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Climate change and health in informal settlements: a narrative review of the health impacts of extreme weather events

Climate change and health in informal settlements: a narrative review of the health impacts of... 1083896 EAU Environment & Urbanization Climate change and health in informal settlements: a narrative review of the health impacts of extreme weather events Emma HambrECHt, raCHEl tOlHUrst anD lana WHIttakEr emma Hambrecht is a final- year medical student at the university of sheffield. AbstrACt In this paper, we present a narrative review of primary research on the emma undertook the health impacts of extreme weather events in urban informal settlements published review that informs this between 1990 and June 2021. We include 54 studies and examine the health paper as part of an Msc in impacts of extreme weather events and how these were determined. We find that Humanitarian studies at the these events impact health directly by causing mortality, injury and disease and Liverpool school of tropical through indirect pathways by impacting livelihoods, access to healthcare, coping Medicine (LstM). strategies and adaptive capacity. Drawing on the social determinants of health email: ehambrecht1@ framework to frame our analysis, we find that health impacts are determined sheffield.ac.uk by multiple intersecting factors, relating to individual circumstances, material rachel tolhurst is a reader conditions, health status, and political and socio-economic context. Consequently, at the department of vulnerability varies between and within informal settlements. Overall, we show International Public Health, that responding to and minimising these health impacts requires an intersectional LstM and is research approach to understand and address these contextual root causes of vulnerability. director for the GCrF Accountability for Informal urban equity Hub (ArIse). Keywords climate change / extreme weather / health / informal settlements / vulnerability email: rachel.tolhurst@ lstmed.ac.uk Lana whittaker (corresponding author) I. IntroduCtIon is a Post-doctoral research Associate at the The impacts of human-induced climate change are already being department of International (1) experienced, particularly through extreme weather events. There is now Public Health, LstM and considerable evidence that climate change has resulted, and will continue works in the ArIse Hub. to result, in increased extremes, including increased frequency and Address: Liverpool school intensity of heatwaves and heavy precipitation, increased droughts and of tropical Medicine, (2) Pembroke Place, Liverpool, major tropical cyclones. Climate change, including extreme weather L3 5QA, uK; email: lana. events, will have overwhelmingly negative consequences for human whittaker@lstmed.ac.uk (3) (4) health, through both direct and indirect effects. The impacts of climate change in cities, including those on health, will particularly affect those living in informal settlements, who are widely recognised to be especially vulnerable to the impacts of climate (5) change. Residents in informal settlements already experience ill health disproportionately compared to other urban dwellers and these (6) 1. IPCC (2021). inequalities will continue to be reproduced by climate change. The 2. IPCC (2021). vulnerability of informal settlements to these health impacts is widely 3. WHO (2018). accepted, including by the Intergovernmental Panel on Climate Change 122 Environment & Urbanization Copyright © Environment & Urbanization Copyright © 2022 International Institute for Environment and Development (IIED). 2022 International Institute for Environment and Development (IIED). https://doi.org/10.1177/09562478221083896 Vol 34(1): 122–150. DOI: 10.1177/09562478221083896 www.sagepublications xx–xx. DOI:.com 10.1177/09562478221083896 www.sagepublications.com CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents (7) 4. Direct effects are those (IPCC). However, specific evidence on the impacts of weather and resulting directly from (8) climatic changes on health in informal settlements is lacking and in changes in temperature and general the impacts of climate change in informal settlements is a major precipitation including extreme (9) weather events which cause research gap. injuries, illness and death. First, there has been a lack of synthesis of this research. To our Indirect effects include those knowledge, there has been to date only one formal review of the literature, caused by changes in natural (10) that of Borg et  al. Although insightful, this review provides only a systems such as vector-borne diseases and those shaped cursory discussion of the health impacts in informal settlements, based by social responses such as on just 15 studies. displacement. see Haines and Second, there has been limited discussion of how vulnerabilities Ebi (2019) and smith et al. (2014). are determined and differ within and between informal settlements. 5. revi et al. (2014); scovronick It is estimated that approximately one billion people live in informal et al. (2015); sverdlik (2011). (11) settlements. Although there may be similarities between such (12) 6. sverdlik (2011). settlements, definitions and preferred terminologies, which can be 7. revi et al. (2014). imprecise, vary by country. Moreover, within these settlements, the (13) 8. borg et al. (2021); scovronick degree of informality and exclusion varies. et al. (2015). Discussions of the vulnerability of informal settlements to climate 9. bai (2018). change are often broad and sweeping, thereby missing the complex, fine- 10. borg et al. (2021). grained variations between and within informal settlements. It is widely 11. revi et al. (2014). known, for instance, that locations on or near hillsides or in low-lying 12. t he United nations Human or river-adjacent areas can expose settlements to landslides and flooding settlements Programme (14) respectively. Vulnerability is widely considered to be determined by (Un Habitat, 2015) defines material and physical circumstances such as poor housing, inadequate informal settlements as (15) areas where residents have sanitation, lack of infrastructure and overcrowding. The interaction no tenure security, there is of these factors with markers of disadvantage, such as income, age and a lack of basic infrastructure (16) gender, have been noted in the literature along with the wider political and housing may not comply (17) with regulations and be in determinants such as government neglect and lack of access to services. hazardous locations. Un Habitat However, there has been no synthesis of the literature on health and considers slums to be the most climate change that considers these determinants of vulnerability and deprived and excluded forms how they cause health impacts to vary at the sub-settlement level. of these settlements, with slum dwellers experiencing Knowledge of the impacts on individuals, households and communities a lack of at least one of the (18) is vital to inform policy responses. following: improved water Here we present the results from a narrative review of the literature source, improved sanitation facilities, sufficient living area, on extreme weather events, health and informal settlements through housing durability and security the lens of vulnerability. We focus on extreme weather events (flooding, of tenure. However, there is extreme temperatures, droughts and storms) rather than climate change also great variation in informal more broadly as the need to understand the impacts of extreme weather settlements. events is particularly pressing. Using a more comprehensive search 13. satterthwaite et al. (2020). (19) strategy than Borg et al., we include 54 studies in our review. 14. satterthwaite et al. (2020). We begin in the next section by outlining the conceptual framework 15. borg et al. (2021); scovronick et al. (2015). underpinning this review, before detailing the methodology used. We 16. revi et al. (2014); then present an overview of the search results and outline the health satterthwaite et al. (2020); impacts of the extreme weather events reported in these studies. We sverdlik (2011). find these events impact health and mortality directly through injury, 17. satterthwaite et al. (2020). disease, and their implications for mental health; and indirectly through 18. Dodman et al. (2019). their effect on livelihoods, access to healthcare, coping strategies and 19. borg et al. (2021). adaptive capacity. Finally, we examine the reported determinants of these health impacts, showing that vulnerability is determined by multiple intersecting factors at the level of the individual, settlement and wider socio-economic and political context. Overall, we argue for a broader, more intersectional approach to researching and responding to the health impacts of extreme weather events and climate change in informal settlements. 123 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 II. ConCePtu AL FrAMeworK Here we follow the IPCC, which considers climate change risks and impacts as the result of the interaction between hazards, exposure and (20) vulnerability. Hazards are defined as the potential occurrence of events or 20. IPCC (2021). trends that may cause adverse impacts, and exposure is defined as presence (21) in places or settings that could be adversely affected. Vulnerability, 21. IPCC (2021), n.p. (22) defined as the “propensity or predisposition to being adversely affected”, 22. IPCC (2021). is not solely understood as an outcome of exposure to hazards, but as a contextual starting point encompassing sensitivity, susceptibility and (23) the ability to cope and adapt, also considering the socio-economic and 23. IPCC (2021); sharma and (24) ravindranath (2019). political context. Based on this conceptualisation, the extent to which 24. O’brien et al. (2007). extreme weather events will impact people and vary among populations depends not only on hazard and exposure, but also on the factors that shape vulnerability. Risk is the “potential for adverse consequences” resulting from the interaction between hazards, exposure and vulnerability, and impacts are the consequences when risks are realised on both natural and (25) 25. IPCC (2021), n.p. human systems, including on health and well-being. To analyse the health impacts of extreme weather events in informal settlements through this lens of contextual vulnerability, our conceptual framework draws on the World Health Organization’s (WHO) social determinants of health (SDH) model which emphasises how wider (26) structural and intermediary determinants define and underpin health. 26. WHO (2010). The SDH framework has been effectively applied to urban areas, including informal settlements, showing how multiple determinants shape health including place of residence (situated within a socio-political context), (27) socio-economic status, gender, race and ethnicity, and education. 27. Ompad et al. (2007); Vlahov et al. (2007). To fully understand the health impacts of extreme weather events in informal settlements, the context in which hazards, exposure and vulnerability interact to create risks and impacts needs to be understood. III. MetHodoLoGy The overall aim of this study was to critically review existing research on the impacts of extreme weather events on health in informal settlements. The specific research questions were: 1. How do extreme weather events, which are expected to increase in frequency, intensity and duration with climate change, impact health in urban informal settlements? 2. What factors contribute to the vulnerability of people living in these settlements? 3. How does vulnerability to these health impacts vary within informal settlements? A narrative review was chosen as it allows an extensive, broad and holistic overview of the current state of knowledge and enables the critical analysis of existing research to identify themes and gaps. This review further used the guiding principles of a systematic review, including a defined research (28) aim and objectives, a focused search strategy, and framework for analysis. 28. a veyard et al. (2016). The LSTM (Liverpool School of Tropical Medicine) EDS Discover tool and additional systematic searches of Medline, CINAHL, Global Health, 124 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents Web of Science, Cochrane, PubMed databases and Google Scholar were used to identify relevant literature. Searches followed a comprehensive strategy based on three key ideas: urban informal settlements, health and extreme weather events related to climate change (see Table 1). Initial searches were conducted in May–June 2020 and updated in July–August 2021. The following inclusion criteria were used: •• linked full-text available; •• published between January 1990 to June 2021; •• written in English; •• studies, case reports or discussion papers containing primary research data from informal settlements, formally published in an academic journal; •• specific to three main ideas: urban informal settlements, health, and extreme weather events related to climate change. The following exclusion criteria were used: •• published before January 1990; •• not written in English; •• theses, dissertations and books; •• literature not containing empirical evidence or primary research data from urban informal settlements; •• literature not covering all three key ideas named in the inclusion criteria; •• literature about long-term climate change impacts; the science of climate change; or only about adaptation, mitigation and resilience. After removing duplicates, all results were recorded in Excel files and titles and abstracts were screened for relevance, using the inclusion and exclusion criteria outlined above. This was followed by full-text screening of identified results, using the inclusion and exclusion criteria. For data extraction, collection and analysis of included results, summary tables were created in an Excel file documenting study information, publication details, methods, main findings, and strengths and limitations. Strengths and limitations were considered to critically appraise and assess the quality, value and relevance of studies to determine (29) 29. a veyard (2014). the weight given to their findings in addressing the research questions. (30) 30. a veyard (2014). An adapted thematic analysis method as described by Aveyard was used to guide the analysis and synthesis of literature. This included the use of summary tables, thematic coding using NVivo 11 software, and the development of a thematic framework. Themes naturally emerged from the literature and were continuously identified and adapted throughout the coding process. Codes were then organised into a framework of sub- themes and overarching themes which was used to structure results. IV. resuL ts a. search results The initial search produced 2,982 results, of which 2,795 were removed during initial screening. Of the remaining 187 studies, 133 were removed after screening the full text. The remaining 54 studies were deemed 125 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 tA b L e 1 search strategy for LstM eds discover search, CInAHL, Medline, Global Health, web of science, PubMed, Cochrane databases and Google scholar Strategy 1 and 2 and 3 1 Keywords: “informal settlement*” OR “informal urban settlement*” OR “urban informal settlement*” OR “urban informal space*” OR “informal urban space*” OR “informal camp*” OR slum* OR favela* OR jhuggi* OR “shanty town*” OR hovel* OR ghetto OR bastee* OR shack* ii or CsH terms: “poverty areas” iii or MesH terms: “poverty areas” 2 Keywords: health OR illness OR disease OR infect OR mortality OR morbidity OR “infectious disease” OR “physiological effect” OR “cause of death” ii or CsH terms: “health+” OR “health status+” OR “health and disease+” OR “disease+” OR “communicable diseases+” OR “noncommunicable disease+” OR “critical illness” OR “catastrophic illness” OR “acute disease” OR “chronic disease+” OR “mental health” OR “mental disorders+” OR “morbidity+” OR “child health” OR “adolescent health” OR “women’s health” OR “maternal-child health” OR “mortality+” OR “infant mortality” OR “child mortality” OR “maternal mortality” OR “world health” OR “population health” OR “public health” OR “environment and public health+” OR “environmental health” OR “environmental illness” OR “urban health” OR “health status disparities” OR “social determinants of health” iii or MesH terms: “health+” OR “disease+” OR “disease outbreaks+” OR “communicable diseases+” OR “infectious+” OR “infectious disease medicine” OR “disease transmission” OR “noncommunicable diseases” OR “critical illness” OR “catastrophic illness” OR “mental health” OR “morbidity+” OR “infant health” OR “child health” OR “adolescent health” OR “maternal health” OR “mortality+” OR “infant mortality” OR “child mortality” OR “global health” OR “public health+” OR “public health surveillance” OR “environment and public health+” OR “environmental health+” OR “environmental illness+” OR “urban health” OR “health status disparities” OR “social determinants of health” iv or Global Health thesaurus terms: health OR illness OR “health hazards” OR morbidity OR “infectious disease” OR “emerging infectious diseases” OR infection OR “airborne infection” OR “microbial contamination” OR “mental health” OR mortality OR “neonatal mortality” OR infant mortality” OR “maternal mortality” OR “public health” OR “community health” OR “occupational health” 3 Keywords: “climate change*” OR “environmental change*” OR “global warming” OR “extreme weather” OR “extreme weather event*” OR disaster* OR storm* OR hurricane* OR cyclone* OR typhoon* OR “heavy rain*” OR “extreme precipitation” OR flood* OR “flash flood*” OR “storm surge*” OR “sea level ris*” OR “coastal flood*” OR “extreme heat” OR heat* OR “temperature* ris*” OR “ris* temperature*” OR “urban heat island*” OR drought* OR “water insecurity” ii or CsH terms: “climate change” OR “natural disaster” OR heat OR “weather+” iii or MesH terms: “climate change+” OR “global warming” OR “extreme weather+” OR “extreme hot weather” OR “extreme cold weather” OR “extreme heat” OR “cyclonic storms” OR “rain+” OR floods OR “natural disasters” iv or Global Health thesaurus terms: “climatic change” OR “environmental factors” OR “climatic factors” OR “meteorological factors” OR “weather patterns” OR “global warming” OR heat OR temperature OR “critical temperature” OR “environmental temperature” OR rain OR “rain damage” OR floods OR flooding OR floodplains OR storms OR cyclones OR hurricanes OR drought OR “natural disasters” Expanders Apply related words, apply equivalent subjects Limiters Linked full text, date of publication 1990–2021, English language NOTE: Keywords were used for all searches including LSTM EDS Discover, CINAHL, Medline, Global Health, Cochrane, Web of Science and PubMed databases and the Google Scholar search. ii CInAHL subject Headings (CsH) terms were used only in the CINAHL database search in addition to keywords. iii Medical subject Headings (MesH) terms were used only in the Medline database search in addition to keywords. iv Global Health thesaurus terms were used only in the Global Health database search in addition to keywords. 126 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents relevant and suitable for inclusion in the narrative review. A full list is provided in the supplementary material. Figure 1 provides an overview of (31) 31. PrIsma (Preferred the search results. reporting Items for systematic The majority of included results were primary research articles (n = 48) reviews and meta-analyses) is including cross-sectional studies (n = 33), longitudinal studies (n = 11), an evidence-based minimum case-control studies (n = 2) and case reports (n = 2). Several discussion set of items for reporting in systematic reviews and papers (n = 6) all included primary research data or primary research case meta-analyses. a PrIsma studies (see supplementary material). flow diagram depicts the The reviewed studies were published between January 2000 and June flow of information through the different phases of a 2021. Unsurprisingly, the publication rate has increased over time: 30 of systematic review. see http:// the 54 studies have been published since 2015 and 12 since 2020. The prisma-statement.org/ increasing rate suggests ongoing evidence synthesis will be required. prismastatement/flowdiagram. aspx Most studies were conducted in Asia (n = 26) and Africa (n = 20). A further seven studies were conducted in South America and one in North America (see supplementary material). Most studies (n = 42) focused exclusively on informal settlements or slums while some (n = 12) also studied formal areas. Only 12 studies explicitly defined informal settlements or slums, most commonly using the UN Habitat definitions, although most mentioned characteristics such as lack of secure tenure without specifying a definition. b. extreme weather events Flooding was the most discussed extreme weather event. Of the 54 studies, 40 discussed flooding and heavy rainfall events. This contrasts with Borg (32) et al., who found temperature-related exposure to be the most common 32. borg et al. (2021). weather event discussed in their sample of 15 studies. The impacts 33. Hagan et al. (2016); of landslides were explored in two studies in our sample focused on samnang and Chanthol (2018). (33) flooding, although the occurrence of landslides in informal settlements was more widely noted. Storms were discussed in four studies, although many of their health impacts were discussed in terms of the associated (34) 34. morin et al. (2016). flooding. One of these four studies discussed wind; however, intense wind was not more widely discussed. Although “storm”, “hurricane”, “cyclone” and “typhoon” were included in the search strategy, including the term “wind” in future reviews may be beneficial. Extreme temperatures were discussed in 19 studies; 12 focused on heat specifically, the remaining seven discussed other forms of extreme weather as well, including the impact of cold temperatures in three studies. Six studies discussed droughts and water scarcity, but not exclusively. While the occurrence of fires was (35) 35. ajibade and mcbean (2014); noted, surprisingly the relationship between fires and extreme weather schwerdtle et al. (2021). events and the resulting impacts on health were not explored in depth. Again, future reviews may consider adding “fire” to their search terms. While many studies suggested the more general health impacts of extreme weather events and climate change while emphasising the vulnerability of informal settlements, this analysis only includes the health impacts found in the studied informal settlements. c. Health impacts of extreme weather events Health impacts of floods Seventeen studies found informal settlements were in areas exposed to flooding, including coastal areas, low-lying areas, floodplains, and near 127 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 F IG ure 1 PrIsMA flow diagram of search results rivers and waterways. Immediate health impacts of floods included injuries and high mortality (see Table 2). During floods in Lagos, Nigeria in 2011, of 607 households surveyed in Badia informal settlement, 27 (36) people reported the death of a household member. In another study of 36. ajibade and mcbean (2014). the same settlement, 7.6 per cent of surveyed women (n = 262) reported the death of a household member and 14.1 per cent reported injuries sustained by household members. Women in more affluent areas reported (37) 37. ajibade et al. (2013). no deaths or injuries. Studies also identified the contamination of water sources, homes and living environments during floods as a major health hazard (see Table 2). Several studies found that the contamination of water sources led to water shortages and limited access to safe water, resulting in worsened sanitation and hygiene. During floods, many pit latrines were submerged by floodwater and overflowed, and human waste spread into homes and around the settlements. Residents also reported problems in accessing (38) (39) 38. ajibade et al. (2013). latrines. In Lagos, Nigeria and Dhaka, Bangladesh for example, 39. rashid (2000). women were constrained by insecurity and lack of privacy during floods and had to relieve themselves at night or in their own homes. Limited 128 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents access to sanitation facilities also affected bathing and personal hygiene. (40) 40. kwiringira et al. (2016). In an informal settlement in Kampala, Uganda, Kwiringira et al. found that sanitation facilities overflowed, and were dirtier and more difficult to clean compared to the dry season. In these studies, the impacts of floods were shaped by existing inequities in access to water and sanitation facilities, including those related to gender. Both gender and provision of water and sanitation will be discussed further as determinants of vulnerability in Section IV d. Many studies found that infectious disease burdens significantly increased during and after flooding events, including from water- and food-borne diseases (diarrhoea, typhoid, gastroenteritis, leptospirosis, cholera and rotavirus), skin problems, respiratory conditions and vector-borne diseases (see Table 2). Direct contact with dirty floodwater and contaminated drinking water sources increased the risk of disease during floods, especially for children who often played in contaminated (41) 41. Fuhrimann et al. (2016a); floodwater. Households at a lower elevation in informal settlements (42) karande et al. (2002); sakijege were more exposed to flooding and had increased risk of typhoid, et al. (2012). (43) (44) leptospirosis and diarrhoea. 42. akullian et al. (2015). Studies also found an increase in mental health problems associated 43. Casanovas-massana et al. with floods. In informal settlements in Mombasa, Kenya, 80.8 per cent (2018); Hagan et al. (2016); reis of 390 households reported problems with mental health during the et al. (2008). last flooding event, linked to the trauma of losing property and having 44. Uwizeye et al. (2014). (45) (46) nowhere to live. In Lagos, Nigeria, households reported the inability 45. Okaka and Odhiambo to sleep, loss of appetite, stress, and fear of future floods. (2019a). (47) Women across informal settlements in Lima, Peru and Dhaka, 46. adelekan (2010). (48) Bangladesh reported an increase in domestic violence during 47. Contreras et al. (2018). floods. Women in Dhaka said this was due to increased stress on their 48. rashid (2000). husbands to provide for their families in times of financial hardship and unemployment. Floods also had less direct impacts on health, related to changes in food consumption, food security, increased food and water prices, livelihood disruption and loss of income (see Table 2). Damage and destruction of homes and displacement added to both economic and health burdens. Health impacts of extreme temperatures Five studies described settlements in areas that were vulnerable to extreme temperatures. Cross-sectional studies in informal settlements in Nairobi, (49) (50) 49. scott et al. (2017). Kenya, Kolkata, India and informal townships in Gauteng and (51) 50. mukhopadhyay et al. (2021). Mpumalanga, South Africa found that populations there were exposed to temperatures over 40°C. Although the health impacts were not recorded, 51. mabuya and scholes (2020). these temperatures exceeded the thresholds at which negative health (52) 52. scott et al. (2017). impacts and increased mortality would be expected. Three further (53) (54) 53. Egondi et al. (2012, 2015). studies in Nairobi, Kenya and Ahmedabad, India found associations between high temperatures and increased mortality in informal settlement 54. Wei et al. (2021). (55) populations, specifically in Egondi et al. for children under four years of 55. Egondi et al. (2012). age and people with non-communicable diseases. Populations living in informal settlements reported heat-related symptoms and serious impacts of heat including heat-related illness, infectious diseases, poor mental health and other non-communicable health problems (see Table 3). In three studies, people reported that (56) 56. bambrick et al. (2015); heatwaves and hot summer temperatures affected their ability to work. Pasquini et al. (2020); sinha Four studies examined the effects of cold weather on health (see et al. (2008). Table 3). Two studies in Nairobi found higher mortality rates in colder 129 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 tAbLe 2 tAbLe 2 (ContInued) Health impacts of floods Con- Expo- Dam- Con- tami- Water sure age tami- nation short- to Eco- Mal- In- (de- Lim- nation of age/ Sub- Prob- con- In- nom- nutri- creased struc- ited Para- Fun- Respi- Poor of Con- living lack of merged/ lems tami- creased ic/job tion food tion access Lep- Gas- sitic Skin gal ratory Pneu- men- water tamina- envi- access over- with nated domes- distur- Loss (food and (dis- to Study by author tospi- Rota- troen- infec- infec- infec- Coughs/ infec- mo- Tuber- Ma- Den- tal sourc- tion of ron- to flowing latrine flood- tic vio- banc- of in- inse- water place- health- and year Mortality Injuries Diarrhoea Cholera rosis Typhoid virus teritis tions tions tions Scabies colds tions nia culosis laria gue health es homes ment water latrines access water lence es come curity prices ment care Adelekan (2010) X X X X X X Ajibade and X X X X X X X X X McBean (2014) Ajibade et al. (2013) X X X X X X X X X X X X X X X Bambrick et al. X (2015) Casanovas- X Massana et al. (2018) Contreras et al. X X X (2018) Douglas et al. X X X X X (2008) French et al. (2021) X X X Fuhrimann et al. X X X X (2016a) Fuhrimann et al. X X X (2016b) Giri et al. (2021) X X X X X Goudet et al. X X X X X X X X (2011a) Goudet et al. X X X X X X X X X X (2011b) Gruebner et al. X X (2011) Gruebner et al. X (2012) Hacker et al. (2020) X Hagan et al. (2016) X X X Johnson et al. X (2004) Karande et al. X X X (2002) Khan et al. (2014) X X X Kulabako et al. X X (2010) Kwiringira et al. X X (2016) Morin et al. (2016) X X X X X X X X X X Nix et al. (2020) X Okaka and X X X X X X X X Odhiambo (2019a) Okaka and X X X X X X X X X Odhiambo (2019b) Pandey et al. (2018) X X X Pawar et al. (2008) X Phiri (2016) X X X X Porio (2011) X X X X X X X X X X X X X X X X X Rashid et al. (2007) X X X Rashid (2000) X X X X X X X X X X X X X X X X X X Rashid (2009) X X Reis et al. (2008) X Ricardo et al. (2018) X Sakijege et al. X X X X X X X X X X X X X X X X X (2012) Samnang and X Chanthol (2018) Schwerdtle et al. X X (2021) Uwizeye et al. X X (2014) (Continued) 130 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents tAbLe 2 tAbLe 2 (ContInued) Health impacts of floods Con- Expo- Dam- Con- tami- Water sure age tami- nation short- to Eco- Mal- In- (de- Lim- nation of age/ Sub- Prob- con- In- nom- nutri- creased struc- ited Para- Fun- Respi- Poor of Con- living lack of merged/ lems tami- creased ic/job tion food tion access Lep- Gas- sitic Skin gal ratory Pneu- men- water tamina- envi- access over- with nated domes- distur- Loss (food and (dis- to Study by author tospi- Rota- troen- infec- infec- infec- Coughs/ infec- mo- Tuber- Ma- Den- tal sourc- tion of ron- to flowing latrine flood- tic vio- banc- of in- inse- water place- health- and year Mortality Injuries Diarrhoea Cholera rosis Typhoid virus teritis tions tions tions Scabies colds tions nia culosis laria gue health es homes ment water latrines access water lence es come curity prices ment care Adelekan (2010) X X X X X X Ajibade and X X X X X X X X X McBean (2014) Ajibade et al. (2013) X X X X X X X X X X X X X X X Bambrick et al. X (2015) Casanovas- X Massana et al. (2018) Contreras et al. X X X (2018) Douglas et al. X X X X X (2008) French et al. (2021) X X X Fuhrimann et al. X X X X (2016a) Fuhrimann et al. X X X (2016b) Giri et al. (2021) X X X X X Goudet et al. X X X X X X X X (2011a) Goudet et al. X X X X X X X X X X (2011b) Gruebner et al. X X (2011) Gruebner et al. X (2012) Hacker et al. (2020) X Hagan et al. (2016) X X X Johnson et al. X (2004) Karande et al. X X X (2002) Khan et al. (2014) X X X Kulabako et al. X X (2010) Kwiringira et al. X X (2016) Morin et al. (2016) X X X X X X X X X X Nix et al. (2020) X Okaka and X X X X X X X X Odhiambo (2019a) Okaka and X X X X X X X X X Odhiambo (2019b) Pandey et al. (2018) X X X Pawar et al. (2008) X Phiri (2016) X X X X Porio (2011) X X X X X X X X X X X X X X X X X Rashid et al. (2007) X X X Rashid (2000) X X X X X X X X X X X X X X X X X X Rashid (2009) X X Reis et al. (2008) X Ricardo et al. (2018) X Sakijege et al. X X X X X X X X X X X X X X X X X (2012) Samnang and X Chanthol (2018) Schwerdtle et al. X X (2021) Uwizeye et al. X X (2014) 131 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 tAbLe 3 tAbLe 3 (ContInued) Health impacts of extreme temperatures Heat Car- Sleep Study by ex- Japanese diovas- High Cold- Poor Dis- Weak- im- author and haus- Heat Heat Heat Diar- Pneu- Eye Fungal enceph- cular blood related mental com- Dehy- ness/ Tired- pair- Head- Dizzi- Faint- Nau- Fe- year Mortality tion cramp stroke rashes Oedema rhoea Influenza monia disease infections Malaria Dengue alitis disease pressure illness health fort dration malaise ness ment ache ness ing sea ver Cough Health impacts of heat Banerjee X et al. (2020) Egondi X et al. (2012) Egondi X et al. (2015) Ehsan et al. X X X X X X X X (2021) Mabuya X and Scholes (2020) Nix et al. X X (2020) Pasquini X X X X X X X X X X X X X X X X et al. (2020) Schwerdtle X X X et al. (2021) Sinha et al. X X X X X X X (2008) Swain et al. X X X (2019) Toan et al. X X X X X (2014) Tran et al. X X X (2013) Wei et al. X (2021) Health impacts of cold Egondi X et al. (2012) Egondi X et al. (2015) Mabuya X and Scholes (2020) Toan et al. X X X X X X (2014) (Continued) 132 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents tAbLe 3 tAbLe 3 (ContInued) Health impacts of extreme temperatures Heat Car- Sleep Study by ex- Japanese diovas- High Cold- Poor Dis- Weak- im- author and haus- Heat Heat Heat Diar- Pneu- Eye Fungal enceph- cular blood related mental com- Dehy- ness/ Tired- pair- Head- Dizzi- Faint- Nau- Fe- year Mortality tion cramp stroke rashes Oedema rhoea Influenza monia disease infections Malaria Dengue alitis disease pressure illness health fort dration malaise ness ment ache ness ing sea ver Cough Health impacts of heat Banerjee X et al. (2020) Egondi X et al. (2012) Egondi X et al. (2015) Ehsan et al. X X X X X X X X (2021) Mabuya X and Scholes (2020) Nix et al. X X (2020) Pasquini X X X X X X X X X X X X X X X X et al. (2020) Schwerdtle X X X et al. (2021) Sinha et al. X X X X X X X (2008) Swain et al. X X X (2019) Toan et al. X X X X X (2014) Tran et al. X X X (2013) Wei et al. X (2021) Health impacts of cold Egondi X et al. (2012) Egondi X et al. (2015) Mabuya X and Scholes (2020) Toan et al. X X X X X X (2014) 133 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 (57) 57. Egondi et al. (2012). periods with high rainfall and significant associations between lower (58) 58. Egondi et al. (2015). temperatures and years of life lost. “Shack dwellers” in townships in South Africa were found to be at higher risk of cold-related illness than (59) 59. mabuya and scholes (2020). people living in housing of better quality. Informal settlement residents (60) in Hanoi, Vietnam associated infectious diseases with cold weather. 60. t oan et al. (2014). Health impacts of droughts and water scarcity Few studies focused specifically on the health impacts of droughts and (61) 61. bambrick et al. (2015). water scarcity; however, in informal settlements in Shasheme, Ethiopia, residents experienced problems with washing and hygiene related to water shortages, and found malaria and typhoid were more common during the dry season, when temperatures were also higher. In informal (62) 62. kwiringira et al. (2016). settlements in Kampala, Uganda, Kwiringira et al. observed that water scarcity during the dry season made it difficult to clean latrines. In Nairobi, Kenya, adolescents over the age of 10 and adults had three times (63) 63. akullian et al. (2015). the risk of typhoid after long periods without rain. In four informal settlements in Dehradun, India, 25 per cent of 121 participants reported (64) 64. Pandey et al. (2018). “health-related problems” due to droughts. Health impacts of storms (65) 65. shultz et al. (2020). Shultz et al. reported on the impacts of Hurricane Dorian in shanty towns in Marsh Harbour, Abaco Islands in the Bahamas in 2019. The study, mainly focused on mental health impacts, found the affected population suffered from acute psychological distress, acute grief reactions, major depression, generalised anxiety and post-traumatic stress disorder immediately after and in the months following the disaster. These responses were linked to loss, destruction, displacement, homelessness and unemployment resulting from the hurricane, which caused high mortality and severe injuries. (66) In the aftermath of Typhoon Pedring in 2011, Morin et  al. identified 66. morin et al. (2016). vulnerability to typhoons and cyclones due to settlement location in Manila, mainly discussing the consequences of flooding and storm surges. d. determinants of vulnerability We examined the determinants mentioned in the studies to understand how the local context in informal settlements shapes vulnerability, including to the impacts of extreme weather events, and creates variation in health impacts. The overarching factors identified in the included studies are shown in Table 4 and are explored in more depth in the following section. We do not rigidly adhere to the broad categories of structural and intermediary determinants of health used in the SDH framework to structure our discussion. Instead, we consider specific determinants of health from the framework in the most logical sequence for this topic: beginning with the socio-economic and political context, then discussing material circumstances at settlement-level, and then individual-level determinants, including socio-economic status, demographic factors and health status. socio-economic and political context In several informal settlements, the socio-economic and political context, including tenure insecurity and political and social exclusion, was found to contribute to the vulnerability to the health impacts of extreme weather events (see Table 4). 134 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents Housing rights, land security and evictions. Urban informal (67) 67. ajibade and mcbean (2014); settlements are often considered illegal. Studies noted that many morin et al. (2016). residents have no legal title to their land and occupy marginal land (68) 68. ajibade and mcbean including unauthorised governmental land. As a result, many commu- (2014); French et al. (2021); (69) nities live under the threat of eviction and demolition. Due to such Hagan et al. (2016); morin et al. threats, residents were reluctant to build more permanent and stronger (2016); Porio (2011); rashid et al. (2007); reis et al. (2008); housing structures that would provide them with more protection samnang and Chanthol (2018). (70) (71) from extreme weather. Samnang and Chanthol also found that in 69. ajibade and mcbean (2014); informal settlements in Battambang, Cambodia, people were unable Giri et al. (2021); morin et al. to relocate to safer land as they could not sell the land they currently (2016); rashid (2000, 2009); (72) lived on because they lacked formal land titles. Morin et al. noted the samnang and Chanthol (2018); (73) schwerdtle et al. (2021). occurrence of evictions following a typhoon. Okaka and Odhiambo 70. ajibade and mcbean (2014); found fear of losing their homes stopped 4.3 per cent of respondents from Giri et al. (2021); morin et al. evacuating during floods. The need to protect household belongings from (2016). (74) theft was another reason for not evacuating. 71. samnang and Chanthol (2018). Political and social exclusion. Several studies suggested that 72. morin et al. (2016). governments refuse to provide infrastructure and services in informal 73. Okaka and Odhiambo settlements due to their illegal status. As a result, residents are often (2019a). excluded from access to basic infrastructure and services, increasing their 74. Porio (2011); rashid (2000). exposure and vulnerability to climate change impacts. In three studies in (75) (76) informal settlements in Lagos, Nigeria, Accra, Ghana and Mombasa, 75. adelekan (2010). (77) Kenya participants believed poor planning and governmental exclusion 76. Douglas et al. (2008). and neglect increased the risk of flooding and flood impacts. Ajibade and 77. Okaka and Odhiambo (78) McBean found that households in Badia informal settlement in Lagos, (2019a). Nigeria ignored government-issued typhoon warnings and did not evacuate 78. ajibade and mcbean (2014). because of distrust in the government, including fear of evictions. In several studies, informal settlement residents reported receiving limited or no social and governmental support during and after extreme (79) 79. morin et al. (2016). weather events. Morin et  al. found that although relief supplies and financial assistance were available for most typhoon-affected communities in Manila, there were many structural barriers to accessing this assistance. Many lacked the documents to apply for assistance and relocation and could not afford the fees to obtain them. Consequently, most households received relief supplies and financial assistance from families, friends and (80) 80. rashid (2000). neighbours. Rashid also found that flood-affected households helped (81) 81. Douglas et al. (2008); each other. The absence or inadequacy of emergency responses were (82) morin et al. (2016); Okaka and also noted including the absence of emergency services. Odhiambo (2019b); Pasquini (83) (84) Studies in Dhaka, Bangladesh and Lagos, Nigeria found that the et al. (2020); rashid (2000). stigma attached to living in informal settlements limited the ability of 82. ajibade and mcbean (2014). women to find better jobs, increase their income, apply for loans and 83. rashid (2009). expand their social networks, thereby increasing their vulnerability 84. ajibade and mcbean (2014). during floods. These wider social, economic and political factors, more difficult to research using conventional health research methodologies, are underexplored and significant knowledge gaps still exist, including limited community-level analysis of the contribution of socio-political marginalisation to vulnerability. Material circumstances (physical environment) Living environment. The living environment in informal settle- ments was found to contribute to increased risk of disease, flooding and the health impacts of floods and heat (see Table 4). Inequities in access 135 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 tAbLe 4 tAbLe 4 (ContInued) overview of the determinants of vulnerability to the health impacts of extreme weather events Socio-economic and political context Material circumstances Individual determinants Housing Access to Living environment quality healthcare Social and economic Demographic Housing (land Political Poor solid- Income Existing security and social Poor waste Poor Poor sewage Poor water and health Study by author and year (evictions exclusion drainage management sanitation Overcrowding management provision poverty Occupation Education Gender Age status Adelekan (2010) X X X X X X X Ajibade and McBean (2014) X X X X X X X X X X X X X X Ajibade et al. (2013) X X X X X X X X X Akullian et al. (2015) X X X X X Bambrick et al. (2015) X X X X X X X Casanovas-Massana et al. (2018) X X X X Contreras et al. (2018) X Douglas et al. (2008) X X X X X Egondi et al. (2012) X X X X X X Egondi et al. (2015) X Ehsan et al. (2021) X X X X X French et al. (2021) X X X X X X X X X Fuhrimann et al. (2016a) X X Fuhrimann et al. (2016b) X X X Giri et al. (2021) X X X X X X X X X X X X Goudet et al. (2011a) X X X X X X X X Goudet et al. (2011b) X X X X X X X X X X Gruebner et al. (2011) X X X X X Gruebner et al. (2012) X X Hacker et al. (2020) X X Hagan et al. (2016) X X X X X X X X Johnson et al. (2004) X X X Karande et al. (2002) X Khan et al. (2014) X X X X X X X Kulabako et al. (2010) X X X X X Mabuya and Scholes (2020) X X Morin et al. (2016) X X X X X X X X X X X Mukhopadhyay et al. (2021) X X Nix et al. (2020) X X X X X X X Okaka and Odhiambo (2019a) X X X X X X Okaka and Odhiambo (2019b) X X X X X X X X X X X X Pandey et al. (2018) X X X X X X X X Pasquini et al. (2020) X X X X X X X X X X Phiri (2016) X X X X Porio (2011) X X X X X X X X X X Rashid et al. (2007) X X X X X X Rashid (2000) X X X X X X X X Rashid (2009) X X X X X X X X Reis et al. (2008) X X X X X X X X Ricardo et al. (2018) X X X X X Sakijege et al. (2012) X X X X X Samnang and Chanthol (2018) X X X X Schwerdtle et al. (2021) X X X X X X X X X Scott et al. (2017) X X X Shultz et al. (2020) X X Swain et al. (2019) X X X X X X Toan et al. (2014) X X Tran et al. (2013) X X X X X X Uwizeye et al. (2014) X X X X X X Wei et al. (2021) X (Continued) 136 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents tAbLe 4 tAbLe 4 (ContInued) overview of the determinants of vulnerability to the health impacts of extreme weather events Socio-economic and political context Material circumstances Individual determinants Housing Access to Living environment quality healthcare Social and economic Demographic Housing (land Political Poor solid- Income Existing security and social Poor waste Poor Poor sewage Poor water and health Study by author and year (evictions exclusion drainage management sanitation Overcrowding management provision poverty Occupation Education Gender Age status Adelekan (2010) X X X X X X X Ajibade and McBean (2014) X X X X X X X X X X X X X X Ajibade et al. (2013) X X X X X X X X X Akullian et al. (2015) X X X X X Bambrick et al. (2015) X X X X X X X Casanovas-Massana et al. (2018) X X X X Contreras et al. (2018) X Douglas et al. (2008) X X X X X Egondi et al. (2012) X X X X X X Egondi et al. (2015) X Ehsan et al. (2021) X X X X X French et al. (2021) X X X X X X X X X Fuhrimann et al. (2016a) X X Fuhrimann et al. (2016b) X X X Giri et al. (2021) X X X X X X X X X X X X Goudet et al. (2011a) X X X X X X X X Goudet et al. (2011b) X X X X X X X X X X Gruebner et al. (2011) X X X X X Gruebner et al. (2012) X X Hacker et al. (2020) X X Hagan et al. (2016) X X X X X X X X Johnson et al. (2004) X X X Karande et al. (2002) X Khan et al. (2014) X X X X X X X Kulabako et al. (2010) X X X X X Mabuya and Scholes (2020) X X Morin et al. (2016) X X X X X X X X X X X Mukhopadhyay et al. (2021) X X Nix et al. (2020) X X X X X X X Okaka and Odhiambo (2019a) X X X X X X Okaka and Odhiambo (2019b) X X X X X X X X X X X X Pandey et al. (2018) X X X X X X X X Pasquini et al. (2020) X X X X X X X X X X Phiri (2016) X X X X Porio (2011) X X X X X X X X X X Rashid et al. (2007) X X X X X X Rashid (2000) X X X X X X X X Rashid (2009) X X X X X X X X Reis et al. (2008) X X X X X X X X Ricardo et al. (2018) X X X X X Sakijege et al. (2012) X X X X X Samnang and Chanthol (2018) X X X X Schwerdtle et al. (2021) X X X X X X X X X Scott et al. (2017) X X X Shultz et al. (2020) X X Swain et al. (2019) X X X X X X Toan et al. (2014) X X Tran et al. (2013) X X X X X X Uwizeye et al. (2014) X X X X X X Wei et al. (2021) X 137 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 to adequate water and sanitation shaped the health impacts of flooding for many. For example, in flood-affected informal settlements in Lagos, (85) (86) (87) Nigeria, Dhaka, Bangladesh and Dar es Salaam, Tanzania, floodwater 85. ajibade and mcbean (2014). was contaminated with human excreta from overflowing latrines, sewage 86. Goudet et al. (2011a). and garbage and increased the risk of diarrhoea, typhoid and cholera. Several 87. sakijege et al. (2012). studies found increased risk of leptospirosis in households in closer proximity (88) to open sewers. Poor water supply and high water prices were identified 88. Casanovas-massana et al. (89) (2018); Hagan et al. (2016); as risk factors in many informal settlement communities. Several studies reis et al. (2008); ricardo et al. found that wells, springs and other water sources were contaminated (2018). (90) with faecal products, even without flooding. Phiri found that wells 89. ajibade and mcbean (2014); built near latrines posed a great risk of contamination, especially during Okaka and Odhiambo (2019b); Phiri (2016); Porio (2011); floods. A reliance on shallow wells, often submerged by floodwater, was samnang and Chanthol (2018). (91) also a risk. Many people resorted to drinking dirty water during floods, (92) (93) 90. Phiri (2016). increasing their risk of disease. Goudet et al. reported that even water 91. adelekan (2010); Okaka and in pipes became polluted during floods, increasing the risk of diarrhoea. Odhiambo (2019b); Phiri (2016); Several studies found that the lack of access to safe drinking water Porio (2011); rashid (2000); (94) (95) increased the risk of diarrhoeal disease. Water used for drinking and sakijege et al. (2012). (96) bathing was also identified as an important coping strategy against 92. Okaka and Odhiambo (2019b); rashid (2000). heat; however, this also relied on water availability. 93. Goudet et al. (2011a). Several studies identified health impacts related to crowding and population density. In an informal settlement in Dar es Salaam, Tanzania, 94. Phiri (2016); sakijege et al. (97) (2012); Uwizeye et al. (2014). participants noted that the high building density increased heat. (98) 95. banerjee et al. (2020); Ehsan Ehsan et al. also suggested that a densely populated environment adds et al. (2021); swain et al. (2019); (99) to the urban heat island effect. Scott et  al. found significantly higher t ran et al. (2013). temperatures in the densely populated informal settlements in Nairobi 96. Ehsan et al. (2021); nix et al. than those recorded by the local weather station, especially at night. (2020); Pasquini et al. (2020); (100) samnang and Chanthol (2018). Mukhopadhyay et al. found longer periods of dangerous heat stress in 97. Pasquini et al. (2020). households with greater numbers of occupants in Kolkata, India. In Lagos, (101) (102) (103) Nigeria, Accra, Ghana and Mombasa, Kenya, informal settlement 98. Ehsan et al. (2021). residents perceived overpopulation and overcrowding as causes of flooding. 99. scott et al. (2017). Housing quality. In several informal settlements, poor-quality 100. mukhopadhyay et al. (2021). homes were more vulnerable to flooding and heavy rain (see Table 4). (104) 101. ajibade and mcbean Morin et al. found that during the 2011 typhoon in Manila, homes in (2014). informal settlements made from wood, sheet metal and plastic were 102. Douglas et al. (2008). often not strong enough to withstand storm surges. Several studies 103. Okaka and Odhiambo found that poor housing quality increased exposure to heat. Mabuya (2019a). (105) and Scholes found that “shacks” made from corrugated iron, mud 104. morin et al. (2016). blocks, and other cheap materials were most vulnerable to high indoor 105. mabuya and scholes temperatures and temperature fluctuations compared to houses made of (2020). (106) more durable materials. Ehsan et al. studied low-income neighbourhoods 106. Ehsan et al. (2021). in Faisalabad, Pakistan and found that houses in the shade of trees or neighbouring buildings and with well-ventilated rooms had a lower heat discomfort index. Another study in two informal settlements in Kolkata, India, found longer periods of dangerous heat stress were positively associated with corrugated tin and asbestos sheet roofs, dwellings with only one room, (107) and households with greater numbers of occupants. Housing material 107. mukhopadhyay et al. (2021). may combine with other factors such as energy sources to increase the (108) risk of fires. In Lagos, Ajibade and McBean found that accidental fire 108. ajibade and mcbean (2014). outbreaks were related to wood construction and the use of kerosene lamps and candles. Accidental fires also undermined housing quality, increasing the impacts resulting from heavy rain. Access to healthcare. In many informal settlements, access to (109) healthcare was identified as a problem, both lack of provision and 109. Giri et al. (2021); rashid (2009); ricardo et al. (2018). 138 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents (110) 110. Goudet et al. (2011b); affordability. Participants in several studies associated this with the morin et al. (2016); Pasquini (111) increased risk of illness. A lack of access to healthcare was found to et al. (2020); Porio (2011); (112) (113) be exacerbated during floods. Porio found that in three informal schwerdtle et al. (2021). settlements in Manila, those with lower incomes resorted to using traditional 111. Giri et al. (2021); Goudet (114) healers during floods. In Mombasa, Kenya, Okaka and Odhiambo et al. (2011a). found that of 390 studied households, 22.3 per cent had to walk through 112. ajibade and mcbean (2014); Giri et al. (2021); Okaka floodwater to access healthcare services and 13.1 per cent found this and Odhiambo (2019b); Porio difficult or impossible. (2011); rashid (2009). 113. Porio (2011). Individual determinants: social, economic and demographic 114. Okaka and Odhiambo determinants and health status (2019b). Several studies emphasised that poverty, low income, occupation, education, gender, age and existing health status shaped and diversified the vulnerability of informal settlement residents to health impacts of extreme weather events (see Table 4). Income and poverty. While many studies described the greater exposure to environmental hazards of those who cannot afford to live in safer locations, only three studies discussed in depth how poverty (115) increases exposure to environmental hazards and contributes to vulnerability. (116) 115. adelekan (2010); ajibade For example, Hagan et  al. found that households in Salvador, Brazil et al. (2013); Hagan et al. (2016). with lower incomes lived at lower elevations and had greater exposure 116. Hagan et al. (2016). to contaminated soil, mud and water during floods, leading to higher leptospirosis infection risk. Immediate coping strategies and longer-term adaptive capacity were also influenced by income. For example, in informal settlements (117) (118) 117. Pasquini et al. (2020). in Dar es Salaam, Tanzania and Bhubaneswar and Cuttack, India, 118. swain et al. (2019). income limited adaptive responses to heat such as air conditioning and (119) refrigeration. Rashid et  al. found that in informal settlements in 119. rashid et al. (2007). Dhaka, financial constraints prevented people from flood-proofing their homes and adopting other effective adaptive responses. They also found that without significant economic incentives, participants chose not 120. ajibade et al. (2013). to relocate from flood-prone areas, partly due to moving costs. Ajibade (120) et al. found that after flooding in Lagos in 2011, women in informal settlements were more severely affected than women living in more affluent areas. They struggled to restart their businesses due to lack of (121) 121. morin et al. (2016). capital and an inability to rebuild. Morin et al. found that 45 per cent of typhoon-affected households in informal settlements had to take out (122) 122. Okaka and Odhiambo loans to cope with the storm’s impacts. Okaka and Odhiambo found (2019a). that 73 per cent of 390 participants in flood-affected settlements in Mombasa would not evacuate, mainly due to financial constraints. Occupation. Several studies found that the occupations of informal settlement residents often exposed them to climate hazards (see Table 4). In (123) 123. Okaka and Odhiambo Mombasa, Okaka and Odhiambo found that small traders were among (2019b). those more vulnerable to the health risks of flooding but did not expand on (124) (125) 124. Pasquini et al. (2020). reasons for this. Studies in Dar es Salaam, Tanzania, Dhaka, Bangladesh , (126) (127) 125. schwerdtle et al. (2021). Bhubaneswar and Cuttack, India and Ahmedabad, India found increased vulnerability to heat exposure and related health impacts 126. swain et al. (2019). among residents who worked outdoors or in poorly ventilated areas. Poor 127. t ran et al. (2013). job security made it impossible for participants in Dar es Salaam to reduce (128) 128. Pasquini et al. (2020). their hours to avoid the heat. In an informal settlement in Manila, 129. morin et al. (2016). people received no compensation for missed days of work during the (129) (130) 130. Goudet et al. (2011a, typhoon disaster, and some were fired. Goudet et  al. found that 2011b). rickshaw pullers in Dhaka could not work during floods, limiting their 139 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 ability to buy food. Home-based work, common in informal settlements (131) and particularly among women, was found to be adversely affected by 131. ajibade et al. (2013); Giri (132) et al. (2021); morin et al. (2016). extreme weather. (133) (134) 132. ajibade et al. (2013); Porio Education. Studies in Manila and Mombasa found that low (2011). educational status and illiteracy made households more vulnerable to the 133. morin et al. (2016). health impacts of floods. Low educational status and illiteracy were also 134. Okaka and Odhiambo linked to increased risk of leptospirosis in informal settlements Salvador, (2019a, 2019b). (135) (136) Brazil and Iquitos, Peru, a disease often exacerbated during floods. 135. Hagan et al. (2016). (137) Morin et  al. found that during a typhoon disaster and subsequent 136. Johnson et al. (2004). floods in Manila, households with limited education could not read 137. morin et al. (2016). warning information and had limited access to post-disaster assistance due to the required paperwork. Knowledge and awareness of information related to extreme weather (138) were also found to be a determinant of vulnerability. Tran et  al. 138. t ran et al. (2013). noted that those in Ahmedabad, India who sought information about heat illness had reduced odds of heat-related illness, possibly because they were more likely to avoid heat exposure. Several studies identified limited knowledge and poor awareness about climate change, risks and 139. Giri et al. (2021); Pandey (139) (140) et al. (2018); Pasquini et al. impacts and limited disaster-related training. (2020). Gender. While women were generally considered to be more vulnerable 140. morin et al. (2016). to the impacts of climate change and extreme weather, few studies (141) examined this in great depth (see Table 4). Pasquini et al. found that 141. Pasquini et al. (2020). women and children suffered more from heat exposure as they had to (142) remain indoors at night due to safety concerns. Ajibade and McBean 142. ajibade and mcbean (143) (2014). and Okaka and Odhiambo found that women were more vulnerable to 143. Okaka and Odhiambo the health impacts of floods but neither study expanded on this. Goudet (2019b). (144) et al. found in two separate studies that during floods, mothers often 144. Goudet et al. (2011a, significantly reduced their own food intake to feed their husbands and 2011b). (145) children. As discussed earlier, women suffered from domestic violence 145. Contreras et al. (2018); (146) (147) and problems with sanitation during floods. Gruebner et al. noted Goudet et al. (2011b); rashid that in flood-affected informal settlements in Dhaka, Bangladesh, men (2000). had better mental well-being, but did not explore this. Only one study 146. ajibade et al. (2013); rashid (2000, 2009). provided an in-depth analysis of the gendered impacts of floods in (148) 147. Gruebner et al. (2011, an informal settlement. Ajibade et  al. found that in Badia informal 2012). settlement in Lagos, polygamy played an important role in shaping 148. ajibade et al. (2013). financial vulnerability and ability to recover from disaster. Because husbands could not provide for all their wives and children, women were obliged to generate additional income. Most women did not perceive flood impacts to be gendered, but researchers found that women suffered greater economic and material losses working from inside their homes, greater difficulty caring for their children, and more problems with sanitation, privacy and access to clean water. (149) (150) On the other hand, in Salvador, Brazil and Santa Fe, Argentina, 149. Hacker et al. (2020); Hagan (151) et al. (2016). men faced a higher risk of leptospirosis. Ricardo et al. suggested that in (152) 150. ricardo et al. (2018). Santa Fe this was due to increased occupational exposure. Egondi et al. 151. ricardo et al. (2018). identified higher cold-related mortality among men in a study from (153) 152. Egondi et al. (2012, 2015). Nairobi but suggested no reason for this. Swain et  al. found that in Bhubaneswar and Cuttack, India, men were at higher risk of heat-related 153. swain et al. (2019). illness due to their occupations and outdoor activities. Social class (beyond income), ethnicity, race and religion were not discussed as determinants of vulnerability in any of the included studies. The potential contribution of cultural influences, including health beliefs, 140 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents climate change risk perception, traditions, gendered health inequalities and social structures, is also underexplored in the literature. Age. Age was found to influence vulnerability to the health impacts of extreme weather events (see Table 4). Children had greater exposure to (154) 154. French et al. (2021); contaminated water during floods, increasing their risk of diarrhoea, (155) (156) (157) (158) Goudet et al. (2011a); rashid rotavirus, leptospirosis, water-borne infections, dengue, and (2000). (159) respiratory infections. Vulnerability also varied within the under-18 155. Fuhrimann et al. (2016a). (160) category. Akullian et  al. found that the risk of typhoid in children 156. karande et al. (2002). under 10 almost doubled for every 10-metre decrease in elevation of 157. sakijege et al. (2012). households in Kibera, Nairobi, Kenya; however, the risk of typhoid was 158. Porio (2011). not associated with elevation or location in adolescents and adults. In (161) 159. Porio (2011); sakijege et al. Makassar, Indonesia, French et  al. identified a higher prevalence of (2012). diarrhoea in children under five compared to older children and adults. 160. akullian et al. (2015). (162) Children were also vulnerable to malnutrition during floods. Egondi 161. French et al. (2021). (163) et  al. found significant associations between child mortality and 162. Goudet et al. (2011a, both increased and colder temperatures in two informal settlements in 2011b). (164) (165) Nairobi. Pasquini et  al. identified children as more vulnerable to 163. Egondi et al. (2012). (166) heat but did not expand on this. In contrast, Shultz et al. found that 164. Egondi et al. (2012). children showed fewer mental health impacts compared to adults in the 165. Pasquini et al. (2020). aftermath of Hurricane Dorian in the Bahamas in 2019. 166. shultz et al. (2020). The elderly have also been identified as especially vulnerable to the health impacts of extreme weather. In Mombasa, Kenya, Okaka and (167) 167. Okaka and Odhiambo Odhiambo found adults over the age of 51 were among the most (2019b). vulnerable to the health risks of flooding, but did not expand on this. In (168) 168. t ran et al. (2013). Ahmedabad, India, Tran et  al. noted increased odds of self-reported (169) heat-related illness and symptoms among those over 60. Wei et  al. 169. Wei et al. (2021). found people over 65 the most susceptible to heat mortality, while Egondi (170) 170. Egondi et al. (2012). et al. found those over 50 years most susceptible to cold temperatures. Existing health status. Across different studied informal settle- ments, health status was found to be poor, with high burdens of infectious diseases (including diarrhoeal diseases and other food- and water-borne and water-related diseases), vector-borne diseases (including malaria and dengue), parasitic infections, pneumonia, tuberculosis, and HIV and AIDS, as well as malnutrition, poor mental health, and other non-communicable diseases (see Table 5). Several studies found those with pre-existing disease to be more (171) 171. swain et al. (2019). vulnerable to the health impacts of heat and flooding. Swain et al. and (172) 172. t ran et al. (2013). Tran et al. found in study sites in India that people with pre-existing chronic conditions and infectious diseases had an increased risk of (173) developing heat-related symptoms and illness. Egondi et al. identified significant associations between mortality and high temperatures among 173. Egondi et al. (2012). people with non-communicable diseases in Nairobi. A study in Mombasa found that households with a member with a chronic illness or disability were among those most likely to be highly vulnerable to the health (174) impacts of flooding. Only one other study mentions disability, but 174. Okaka and Odhiambo (175) (2019b). does not discuss this further as a determinant of vulnerability. Interactions between the determinants of vulnerability and 175. Okaka and Odhiambo (2019a). health impacts of extreme weather events. Previous sections have demonstrated how each of these contextual factors shape the vulnerability of people living in informal settlements to the health impacts of extreme weather events. Although sometimes these factors contribute to vulnerability in isolation, often they overlap, influence each other, and shape vulnerability through a complex web of interactions and 141 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 tA b L e 5 existing health status Water- borne/ Diarrhoea Para- Other Infectious water- and sitic HIV Poor non-com- disease related diarrhoeal Lepto- infec- Pneu- Tuber- and Malnu- mental municable Study by author and year (general) disease diseases Dysentery Typhoid Cholera spirosis tions monia culosis AIDS Malaria Dengue trition* health disease Akullian et al. (2015) X X X X Bambrick et al. (2015) X X X Casanovas-Massana et al. (2018) X Egondi et al. (2012) X X X X X X Egondi et al. (2015) X French et al. (2021) X X X X Fuhrimann et al. (2016b) X Giri et al. (2021) X X X X Goudet et al. (2011a) X X X X Goudet et al. (2011b) X Gracie et al. (2014) X Gruebner et al. (2012) X Hacker et al. (2020) X Hagan et al. (2016) X X Johnson et al. (2004) X Khan et al. (2014) X X Kulabako et al. (2010) X X X X Nix et al. (2020) X Phiri (2016) X X X X Reis et al. (2008) X Ricardo et al. (2018) X Schwerdtle et al. (2021) X Swain et al. (2019) X Toan et al. (2014) X Tran et al. (2013) X X X Malnutrition includes stunting, underweight, wasting. CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents interdependencies, as exemplified in Figure 2. The complexity of these interactions creates variations and diversity in the vulnerability among individuals living in informal settlements. A limitation of the use of the SDH framework to guide the analysis of this review is that it may lead to the erroneous understanding that determinants operate in isolation, whereas in reality they overlap both within and across structural, intermediary and individual levels. For example, the living environment is heavily determined by the inadequate service provision that is a product of the socio-economic and political context. Socio-economic factors, such as the inability to recover after floods, could be considered as both individual and community-level impacts with structural-level determinants. However, the SDH framework locates poverty at the individual level. To effectively respond to climate change, individual, social and economic determinants must be understood and addressed as products of larger, intersecting socio-economic and political systems of power. V. dIsCussIon And ConCLusIons This paper presents the most comprehensive review to date of the literature on the health impacts of climate change in informal settlements, focusing specifically on extreme weather events. The narrative review has considered 54 studies, published between 2000 and June 2021. Our search results show that this is, unsurprisingly, an expanding body of research and that a continuing synthesis of findings will be required. Moreover, we found that the extent of the available research on extreme weather events varies by topic. While flooding is relatively well-studied within the sample, few studies consider water scarcity and drought, which is evidently an area for future research. Notably, only 12 of the 54 studies explicitly defined informal settlements/slums, most of these using UN Habitat definitions. Given the heterogeneity of these contexts, we recommend that future studies provide a detailed characterisation of their context with reference to existing definitions to enable more granular analysis of the way specific features relate to health impacts and their social determinants. Our analysis of the 54 studies shows the wide-ranging health impacts of floods, extreme temperatures, droughts and storms in informal settlements. These include both direct impacts such as injury, disease and death, and the more indirect health impacts resulting from the effects on livelihoods, environmental conditions, access to healthcare, coping strategies and adaptive capacities. Importantly, when compared to the (176) 176. borg et al. (2021). review by Borg et  al., this review has drawn on a greater body of evidence on the mental health impacts of flooding, and indicates that other extreme weather events, including extreme temperatures and storms, can also negatively impact mental health. The review of the health impacts, combined with the thematic analysis of their social determinants, highlights the fact that health impacts are not uniformly experienced within informal settlements, but are first shaped by the extent of the exposure, often influenced by location, including where people live within settlements. Then, individual characteristics and markers of disadvantage (including age, gender and socio-economic position) interact with material circumstances and access to healthcare influenced by the wider socio-economic and political context to shape adaptive capacity, 143 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 A to C: Socio-economic and polical exclusion and the criminalisaon of informal se‚lements leads to the denial and lack of provision of services (including healthcare), contribung to poor environmental condions. The threat of evicon is a disincenve to build A. Socio-economic and polical context A to B: Due to social and polical exclusion, populaons more permanent and be‚er-quality homesand Housing rights, land security and evicons in informal se‚lements oˆen face limited opportunies influences responses to extreme events such as decisions Polical and social exclusion in formal employment and educaon, therefore also on evacuaon and relocaon. liming their income. C to A: Poor living condions in informal se‚lements B to A: Poverty leads to occupaon of marginal and contribute to sgma and social exclusion. The locaon illegallandwhere homes are at risk of evicon and and living condions in informal se‚lements are c ited as demolion and residents are polically and socially reasons for demolion by governments. excluded. C. Material circumstances (physical environment) B to C: Financial resources and constraints influence B. Individual-level determinants: Living environmentincluding water, sanitaon, living environmentand access to services,including Income and poverty and waste healthcare and housing quality. Occupaon Housing quality Educaon Access to healthcare C to B: Inadequate shelter, poor environmental Gender condions and limited access to services including Age healthcare, safe water and sanitaon facilies in Exisng health status and disability informal se‚lements causes and exacerbates disease and ill health. Limited opportunies and sgma a‚ached to living in informal se‚lements impact income, occupaons and educaon. Interacons between individual factors in B: Occupaons of informal se‚lers impacts their income and level of poverty. Limited access to services, food and shelter due to financial constraints, occupaonal exposure due to high-risk jobs, gendered health inequalies and domesc violence contribute to poor health. Children and the elderly are considered at higher risk of poor health and disease. F IG ure 2 Interactions between the determinants of vulnerability to the health impacts of extreme weather events CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents causing variations in vulnerability to the impacts of climate change. For example, differing degrees of exposure related to location and the presence or lack of infrastructure and service provision, combine with individual vulnerabilities to determine the impacts of extreme weather events. However, some determinants of vulnerability to extreme weather have been insufficiently researched. For example, some aspects of health, such as disability, are rarely mentioned. Socio-economic characteristics including class, religion and culture or community dynamics such as social capital and community-level power inequities are not considered in the studies. Moreover, access to healthcare and the response of the health system during disasters has been relatively underexplored. These are all areas in need of further research. These findings have clear implications for policy responses. First, responses need to consider variation in within-settlement vulnerabilities. (177) 177. sverdlik (2011), page 147. Our review has reinforced the need identified by Sverdlik for local governments to prioritise vulnerable groups and to be sensitive to “axes of difference” in their response to climate change, including age and gender. We have shown that the relationship between gender and vulnerability is not necessarily straightforward and needs to be understood in context. Strategies to minimise the impacts of climate change need to reflect and respond to these different vulnerabilities. To inform policy, further research into these other axes of difference is also required. This review has shown that for some factors, such as income, occupation and education, there is a small body of evidence, whereas other axes of difference such as religion, social capital and disability have not been explored. Furthermore, intersectional analysis is required to identify how different axes of vulnerability – and the systems of power that underlie them – interact to intensify or mediate vulnerabilities in specific contexts. For example, gender, socio-economic status, age and (dis)ability all interact to create specific positionalities and thus vulnerabilities for individuals. These positionalities and vulnerabilities are shaped by dynamic intersections between systems of power, including patriarchy, ableism, class relations and the political economy of informality in specific contexts. To illustrate, when we combine the analyses of gender and occupation within the studies, it is clear that these two factors interact in context-specific ways, to shape vulnerabilities and ultimately the impacts of extreme weather events. Researchers and policymakers must take an intersectional approach, examining and responding to these intersecting identities and determinants. Here we can learn from and expand on existing intersectional analyses of (178) 178. Hogan et al. (2018). the social determinants of health (such as that of Hogan et al. ) and of (179) urban development (for example Rigon and Broto ). 179. rigon and broto (2021). Second, to adapt to and minimise the health impacts of climate change including extreme weather events in informal settlements, comprehensive multi-sectoral responses are required which address the wider social determinants of health. National and local governments must ensure that health services are physically and financially accessible at all times, including during extreme weather events. Actors from diverse sectors, representatives of grassroots organisations, and those living and working in informal settlements must be brought together to build climate-resilient health systems. Addressing health impacts requires not only improved access to healthcare, but also improvements in livelihoods, education and access to services including water and sanitation, with attention to government provision and health inequities. 145 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 The theory of syndemics, which analyses how diseases synergistically interact with each other and their social context to increase health (180) burdens in specific populations, may have utility here. The material 180. singer et al. (2017). conditions within informal settlements increase the risk of a range of diseases, which we have shown to be amplified by extreme weather events. Adaptive and coping strategies are constrained by the same material conditions, which share common socio-economic and political determinants. Individual vulnerabilities are further shaped by various intersecting axes of disadvantage and existing health status, both of which further interact. The health impacts of informality and climate change therefore cluster and reinforce each other in specific contexts. Many of the health impacts of climate change and poor health in informal settlements can be linked to the same root causes, embedded in contextual factors, that determine vulnerability. Addressing these health impacts therefore means addressing these root causes. For example, we found that the pre- existing risk of diarrhoeal diseases for informal settlement populations was exacerbated during floods. Increases in diarrhoeal diseases were found to exacerbate child malnutrition, showing the negative synergy between (181) 181. Goudet et al. (2011a). health impacts. These synergistic health impacts occurred because floods exacerbated existing deficiencies in provision of sanitation and safe drinking water, and often in food security, which are underpinned by the political economy of informality. Promoting resilience to the health effects of climate change requires that these social determinants be tackled. Overall, we must go beyond simply labelling informal settlements or even slums as “vulnerable to climate change”. As we have shown, vulnerabilities vary within and between settlements and are caused by multiple intersecting inequalities and determinants. Further detailed empirical research at the individual, household and community level, fully embedded in the wider social and political context, is needed to both understand and minimise the health impacts of climate change. FundInG The research which informs this article was undertaken by the first author as part of their Master’s dissertation at the Liverpool School of Tropical Medicine (LSTM) and was supervised by the second and third authors. The second and third authors’ time for supervision and the writing of this article was supported by the Global Challenges Research Fund (GCRF) Accountability for Informal Urban Equity Hub (ARISE), which is a UK Research and Innovation (UKRI) Collective Fund award with award reference ES/S00811X/1. orCId Id Lana Whittaker https://orcid.org/0000-0002-4133-3827 suPPLeMent AL MAterIAL Supplemental material for this article is available online. 146 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents reFerenCes Adelekan, I O (2010), “Vulnerability of poor coastal “Community strengthening and mental health communities to flooding in Lagos, Nigeria”, system linking after flooding in two informal Environment and Urbanization Vol 22, No 2, pages human settlements in Peru: a model for small- 443–450. scale disaster response”, Global Mental Health Ajibade, I and G McBean (2014), “Climate extremes (Cambridge) Vol 5, e11. and housing rights: a political ecology of impacts, Dodman, D, D Archer and D Satterthwaite (2019), early warning and adaptation constraints in Lagos “Editorial: responding to climate change in slum communities”, Geoforum 55, pages 76–86. contexts of urban poverty and informality”, Ajibade, I, G McBean and R Bezner-Kerr (2013), Environment and Urbanization Vol 31, No 1, pages “Urban flooding in Lagos, Nigeria: patterns of 3–12. vulnerability and resilience among women”, Douglas, I, K Alam, M Maghenda, Y Mcdonell, L Global Environmental Change Vol 23, No 6, pages Mclean and J Campbell (2008), “Unjust waters: 1714–1725. climate change, flooding and the urban poor in Akullian, A, E Ng’eno, A I Matheson, L Cosmas, Africa”, Environment and Urbanization Vol 20, No D Macharia, B Fields, G Bigogo, M Mugoh, 1, pages 187–205. 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Climate change and health in informal settlements: a narrative review of the health impacts of extreme weather events

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Abstract

1083896 EAU Environment & Urbanization Climate change and health in informal settlements: a narrative review of the health impacts of extreme weather events Emma HambrECHt, raCHEl tOlHUrst anD lana WHIttakEr emma Hambrecht is a final- year medical student at the university of sheffield. AbstrACt In this paper, we present a narrative review of primary research on the emma undertook the health impacts of extreme weather events in urban informal settlements published review that informs this between 1990 and June 2021. We include 54 studies and examine the health paper as part of an Msc in impacts of extreme weather events and how these were determined. We find that Humanitarian studies at the these events impact health directly by causing mortality, injury and disease and Liverpool school of tropical through indirect pathways by impacting livelihoods, access to healthcare, coping Medicine (LstM). strategies and adaptive capacity. Drawing on the social determinants of health email: ehambrecht1@ framework to frame our analysis, we find that health impacts are determined sheffield.ac.uk by multiple intersecting factors, relating to individual circumstances, material rachel tolhurst is a reader conditions, health status, and political and socio-economic context. Consequently, at the department of vulnerability varies between and within informal settlements. Overall, we show International Public Health, that responding to and minimising these health impacts requires an intersectional LstM and is research approach to understand and address these contextual root causes of vulnerability. director for the GCrF Accountability for Informal urban equity Hub (ArIse). Keywords climate change / extreme weather / health / informal settlements / vulnerability email: rachel.tolhurst@ lstmed.ac.uk Lana whittaker (corresponding author) I. IntroduCtIon is a Post-doctoral research Associate at the The impacts of human-induced climate change are already being department of International (1) experienced, particularly through extreme weather events. There is now Public Health, LstM and considerable evidence that climate change has resulted, and will continue works in the ArIse Hub. to result, in increased extremes, including increased frequency and Address: Liverpool school intensity of heatwaves and heavy precipitation, increased droughts and of tropical Medicine, (2) Pembroke Place, Liverpool, major tropical cyclones. Climate change, including extreme weather L3 5QA, uK; email: lana. events, will have overwhelmingly negative consequences for human whittaker@lstmed.ac.uk (3) (4) health, through both direct and indirect effects. The impacts of climate change in cities, including those on health, will particularly affect those living in informal settlements, who are widely recognised to be especially vulnerable to the impacts of climate (5) change. Residents in informal settlements already experience ill health disproportionately compared to other urban dwellers and these (6) 1. IPCC (2021). inequalities will continue to be reproduced by climate change. The 2. IPCC (2021). vulnerability of informal settlements to these health impacts is widely 3. WHO (2018). accepted, including by the Intergovernmental Panel on Climate Change 122 Environment & Urbanization Copyright © Environment & Urbanization Copyright © 2022 International Institute for Environment and Development (IIED). 2022 International Institute for Environment and Development (IIED). https://doi.org/10.1177/09562478221083896 Vol 34(1): 122–150. DOI: 10.1177/09562478221083896 www.sagepublications xx–xx. DOI:.com 10.1177/09562478221083896 www.sagepublications.com CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents (7) 4. Direct effects are those (IPCC). However, specific evidence on the impacts of weather and resulting directly from (8) climatic changes on health in informal settlements is lacking and in changes in temperature and general the impacts of climate change in informal settlements is a major precipitation including extreme (9) weather events which cause research gap. injuries, illness and death. First, there has been a lack of synthesis of this research. To our Indirect effects include those knowledge, there has been to date only one formal review of the literature, caused by changes in natural (10) that of Borg et  al. Although insightful, this review provides only a systems such as vector-borne diseases and those shaped cursory discussion of the health impacts in informal settlements, based by social responses such as on just 15 studies. displacement. see Haines and Second, there has been limited discussion of how vulnerabilities Ebi (2019) and smith et al. (2014). are determined and differ within and between informal settlements. 5. revi et al. (2014); scovronick It is estimated that approximately one billion people live in informal et al. (2015); sverdlik (2011). (11) settlements. Although there may be similarities between such (12) 6. sverdlik (2011). settlements, definitions and preferred terminologies, which can be 7. revi et al. (2014). imprecise, vary by country. Moreover, within these settlements, the (13) 8. borg et al. (2021); scovronick degree of informality and exclusion varies. et al. (2015). Discussions of the vulnerability of informal settlements to climate 9. bai (2018). change are often broad and sweeping, thereby missing the complex, fine- 10. borg et al. (2021). grained variations between and within informal settlements. It is widely 11. revi et al. (2014). known, for instance, that locations on or near hillsides or in low-lying 12. t he United nations Human or river-adjacent areas can expose settlements to landslides and flooding settlements Programme (14) respectively. Vulnerability is widely considered to be determined by (Un Habitat, 2015) defines material and physical circumstances such as poor housing, inadequate informal settlements as (15) areas where residents have sanitation, lack of infrastructure and overcrowding. The interaction no tenure security, there is of these factors with markers of disadvantage, such as income, age and a lack of basic infrastructure (16) gender, have been noted in the literature along with the wider political and housing may not comply (17) with regulations and be in determinants such as government neglect and lack of access to services. hazardous locations. Un Habitat However, there has been no synthesis of the literature on health and considers slums to be the most climate change that considers these determinants of vulnerability and deprived and excluded forms how they cause health impacts to vary at the sub-settlement level. of these settlements, with slum dwellers experiencing Knowledge of the impacts on individuals, households and communities a lack of at least one of the (18) is vital to inform policy responses. following: improved water Here we present the results from a narrative review of the literature source, improved sanitation facilities, sufficient living area, on extreme weather events, health and informal settlements through housing durability and security the lens of vulnerability. We focus on extreme weather events (flooding, of tenure. However, there is extreme temperatures, droughts and storms) rather than climate change also great variation in informal more broadly as the need to understand the impacts of extreme weather settlements. events is particularly pressing. Using a more comprehensive search 13. satterthwaite et al. (2020). (19) strategy than Borg et al., we include 54 studies in our review. 14. satterthwaite et al. (2020). We begin in the next section by outlining the conceptual framework 15. borg et al. (2021); scovronick et al. (2015). underpinning this review, before detailing the methodology used. We 16. revi et al. (2014); then present an overview of the search results and outline the health satterthwaite et al. (2020); impacts of the extreme weather events reported in these studies. We sverdlik (2011). find these events impact health and mortality directly through injury, 17. satterthwaite et al. (2020). disease, and their implications for mental health; and indirectly through 18. Dodman et al. (2019). their effect on livelihoods, access to healthcare, coping strategies and 19. borg et al. (2021). adaptive capacity. Finally, we examine the reported determinants of these health impacts, showing that vulnerability is determined by multiple intersecting factors at the level of the individual, settlement and wider socio-economic and political context. Overall, we argue for a broader, more intersectional approach to researching and responding to the health impacts of extreme weather events and climate change in informal settlements. 123 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 II. ConCePtu AL FrAMeworK Here we follow the IPCC, which considers climate change risks and impacts as the result of the interaction between hazards, exposure and (20) vulnerability. Hazards are defined as the potential occurrence of events or 20. IPCC (2021). trends that may cause adverse impacts, and exposure is defined as presence (21) in places or settings that could be adversely affected. Vulnerability, 21. IPCC (2021), n.p. (22) defined as the “propensity or predisposition to being adversely affected”, 22. IPCC (2021). is not solely understood as an outcome of exposure to hazards, but as a contextual starting point encompassing sensitivity, susceptibility and (23) the ability to cope and adapt, also considering the socio-economic and 23. IPCC (2021); sharma and (24) ravindranath (2019). political context. Based on this conceptualisation, the extent to which 24. O’brien et al. (2007). extreme weather events will impact people and vary among populations depends not only on hazard and exposure, but also on the factors that shape vulnerability. Risk is the “potential for adverse consequences” resulting from the interaction between hazards, exposure and vulnerability, and impacts are the consequences when risks are realised on both natural and (25) 25. IPCC (2021), n.p. human systems, including on health and well-being. To analyse the health impacts of extreme weather events in informal settlements through this lens of contextual vulnerability, our conceptual framework draws on the World Health Organization’s (WHO) social determinants of health (SDH) model which emphasises how wider (26) structural and intermediary determinants define and underpin health. 26. WHO (2010). The SDH framework has been effectively applied to urban areas, including informal settlements, showing how multiple determinants shape health including place of residence (situated within a socio-political context), (27) socio-economic status, gender, race and ethnicity, and education. 27. Ompad et al. (2007); Vlahov et al. (2007). To fully understand the health impacts of extreme weather events in informal settlements, the context in which hazards, exposure and vulnerability interact to create risks and impacts needs to be understood. III. MetHodoLoGy The overall aim of this study was to critically review existing research on the impacts of extreme weather events on health in informal settlements. The specific research questions were: 1. How do extreme weather events, which are expected to increase in frequency, intensity and duration with climate change, impact health in urban informal settlements? 2. What factors contribute to the vulnerability of people living in these settlements? 3. How does vulnerability to these health impacts vary within informal settlements? A narrative review was chosen as it allows an extensive, broad and holistic overview of the current state of knowledge and enables the critical analysis of existing research to identify themes and gaps. This review further used the guiding principles of a systematic review, including a defined research (28) aim and objectives, a focused search strategy, and framework for analysis. 28. a veyard et al. (2016). The LSTM (Liverpool School of Tropical Medicine) EDS Discover tool and additional systematic searches of Medline, CINAHL, Global Health, 124 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents Web of Science, Cochrane, PubMed databases and Google Scholar were used to identify relevant literature. Searches followed a comprehensive strategy based on three key ideas: urban informal settlements, health and extreme weather events related to climate change (see Table 1). Initial searches were conducted in May–June 2020 and updated in July–August 2021. The following inclusion criteria were used: •• linked full-text available; •• published between January 1990 to June 2021; •• written in English; •• studies, case reports or discussion papers containing primary research data from informal settlements, formally published in an academic journal; •• specific to three main ideas: urban informal settlements, health, and extreme weather events related to climate change. The following exclusion criteria were used: •• published before January 1990; •• not written in English; •• theses, dissertations and books; •• literature not containing empirical evidence or primary research data from urban informal settlements; •• literature not covering all three key ideas named in the inclusion criteria; •• literature about long-term climate change impacts; the science of climate change; or only about adaptation, mitigation and resilience. After removing duplicates, all results were recorded in Excel files and titles and abstracts were screened for relevance, using the inclusion and exclusion criteria outlined above. This was followed by full-text screening of identified results, using the inclusion and exclusion criteria. For data extraction, collection and analysis of included results, summary tables were created in an Excel file documenting study information, publication details, methods, main findings, and strengths and limitations. Strengths and limitations were considered to critically appraise and assess the quality, value and relevance of studies to determine (29) 29. a veyard (2014). the weight given to their findings in addressing the research questions. (30) 30. a veyard (2014). An adapted thematic analysis method as described by Aveyard was used to guide the analysis and synthesis of literature. This included the use of summary tables, thematic coding using NVivo 11 software, and the development of a thematic framework. Themes naturally emerged from the literature and were continuously identified and adapted throughout the coding process. Codes were then organised into a framework of sub- themes and overarching themes which was used to structure results. IV. resuL ts a. search results The initial search produced 2,982 results, of which 2,795 were removed during initial screening. Of the remaining 187 studies, 133 were removed after screening the full text. The remaining 54 studies were deemed 125 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 tA b L e 1 search strategy for LstM eds discover search, CInAHL, Medline, Global Health, web of science, PubMed, Cochrane databases and Google scholar Strategy 1 and 2 and 3 1 Keywords: “informal settlement*” OR “informal urban settlement*” OR “urban informal settlement*” OR “urban informal space*” OR “informal urban space*” OR “informal camp*” OR slum* OR favela* OR jhuggi* OR “shanty town*” OR hovel* OR ghetto OR bastee* OR shack* ii or CsH terms: “poverty areas” iii or MesH terms: “poverty areas” 2 Keywords: health OR illness OR disease OR infect OR mortality OR morbidity OR “infectious disease” OR “physiological effect” OR “cause of death” ii or CsH terms: “health+” OR “health status+” OR “health and disease+” OR “disease+” OR “communicable diseases+” OR “noncommunicable disease+” OR “critical illness” OR “catastrophic illness” OR “acute disease” OR “chronic disease+” OR “mental health” OR “mental disorders+” OR “morbidity+” OR “child health” OR “adolescent health” OR “women’s health” OR “maternal-child health” OR “mortality+” OR “infant mortality” OR “child mortality” OR “maternal mortality” OR “world health” OR “population health” OR “public health” OR “environment and public health+” OR “environmental health” OR “environmental illness” OR “urban health” OR “health status disparities” OR “social determinants of health” iii or MesH terms: “health+” OR “disease+” OR “disease outbreaks+” OR “communicable diseases+” OR “infectious+” OR “infectious disease medicine” OR “disease transmission” OR “noncommunicable diseases” OR “critical illness” OR “catastrophic illness” OR “mental health” OR “morbidity+” OR “infant health” OR “child health” OR “adolescent health” OR “maternal health” OR “mortality+” OR “infant mortality” OR “child mortality” OR “global health” OR “public health+” OR “public health surveillance” OR “environment and public health+” OR “environmental health+” OR “environmental illness+” OR “urban health” OR “health status disparities” OR “social determinants of health” iv or Global Health thesaurus terms: health OR illness OR “health hazards” OR morbidity OR “infectious disease” OR “emerging infectious diseases” OR infection OR “airborne infection” OR “microbial contamination” OR “mental health” OR mortality OR “neonatal mortality” OR infant mortality” OR “maternal mortality” OR “public health” OR “community health” OR “occupational health” 3 Keywords: “climate change*” OR “environmental change*” OR “global warming” OR “extreme weather” OR “extreme weather event*” OR disaster* OR storm* OR hurricane* OR cyclone* OR typhoon* OR “heavy rain*” OR “extreme precipitation” OR flood* OR “flash flood*” OR “storm surge*” OR “sea level ris*” OR “coastal flood*” OR “extreme heat” OR heat* OR “temperature* ris*” OR “ris* temperature*” OR “urban heat island*” OR drought* OR “water insecurity” ii or CsH terms: “climate change” OR “natural disaster” OR heat OR “weather+” iii or MesH terms: “climate change+” OR “global warming” OR “extreme weather+” OR “extreme hot weather” OR “extreme cold weather” OR “extreme heat” OR “cyclonic storms” OR “rain+” OR floods OR “natural disasters” iv or Global Health thesaurus terms: “climatic change” OR “environmental factors” OR “climatic factors” OR “meteorological factors” OR “weather patterns” OR “global warming” OR heat OR temperature OR “critical temperature” OR “environmental temperature” OR rain OR “rain damage” OR floods OR flooding OR floodplains OR storms OR cyclones OR hurricanes OR drought OR “natural disasters” Expanders Apply related words, apply equivalent subjects Limiters Linked full text, date of publication 1990–2021, English language NOTE: Keywords were used for all searches including LSTM EDS Discover, CINAHL, Medline, Global Health, Cochrane, Web of Science and PubMed databases and the Google Scholar search. ii CInAHL subject Headings (CsH) terms were used only in the CINAHL database search in addition to keywords. iii Medical subject Headings (MesH) terms were used only in the Medline database search in addition to keywords. iv Global Health thesaurus terms were used only in the Global Health database search in addition to keywords. 126 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents relevant and suitable for inclusion in the narrative review. A full list is provided in the supplementary material. Figure 1 provides an overview of (31) 31. PrIsma (Preferred the search results. reporting Items for systematic The majority of included results were primary research articles (n = 48) reviews and meta-analyses) is including cross-sectional studies (n = 33), longitudinal studies (n = 11), an evidence-based minimum case-control studies (n = 2) and case reports (n = 2). Several discussion set of items for reporting in systematic reviews and papers (n = 6) all included primary research data or primary research case meta-analyses. a PrIsma studies (see supplementary material). flow diagram depicts the The reviewed studies were published between January 2000 and June flow of information through the different phases of a 2021. Unsurprisingly, the publication rate has increased over time: 30 of systematic review. see http:// the 54 studies have been published since 2015 and 12 since 2020. The prisma-statement.org/ increasing rate suggests ongoing evidence synthesis will be required. prismastatement/flowdiagram. aspx Most studies were conducted in Asia (n = 26) and Africa (n = 20). A further seven studies were conducted in South America and one in North America (see supplementary material). Most studies (n = 42) focused exclusively on informal settlements or slums while some (n = 12) also studied formal areas. Only 12 studies explicitly defined informal settlements or slums, most commonly using the UN Habitat definitions, although most mentioned characteristics such as lack of secure tenure without specifying a definition. b. extreme weather events Flooding was the most discussed extreme weather event. Of the 54 studies, 40 discussed flooding and heavy rainfall events. This contrasts with Borg (32) et al., who found temperature-related exposure to be the most common 32. borg et al. (2021). weather event discussed in their sample of 15 studies. The impacts 33. Hagan et al. (2016); of landslides were explored in two studies in our sample focused on samnang and Chanthol (2018). (33) flooding, although the occurrence of landslides in informal settlements was more widely noted. Storms were discussed in four studies, although many of their health impacts were discussed in terms of the associated (34) 34. morin et al. (2016). flooding. One of these four studies discussed wind; however, intense wind was not more widely discussed. Although “storm”, “hurricane”, “cyclone” and “typhoon” were included in the search strategy, including the term “wind” in future reviews may be beneficial. Extreme temperatures were discussed in 19 studies; 12 focused on heat specifically, the remaining seven discussed other forms of extreme weather as well, including the impact of cold temperatures in three studies. Six studies discussed droughts and water scarcity, but not exclusively. While the occurrence of fires was (35) 35. ajibade and mcbean (2014); noted, surprisingly the relationship between fires and extreme weather schwerdtle et al. (2021). events and the resulting impacts on health were not explored in depth. Again, future reviews may consider adding “fire” to their search terms. While many studies suggested the more general health impacts of extreme weather events and climate change while emphasising the vulnerability of informal settlements, this analysis only includes the health impacts found in the studied informal settlements. c. Health impacts of extreme weather events Health impacts of floods Seventeen studies found informal settlements were in areas exposed to flooding, including coastal areas, low-lying areas, floodplains, and near 127 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 F IG ure 1 PrIsMA flow diagram of search results rivers and waterways. Immediate health impacts of floods included injuries and high mortality (see Table 2). During floods in Lagos, Nigeria in 2011, of 607 households surveyed in Badia informal settlement, 27 (36) people reported the death of a household member. In another study of 36. ajibade and mcbean (2014). the same settlement, 7.6 per cent of surveyed women (n = 262) reported the death of a household member and 14.1 per cent reported injuries sustained by household members. Women in more affluent areas reported (37) 37. ajibade et al. (2013). no deaths or injuries. Studies also identified the contamination of water sources, homes and living environments during floods as a major health hazard (see Table 2). Several studies found that the contamination of water sources led to water shortages and limited access to safe water, resulting in worsened sanitation and hygiene. During floods, many pit latrines were submerged by floodwater and overflowed, and human waste spread into homes and around the settlements. Residents also reported problems in accessing (38) (39) 38. ajibade et al. (2013). latrines. In Lagos, Nigeria and Dhaka, Bangladesh for example, 39. rashid (2000). women were constrained by insecurity and lack of privacy during floods and had to relieve themselves at night or in their own homes. Limited 128 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents access to sanitation facilities also affected bathing and personal hygiene. (40) 40. kwiringira et al. (2016). In an informal settlement in Kampala, Uganda, Kwiringira et al. found that sanitation facilities overflowed, and were dirtier and more difficult to clean compared to the dry season. In these studies, the impacts of floods were shaped by existing inequities in access to water and sanitation facilities, including those related to gender. Both gender and provision of water and sanitation will be discussed further as determinants of vulnerability in Section IV d. Many studies found that infectious disease burdens significantly increased during and after flooding events, including from water- and food-borne diseases (diarrhoea, typhoid, gastroenteritis, leptospirosis, cholera and rotavirus), skin problems, respiratory conditions and vector-borne diseases (see Table 2). Direct contact with dirty floodwater and contaminated drinking water sources increased the risk of disease during floods, especially for children who often played in contaminated (41) 41. Fuhrimann et al. (2016a); floodwater. Households at a lower elevation in informal settlements (42) karande et al. (2002); sakijege were more exposed to flooding and had increased risk of typhoid, et al. (2012). (43) (44) leptospirosis and diarrhoea. 42. akullian et al. (2015). Studies also found an increase in mental health problems associated 43. Casanovas-massana et al. with floods. In informal settlements in Mombasa, Kenya, 80.8 per cent (2018); Hagan et al. (2016); reis of 390 households reported problems with mental health during the et al. (2008). last flooding event, linked to the trauma of losing property and having 44. Uwizeye et al. (2014). (45) (46) nowhere to live. In Lagos, Nigeria, households reported the inability 45. Okaka and Odhiambo to sleep, loss of appetite, stress, and fear of future floods. (2019a). (47) Women across informal settlements in Lima, Peru and Dhaka, 46. adelekan (2010). (48) Bangladesh reported an increase in domestic violence during 47. Contreras et al. (2018). floods. Women in Dhaka said this was due to increased stress on their 48. rashid (2000). husbands to provide for their families in times of financial hardship and unemployment. Floods also had less direct impacts on health, related to changes in food consumption, food security, increased food and water prices, livelihood disruption and loss of income (see Table 2). Damage and destruction of homes and displacement added to both economic and health burdens. Health impacts of extreme temperatures Five studies described settlements in areas that were vulnerable to extreme temperatures. Cross-sectional studies in informal settlements in Nairobi, (49) (50) 49. scott et al. (2017). Kenya, Kolkata, India and informal townships in Gauteng and (51) 50. mukhopadhyay et al. (2021). Mpumalanga, South Africa found that populations there were exposed to temperatures over 40°C. Although the health impacts were not recorded, 51. mabuya and scholes (2020). these temperatures exceeded the thresholds at which negative health (52) 52. scott et al. (2017). impacts and increased mortality would be expected. Three further (53) (54) 53. Egondi et al. (2012, 2015). studies in Nairobi, Kenya and Ahmedabad, India found associations between high temperatures and increased mortality in informal settlement 54. Wei et al. (2021). (55) populations, specifically in Egondi et al. for children under four years of 55. Egondi et al. (2012). age and people with non-communicable diseases. Populations living in informal settlements reported heat-related symptoms and serious impacts of heat including heat-related illness, infectious diseases, poor mental health and other non-communicable health problems (see Table 3). In three studies, people reported that (56) 56. bambrick et al. (2015); heatwaves and hot summer temperatures affected their ability to work. Pasquini et al. (2020); sinha Four studies examined the effects of cold weather on health (see et al. (2008). Table 3). Two studies in Nairobi found higher mortality rates in colder 129 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 tAbLe 2 tAbLe 2 (ContInued) Health impacts of floods Con- Expo- Dam- Con- tami- Water sure age tami- nation short- to Eco- Mal- In- (de- Lim- nation of age/ Sub- Prob- con- In- nom- nutri- creased struc- ited Para- Fun- Respi- Poor of Con- living lack of merged/ lems tami- creased ic/job tion food tion access Lep- Gas- sitic Skin gal ratory Pneu- men- water tamina- envi- access over- with nated domes- distur- Loss (food and (dis- to Study by author tospi- Rota- troen- infec- infec- infec- Coughs/ infec- mo- Tuber- Ma- Den- tal sourc- tion of ron- to flowing latrine flood- tic vio- banc- of in- inse- water place- health- and year Mortality Injuries Diarrhoea Cholera rosis Typhoid virus teritis tions tions tions Scabies colds tions nia culosis laria gue health es homes ment water latrines access water lence es come curity prices ment care Adelekan (2010) X X X X X X Ajibade and X X X X X X X X X McBean (2014) Ajibade et al. (2013) X X X X X X X X X X X X X X X Bambrick et al. X (2015) Casanovas- X Massana et al. (2018) Contreras et al. X X X (2018) Douglas et al. X X X X X (2008) French et al. (2021) X X X Fuhrimann et al. X X X X (2016a) Fuhrimann et al. X X X (2016b) Giri et al. (2021) X X X X X Goudet et al. X X X X X X X X (2011a) Goudet et al. X X X X X X X X X X (2011b) Gruebner et al. X X (2011) Gruebner et al. X (2012) Hacker et al. (2020) X Hagan et al. (2016) X X X Johnson et al. X (2004) Karande et al. X X X (2002) Khan et al. (2014) X X X Kulabako et al. X X (2010) Kwiringira et al. X X (2016) Morin et al. (2016) X X X X X X X X X X Nix et al. (2020) X Okaka and X X X X X X X X Odhiambo (2019a) Okaka and X X X X X X X X X Odhiambo (2019b) Pandey et al. (2018) X X X Pawar et al. (2008) X Phiri (2016) X X X X Porio (2011) X X X X X X X X X X X X X X X X X Rashid et al. (2007) X X X Rashid (2000) X X X X X X X X X X X X X X X X X X Rashid (2009) X X Reis et al. (2008) X Ricardo et al. (2018) X Sakijege et al. X X X X X X X X X X X X X X X X X (2012) Samnang and X Chanthol (2018) Schwerdtle et al. X X (2021) Uwizeye et al. X X (2014) (Continued) 130 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents tAbLe 2 tAbLe 2 (ContInued) Health impacts of floods Con- Expo- Dam- Con- tami- Water sure age tami- nation short- to Eco- Mal- In- (de- Lim- nation of age/ Sub- Prob- con- In- nom- nutri- creased struc- ited Para- Fun- Respi- Poor of Con- living lack of merged/ lems tami- creased ic/job tion food tion access Lep- Gas- sitic Skin gal ratory Pneu- men- water tamina- envi- access over- with nated domes- distur- Loss (food and (dis- to Study by author tospi- Rota- troen- infec- infec- infec- Coughs/ infec- mo- Tuber- Ma- Den- tal sourc- tion of ron- to flowing latrine flood- tic vio- banc- of in- inse- water place- health- and year Mortality Injuries Diarrhoea Cholera rosis Typhoid virus teritis tions tions tions Scabies colds tions nia culosis laria gue health es homes ment water latrines access water lence es come curity prices ment care Adelekan (2010) X X X X X X Ajibade and X X X X X X X X X McBean (2014) Ajibade et al. (2013) X X X X X X X X X X X X X X X Bambrick et al. X (2015) Casanovas- X Massana et al. (2018) Contreras et al. X X X (2018) Douglas et al. X X X X X (2008) French et al. (2021) X X X Fuhrimann et al. X X X X (2016a) Fuhrimann et al. X X X (2016b) Giri et al. (2021) X X X X X Goudet et al. X X X X X X X X (2011a) Goudet et al. X X X X X X X X X X (2011b) Gruebner et al. X X (2011) Gruebner et al. X (2012) Hacker et al. (2020) X Hagan et al. (2016) X X X Johnson et al. X (2004) Karande et al. X X X (2002) Khan et al. (2014) X X X Kulabako et al. X X (2010) Kwiringira et al. X X (2016) Morin et al. (2016) X X X X X X X X X X Nix et al. (2020) X Okaka and X X X X X X X X Odhiambo (2019a) Okaka and X X X X X X X X X Odhiambo (2019b) Pandey et al. (2018) X X X Pawar et al. (2008) X Phiri (2016) X X X X Porio (2011) X X X X X X X X X X X X X X X X X Rashid et al. (2007) X X X Rashid (2000) X X X X X X X X X X X X X X X X X X Rashid (2009) X X Reis et al. (2008) X Ricardo et al. (2018) X Sakijege et al. X X X X X X X X X X X X X X X X X (2012) Samnang and X Chanthol (2018) Schwerdtle et al. X X (2021) Uwizeye et al. X X (2014) 131 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 tAbLe 3 tAbLe 3 (ContInued) Health impacts of extreme temperatures Heat Car- Sleep Study by ex- Japanese diovas- High Cold- Poor Dis- Weak- im- author and haus- Heat Heat Heat Diar- Pneu- Eye Fungal enceph- cular blood related mental com- Dehy- ness/ Tired- pair- Head- Dizzi- Faint- Nau- Fe- year Mortality tion cramp stroke rashes Oedema rhoea Influenza monia disease infections Malaria Dengue alitis disease pressure illness health fort dration malaise ness ment ache ness ing sea ver Cough Health impacts of heat Banerjee X et al. (2020) Egondi X et al. (2012) Egondi X et al. (2015) Ehsan et al. X X X X X X X X (2021) Mabuya X and Scholes (2020) Nix et al. X X (2020) Pasquini X X X X X X X X X X X X X X X X et al. (2020) Schwerdtle X X X et al. (2021) Sinha et al. X X X X X X X (2008) Swain et al. X X X (2019) Toan et al. X X X X X (2014) Tran et al. X X X (2013) Wei et al. X (2021) Health impacts of cold Egondi X et al. (2012) Egondi X et al. (2015) Mabuya X and Scholes (2020) Toan et al. X X X X X X (2014) (Continued) 132 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents tAbLe 3 tAbLe 3 (ContInued) Health impacts of extreme temperatures Heat Car- Sleep Study by ex- Japanese diovas- High Cold- Poor Dis- Weak- im- author and haus- Heat Heat Heat Diar- Pneu- Eye Fungal enceph- cular blood related mental com- Dehy- ness/ Tired- pair- Head- Dizzi- Faint- Nau- Fe- year Mortality tion cramp stroke rashes Oedema rhoea Influenza monia disease infections Malaria Dengue alitis disease pressure illness health fort dration malaise ness ment ache ness ing sea ver Cough Health impacts of heat Banerjee X et al. (2020) Egondi X et al. (2012) Egondi X et al. (2015) Ehsan et al. X X X X X X X X (2021) Mabuya X and Scholes (2020) Nix et al. X X (2020) Pasquini X X X X X X X X X X X X X X X X et al. (2020) Schwerdtle X X X et al. (2021) Sinha et al. X X X X X X X (2008) Swain et al. X X X (2019) Toan et al. X X X X X (2014) Tran et al. X X X (2013) Wei et al. X (2021) Health impacts of cold Egondi X et al. (2012) Egondi X et al. (2015) Mabuya X and Scholes (2020) Toan et al. X X X X X X (2014) 133 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 (57) 57. Egondi et al. (2012). periods with high rainfall and significant associations between lower (58) 58. Egondi et al. (2015). temperatures and years of life lost. “Shack dwellers” in townships in South Africa were found to be at higher risk of cold-related illness than (59) 59. mabuya and scholes (2020). people living in housing of better quality. Informal settlement residents (60) in Hanoi, Vietnam associated infectious diseases with cold weather. 60. t oan et al. (2014). Health impacts of droughts and water scarcity Few studies focused specifically on the health impacts of droughts and (61) 61. bambrick et al. (2015). water scarcity; however, in informal settlements in Shasheme, Ethiopia, residents experienced problems with washing and hygiene related to water shortages, and found malaria and typhoid were more common during the dry season, when temperatures were also higher. In informal (62) 62. kwiringira et al. (2016). settlements in Kampala, Uganda, Kwiringira et al. observed that water scarcity during the dry season made it difficult to clean latrines. In Nairobi, Kenya, adolescents over the age of 10 and adults had three times (63) 63. akullian et al. (2015). the risk of typhoid after long periods without rain. In four informal settlements in Dehradun, India, 25 per cent of 121 participants reported (64) 64. Pandey et al. (2018). “health-related problems” due to droughts. Health impacts of storms (65) 65. shultz et al. (2020). Shultz et al. reported on the impacts of Hurricane Dorian in shanty towns in Marsh Harbour, Abaco Islands in the Bahamas in 2019. The study, mainly focused on mental health impacts, found the affected population suffered from acute psychological distress, acute grief reactions, major depression, generalised anxiety and post-traumatic stress disorder immediately after and in the months following the disaster. These responses were linked to loss, destruction, displacement, homelessness and unemployment resulting from the hurricane, which caused high mortality and severe injuries. (66) In the aftermath of Typhoon Pedring in 2011, Morin et  al. identified 66. morin et al. (2016). vulnerability to typhoons and cyclones due to settlement location in Manila, mainly discussing the consequences of flooding and storm surges. d. determinants of vulnerability We examined the determinants mentioned in the studies to understand how the local context in informal settlements shapes vulnerability, including to the impacts of extreme weather events, and creates variation in health impacts. The overarching factors identified in the included studies are shown in Table 4 and are explored in more depth in the following section. We do not rigidly adhere to the broad categories of structural and intermediary determinants of health used in the SDH framework to structure our discussion. Instead, we consider specific determinants of health from the framework in the most logical sequence for this topic: beginning with the socio-economic and political context, then discussing material circumstances at settlement-level, and then individual-level determinants, including socio-economic status, demographic factors and health status. socio-economic and political context In several informal settlements, the socio-economic and political context, including tenure insecurity and political and social exclusion, was found to contribute to the vulnerability to the health impacts of extreme weather events (see Table 4). 134 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents Housing rights, land security and evictions. Urban informal (67) 67. ajibade and mcbean (2014); settlements are often considered illegal. Studies noted that many morin et al. (2016). residents have no legal title to their land and occupy marginal land (68) 68. ajibade and mcbean including unauthorised governmental land. As a result, many commu- (2014); French et al. (2021); (69) nities live under the threat of eviction and demolition. Due to such Hagan et al. (2016); morin et al. threats, residents were reluctant to build more permanent and stronger (2016); Porio (2011); rashid et al. (2007); reis et al. (2008); housing structures that would provide them with more protection samnang and Chanthol (2018). (70) (71) from extreme weather. Samnang and Chanthol also found that in 69. ajibade and mcbean (2014); informal settlements in Battambang, Cambodia, people were unable Giri et al. (2021); morin et al. to relocate to safer land as they could not sell the land they currently (2016); rashid (2000, 2009); (72) lived on because they lacked formal land titles. Morin et al. noted the samnang and Chanthol (2018); (73) schwerdtle et al. (2021). occurrence of evictions following a typhoon. Okaka and Odhiambo 70. ajibade and mcbean (2014); found fear of losing their homes stopped 4.3 per cent of respondents from Giri et al. (2021); morin et al. evacuating during floods. The need to protect household belongings from (2016). (74) theft was another reason for not evacuating. 71. samnang and Chanthol (2018). Political and social exclusion. Several studies suggested that 72. morin et al. (2016). governments refuse to provide infrastructure and services in informal 73. Okaka and Odhiambo settlements due to their illegal status. As a result, residents are often (2019a). excluded from access to basic infrastructure and services, increasing their 74. Porio (2011); rashid (2000). exposure and vulnerability to climate change impacts. In three studies in (75) (76) informal settlements in Lagos, Nigeria, Accra, Ghana and Mombasa, 75. adelekan (2010). (77) Kenya participants believed poor planning and governmental exclusion 76. Douglas et al. (2008). and neglect increased the risk of flooding and flood impacts. Ajibade and 77. Okaka and Odhiambo (78) McBean found that households in Badia informal settlement in Lagos, (2019a). Nigeria ignored government-issued typhoon warnings and did not evacuate 78. ajibade and mcbean (2014). because of distrust in the government, including fear of evictions. In several studies, informal settlement residents reported receiving limited or no social and governmental support during and after extreme (79) 79. morin et al. (2016). weather events. Morin et  al. found that although relief supplies and financial assistance were available for most typhoon-affected communities in Manila, there were many structural barriers to accessing this assistance. Many lacked the documents to apply for assistance and relocation and could not afford the fees to obtain them. Consequently, most households received relief supplies and financial assistance from families, friends and (80) 80. rashid (2000). neighbours. Rashid also found that flood-affected households helped (81) 81. Douglas et al. (2008); each other. The absence or inadequacy of emergency responses were (82) morin et al. (2016); Okaka and also noted including the absence of emergency services. Odhiambo (2019b); Pasquini (83) (84) Studies in Dhaka, Bangladesh and Lagos, Nigeria found that the et al. (2020); rashid (2000). stigma attached to living in informal settlements limited the ability of 82. ajibade and mcbean (2014). women to find better jobs, increase their income, apply for loans and 83. rashid (2009). expand their social networks, thereby increasing their vulnerability 84. ajibade and mcbean (2014). during floods. These wider social, economic and political factors, more difficult to research using conventional health research methodologies, are underexplored and significant knowledge gaps still exist, including limited community-level analysis of the contribution of socio-political marginalisation to vulnerability. Material circumstances (physical environment) Living environment. The living environment in informal settle- ments was found to contribute to increased risk of disease, flooding and the health impacts of floods and heat (see Table 4). Inequities in access 135 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 tAbLe 4 tAbLe 4 (ContInued) overview of the determinants of vulnerability to the health impacts of extreme weather events Socio-economic and political context Material circumstances Individual determinants Housing Access to Living environment quality healthcare Social and economic Demographic Housing (land Political Poor solid- Income Existing security and social Poor waste Poor Poor sewage Poor water and health Study by author and year (evictions exclusion drainage management sanitation Overcrowding management provision poverty Occupation Education Gender Age status Adelekan (2010) X X X X X X X Ajibade and McBean (2014) X X X X X X X X X X X X X X Ajibade et al. (2013) X X X X X X X X X Akullian et al. (2015) X X X X X Bambrick et al. (2015) X X X X X X X Casanovas-Massana et al. (2018) X X X X Contreras et al. (2018) X Douglas et al. (2008) X X X X X Egondi et al. (2012) X X X X X X Egondi et al. (2015) X Ehsan et al. (2021) X X X X X French et al. (2021) X X X X X X X X X Fuhrimann et al. (2016a) X X Fuhrimann et al. (2016b) X X X Giri et al. (2021) X X X X X X X X X X X X Goudet et al. (2011a) X X X X X X X X Goudet et al. (2011b) X X X X X X X X X X Gruebner et al. (2011) X X X X X Gruebner et al. (2012) X X Hacker et al. (2020) X X Hagan et al. (2016) X X X X X X X X Johnson et al. (2004) X X X Karande et al. (2002) X Khan et al. (2014) X X X X X X X Kulabako et al. (2010) X X X X X Mabuya and Scholes (2020) X X Morin et al. (2016) X X X X X X X X X X X Mukhopadhyay et al. (2021) X X Nix et al. (2020) X X X X X X X Okaka and Odhiambo (2019a) X X X X X X Okaka and Odhiambo (2019b) X X X X X X X X X X X X Pandey et al. (2018) X X X X X X X X Pasquini et al. (2020) X X X X X X X X X X Phiri (2016) X X X X Porio (2011) X X X X X X X X X X Rashid et al. (2007) X X X X X X Rashid (2000) X X X X X X X X Rashid (2009) X X X X X X X X Reis et al. (2008) X X X X X X X X Ricardo et al. (2018) X X X X X Sakijege et al. (2012) X X X X X Samnang and Chanthol (2018) X X X X Schwerdtle et al. (2021) X X X X X X X X X Scott et al. (2017) X X X Shultz et al. (2020) X X Swain et al. (2019) X X X X X X Toan et al. (2014) X X Tran et al. (2013) X X X X X X Uwizeye et al. (2014) X X X X X X Wei et al. (2021) X (Continued) 136 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents tAbLe 4 tAbLe 4 (ContInued) overview of the determinants of vulnerability to the health impacts of extreme weather events Socio-economic and political context Material circumstances Individual determinants Housing Access to Living environment quality healthcare Social and economic Demographic Housing (land Political Poor solid- Income Existing security and social Poor waste Poor Poor sewage Poor water and health Study by author and year (evictions exclusion drainage management sanitation Overcrowding management provision poverty Occupation Education Gender Age status Adelekan (2010) X X X X X X X Ajibade and McBean (2014) X X X X X X X X X X X X X X Ajibade et al. (2013) X X X X X X X X X Akullian et al. (2015) X X X X X Bambrick et al. (2015) X X X X X X X Casanovas-Massana et al. (2018) X X X X Contreras et al. (2018) X Douglas et al. (2008) X X X X X Egondi et al. (2012) X X X X X X Egondi et al. (2015) X Ehsan et al. (2021) X X X X X French et al. (2021) X X X X X X X X X Fuhrimann et al. (2016a) X X Fuhrimann et al. (2016b) X X X Giri et al. (2021) X X X X X X X X X X X X Goudet et al. (2011a) X X X X X X X X Goudet et al. (2011b) X X X X X X X X X X Gruebner et al. (2011) X X X X X Gruebner et al. (2012) X X Hacker et al. (2020) X X Hagan et al. (2016) X X X X X X X X Johnson et al. (2004) X X X Karande et al. (2002) X Khan et al. (2014) X X X X X X X Kulabako et al. (2010) X X X X X Mabuya and Scholes (2020) X X Morin et al. (2016) X X X X X X X X X X X Mukhopadhyay et al. (2021) X X Nix et al. (2020) X X X X X X X Okaka and Odhiambo (2019a) X X X X X X Okaka and Odhiambo (2019b) X X X X X X X X X X X X Pandey et al. (2018) X X X X X X X X Pasquini et al. (2020) X X X X X X X X X X Phiri (2016) X X X X Porio (2011) X X X X X X X X X X Rashid et al. (2007) X X X X X X Rashid (2000) X X X X X X X X Rashid (2009) X X X X X X X X Reis et al. (2008) X X X X X X X X Ricardo et al. (2018) X X X X X Sakijege et al. (2012) X X X X X Samnang and Chanthol (2018) X X X X Schwerdtle et al. (2021) X X X X X X X X X Scott et al. (2017) X X X Shultz et al. (2020) X X Swain et al. (2019) X X X X X X Toan et al. (2014) X X Tran et al. (2013) X X X X X X Uwizeye et al. (2014) X X X X X X Wei et al. (2021) X 137 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 to adequate water and sanitation shaped the health impacts of flooding for many. For example, in flood-affected informal settlements in Lagos, (85) (86) (87) Nigeria, Dhaka, Bangladesh and Dar es Salaam, Tanzania, floodwater 85. ajibade and mcbean (2014). was contaminated with human excreta from overflowing latrines, sewage 86. Goudet et al. (2011a). and garbage and increased the risk of diarrhoea, typhoid and cholera. Several 87. sakijege et al. (2012). studies found increased risk of leptospirosis in households in closer proximity (88) to open sewers. Poor water supply and high water prices were identified 88. Casanovas-massana et al. (89) (2018); Hagan et al. (2016); as risk factors in many informal settlement communities. Several studies reis et al. (2008); ricardo et al. found that wells, springs and other water sources were contaminated (2018). (90) with faecal products, even without flooding. Phiri found that wells 89. ajibade and mcbean (2014); built near latrines posed a great risk of contamination, especially during Okaka and Odhiambo (2019b); Phiri (2016); Porio (2011); floods. A reliance on shallow wells, often submerged by floodwater, was samnang and Chanthol (2018). (91) also a risk. Many people resorted to drinking dirty water during floods, (92) (93) 90. Phiri (2016). increasing their risk of disease. Goudet et al. reported that even water 91. adelekan (2010); Okaka and in pipes became polluted during floods, increasing the risk of diarrhoea. Odhiambo (2019b); Phiri (2016); Several studies found that the lack of access to safe drinking water Porio (2011); rashid (2000); (94) (95) increased the risk of diarrhoeal disease. Water used for drinking and sakijege et al. (2012). (96) bathing was also identified as an important coping strategy against 92. Okaka and Odhiambo (2019b); rashid (2000). heat; however, this also relied on water availability. 93. Goudet et al. (2011a). Several studies identified health impacts related to crowding and population density. In an informal settlement in Dar es Salaam, Tanzania, 94. Phiri (2016); sakijege et al. (97) (2012); Uwizeye et al. (2014). participants noted that the high building density increased heat. (98) 95. banerjee et al. (2020); Ehsan Ehsan et al. also suggested that a densely populated environment adds et al. (2021); swain et al. (2019); (99) to the urban heat island effect. Scott et  al. found significantly higher t ran et al. (2013). temperatures in the densely populated informal settlements in Nairobi 96. Ehsan et al. (2021); nix et al. than those recorded by the local weather station, especially at night. (2020); Pasquini et al. (2020); (100) samnang and Chanthol (2018). Mukhopadhyay et al. found longer periods of dangerous heat stress in 97. Pasquini et al. (2020). households with greater numbers of occupants in Kolkata, India. In Lagos, (101) (102) (103) Nigeria, Accra, Ghana and Mombasa, Kenya, informal settlement 98. Ehsan et al. (2021). residents perceived overpopulation and overcrowding as causes of flooding. 99. scott et al. (2017). Housing quality. In several informal settlements, poor-quality 100. mukhopadhyay et al. (2021). homes were more vulnerable to flooding and heavy rain (see Table 4). (104) 101. ajibade and mcbean Morin et al. found that during the 2011 typhoon in Manila, homes in (2014). informal settlements made from wood, sheet metal and plastic were 102. Douglas et al. (2008). often not strong enough to withstand storm surges. Several studies 103. Okaka and Odhiambo found that poor housing quality increased exposure to heat. Mabuya (2019a). (105) and Scholes found that “shacks” made from corrugated iron, mud 104. morin et al. (2016). blocks, and other cheap materials were most vulnerable to high indoor 105. mabuya and scholes temperatures and temperature fluctuations compared to houses made of (2020). (106) more durable materials. Ehsan et al. studied low-income neighbourhoods 106. Ehsan et al. (2021). in Faisalabad, Pakistan and found that houses in the shade of trees or neighbouring buildings and with well-ventilated rooms had a lower heat discomfort index. Another study in two informal settlements in Kolkata, India, found longer periods of dangerous heat stress were positively associated with corrugated tin and asbestos sheet roofs, dwellings with only one room, (107) and households with greater numbers of occupants. Housing material 107. mukhopadhyay et al. (2021). may combine with other factors such as energy sources to increase the (108) risk of fires. In Lagos, Ajibade and McBean found that accidental fire 108. ajibade and mcbean (2014). outbreaks were related to wood construction and the use of kerosene lamps and candles. Accidental fires also undermined housing quality, increasing the impacts resulting from heavy rain. Access to healthcare. In many informal settlements, access to (109) healthcare was identified as a problem, both lack of provision and 109. Giri et al. (2021); rashid (2009); ricardo et al. (2018). 138 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents (110) 110. Goudet et al. (2011b); affordability. Participants in several studies associated this with the morin et al. (2016); Pasquini (111) increased risk of illness. A lack of access to healthcare was found to et al. (2020); Porio (2011); (112) (113) be exacerbated during floods. Porio found that in three informal schwerdtle et al. (2021). settlements in Manila, those with lower incomes resorted to using traditional 111. Giri et al. (2021); Goudet (114) healers during floods. In Mombasa, Kenya, Okaka and Odhiambo et al. (2011a). found that of 390 studied households, 22.3 per cent had to walk through 112. ajibade and mcbean (2014); Giri et al. (2021); Okaka floodwater to access healthcare services and 13.1 per cent found this and Odhiambo (2019b); Porio difficult or impossible. (2011); rashid (2009). 113. Porio (2011). Individual determinants: social, economic and demographic 114. Okaka and Odhiambo determinants and health status (2019b). Several studies emphasised that poverty, low income, occupation, education, gender, age and existing health status shaped and diversified the vulnerability of informal settlement residents to health impacts of extreme weather events (see Table 4). Income and poverty. While many studies described the greater exposure to environmental hazards of those who cannot afford to live in safer locations, only three studies discussed in depth how poverty (115) increases exposure to environmental hazards and contributes to vulnerability. (116) 115. adelekan (2010); ajibade For example, Hagan et  al. found that households in Salvador, Brazil et al. (2013); Hagan et al. (2016). with lower incomes lived at lower elevations and had greater exposure 116. Hagan et al. (2016). to contaminated soil, mud and water during floods, leading to higher leptospirosis infection risk. Immediate coping strategies and longer-term adaptive capacity were also influenced by income. For example, in informal settlements (117) (118) 117. Pasquini et al. (2020). in Dar es Salaam, Tanzania and Bhubaneswar and Cuttack, India, 118. swain et al. (2019). income limited adaptive responses to heat such as air conditioning and (119) refrigeration. Rashid et  al. found that in informal settlements in 119. rashid et al. (2007). Dhaka, financial constraints prevented people from flood-proofing their homes and adopting other effective adaptive responses. They also found that without significant economic incentives, participants chose not 120. ajibade et al. (2013). to relocate from flood-prone areas, partly due to moving costs. Ajibade (120) et al. found that after flooding in Lagos in 2011, women in informal settlements were more severely affected than women living in more affluent areas. They struggled to restart their businesses due to lack of (121) 121. morin et al. (2016). capital and an inability to rebuild. Morin et al. found that 45 per cent of typhoon-affected households in informal settlements had to take out (122) 122. Okaka and Odhiambo loans to cope with the storm’s impacts. Okaka and Odhiambo found (2019a). that 73 per cent of 390 participants in flood-affected settlements in Mombasa would not evacuate, mainly due to financial constraints. Occupation. Several studies found that the occupations of informal settlement residents often exposed them to climate hazards (see Table 4). In (123) 123. Okaka and Odhiambo Mombasa, Okaka and Odhiambo found that small traders were among (2019b). those more vulnerable to the health risks of flooding but did not expand on (124) (125) 124. Pasquini et al. (2020). reasons for this. Studies in Dar es Salaam, Tanzania, Dhaka, Bangladesh , (126) (127) 125. schwerdtle et al. (2021). Bhubaneswar and Cuttack, India and Ahmedabad, India found increased vulnerability to heat exposure and related health impacts 126. swain et al. (2019). among residents who worked outdoors or in poorly ventilated areas. Poor 127. t ran et al. (2013). job security made it impossible for participants in Dar es Salaam to reduce (128) 128. Pasquini et al. (2020). their hours to avoid the heat. In an informal settlement in Manila, 129. morin et al. (2016). people received no compensation for missed days of work during the (129) (130) 130. Goudet et al. (2011a, typhoon disaster, and some were fired. Goudet et  al. found that 2011b). rickshaw pullers in Dhaka could not work during floods, limiting their 139 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 ability to buy food. Home-based work, common in informal settlements (131) and particularly among women, was found to be adversely affected by 131. ajibade et al. (2013); Giri (132) et al. (2021); morin et al. (2016). extreme weather. (133) (134) 132. ajibade et al. (2013); Porio Education. Studies in Manila and Mombasa found that low (2011). educational status and illiteracy made households more vulnerable to the 133. morin et al. (2016). health impacts of floods. Low educational status and illiteracy were also 134. Okaka and Odhiambo linked to increased risk of leptospirosis in informal settlements Salvador, (2019a, 2019b). (135) (136) Brazil and Iquitos, Peru, a disease often exacerbated during floods. 135. Hagan et al. (2016). (137) Morin et  al. found that during a typhoon disaster and subsequent 136. Johnson et al. (2004). floods in Manila, households with limited education could not read 137. morin et al. (2016). warning information and had limited access to post-disaster assistance due to the required paperwork. Knowledge and awareness of information related to extreme weather (138) were also found to be a determinant of vulnerability. Tran et  al. 138. t ran et al. (2013). noted that those in Ahmedabad, India who sought information about heat illness had reduced odds of heat-related illness, possibly because they were more likely to avoid heat exposure. Several studies identified limited knowledge and poor awareness about climate change, risks and 139. Giri et al. (2021); Pandey (139) (140) et al. (2018); Pasquini et al. impacts and limited disaster-related training. (2020). Gender. While women were generally considered to be more vulnerable 140. morin et al. (2016). to the impacts of climate change and extreme weather, few studies (141) examined this in great depth (see Table 4). Pasquini et al. found that 141. Pasquini et al. (2020). women and children suffered more from heat exposure as they had to (142) remain indoors at night due to safety concerns. Ajibade and McBean 142. ajibade and mcbean (143) (2014). and Okaka and Odhiambo found that women were more vulnerable to 143. Okaka and Odhiambo the health impacts of floods but neither study expanded on this. Goudet (2019b). (144) et al. found in two separate studies that during floods, mothers often 144. Goudet et al. (2011a, significantly reduced their own food intake to feed their husbands and 2011b). (145) children. As discussed earlier, women suffered from domestic violence 145. Contreras et al. (2018); (146) (147) and problems with sanitation during floods. Gruebner et al. noted Goudet et al. (2011b); rashid that in flood-affected informal settlements in Dhaka, Bangladesh, men (2000). had better mental well-being, but did not explore this. Only one study 146. ajibade et al. (2013); rashid (2000, 2009). provided an in-depth analysis of the gendered impacts of floods in (148) 147. Gruebner et al. (2011, an informal settlement. Ajibade et  al. found that in Badia informal 2012). settlement in Lagos, polygamy played an important role in shaping 148. ajibade et al. (2013). financial vulnerability and ability to recover from disaster. Because husbands could not provide for all their wives and children, women were obliged to generate additional income. Most women did not perceive flood impacts to be gendered, but researchers found that women suffered greater economic and material losses working from inside their homes, greater difficulty caring for their children, and more problems with sanitation, privacy and access to clean water. (149) (150) On the other hand, in Salvador, Brazil and Santa Fe, Argentina, 149. Hacker et al. (2020); Hagan (151) et al. (2016). men faced a higher risk of leptospirosis. Ricardo et al. suggested that in (152) 150. ricardo et al. (2018). Santa Fe this was due to increased occupational exposure. Egondi et al. 151. ricardo et al. (2018). identified higher cold-related mortality among men in a study from (153) 152. Egondi et al. (2012, 2015). Nairobi but suggested no reason for this. Swain et  al. found that in Bhubaneswar and Cuttack, India, men were at higher risk of heat-related 153. swain et al. (2019). illness due to their occupations and outdoor activities. Social class (beyond income), ethnicity, race and religion were not discussed as determinants of vulnerability in any of the included studies. The potential contribution of cultural influences, including health beliefs, 140 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents climate change risk perception, traditions, gendered health inequalities and social structures, is also underexplored in the literature. Age. Age was found to influence vulnerability to the health impacts of extreme weather events (see Table 4). Children had greater exposure to (154) 154. French et al. (2021); contaminated water during floods, increasing their risk of diarrhoea, (155) (156) (157) (158) Goudet et al. (2011a); rashid rotavirus, leptospirosis, water-borne infections, dengue, and (2000). (159) respiratory infections. Vulnerability also varied within the under-18 155. Fuhrimann et al. (2016a). (160) category. Akullian et  al. found that the risk of typhoid in children 156. karande et al. (2002). under 10 almost doubled for every 10-metre decrease in elevation of 157. sakijege et al. (2012). households in Kibera, Nairobi, Kenya; however, the risk of typhoid was 158. Porio (2011). not associated with elevation or location in adolescents and adults. In (161) 159. Porio (2011); sakijege et al. Makassar, Indonesia, French et  al. identified a higher prevalence of (2012). diarrhoea in children under five compared to older children and adults. 160. akullian et al. (2015). (162) Children were also vulnerable to malnutrition during floods. Egondi 161. French et al. (2021). (163) et  al. found significant associations between child mortality and 162. Goudet et al. (2011a, both increased and colder temperatures in two informal settlements in 2011b). (164) (165) Nairobi. Pasquini et  al. identified children as more vulnerable to 163. Egondi et al. (2012). (166) heat but did not expand on this. In contrast, Shultz et al. found that 164. Egondi et al. (2012). children showed fewer mental health impacts compared to adults in the 165. Pasquini et al. (2020). aftermath of Hurricane Dorian in the Bahamas in 2019. 166. shultz et al. (2020). The elderly have also been identified as especially vulnerable to the health impacts of extreme weather. In Mombasa, Kenya, Okaka and (167) 167. Okaka and Odhiambo Odhiambo found adults over the age of 51 were among the most (2019b). vulnerable to the health risks of flooding, but did not expand on this. In (168) 168. t ran et al. (2013). Ahmedabad, India, Tran et  al. noted increased odds of self-reported (169) heat-related illness and symptoms among those over 60. Wei et  al. 169. Wei et al. (2021). found people over 65 the most susceptible to heat mortality, while Egondi (170) 170. Egondi et al. (2012). et al. found those over 50 years most susceptible to cold temperatures. Existing health status. Across different studied informal settle- ments, health status was found to be poor, with high burdens of infectious diseases (including diarrhoeal diseases and other food- and water-borne and water-related diseases), vector-borne diseases (including malaria and dengue), parasitic infections, pneumonia, tuberculosis, and HIV and AIDS, as well as malnutrition, poor mental health, and other non-communicable diseases (see Table 5). Several studies found those with pre-existing disease to be more (171) 171. swain et al. (2019). vulnerable to the health impacts of heat and flooding. Swain et al. and (172) 172. t ran et al. (2013). Tran et al. found in study sites in India that people with pre-existing chronic conditions and infectious diseases had an increased risk of (173) developing heat-related symptoms and illness. Egondi et al. identified significant associations between mortality and high temperatures among 173. Egondi et al. (2012). people with non-communicable diseases in Nairobi. A study in Mombasa found that households with a member with a chronic illness or disability were among those most likely to be highly vulnerable to the health (174) impacts of flooding. Only one other study mentions disability, but 174. Okaka and Odhiambo (175) (2019b). does not discuss this further as a determinant of vulnerability. Interactions between the determinants of vulnerability and 175. Okaka and Odhiambo (2019a). health impacts of extreme weather events. Previous sections have demonstrated how each of these contextual factors shape the vulnerability of people living in informal settlements to the health impacts of extreme weather events. Although sometimes these factors contribute to vulnerability in isolation, often they overlap, influence each other, and shape vulnerability through a complex web of interactions and 141 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 tA b L e 5 existing health status Water- borne/ Diarrhoea Para- Other Infectious water- and sitic HIV Poor non-com- disease related diarrhoeal Lepto- infec- Pneu- Tuber- and Malnu- mental municable Study by author and year (general) disease diseases Dysentery Typhoid Cholera spirosis tions monia culosis AIDS Malaria Dengue trition* health disease Akullian et al. (2015) X X X X Bambrick et al. (2015) X X X Casanovas-Massana et al. (2018) X Egondi et al. (2012) X X X X X X Egondi et al. (2015) X French et al. (2021) X X X X Fuhrimann et al. (2016b) X Giri et al. (2021) X X X X Goudet et al. (2011a) X X X X Goudet et al. (2011b) X Gracie et al. (2014) X Gruebner et al. (2012) X Hacker et al. (2020) X Hagan et al. (2016) X X Johnson et al. (2004) X Khan et al. (2014) X X Kulabako et al. (2010) X X X X Nix et al. (2020) X Phiri (2016) X X X X Reis et al. (2008) X Ricardo et al. (2018) X Schwerdtle et al. (2021) X Swain et al. (2019) X Toan et al. (2014) X Tran et al. (2013) X X X Malnutrition includes stunting, underweight, wasting. CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents interdependencies, as exemplified in Figure 2. The complexity of these interactions creates variations and diversity in the vulnerability among individuals living in informal settlements. A limitation of the use of the SDH framework to guide the analysis of this review is that it may lead to the erroneous understanding that determinants operate in isolation, whereas in reality they overlap both within and across structural, intermediary and individual levels. For example, the living environment is heavily determined by the inadequate service provision that is a product of the socio-economic and political context. Socio-economic factors, such as the inability to recover after floods, could be considered as both individual and community-level impacts with structural-level determinants. However, the SDH framework locates poverty at the individual level. To effectively respond to climate change, individual, social and economic determinants must be understood and addressed as products of larger, intersecting socio-economic and political systems of power. V. dIsCussIon And ConCLusIons This paper presents the most comprehensive review to date of the literature on the health impacts of climate change in informal settlements, focusing specifically on extreme weather events. The narrative review has considered 54 studies, published between 2000 and June 2021. Our search results show that this is, unsurprisingly, an expanding body of research and that a continuing synthesis of findings will be required. Moreover, we found that the extent of the available research on extreme weather events varies by topic. While flooding is relatively well-studied within the sample, few studies consider water scarcity and drought, which is evidently an area for future research. Notably, only 12 of the 54 studies explicitly defined informal settlements/slums, most of these using UN Habitat definitions. Given the heterogeneity of these contexts, we recommend that future studies provide a detailed characterisation of their context with reference to existing definitions to enable more granular analysis of the way specific features relate to health impacts and their social determinants. Our analysis of the 54 studies shows the wide-ranging health impacts of floods, extreme temperatures, droughts and storms in informal settlements. These include both direct impacts such as injury, disease and death, and the more indirect health impacts resulting from the effects on livelihoods, environmental conditions, access to healthcare, coping strategies and adaptive capacities. Importantly, when compared to the (176) 176. borg et al. (2021). review by Borg et  al., this review has drawn on a greater body of evidence on the mental health impacts of flooding, and indicates that other extreme weather events, including extreme temperatures and storms, can also negatively impact mental health. The review of the health impacts, combined with the thematic analysis of their social determinants, highlights the fact that health impacts are not uniformly experienced within informal settlements, but are first shaped by the extent of the exposure, often influenced by location, including where people live within settlements. Then, individual characteristics and markers of disadvantage (including age, gender and socio-economic position) interact with material circumstances and access to healthcare influenced by the wider socio-economic and political context to shape adaptive capacity, 143 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 A to C: Socio-economic and polical exclusion and the criminalisaon of informal se‚lements leads to the denial and lack of provision of services (including healthcare), contribung to poor environmental condions. The threat of evicon is a disincenve to build A. Socio-economic and polical context A to B: Due to social and polical exclusion, populaons more permanent and be‚er-quality homesand Housing rights, land security and evicons in informal se‚lements oˆen face limited opportunies influences responses to extreme events such as decisions Polical and social exclusion in formal employment and educaon, therefore also on evacuaon and relocaon. liming their income. C to A: Poor living condions in informal se‚lements B to A: Poverty leads to occupaon of marginal and contribute to sgma and social exclusion. The locaon illegallandwhere homes are at risk of evicon and and living condions in informal se‚lements are c ited as demolion and residents are polically and socially reasons for demolion by governments. excluded. C. Material circumstances (physical environment) B to C: Financial resources and constraints influence B. Individual-level determinants: Living environmentincluding water, sanitaon, living environmentand access to services,including Income and poverty and waste healthcare and housing quality. Occupaon Housing quality Educaon Access to healthcare C to B: Inadequate shelter, poor environmental Gender condions and limited access to services including Age healthcare, safe water and sanitaon facilies in Exisng health status and disability informal se‚lements causes and exacerbates disease and ill health. Limited opportunies and sgma a‚ached to living in informal se‚lements impact income, occupaons and educaon. Interacons between individual factors in B: Occupaons of informal se‚lers impacts their income and level of poverty. Limited access to services, food and shelter due to financial constraints, occupaonal exposure due to high-risk jobs, gendered health inequalies and domesc violence contribute to poor health. Children and the elderly are considered at higher risk of poor health and disease. F IG ure 2 Interactions between the determinants of vulnerability to the health impacts of extreme weather events CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents causing variations in vulnerability to the impacts of climate change. For example, differing degrees of exposure related to location and the presence or lack of infrastructure and service provision, combine with individual vulnerabilities to determine the impacts of extreme weather events. However, some determinants of vulnerability to extreme weather have been insufficiently researched. For example, some aspects of health, such as disability, are rarely mentioned. Socio-economic characteristics including class, religion and culture or community dynamics such as social capital and community-level power inequities are not considered in the studies. Moreover, access to healthcare and the response of the health system during disasters has been relatively underexplored. These are all areas in need of further research. These findings have clear implications for policy responses. First, responses need to consider variation in within-settlement vulnerabilities. (177) 177. sverdlik (2011), page 147. Our review has reinforced the need identified by Sverdlik for local governments to prioritise vulnerable groups and to be sensitive to “axes of difference” in their response to climate change, including age and gender. We have shown that the relationship between gender and vulnerability is not necessarily straightforward and needs to be understood in context. Strategies to minimise the impacts of climate change need to reflect and respond to these different vulnerabilities. To inform policy, further research into these other axes of difference is also required. This review has shown that for some factors, such as income, occupation and education, there is a small body of evidence, whereas other axes of difference such as religion, social capital and disability have not been explored. Furthermore, intersectional analysis is required to identify how different axes of vulnerability – and the systems of power that underlie them – interact to intensify or mediate vulnerabilities in specific contexts. For example, gender, socio-economic status, age and (dis)ability all interact to create specific positionalities and thus vulnerabilities for individuals. These positionalities and vulnerabilities are shaped by dynamic intersections between systems of power, including patriarchy, ableism, class relations and the political economy of informality in specific contexts. To illustrate, when we combine the analyses of gender and occupation within the studies, it is clear that these two factors interact in context-specific ways, to shape vulnerabilities and ultimately the impacts of extreme weather events. Researchers and policymakers must take an intersectional approach, examining and responding to these intersecting identities and determinants. Here we can learn from and expand on existing intersectional analyses of (178) 178. Hogan et al. (2018). the social determinants of health (such as that of Hogan et al. ) and of (179) urban development (for example Rigon and Broto ). 179. rigon and broto (2021). Second, to adapt to and minimise the health impacts of climate change including extreme weather events in informal settlements, comprehensive multi-sectoral responses are required which address the wider social determinants of health. National and local governments must ensure that health services are physically and financially accessible at all times, including during extreme weather events. Actors from diverse sectors, representatives of grassroots organisations, and those living and working in informal settlements must be brought together to build climate-resilient health systems. Addressing health impacts requires not only improved access to healthcare, but also improvements in livelihoods, education and access to services including water and sanitation, with attention to government provision and health inequities. 145 en VI ron M ent & urb A n IZA t I on Vol 34 n o 1 April 2022 The theory of syndemics, which analyses how diseases synergistically interact with each other and their social context to increase health (180) burdens in specific populations, may have utility here. The material 180. singer et al. (2017). conditions within informal settlements increase the risk of a range of diseases, which we have shown to be amplified by extreme weather events. Adaptive and coping strategies are constrained by the same material conditions, which share common socio-economic and political determinants. Individual vulnerabilities are further shaped by various intersecting axes of disadvantage and existing health status, both of which further interact. The health impacts of informality and climate change therefore cluster and reinforce each other in specific contexts. Many of the health impacts of climate change and poor health in informal settlements can be linked to the same root causes, embedded in contextual factors, that determine vulnerability. Addressing these health impacts therefore means addressing these root causes. For example, we found that the pre- existing risk of diarrhoeal diseases for informal settlement populations was exacerbated during floods. Increases in diarrhoeal diseases were found to exacerbate child malnutrition, showing the negative synergy between (181) 181. Goudet et al. (2011a). health impacts. These synergistic health impacts occurred because floods exacerbated existing deficiencies in provision of sanitation and safe drinking water, and often in food security, which are underpinned by the political economy of informality. Promoting resilience to the health effects of climate change requires that these social determinants be tackled. Overall, we must go beyond simply labelling informal settlements or even slums as “vulnerable to climate change”. As we have shown, vulnerabilities vary within and between settlements and are caused by multiple intersecting inequalities and determinants. Further detailed empirical research at the individual, household and community level, fully embedded in the wider social and political context, is needed to both understand and minimise the health impacts of climate change. FundInG The research which informs this article was undertaken by the first author as part of their Master’s dissertation at the Liverpool School of Tropical Medicine (LSTM) and was supervised by the second and third authors. The second and third authors’ time for supervision and the writing of this article was supported by the Global Challenges Research Fund (GCRF) Accountability for Informal Urban Equity Hub (ARISE), which is a UK Research and Innovation (UKRI) Collective Fund award with award reference ES/S00811X/1. orCId Id Lana Whittaker https://orcid.org/0000-0002-4133-3827 suPPLeMent AL MAterIAL Supplemental material for this article is available online. 146 CLIMA te CHA n G e & H e AL t H I n I n F or MAL sett L e M ents reFerenCes Adelekan, I O (2010), “Vulnerability of poor coastal “Community strengthening and mental health communities to flooding in Lagos, Nigeria”, system linking after flooding in two informal Environment and Urbanization Vol 22, No 2, pages human settlements in Peru: a model for small- 443–450. scale disaster response”, Global Mental Health Ajibade, I and G McBean (2014), “Climate extremes (Cambridge) Vol 5, e11. and housing rights: a political ecology of impacts, Dodman, D, D Archer and D Satterthwaite (2019), early warning and adaptation constraints in Lagos “Editorial: responding to climate change in slum communities”, Geoforum 55, pages 76–86. contexts of urban poverty and informality”, Ajibade, I, G McBean and R Bezner-Kerr (2013), Environment and Urbanization Vol 31, No 1, pages “Urban flooding in Lagos, Nigeria: patterns of 3–12. vulnerability and resilience among women”, Douglas, I, K Alam, M Maghenda, Y Mcdonell, L Global Environmental Change Vol 23, No 6, pages Mclean and J Campbell (2008), “Unjust waters: 1714–1725. climate change, flooding and the urban poor in Akullian, A, E Ng’eno, A I Matheson, L Cosmas, Africa”, Environment and Urbanization Vol 20, No D Macharia, B Fields, G Bigogo, M Mugoh, 1, pages 187–205. 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