purposes to enhance and coordinate the activities of state authorities in planning measures that are aimed at mitigation of climate change, adaptation to the changes, and at the monitoring of the implementation of these measures.
Paris Agreement (2015) includes the preparation of health professionals to address the climate impacts and in the autumn of 2018, The International Council of Nurses (ICN) revised the climate and nursing position statement and addressed the needs to prepare nurses related to climate change. The Finland nurses’ association is a member of ICN. (Sairaanhoitajaliitto 2014, ICN 2018.)
Climate change affects people’s health directly and indirectly. Changes in temperature and air quality are essential environmental climate change factors that affect people directly. Climate changes indirect health effect can be transmitted through ecosystems and the services they produce, such as changes in water, soil, and air quality also effect the health of people.
According to latest estimates, global average temperatures will increase three to five degrees Centigrade by the end of century. In Finland, temperature rise is estimated to be 1,5-2 times greater than other countries in Europe; with average temperatures causing an overall increase
of daily temperatures. (Maa- ja metsätalousministeriö 2014, De’Donato et al. 2015, Ilmasto- opas 2018, IPCC 2018.)
It is estimated that especially in Finland, winter temperatures will rise and that severe cold temperatures will become increasingly rare. In the summertime temperatures are expected to rise, and heat waves will become more frequent. Due to the change in temperature, it is projected that there will be less snow-cover, the thickness of the snow layer will decrease, and there will be less ground frost. All these changes will influence people’s health in many ways.
(Maa- ja metsätalousministeriö 2014, Tuomenvirta et al. 2018.)
In Finland the climate change is estimated to have an impact at least on the following health risks: heat-related illness, water epidemics, vector-borne infectious diseases, slip accidents, and indoor air problems related to moist damages in buildings. In Finland the potential for healthcare adaptation to climate change effects is good. The adaption can be done by developing health and social care units to prepare for disruptions caused by extreme weather events, improving citizens' awareness of the health risks of climate change and their readiness to respond to them, and tracking the effects of weather and climate using data collection systems in the environment and health sectors. (Maa- ja metsätalousministeriö 2014, THL 2019b.)
In July 2018, there were 27 days that the temperatures exceeded 25 degrees in Finland and in Helsinki for six consecutive days temperatures were over 30 degrees. This gives cause for concern in healthcare. During this millennium, significant heat waves have been occurring in Finland in summers 2003, 2010, 2014 and 2018. During earlier heat wave periods in Finland, the mortality of elderly people has increased significantly. The effect was particularly evident in people over 75 years of age. The Finnish National Institute of Health and Welfare (THL) is researching how extreme weather events, climate change, and its prevention measures can affect people’s health, and how to prevent adverse effects and how the healthcare system can adapt to the challenges of climate change. (Kollanius & Lanki 2014, Ruuhela et al. 2017, Pilli- Sihvola et al. 2018, THL 2019b.)
With climate change affecting people’s health, the need for social and healthcare help and support is rising. Current health policies related to climate change should reflect the risk to human health. Healthcare professionals must be prepared to face new illnesses, climate refugees, and increases in severity of existing illnesses; thus. healthcare professionals must
adapt to a changing working environment. (Maa- ja metsätalousministeriö 2014, THL 2019a, McMichael 2018.)
In United States and Canada, nurses have reported that they do not have ways to address climate change affected health problems for their patients. Climate health knowledge education can help bridge that gap. (Polivka et al. 2012, Valois et al. 2016, Leffers et al, 2017.) ICN (2018) has made statement that nurses work in frontline in battle to climate changes health effects.
Registered nurses as healthcare professionals are obligated to contribute climate change adaption (reduce vulnerability to harmful effects) and mitigation (reduce or prevent greenhouse gas emissions) as they are committed to protecting and promoting health of their patients. ICN (2018) states also that there is need for educated and prepared nurses in this area.
In Finland, there are no published studies about nurses’ observations regarding climate change and health impacts; nor is there evidence about the nurses’ role in addressing health problems related to climate change. In this way this study is unique and first of its kind. The aim of this study is to identify the climate change related health problems observed by RNs. Another aim is to identify nurses’ perception of their preparation to address climate changes health impacts.
Findings from this study can be used to identify areas for educational preparation to integrate the identified health effects and learning needs into nursing curricula and professional development. Results will also add to the body of literature about climate change health effects in Finland.
2 CLIMATE CHANGES HEALTH EFFECTS IN EUROPE
Climate changes affected health problems are viewed in study’s theoretical framework.
Framework for the study is based on the international research and literature. (Grove et al.
2013.) One research question was addressed in literature search: What health effects are associated to climate change in European region?
2.1 Literature review
Systematic literature search was used to conduct the literature review in this thesis. The following seven stages were used in the literature review process (Valkeapää 2016.):
1. Review question
2. Inclusion and exclusion criteria 3. Search strategy
4. Study selection 5. Data extraction 6. Quality assessment
7. Data synthesis and plans for dissemination
Specified and exact inclusion criteria help to choose the studies for the review and reduces chance of bias in review(Valkeapää 2016). Specific inclusion and exclusion criteria were made with the help expertise of Dr. Ruth McDermott-Levy and the supervisors of the thesis.
The literature review was conducted between August - October 2018. Literature search was updated throughout whole thesis process. A review of the literature was done systematically from reliable databases (PubMed, Scopus, CINAHL and Medic). Search phrases were developed related to climate and health for the database searches. Knowledge of information specialist and supervisors of the thesis were used in forming keywords for searches. This increases the reliability of the review. Search phrases for the databases were: “Climate change”
OR “Global warming” AND Health* AND Europe OR EU. Searches were limited to five years;
year limitations were from 2012 to 2018 so that complete five years would be included. Selected literature was limited to peer reviewed literature and by language of English and Finnish.
Results from database research is described in Table 1.
Table 1. Database searches
Selection of studies to include started by limiting results by title. Studies that did not answer the study question, did not cover humans, were conducted outside Europe, or covered agriculture or car industry were excluded. In the second phase of review, studies were limited by abstract. In this phase the same inclusion criteria were used as in title selection. Limitations by title and abstract were conducted in September 2018. Inclusion and exclusion criteria are described in table 2.
Database Keywords Limitations Results Selected
Cinahl “Climate change” OR “Global warming” AND Health* AND Europe OR EU
year 2012-2018 Language: English Research article, Peer reviewed
199 6
PubMed “Climate change” OR “Global warming” AND Health* AND Europe OR EU
year 2012-2018 Language: English Research article, Peer reviewed
55 6
Scopus “Climate change” OR “Global warming” AND Health* AND Europe OR EU
year 2012-2018 Language: English Research article, Peer reviewed
201 9
Medic "Climate Change" OR Ilmastonmuutos OR
"Environmental Health" AND Health OR Terveys
year 2012-2018 Language:
English/Finnish Research article Peer reviewed
46 0
Manual research
Reference lists from approved studies, Course material
year 2012-2018 Language:
English/Finnish Research article Peer reviewed
2 2
Tablet 2. Inclusion and exclusion criteria for studies
Inclusion criteria Exclusion criteria
• Publication year 2012 – 2018
• Language English or Finnish
• Study is focused on climate change or global warming and its health effects
• Study is focused on human health
• Literature is peer reviewed
• Original study or article about study or research
• Publication year is before 2012
• Not a scientific article
• Study does not cover humans
• Article is about industry or animals
• Study is conducted outside Europe
• Article is not available
Before the quality evaluation phase, studies were read completely. After this phase, a manual search was conducted from the included studies reference list. This search yielded two studies for quality evaluation. After evaluation 23 research articles were chosen for the literature review (Appendix 1). Reading and evaluation were conducted in October - November 2018. The literature search process is described in figure 1.
Figure 1. Literature search process: including and excluding studies Dublicates removed
(n = 352)
Studies included in literature review (n =23) Included by title
(n = 149) Results
Cinahl (n=199), PubMed (n=55) Scopus (n=201), Medic (n=46)
Excluded by title (n= 216)
Studies for the quality evaluation
(n =21)
Excluded by whole text (n = 34)
Included by abstract (n = 55)
Excluded by abstract (n = 94)
ScreeningCompabilityIdentifyingIncluded in thesis
Manual search (n = 2)
The literature included in this study were systematically evaluated with Joanna Briggs Institutes (JBI) critical appraisal tool (Joanna Briggs Institute 2014). Studies included in this literature review (=23) were evaluated with an appraisal tool that is suited for the study in question.
According to Joanna Briggs Institutes guidelines, the evaluation of research articles should be done by using a critical appraisal tool and by two independent researchers and the result gained from appraisal should be compared to ensure quality of the research. Appraisal of the studies was done in November 2018. All the studies chosen for evaluation met the appointed criteria and were included in thesis (Joanna Briggs institute 2014.)
2.2 Health problems related to climate change
There is a distinct connection with climate change and health. Climate change causes extreme weather events, such as heat waves, flooding, and wildfires. All these events have human health effects; extreme heat causes cardiovascular problems, flooding has effect on mortality by drownings and secondary effects on flooding is mental health problems such as depression and wildfires lead to server respiratory impacts, loss of life and shelter. (Gasparrini et al. 2015, Heaviside et al. 2016, Curtis et al. 2017.)
In studies included in the literature review there were two main themes that were noted; extreme temperatures (hot and cold) and problems with air quality and their effects on health. Most of the studies mentioned increase of respiratory and cardiovascular problems as climate changes’
impact on human health; also, injuries were mentioned as a result of cold weather. Climate changes effect on infectious disease is acknowledged, but more studies are needed considering variations in demographic and non-climatic conditions that effect people’s health. (Åström et al. 2013, Suk et al. 2104, Akin et al. 2015, De’Donato et al. 2015, Gasparrini et al. 2015, Curtis et al. 2017, Doherty et al. 2017.)
The reviewed studies showed that more research is needed to assess current and future impacts of extreme weather events caused by climate change. For example, more research is needed on extreme heat effects on facilities, such as care homes for elderly. Also, studies that examine climate change effecting human health burdens from air quality are needed (Amengual et al.
2014, Hajat et al. 2014, Heaviside et al. 2016, Curtis et al. 2017, Doherty et al. 2017.)
2.2.1 Extreme temperatures
The studies that were reviewed showed that extreme temperatures, both heat and cold, have had an effect on mortality throughout Europe. Projections and assessments report that there will be heat waves in Europe more often and mortality will rise without adaption in the healthcare system and building structure. Understanding both, the impacts of extreme temperatures on health and the measures that can be taken to reduce those impacts is important for planning actions for to protect public health. (Leone et al. 2013, Amengual et al. 2014, Hajat et al. 2014, Martinez et al. 2016, Gasparrini et al. 2017.)
Extreme temperatures, heat and cold, as associated with increases in hospital admissions and mortality rates in European countries. However, there was no clear evidence of association between heat extremes and emergency hospital admissions. Cold waves increased treatment for the respiratory conditions and increase of emergency treatment of different kind of injuries from falling. (Alcoforado et al. 2015, De’Donato et al. 2015, Gasparrini et al. 2015, Oudin et al.
2015, Heaviside et al. 2016, Oudin et al. 2016, Curtis et al. 2017, De’Donato et al. 2018.)
Even a rise in ambient temperature of 1° Celsius increased mortality rates and hospital admissions in the United Kingdom. In Europe there were more deaths associated with extreme heat events, than in other climate change related weather events. (Hajat et al. 2014, Heaviside et al. 2016, Curtis et al. 2017.) Low temperatures can also create difficulties for patients in accessing hospital facilities and emergency staff. Extreme temperature conditions, such a high heat or severe cold have been associated with death in European countries. (Debono et al. 2012, Leone et al. 2013, De’Donato et al. 2015, Oudin et al. 2016.)
Without climate adaption, it is predicted that mortality rates will rise as much as 257% by 2050 (Hajat et al. 2014, 644).
There are similarities with deaths caused by high temperature and low temperatures. Both heat and cold effects human cardiovascular and respiratory health and mortality. Heat and cold affect people differently, heat causes heatstroke and dehydration and cold leads to hypothermia.
(Gasparrini et al. 2015, Curtis et al. 2017.) Heat waves are associated with increases in hospital admissions for respiratory disease. Additionally, heat affects electrolytic balance, homeostasis, and infants, children, older adults, outdoor workers, and people with chronic diseases are especially vulnerable to extreme heat. In severe cold cardiovascular mortality increases;
although, there have not been observed increases in hospital admissions. (Åström et al. 2013, Amengual et al. 2014, Hajat et al. 2014, Gasparrini et al. 2015, Curtis et al. 2017.)
Studies showed heterogeneity in temperature related mortalities. In Stockholm and Helsinki, the heat related mortality was mostly attributable to rise of cardiovascular deaths comparing to London, where there was increase of respiratory deaths (Leone et al. 2013, De’Donoto et al.
2015.) The elderly are more vulnerable to the effects of heat than younger people. Also, people with pre-existing health conditions are more likely have temperature related health problems.
Hospital admissions associated to heat waves were more pronounced in Southern Europe than in Northern and Central European countries. (Leone et al. 2013, Suk et al. 2014, Gasparrini et al. 2015, Oudin et al. 2015, Curtis et al. 2017, Leyva et al. 2017.)
Despite the relationship between climate change and human health, studies have not noted a relationship between seasonal mortality and climate change. Extreme temperatures are projected to increase in the future with associated health related problems. Additionally, cold waves are projected to become less frequent in the long term, but heat waves are likely to increase. (Forsberg et al. 2012, Leone et al. 2013, Amengual et al. 2014, Heaviside et al. 2016, Oudin et al. 2016, Garparrini et al. 2017.)
2.2.2 Air quality
Climate change affects air quality through heat waves. Extreme air pollution events are associated with heat waves. Quantity of ozone (O3), pollens, and air borne particulate matter (PM) have increased in the air with subsequent human health effects of allergies, cardiovascular, and respiratory problems and mortality. Long-term and short-term exposure to particulate matter is associated with increases in mortality. (Hänninen et al. 2014, Doherty et al. 2017.)
Short-term exposure to ozone is also associated with cardiovascular problems; while long-term exposure to ozone causes respiratory problems. Increases in pollen quantity leads to greater allergic response, more respiratory and sinus problems for pollen sensitive persons. (Forsberg et al. 2012, Hänninen et al. 2014, Doherty et al. 2017.) Exposure to high levels of ozone or particulate matter has been estimated to affect mortality in Europe during the summer 2003.
Particulate matter (PM) is one of the biggest environmental burdens in Europe and exposure to
high levels of PM was estimated to attribute to rises in mortality in Europe. (Hänninen et al.
2014, Doherty et al. 2107.)
Environmental and respiratory specialists have estimated that health risks to humans are more severe and direct from extreme temperatures, but health effects from air quality should also be considered as a human health risk. There is strong evidence that heat waves effect air quality and therefore affects human health and mortality. It is estimated that ozone and PM contributed to one third of the deaths from the 2003 heat wave in the United Kingdom. (Åström et al. 2013, Hänninen et al. 2014, Curtis et al. 2017.)
It is projected that with rising temperatures and worsening air quality, respiratory problems and respiratory affected hospital admissions will increase in Europe. In assessments, Southern Europe is projected to have increase with respiratory affected hospital admissions and mortality.
There are also projections of increases in summertime ozone in Southern Europe, with less change in ground level ozone in Northern Europe. (Curtis et al. 2017, Doherty et al. 2017.) For airborne particulate matter there are uncertainties in future predictions, because of studies related to effect of climate change on PM are limited. Also changing effects of temperature on PM makes it hard to make assessment about future. (Forsberg et al. 2012, Åström et al. 2013, Hänninen et al. 2014, Curtis et al. 2017.)
2.2.3 Infectious diseases
Risk of infectious diseases rises with climate change. Experts on climate change agree that health authorities or governments are the most capable to respond to climate change influenced infectious disease risk. (Akin et al. 2015, Curtis et al. 2017.) Due to warmer temperatures tick- borne infections have spread to higher latitudes, high summer temperatures facilitated transmission of West Nile virus in 2010. High summer temperatures and changing temperatures possible have been the cause of outbreaks of water- and foodborne diseases such as salmonella and campylobacter in Southeast Europe. (Suk et al. 2014.)
Vulnerability of populations and disease burden of infectious diseases varies greatly across countries and regions. Infectious disease variation is caused by non-climatic factors like changes in economic development, income level, demographic structure of a population, and
social capital of the country. Therefore, infectious disease risk from climate change of Europe is comparatively limited. (Suk et al. 2014, Akin et al. 2105.)
2.2.4 Cultural effects
The effect of climate change also influences culture and social structures of indigenous populations in Finland. Jaakkola et al. (2018) found that besides health, climate change has effects on cultural well-being on Saami people. Adaption and mitigation measures might affect health and well-being of the Saami, while climate change is affecting the Saami people’s way of living and health. As assessments show, temperature will change and that will increase secondary health risk for both Saami people and reindeer in the arctic. Projections shows that climate change will affect temperatures and that way infectious diseases will expand into new territories and to northern territories also. (Suk et al. 2014, Curtis et al. 2017, Jaakkola et al.
2018.)
2.2.5 Mitigation and adaptation to climate change
It is important that healthcare professionals and the public have understanding about the magnitude of climate change and its health effects. Additionally, understanding areas of vulnerability and ability to adapt is important to health care professionals. (Suk et. Al 2014, Anåker et.al 2015.) Public opinion is that climate change is a health threat and mitigation policy is needed. There is willingness by the public and climate change experts to implement measures to address climate change. In health care, professionals felt that environmental issues such as climate change were overshadowed by other work requirements. (DeBono et al. 2012, Forsberg et al. 2012, Akin et al.2015, Anåker et.al 2015.)
In a Swedish study (Anåker et al. 2015.) researchers find out that nurses felt they needed more support and guidelines to address climate change. Nurses also stated that climate change is not their main priority in healthcare, since there is not time to address it. Dutch experts on climate change says that there should be preventive action and associated adaption and mitigation policies. (Forsbeg et al. 2012, Akin et al. 2015, De’Donato et al. 2018.) In Italy a national heat advisory plan was developed after the summer of 2003 heat wave. The plan included local free of charge helplines and training toolkits for healthcare providers. The training toolkit included seminars, workshops, courses and emergency guidelines or heat related procedures. The plan
also has recommendations for hospitals, nursing homes, and residential homes for elderly. With this plan there were not only reduction in heat-related mortality, but also an overall reduction in heat-related effects on health. (DeBono et al. 2012, Forsberg et al. 2012, De’Donato et al.
2018.)
2.3 Summary about basis for study
The literature review was completed to determine impacts of climate change on human health in European countries and in Finland within last five years.
There is a well-established link between climate change and human health. The public and experts are aware of climate change attributed health effects. People are willing to make changes in their lives to address climate change, but they need clearer policies regarding actions to take. The health care sector needs adaption and mitigation policies to address health problems caused by climate change. There is evidence from an Italian study that there is a clear plan for heat waves that can reduce mortality and heat effects. (Debono et al. 2012, Forsberg et al. 2012, Akin et al. 2015, Curtis et al. 2017, De’Donato et al. 2018.)
The impacts of extreme heat events were included in most of the studies. Future projections about heat waves and the effects on health and mortality in Europe reveal that without adaption and mitigation heat caused mortality will rise. The heat wave in the summer 2003 was mentioned often in studies and many of studies were conducted after that heat wave and were addressing health effects caused by extreme heat. Flooding and its health effect were mentioned in one study, there were no resent studies on flooding. (Leone et al. 2013, Alcoforado et al.
2015, De’Donato et al. 2015, Gasparrini et al. 2015, Oudin et al. 2015, Heaviside et al. 2016, Oudin et al. 2016, Curtis et al. 2017, De’Donato et al. 2018.)
Heat waves impact worsening air quality with subsequent impact on mortality. (Forsberg et al.
2012, Hänninen et al. 2014, Doherty et al. 2017.) Infectious diseases were linked to climate change in two studies, in both studies it was mentioned that more studies are needed to establish adequate responses to infectious diseases and climate change (Suk et al. 2014, Akin et al. 2015).
There were no resent studies on climate changes effect on people’s mental health, but there was mention about mental health and physical morbidity as secondary effect with exposure to flooding (Curtis et al. 2017).
Nurses’ perceptions and observations of climate change health effects have not been studied in Europe. There was only one study was conducted in Sweden, but it did not include nurses’
observations on climate change and the health effects on their patients, it was focused on exploring nurses' perceptions of climate and environmental issues. The studies show that healthcare professionals play a critical role in healthcare sustainable development. Healthcare professionals needs clear adaption and mitigation guidelines (Akin et al. 2015, Anåker et al.
2015, De’Donato et al. 2018.) The literature review showed that there is a clear gap in knowledge about nurses’ observations on climate change and the health effects on their patients.
Finland was included in two international studies (Hänninen et al. 2014, De’Donato et al. 2015.) and there was one study (Jaakkola et al. 2018) about Saami people’s health and well-being related to climate change. This shows that there is gap in knowledge regarding specifically what health effects related to climate change are observed by nurses in Finland.
3 AIMS OF STUDY AND STUDY QUESTIONS
The aim of this study is to identify the health effects Finnish RNs associate to climate change.
Additionally, the aim is to find out how prepared nurses feel to address climate changes effects.
Findings from this study can be used to identify areas for educational preparation to integrate the identified health effects and learning needs into nursing curricula and professional development. Results will also add to the body of literature about climate change health impacts in Finland.
Study questions are:
1. What health effects are associated to climate change in European region?
2. What health effects do Finnish registered nurses associate to climate change?
3. How prepared registered nurses are to address the health effects of climate change?
4 DATA COLLECTION AND ANALYSIS
A qualitative descriptive study was done to add the literature regarding the health effects related to climate change that Finnish RNs have observed. In qualitative descriptive methods new knowledge is generated about concepts for which there is limited research (Burns & Grove 2013, Elo et al. 2014, Sandelowski 2012).
The qualitative descriptive research method was used in this study, because the purpose of the study was to describe nurses’ experiences, observations, and interpretations. The focus group interviews were conducted, as data collecting method, to ascertain what health conditions Finnish registered nurses have observed in their nursing practice related to climate change (Hirsjärvi et al. 2007, Kankkunen & Vehviläinen-Julkunen 2010.)
4.1 Research Design
The topic of this study was RNs and their observations of their patients’ health. Therefore, the descriptive study method was used in this research. Qualitative descriptive study methods provide comprehensive summaries of the phenomenon. Descriptive study design is relevant in research, where information is required directly from those who have experience of the phenomenon; when time and resources are limited; and when little is known about the topic under investigation. (Sandelowski 2010, Bradshaw et al. 2017, Polit & Beck 2017.) The descriptive study design tends to be subtle and often adapts techniques and methods from other qualitative study traditions. Qualitative descriptions are interpretive and brings findings closer to researcher like in phenomenology. (Sandelowski 2010, Vaismoradi et al. 2013, Polit & Beck 2017.)
Focus group as interview format has been used in social science research more than 60 years and has become popular in health research. The purpose of focus group interviews is to collect beliefs, attitudes, and knowledge from a defined set of participants. Typically, selected participants in focus group are homogenous and share similar background. The advantage of focus group interviews is that participants hear other viewpoints and interact with the other focus group members in one interview. Also, participants may react to what is being said by
others, therefore leading to deeper knowledge on subject in study. (Peter 2015, Polit & Beck 2017.)
4.2 Data Collection
Research participants were selected by the following inclusion criteria;
1. Age over 18 years old.
2. Have worked in Finland as nurse over 10years.
3. Speaks Finnish or English.
The inclusion criteria assured that the participants would have their own perceptions and experience of the phenomenon being studied. (Grove et al. 2013, Kankkunen & Vehviläinen- Julkunen 2013, Elo et al. 2014.)
Participants were recruited through a contact person from the Faculty of Health Sciences in University of Eastern Finland, both masters and doctoral students, with registered nurses’ basic education, were contacted by email (Appendix 2). Snowball sampling was also used, as people were asked to share the information about the study with their colleagues. RNs who stated their willingness to participate in the interviews were given the interview questions beforehand, so they could prepare themselves for the interviews. (Grove et al. 2013, Josselson 2013.) The aim was to get two to three focus groups to interview and two to eight people in each focus group.
The result of recruitment was two groups with a total of six participants (n=6). Both interviews yielded a total of two hours and ten minutes of recorded data.
Before the interviews, participants received a fact sheet about study (Appendix 3). They also got information and consent about study orally. After reading and listening information participants had opportunity to ask questions from researcher. All the voluntary participants, agreed to participate, and signed informed consent (Appendix 4).
Focus group interviews were semi-structured interviews. In semi-structured interviews the interviewer leads the conversation with the questions or themes, but interviewees can discuss about their thoughts freely. Also, the interviewer might ask clarifying questions and even the order of the questions might vary. For interviews the interview questions gave direction; not previous research data on the subject. (Tuomi & Sarajärvi 2009, Kankkunen & Vehviläinen- Julkunen 2013.)
Interviews were conducted in Finnish.Registered nurses were asked about the effects of climate change that they have observed in their patients. Questions in focus group interviews dealt with the changes in patients’ health affected by climate change, that participating nurses had seen in their patients based on each body system (Appendix 5).
4.3 Data analysis
In the beginning the audio-recorded interviews were transcribed verbatim by the investigator.
The transcription was done soon after the interviews, so the materials were quickly ready for the analysis. Forty-five pages of written material, with font size 12 (Times New Roman) and line spacing 1,5. Transcripts were translated to English by an independent translator. This was done because main investigator did not speak Finnish. Transcripts were read repeatedly, and themes were developed by using content analysis. Two investigators analyzed data independently and there was agreement of themes. (Elo et al. 2014, Bengtsson 2016.)
Inductive qualitative content analysis was used in this study. Words and phrases were categorized by the meaning of the phases. Key terms from the verbatim transcripts were placed in categories; the categories were developed from the research questions. (Kankkunen &
Vehviläinen- Julkunen 2010, Kyngäs et al. 2011, Elo et al. 2014.) Broad categories were developed and then themes about research subject were created (Tuomi & Sarajärvi 2009, Polit
& Beck 2017).
Inductive content analysis has three steps: 1) reduction, 2) clustering, and 3) abstraction. In data reduction you simplify data from interviews, so all the unnecessary data is eliminated. In clustering, the researcher creates the preliminary descriptions about research subject. This is done by carefully processing the research data and by identifying concepts that describe similarities and differences in the data. After clustering, the researcher does abstraction. In abstraction the essential data for research is gathered and theoretical concepts are formed from abstracted data. (Tuomi & Sarajajärvi 2009, Kankkunen & Vehviläinen- Julkunen 2010, Polit
& Beck 2017.)
Original expressions were underlined based on aim of the research and research questions.
Whole sentences and contents were selected for the analysis unit in this study. The analysis
units were put on the table and reduced so their core content stayed the same. All the expressions for the same phenomenon were put in the same group inductively. The researcher reviewed several times that all the expressions answer for the group and all substantive information was taken into analysis. (Elo et al. 2014, Bengtsson 2016.)
After clustering, the researcher categorized statements by their content. In this phase accuracy of the clustering was re-examined. All the categories became more accurate as analyzing proceeded and all categories were based on interview materials. In the classification, the material was conceptualized by combining concepts based on the contents of different categories. In the abstraction phase main categories were formed (Appendix 6). (Elo et al. 2014, Bengtsson 2016.)
Using inductive content analysis one main category, three main themes and 16 sub themes were formed, to describe RNs’ observation of health effects from climate change in Finland.
5 RESULTS
In focus group interviews, RNs identified four main groups of people who were more vulnerable to climate change. These groups were the elderly, children, immigrants and refugees, and health care professionals. Nurse participants thought that these more vulnerable groups should be more carefully considered in and in their work especially when describing the health impacts of in extreme weather events.
The main climate change related health problem that was identified was respiratory diseases, mainly asthma and caused by dust in the air. Participants also had observed more skin, respiratory and gastrointestinal infections than before and greater frequency of accidents, like broken bones. RNs had also noticed an increase in mental health problems with their patients, but they were not sure if it was related to climate change or something else.
The nurse participants felt that they were not professionally prepared to address the impacts of climate change in their patients. They felt that they required education of nurses, both in nurse’s curriculum but also education in workplaces. They felt that they needed clearer policies in their workplaces related to the changing climate in Finland. Participants acknowledged that Finnish people should look beyond Finland to understand the climate change health impacts. The participants also reported that there is a need to develop climate adaption and intervention policies.
Figure 2. Finnish RNs’ observations of climate change
RN s' ob servation s of c lim ate change
Vulnerable groups to climate changes health
effects
Elderly
Children
Immigrants and refugees
Healthcare professionals
Health effects associated to climate change
Respiratory problems
Infections
Injuries and accidents
Mental health problems
RN's preparedness to address climate changes
health effects
Nurses' education
Clearer policies
Adaption and intervention
Global perspective
5.1 Background information of the participants
There were two focus groups, one in Kuopio and one in Helsinki. There were a total six (n=6) participants (one focus group with 2 participants, and one focus group with 4 participants). All the participants (n=6) in the focus groups were registered nurses. Four of them worked as registered nurses in hospitals and two worked in public health. All of them worked in Finnish healthcare. The participants had work experience between 10 to 29 years, with an average of 23 years. Their ages were between 25-64 years. Data regarding age was collected in four different age groups (Appendix 7. demographic data), that is why it appears that the youngest participant is 25, but that is not the case. There were both male and female participants.
Participants lived both in cities and rural areas of Finland.
5.2 Main groups vulnerable to climate change health effects
RNs identified that four groups were most vulnerable to climate change. These four groups were: elderly, children, immigrant and refugees, and healthcare professionals (Figure 3).
Figure 3. Main groups vulnerable to climate change health effects
Main g ro up s vu ln erable to clim ate change h ela th ef fec ts
Elderly
More affected than younger population
Have more accidents in winter
Greater chance for heat related dehydration
Get more infections
Children
Change in accidents, increase in summer
Greater chance to get heat related dehydration
Immigrants and refugees
There will be more immigrants and refugees
They might have different germs
With them comes different diseases
Healthcare Professionals
Working facilities old, nurse are more exposed to
extreme weather events
5.2.1 Elderly
Elderly were considered the most vulnerable to climate changes health effects. RNs had observed that elderly were greatly affected by the summer of 2018 heat waves. Participants described that they had observed dehydration with elderly in the summertime. They also observed more elderly with heart failure, because they might drink too much fluids to remain hydrated in the heat. As a result of preexisting health conditions, the elderly were considered to be more affected by heat waves than a younger patient population. The nurse participants shared that overall the Finnish population is growing older and therefore, there are more elderly admitted to the hospital and seen in emergency rooms
“and overall population is ageing---we have more elderly patients. That’s another reason why I think they are at greater risk of these changes”
“people are older, and they are more…they get easily infections if they are...they don’t drink and don’t eat properly and in home they are alone, and they don’t manage so well. And their immunology is low.”
Participants had observed that there was a relationship between shorter wintertime and accidents with the elderly. It was observed that in the wintertime temperatures change quickly with very cold temperatures and temperatures above 1 OC, and those changes caused roads to be icy. Iciness led to more frequent accidents and injuries and might even cause the elderly to be afraid to leave their homes.
“And then the elderly people without mobility issues…they are too scared to go outside when there are extreme weather conditions, they also won’t be able to move---their mobility is limited”
More infections had been observed, mainly skin infections and respiratory infections among elderly patients. These infections had been observed to be more frequent in the summertime.
The participants thought that skin infections might be caused by increased summer temperatures and therefore more perspiration and no possibility to shower by themselves. They had observed more hospitalizations with the elderly because of infections.
“they are referred to hospital and quite lot urinal infections, skin infections and pneumonia and other respiratory infections…”
Participants also expressed concerns about living situations of the elderly. In the summertime temperatures increase in homes and there might not be ways to cool the indoor temperatures or even get out of their homes. There was also worry about the elderly getting help they needed, especially in in time of extreme temperatures.
“I’m personally worried about the old people living alone in an apartment block, a hot summer like this one, when temperatures are rising to God know what…”
“Old people too. So, they cannot…they are stuck at home if they have difficulty with mobility, the cannot leave and have difficulty getting caregiver to take them out and their apartment is hot in the summer and cold in the winter”
Some older people are known to live alone in their home, and RNs had concerns about how they eat and drink, because in hot days there have been increased hospitalizations because dehydration. Also, they had knowledge that homecare workers had to remind elderly to drink enough in summertime.
“Older people…as summers are hotter, they get dehydrated more easily”
“in home care or home nursing they kind of give fluids to them in advance so they (meaning elderly) won’t get dehydrated…I’m not sure if they do that with IV or by giving them fluids to drink”
Participants had also observed in their workplaces, in summer 2018, that in some cases older patients could not be discharged from the hospital because of their homes were overheating in hotter days. They said that it was like “evacuating” elderly from their homes to cooler places in those hottest days in summer. They had also observations that extreme weather events in wintertime have caused municipalities to remove the elderly from their homes.
“they couldn’t be discharged from hospital to their homes because their rooms were so hot…so we had to evacuate them”
“If there are extreme conditions, such as during last winter, having a ton of snow…they had to be evacuated from their homes to hospitals…”
5.2.2 Children
Children were also considered to be more vulnerable to climate changes than adults. RNs had also observed that accidents happened in seasons, and these terms had changed. The number of wintertime accidents, like skiing accidents, were getting less frequent and the incidence of summer accidents, like accidents in trampoline, were increasing. The nurse participants associated the seasonal change in accidents to climate change
“as winter gets shorter, there has been clear drop in sled accidents related surgeries at the ward—by the contrast, the season for trampoline accidents and cycling accidents are longer”
The participants had concerns about children being more at risk for dehydration in hot summer days, since children are smaller in size and spend more time outside than adults. Also, they had observed that even in hot days children play outside a lot and might forget to drink enough.
Also, there were observations that there were not many opportunities for “real” outdoor activities.
“There aren’t much of these real outdoor activities…these days, there’s no way to get them to go outside (meaning children in winter)”
Participants had noticed that there is inequality in hobby opportunities between children living in cities and living rural areas. Rural areas are getting depopulated and people are moving to cities, so schools are moved to cities. So, the children might spend their free time after school in busses back from school and have no time for hobbies. That creates inequality. They thought that this reduced population in rural areas might be originated from climate change and its effects on agriculture and from that to work opportunities in rural areas.
“children who live near to school and city, have possibilities to go hobbies after school but children from countryside spend their time in bus.”
5.2.3 Immigrants and refugees
There were observations of increase of immigrant and refugee patients in healthcare. The nurse participants noted that there was more unrest in world and that has increased immigration, but also, they had observed that climate change had influenced in immigration worldwide. They had noticed also, when people move more between borders there is increased risk of new diseases in Finland.
“those germs and different kinds of germs and such (germs) that we’ve already been able to get rid of…”
“I mean that is an effect of the climate change if you get climate refugees. “
“That’s something you can already see clearly is that the diseases already disappeared from Finland are on the way back.”
One surprising observation was that drowning accidents in summertime were increased in last ten years and most people who drowned were immigrants. They related the greater number of immigrant drownings to their inability to swim.
“But in summertime drownings is increasing, because there are these immigrants who can’t swim.”
“the drownings we get are more often these immigrants unable to swim”
The RNs acknowledged that with immigrant and refugee patient population comes different and new health problems and diseases than domestic patients. The participants thought that this is an important topic to discus and consider, since all the participants expected that there would be more immigration in future. They acknowledged that there are also climate refugees, not just refugees from wars and other unrests from world.
“Probably some climate refugees in this country and they kind of bring along these kinds of germs which we don’t have in Finland.”
“those are some pretty potent germs that they’ve gotten here…I mean, things we aren’t even that familiar with”
“The fact that climate refugees, food refugees…this sort of immigration is increasing and bringing along certain things, which should be thought about in advance in health care”
5.2.4 Health care professionals
Health care professional were considered vulnerable, because they work at facilities that are not designed to withstand high temperatures, and thus it gets very warm inside during the hotter summers in Finland and the increase temperatures puts both patients’ and healthcare professionals’ wellbeing is at risk. RNs had experience from the summer of 2018 heat waves in Finland and observed that heat is not typically a problem for Finnish healthcare facilities.
They had observed that there are problems with air conditioning and that creates challenges for patient and healthcare professionals who work in those facilities. When outdoor temperatures are 30 degrees Celsius some spaces in healthcare facilities can become extremely hot with indoor temperature up to 35 degrees.
“there are no typically no problem with heat in Finland and people are not prepared for it---so that is the sort of challenge that has come up more often now than previously”
“I think this kind of darkness and humidity, which is increasing here and on the other hand the fact that we’ve never had to really think about hot temperatures here in Finland...that has an effect on the hospital environment”
Participants had observed that in hot weather when health care facilities heat up and there are no air conditioners and not enough fans for patients’ rooms, then there is no way to easy the heat in patients’ room or in nurses’ offices.
“These hot summers are problematic with lack of air condition”
“during a hot summer, so they give those to everyone who needs them…I mean those fans. And there’s been a real shortage of them”
Participants had also observed that climate change might have some effect on wound infections, since beforehand fans were not allowed to be used nearby when nurses treat patient wounds, but in those hot summers they had keep patients cool and use fans to do so.
.
“these fans, they used to be banned in infection prevention facilities, meaning that if you’re treating ulcers, you should not use fan there, but now you may use them –so the way it goes that you have keep patients cool somehow.”
RNs had felt drained and tired during those hot summer days. They felt that climate change had effect on healthcare professionals’ coping at work, mainly during heat waves. The participants have had trouble sleeping and had observed that the wards are hot so working there is harder than in colder weather. Also, they mentioned that they felt that there has been increase in heat waves in Finland in the last ten years and they felt during the heat waves patients were in “poor shape.”
“I think nurses are feeling pretty poor---I personally felt pretty drained on those worst (refers to heatwave in the summer 2018). I slept badly--- there are lots of patients----So it was pretty though, at least during last (2018) summer”
“And in the summertime hot, very hot…last summer, maybe some other summers also in ten years very hot. It’s not ordinary here”
However, the nurse participants had also observed that hospital management had responded to heat waves and the staff’s discomfort during the heat. These responses were making sure that nurses take frequent breaks and have drinks on hot days. Still there were observations that these responses were not enough
“Someone has even fainted in care room, a nurse…”
5.3 Health problems associated to climate change
There were four main health problems that RNs associated to climate change; respiratory problems, different infections, injuries, and mental health problems (Figure 4). The participants had all observed increases or changes in all of these in last ten years and associate these changes to climate change.
Figure 4. Health problems associated to climate change
Health problem s assoc iat ed to cli m ate change
Respiratory problems
More problems with patients with asthma and
allergies
Pollen season longer and more dust in air might cause for the problems
Infections
Gastrointestial infections
Skin infections
Respiratory infections
Injuries
Longer season for summerime accidents and
injuries
Wintertime accident season shorter
Mental health problems
More depression associated to dark seasons
5.3.1 Respiratory problems
RNs had observed more respiratory problems with their patients, especially in patients with asthma and allergies. They had noticed these problems occurring more widely than before.
Participants associated this with climate change and shortening of winter, an earlier spring, and pollen season starts earlier.
.
“you can see more of these asthma patients, so these allergy seasons have also spread out for a much longer period.”
“These very difficult asthmatic diseases which even prevent people from going outdoors”
Participants had observations about the spring season being longer and dustier. They noticed pollen seasons were longer and this caused problems for patients with asthma and allergies.
They also had observed that besides dustier springtime and longer pollen season, also colder freezing temperatures in wintertime have affected patients with asthma and allergies.
“I have noticed that in springtime there is much more longer time dusty and many people are suffering…asthma people, allergic people…they can’t breathe, they can’t go out, they can no train…do training, because it’s too dusty. This time gets longer and longer every spring.”
“Of course, for these asthma patients, this increasing period of dust [exposure]
in the spring and other hand extreme conditions…freezing temperatures, so these things…I’d connect it (means climate change) to these things”
5.3.2 Infections
The RNs noticed increases in different kinds of infections with their patients. They had observed more gastrointestinal infections, skin infections, and respiratory infections. There were also observations of more urinary infections in the elderly, but they did not associate those with effect from climate change.
“you could say that when it comes to asthma and allergies, and different inflammatory diseases of the digestive tract…it crosses my mind that there are more of these than so 20years ago.”
Participants observed that seasons for different infections were longer. They had observed that some infection seasons starts earlier and lasts longer, like human respiratory syncytial virus (HRSV) and Norovirus seasons. Also, they had observed that the season for ticks was longer.
The nurse participants had seen more frequent tick bites in their patients. They associated these phenomena to winter being shorter and warmer. Shorter wintertime allows tick season to be longer and higher winter temperatures might have effect on bacteria.
“There have been these infectious diseases for astonishingly long time, so that also happened earlier before so that now the RSV season [referring to Human respiratory syncytial virus]…the RSV season starts earlier compared to previously and last longer time. Same goes for diarrhea and intestinal diseases, those also…that season is much longer than it was before. There used to be spike in them in the spring…”
“When you think about environment…the winters are perhaps not that cold now in Finland. I mean this idea is installed in me that whenever temperatures get properly freezing, certain bacteria die…I mean in nature”
“In summer, at the health center you get…I feel like everyday someone comes there to have a tick removed”
Participants had noticed an increase in gastrointestinal infections in last ten years. They had observed more Crohn’s disease, different allergies, greater sensitivities to food, and different kinds of bowel syndromes, such as irritable bowel syndrome (IBS) in their patients.
“the digestive systems…they are increasing…last ten years”
“these sort of inflammatory intestinal diseases…various. Chron’s disease, enterocolitis…irritable bowel syndrome, perhaps more of these things have been turning up in recent years.”
RNs could not be sure if the reason for increase of these gastrointestinal infections were from climate change or something else. The nurse participants had observed that there was also more sensitivity and allergies for food. They have observed that their patients were more conscious about their eating habits and diets and these might be reason for different gastrointestinal problems they had observed and not climate change.
“I don’t know if that’s also related to allergies although that isn’t really an allergy, this sort of sensitivity to ingredients”
“It seems that people have more and more bowel symptoms, but what causes that- --but whether this is part of climate change”
The RNs observed an increase in skin infections in last ten years. The participants reported a greater frequency of new and different rashes, skin folds, infections, and more atopic symptoms.
They observed that there were more skin infections in the summertime, and associated these skin problems to people perspiring more from the heat. Also, the nurse participants observed that cold winters had affected patients with atopic skin. These skin problems were associated to climate change and its effects on Finnish temperatures.
“Well, those rashes caused by the heat, when people perspire and cannot wash themselves properly…you have to wonder about older people in particular.”
RNs noted an increase in both bacterial and viral skin infections. These infections were observed to be more of a problem for the elderly. The participants thought that the increase skin infections might be the result of heat, perspiration, and a weakened immune system. They also noted that not all elderly had the opportunity to wash themselves properly in hot days and that lead to skin infections.
“Well, those rashes caused by heat, when people perspire and cannot wash themselves properly…you have to wonder about older people particular”
