The value of a vulnerability assessment is that it allows health departments to understand the people and places that are more susceptible to adverse health impacts associated with the climate-related exposures within their jurisdiction.

Rather than conceptualizing vulnerability as a list of attributes, it facilitates greater clarity to use a conceptual model of vulnerability that is adaptable to local circumstances. The model below reflects three pathways to climate vulnerability: exposure, sensitivity, and ability to adapt.

Exposure refers to contact between people and stressors, which could be biological, psychological, biological, psychosocial, chemical, or physical, impacted by climate change. Often, multiple simultaneous stressors are generated by climate hazards.

Second, sensitivity is the degree to which people and communities are directly affected by climate change. This is typically driven by characteristics that place a person at greater risk of a negative health outcome if exposed, such as underlying health conditions or age. For example, children’s developing lungs and faster respiration make them more at risk for poor health outcomes when exposed to wildfire smoke.¹

A third pathway to climate vulnerability is the ability to adapt, which refers to the ability of communities, institutions, and people to adjust to potential hazards, take advantage of opportunities, or respond to the consequences. This adaptive capacity is also heavily influenced by social determinants of health such as education, social norms, and economic resources. Consider the ways in which these elements of vulnerability overlap and compound each other for certain communities, exacerbating the extent to which people are at risk for negative health outcomes.

Figure 3: Determinants of Vulnerability

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In addition, consider how intersectionality may inform your planning. “Intersectionality’ reflects how different forms of identity characteristics, such as race, ethnicity, class, gender, ability, and sexuality can overlap in ways to create multiple layers of discrimination or disadvantage.²

Some public health approaches have viewed vulnerability as a fixed characteristic or condition of groups of people rather than a consequence of historical and contemporary systemic marginalization and exclusion from opportunity. Too often, the underlying drivers of vulnerability, such as lack of economic resources and opportunities caused by historical or current racist policies, are not considered by public health interventions. For example, low-income and marginalized communities are sometimes intentionally located in flood-prone areas, as was the case with Hurricane Katrina. When historical and social context is not considered, interventions are unable to acknowledge and respond to the root causes and do not earn credibility with communities, thereby reducing their effectiveness. This may also result in the exclusion of populations from democratic or participatory decision-making processes and having a voice in setting policy priorities or allocating resources. Rather than being viewed as victims to be protected and saved, communities with high susceptibility and vulnerability to climate impacts should instead define, develop and drive the solutions.³

The terms “vulnerable populations” or “populations of concern” are often used to describe people with increased risk factors for climate change’s health impacts. However, many people may not think of themselves as “vulnerable,” and some populations could be considered “vulnerable” and “resilient” simultaneously. Carefully considering the most appropriate and empowering language and engaging trusted messengers from existing networks, faith-based organizations, or healthcare providers to communicate mitigation and adaptation planning steps, opportunities and measures helps ensure that information reaches intended communities in ways that are relevant and understood.⁴

Meaningful relationships with key community leaders can lead to increased trust, greater buy-in, and broader reach for your adaptation planning. Community engagement without specific JEDI emphasis risks amplifying the most empowered voices. Engaged stakeholders should be inclusive and representative of the populations your plan intends to serve. Your department’s investment in community members’ expertise can lead to more effective plans and programs. Here are some strategies to begin the stakeholder engagement process:

• Seek input on community perspectives and then elevate their priorities so that resources and services can go directly to the populations that need them.
• When possible, provide resources specific to each population within your jurisdiction or project area, rather than providing resources for the majority demographic. For example, resources can be created in multiple languages or with cultural considerations in mind.
• Choose culturally appropriate and relevant forms of engagement for relationship building. In some places this may mean using technological means over face-to-face to connect to people, but in other places the opposite approach may be better.

Spotlight

For more than 10 years, CalBRACE has developed and updated adaptation plans for the public health sector in California. A variety of qualitative methods were employed in each iteration. To learn more about methods of incorporating qualitative input, read “2009-2010 Building State Capacity for Climate Change and Public Health Grant - California”. More recently, in 2017-2018, California’s Climate Change and Health Equity Section teamed up with a Centers for Disease Control and Prevention’s Associate to cohost the State’s Safeguarding California Workshops for informing its adaptation planning efforts at five locations across California to receive input from communities and grassroots representatives.

Photo by Cade Martin, courtesy of CDC Public Health Image Library

Particularly the community's climate impacts and vulnerable populations

Below are a set of self-reflection questions⁵ to support health departments in considering JEDI thoughtfully in order to complete a needs assessment for Step 1 of BRACE.

Understand local climate risks and exposures.

• Has a climate risk or vulnerability assessment been conducted for the jurisdiction in the past?
  If so, did it include human health impacts? Are these assessments regularly updated with documentation of events such as drought, extreme weather or wildfire, emerging data and community feedback?
  How could these assessments be strengthened?
  How have the assessments informed policies? If they have not, why not?
• Moving forward, what are my jurisdiction’s sources for reliable climate and health data? To what extent are members from the affected communities meaningfully involved in defining climate risks?
• Are there existing health equity or climate change workgroups, such as community-based groups or advocacy organizations, that my department could join, champion, or support to diversify local data and understanding of climate risks?
• Does my department have partnerships with local institutions and organizations that could offer a variety of perspectives and data sources to inform our understanding of climate risks?
• Does my department consider how slower moving indirect climate risks (i.e., food prices, water availability, fossil fuel prices) may compound current or future vulnerabilities or risks in varying ways for specific populations?
• Are there unique local definitions or framing of risk that need to be incorporated, for example, in indigenous communities?

Assess resilience and vulnerability

• What are existing health equity frameworks or models that could support our assessment?
• Is my department equipped with the knowledge, experience and resources to manage disaster risk reduction and climate change adaptation at a community or neighborhood level in culturally specific ways? (If no, could I work with community members to uncover cultural sensitivities to inform health adaptation solutions?)
• Are there existing partnerships between local government departments, the community, healthcare organizations, non-profits, faith-based organizations, public service providers and local authorities to deeply understand local strengths and vulnerabilities?
• How are climate-sensitive populations in my jurisdiction included in defining adaptive capacity, risks and preparedness needs?
• How many social, economic, and environmental factors affect a community’s or individual’s vulnerability in my jurisdiction? Consider concentration or the density of vulnerabilities in certain geographic areas.
• What community partners are actively involved or should be involved? What barriers to entry/involvement need to be removed for them to do so? What data and analysis already exist among community partners?

Employ a variety of data sources to create a comprehensive understanding of adaptation in a jurisdiction. Mapping and census data alone do not tell the complete story. Resist relying on a single data source to capture all factors of vulnerability.

When identifying which communities have disproportionate vulnerability, consider a diverse set of characteristics that strengthen or compromise a neighborhood’s ability to adapt. Consider the conceptual framework of climate vulnerability above. Often, attention is paid to the exposure pathway, but adaptive capacity should also be considered in vulnerability assessments. Factors like transportation access, housing, number of cooling centers, and community cohesion are critical elements to determining a community’s adaptive capacity.

Community leaders are an invaluable resource given their deep knowledge of their neighbors, community history, and available resources. This community expertise can provide a powerful complement to quantitative data in building out an inclusive, comprehensive, and “ground-truthed” vulnerability assessment. Public officials should pair quantitative information with community testimonies and ensure the public processes for climate vulnerability mapping are inclusive and participatory.

Data sources

Data are available available from a wide variety of sources. When feasible and available, location-specific data should be used. Examples of climate, health, and equity data sources include:

• CDC National Environmental Public Health Tracking Network
• CDC/ATSDR Social Vulnerability Index
• CDC Heat and Health Tracker
• EPA EJSCREEN
• US Census
• US Climate Resilience Toolkit
• Data.gov

Local sources of data, such as a metropolitan planning organization, local or state health department, a university, or emergency response departments.

Climate change is a multidisciplinary issue and its impacts are felt in all sectors, in public and private spheres. By forming partnerships with new, non-traditional partners outside of the public health sector, you are likely to strengthen the effectiveness of your adaptation plan. Consider involving stakeholders such as:

• Community health nurses and nursing organizations
• Community health workers and traditional health workers
• Religious organizations
• Community centers
• Local organizations for older adults and the elderly
• Tribal governments
• Local youth leaders
• Community based organizations serving communities of color
• Rural community organizations (such as farmworkers)
• Health equity organizations
• Latinx community groups
• Associations of pediatricians or other clinicians
• Organizations promoting mental wellness and trauma-informed approaches
• Environmental health organizations
• Environmental and climate justice organizations
• Other agencies and their associations (such as planning, transportation, & housing)
• HIV/AIDS support and advocacy groups
• Advocates and organizations for people without housing⁶

Spotlight

The Swinomish Climate Change Initiative created a Climate Change Education and Awareness Group (CCEAG) to assist with community communication and gather tribal perspectives on climate change threats. The group established an engagement process for the Swinomish community to inform and guide policy and decisions on how the tribe will adapt and prepare for the health impacts of climate change. CCEAG members have ties to various sectors of the community such as youth recreation, prevention, education, cultural groups, social services, health, older adults, education, social groups, law enforcement, fisheries and tribal leadership. CCEAG members are encouraged to provide insights as to how climate change intersects with their tribal practices, program or sector.⁷ CCEAG strives to increase public awareness about climate change and engage community members in climate action planning. In particular, CCEAG seeks to connect youth to indigenous and western science opportunities so they are well-informed to participate in decision-making.⁷ The group creates opportunities for youth engagement through public education materials and environmental planning and climate change education opportunities.⁷

Dorette Quintana English, MA, Climate and Health Planning and Policy Specialist, Climate Change and Health Equity Section of the Office of Health Equity, shares experiences with JEDI in the California Department of Public Health’s CalBRACE program.

What resources do you use to conduct vulnerability assessments?

We engaged with a consortium of partners to select and develop the “Climate Change and Health Indicators for California (CCHVIs)”⁸  and for a template for vulnerability assessment reports for counties. The partners included staff from UC Davis, California Department of Public Health Environmental Health Investigations Branch in the Chronic Disease Center (now called the Center for Community Health and Wellness), subject matter experts from CalEPA and the Natural Resources Agency, a disability subject matter expert, CalBRACE staff, and staff from 12 local health departments and their invited community partners. We also held a webinar for all Office of Health Equity Staff to get their input on health equity and accessibility. The local health departments represented wide coverage of the state in terms of diversity in population composition and size, geographic location, types of exposures, incomes, and more. Through a series of online meetings, the local health departments reviewed and provided input to the template for the vulnerability assessment reports, including indicators and narratives, and for a template for climate and health profile reports (CHPRs) that were developed for every county in California.⁹

How does your health department define vulnerable populations; do you consider gender, race, ethnicity, income, education and/or existing environmental justice communities?

Our state and the Office of Health Equity has statutory language for vulnerable populations. According to the California Health and Safety Code Section 131019.5, “Vulnerable communities” include, but are not limited to, women, racial or ethnic groups, low-income individuals and families, individuals who are incarcerated and those who have been incarcerated, individuals with disabilities, individuals with mental health conditions, children, youth and young adults, seniors, immigrants and refugees, individuals who are limited-English proficient (LEP) and lesbian, gay, bisexual, transgender, queer and questioning (LGBTQQ) communities, or combinations of these populations. “Vulnerable places'' means places or communities with inequities in the social, economic, educational, or physical environment or environmental health and that have insufficient resources or capacity to protect and promote the health and well-being of their residents.’¹⁰

Part of identifying vulnerability is identifying the status of the social determinants of health and how these influence vulnerability, adaptability and resilience. The “Climate Change and Health Vulnerability Indicators for California” characterize vulnerability in three domains:

• Environmental exposure — extreme heat days, air quality PM2.5, air quality ozone, drought, wildfires, sea-level rise in coastal areas
• Population sensitivity — children, older adults, poverty, education (25+ years without high school diploma), percent people of color, outdoor workers, vehicle ownership, linguistic isolation, disability (physical and mental), health insurance, and violent crime rate per 1000 residents.
• Adaptive capacity — percent household without air conditioning, percent area not covered by tree canopy, impervious surfaces, public transit access 0.5 miles with less than 15-minute wait time during peak hours.

CalBRACE also included a few indicators in the CCHVIs from the CDPH Office of Health Equity’s Healthy Community Indicators Project (HCI).¹¹ The HCI contributes to assessing vulnerability with its standardized set of statistical measures, data and tools on the social determinants of health in California — including income security; food security and nutrition; child development,; housing; environmental quality; accessible built environments; prevention efforts; neighborhood and collective efficacy. Our Datasets include data for California, as well as its counties, regions, communities and census tracts when available.

Have you used qualitative methodology?

We used qualitative data and methodology in the introduction and afterword of the vulnerability assessment template and the indicator narratives. The template was reformatted into an interactive web-based platform for greater accessibility called the Climate Change and Health Vulnerability Indicators for California Visualized (CCHViz) with indicator data and maps for each county in the state.¹²   As stated above, we engaged several stakeholder groups and actively sought qualitative input in developing the Climate Change and Health Profile Report, the CCHVIs narrative templates for the indicators and the development of the online CCHVIz platform. We are updating the CCHVIs data and the narratives and intend to have robust engagement during this process also. We always recommend ground truthing quantitative data with community knowledge and input, as there are specific circumstances and conditions that aren’t visible or apparent in larger population and aggregated data sets. In a state as diverse as California, this is a critical assessment action especially in frontier and rural counties, Tribe locations, and where small populations with high vulnerabilities are sequestered within locations and populations generally characterized as more resilient based on social determinants of health data.

The most intensive qualitative assessment work we did at the community level is with a very small rural agriculture community, Tooleville in Tulare County, of 80 households. With the Counsel for Justice and Accountability and Tulare County Public Health Department, CivicSpark, and the Tooleville Water District we co-developed a vulnerability assessment using indicators most important to the community. The Counsel’s staff conducted interviews in both English and Spanish with community households to gather vulnerability assessment data. The local health department collaborated to develop the methodology for the assessment and engagement, which included a community meeting at the local water district board to discuss personal experiences with heat, air quality, water quality and availability, and health equity. The community meeting was attended by all partners and was conducted in Spanish. The Tooleville Water District and the Counsel for Accountability and Justice maintains ownership of the assessment and data. A summary of the report was presented at the February 4, 2019, meeting of California Climate Team’s Public Health Workgroup that focused on drought.^13,14

We also used digital storytelling to ground truth data about exposures, and how communities are impacted by wildfires, wildfire smoke and heat as part of an assessment. Leaders and members from the Mixteco Indigenous Community Organizing Project and Lideres Campesinas organizations that represent agriculture workers, and wildfire survivors from northern California shared their experiences in 3-4 minutes videos. Some of the videos have captions in Spanish, Mixteco and English. Using personal narratives and storytelling to document impacts and health effects is another qualitative method of gathering data and also empowering communities to tell their stories and make recommendations.

What resources do you recommend?

• California Heat Assessment Tool (CHAT) provides heat health event projections by census tracts.
• Healthy Places Index provides overall scores and detailed data on specific policy action areas that shape health, like housing, transportation, education and more.
• Tracking California Program shares data on climate, pollution and disease.
• Cal-Adapt.org covers climate exposure indicators and is maintained by the California Energy Commission.
• Mapping Resilience raises public visibility of the needs of frontline communities within statewide climate adaptation and resilience efforts.
• California Environmental Screening Tool is an index that illustrates environmental justice indicators.
• For about CalBRACE, visit https://www.cdph.ca.gov/Programs/OHE/Pages/CalBRACE.aspx

Consider the following resources created by CDC or partner organizations and health departments when undertaking this step in the BRACE framework.

1. Holm SM, Miller MD and Balmes JR. Health effects of wildfire smoke in children and public health tools: a narrative review. J Expo Sci Environ Epidemiol 31, 1–20 (2021). https://doi.org/10.1038/s41370-020-00267-4

2. Crenshaw K. Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum: Vol. 1989: Iss. 1, Article 8. Available at: http://chicagounbound.uchicago.edu/uclf/vol1989/iss1/8

3. Pathways to resilience. Transforming cities in a changing climate. The Kresge Foundation. 2015 January. Retrieved from https://kresge.org/sites/default/files/Pathways-to-resilience-2015.pdf

4. Heat islands and equity. United States Environmental Protection Agency. 2020 December 8. Retrieved from https://www.epa.gov/heat-islands/heat-islands-and-equity

5. Climate risks and community vulnerabilities assessment. Health and Human Services’ Sustainable and Climate Resilient Health Care Facility Initiative. Retrieved from https://toolkit.climate.gov/sites/default/files/SCRHCFI%20Checklist%201%20081415_Form.pdf

6. Homes 4 the homeless. 2021. Retrieved from https://homes4thehomeless.org/about-us/

7. Swinomish climate change initiative. Climate Adaptation Action Plan. Swinomish Indian Tribal Community Office of Planning and Community Development. 2010 October. Retrieved from https://www.swinomish-climate.com/swinomish-climate-change-initiative

8. Climate change and health vulnerability indicators for California. California Department of Public Health. 2020 August 17. Retrieved from https://www.cdph.ca.gov/Programs/OHE/Pages/CC-Health-Vulnerability-Indicators.aspx

9. California building resilience against climate effects (CalBrace). California Department of Public Health. 2021 February 1. Retrieved from https://www.cdph.ca.gov/Programs/OHE/Pages/ClimateHealthProfileReports.aspx

10. Office of Health Equity. California Department of Public Health. 2021 August 27. Retrieved from https://www.cdph.ca.gov/Programs/OHE/Pages/OfficeHealthEquity.aspx

11. Healthy communities data and indicators project. California Department of Public Health. 2021 April 12. Retrieved from https://www.cdph.ca.gov/Programs/OHE/Pages/HCI-Search.aspx

12. Climate change and health equity vulnerability indicators for California visualized (CCHVIz). California Department of Public Health. 2021 April 12. Retrieved from https://skylab.cdph.ca.gov/CCHVIz/

13. Hernandez P. Tooleville community vulnerability assessment. Leadership Counsel for Justice & Accountability. Retrieved from https://ww2.arb.ca.gov/sites/default/files/2020-08/13-p-hernandez-feb-4-2019-phwg-tooleville-va.pdf

14. Preparing for the health effects of drought: A workshop for public health professionals and partners. 2019 February 4 Meeting. California Air Resources Board. Retrieved from https://ww2.arb.ca.gov/resources/documents/climate-action-team-public-health-workgroup-meetings