Indicators to Guide and Monitor Climate Change Adaptation in the US Pacific Northwest

Abstract

Objectives. To develop a set of indicators to guide and monitor climate change adaptation in US state and local health departments.

Methods. We performed a narrative review of literature on indicators of climate change adaptation and public health service capacity, mapped the findings onto activities grouped by the Centers for Disease Control and Prevention’s Ten Essential Services, and drafted potential indicators to discuss with practitioners. We then refined the indicators after key informant interviews with 17 health department officials in the US Pacific Northwest in fall 2018.

Results. Informants identified a need for clarity regarding state and local public health’s role in climate change adaptation, integration of adaptation into existing programs, and strengthening of communication, partnerships, and response capacity to increase resilience. We propose a set of climate change indicators applicable for state and local health departments.

Conclusions. With additional context-specific refinement, the proposed indicators can aid agencies in tracking adaptation efforts. The generalizability, robustness, and relevance of the proposed indicators should be explored in other settings with a broader set of stakeholders.

Climate change presents significant challenges for state and local public health agencies.^1,2 These challenges are diverse and vary widely by location as a result of population health status, hazard exposure, response capacity, differences in the rates at and degrees to which climate-sensitive hazards are changing, and decisions about adaptation in health and other sectors.³

In the United States, public health adaptation activities are under way at the national level,⁴ but relatively limited human and financial resources have been devoted to local adaptation and response, where the majority of adaptation occurs.² Although many state and local health departments recognize the threat of climate change, few have the capacity to develop de novo an understanding of public health’s role in climate change adaptation or effective adaptation programming.⁵ As climate change–related impacts and associated health risks become more pressing, efficiently and effectively developing adaptive capacity,⁶ including engagement by state and local public health decision-makers and practitioners,⁷ will become increasingly urgent.⁶

There is substantial literature on tracking the health impacts of climate change and developing adaptation plans.^8–14 However, limited guidance is available on indicators that promote and track adaptation activities at the state and local health department levels.^8,14 Aimed at national level efforts, the World Health Organization’s framework for public health adaptation presents general conceptual indicators for national level efforts, but it is intended to be specific to climate change, rather than for mainstreamed activities integrated into existing efforts.¹⁵ The Centers for Disease Control and Prevention’s (CDC’s) Building Resilience Against Climate Effects (BRACE) framework¹⁶ describes 5 steps to guide climate change readiness in public health agencies. Step 4, developing and implementing an adaptation plan, highlights the importance of evidence-based adaptation planning, and step 5, evaluation of impacts, provides guidance for evaluation, but neither step gives substantial guidance on monitoring and tracking adaptation activities or on the development of process indicators. The Council of State and Territorial Epidemiologists’ adaptation and policy indicators¹¹ begin to lay the groundwork for the development of additional process indicators catered to state and local health departments, but more process indicators regarding adaptation are needed. Furthermore, an effort by Ebi et al. describes the need for process indicators related to climate change adaptation and health system resilience and lays further groundwork for their development.¹⁴

Attention to established frameworks can facilitate implementation of novel guidance.¹⁷ Public health activities in the United States are guided by a few common frameworks, the most familiar of which is the Ten Essential Services (TES) of Public Health, developed by the Core Public Health Functions Steering Committee in 1994.¹⁸ The TES builds on the 3 functions of public health (assessment, policy development, and assurance) proposed in the Institute of Medicine’s 1988 Future of Public Health Report.⁷ The TES provides state, tribal, territorial, and local public health agencies in the United States with guidelines that outline their basic responsibilities.¹⁹ The TES is a simple and familiar tool used by many state and local health agencies and has been applied in other contexts.^20,21 Therefore, we chose the TES framework as a starting point for organizing indicators of climate change adaptation activity.

Our primary objective was to develop indicators, situated in a familiar framework, for assessing and tracking state and local health agency capacity for effective climate change adaptation.

METHODS

Our methods comprised 4 parts: a narrative literature review,²² development of draft activities and indicators situated within the TES to characterize and track adaptation, key informant interviews regarding the utility and appropriateness of the proposed indicators and the challenges and opportunities for their use, and refinement of the activities and indicators based on interviews.

We conducted a narrative literature review to determine whether indicators existed for use by state and local health departments to track uptake, implementation, and effectiveness of climate change adaptation activities. We were also interested in identifying literature applicable to the development of process indicators for tracking adaptation in this setting. The keywords we used to identify background literature were adaptive capacity AND climate change AND (institutions OR health sector OR public health). We searched articles on Scopus and Web of Science and then reviewed them for relevant indicators. We also searched government reports for climate change and health adaptation indicators.

We used our findings from this literature search to develop a draft set of indicators. We assessed the potentially applicable indicators identified in the narrative literature review for relevance and, where appropriate, modified them for a state or local health department and to fit into the TES framework. We also used themes identified in the narrative review, including constraints and barriers to adaptation,²³ adaptive capacity,²⁴ and adaptation engagement²⁵ and readiness^26,27 to develop additional adaptation and policy indicators.^8,9,11,14 During this process, we consulted theoretical work describing health indicator development^28–30 to ensure that our indicators were measurable and actionable. This resulted in 1 or more draft indicators related to adaptation activities for each TES category. Although we did not prespecify a time horizon for adaptation activities, our goal was to develop indicators relevant for planning in the near-term—over the next 1 to 2 decades—consistent with planning and budget horizons for other activities.

To test the utility, relevance, and comprehensiveness of the activities and indicators, we conducted 11 key informant interviews comprising a purposive sample of 17 tribal, state, and local public health officials working on climate and health in Washington State and Oregon, 2 climatically similar states. State climate and health program administrators in each state helped identify potential informants, who engaged in climate and health across the TES areas. We invited potential informants to participate by e-mail; we recruited additional informants through snowball sampling. We conducted 5 interviews with 11 Washington and local health department staff, 4 interviews with Oregon Health Authority and local health departments, and 2 interviews with staff from tribal communities located within the geographic boundaries of Washington and Oregon. We invited 40 individuals to participate, of whom 17 participated.

We conducted semistructured interviews lasting 45 to 60 minutes in person or remotely in August and September 2018, and 1 or more members of the research team detailed notes. An interview guide that we developed a priori included open-ended questions (Table A, available as a supplement to the online version of this article at http://www.ajph.org) to elicit informants’ feedback on the draft indicators (Table B, available as a supplement to the online version of this article at http://www.ajph.org), as well as on opportunities and challenges to implementation of the indicators. Informants identified the TES area or areas most closely aligned with their professional responsibilities and provided feedback in those areas. We reviewed notes to inductively identify key themes that emerged across the interviews. We then developed codes based on these themes, along with definitions, and institutionalized them into a codebook. Two coders then used NVivo qualitative data analysis software version 10 (QSR International Pty Ltd., Doncaster, Australia) to collaboratively code³¹ the interview notes.

The research team periodically reviewed and discussed the informants’ feedback. We stopped recruitment when saturation was obtained for indicators across all of the TES. We used results and feedback from the key informant interviews to further refine the indicators.

RESULTS

We conducted the literature search in winter 2018 and limited it to publications in English. We identified about 90 publications as relevant to our goals and reviewed their abstracts. Upon review, we found no publications outlining indicators that matched our objective, although several were highly relevant practically and thematically. Of the practically relevant publications, several proposed general categories of indicator or, alternatively, specific indicators that were more relevant to a national scale.

Draft Activity and Indicator Framework

We developed a draft set of indicators (Table B) for discussion and feedback during key informant interviews. We selected indicators to be illustrative and to allow modification and specification in response to key informant input.^28–30

Key Informant Interviews

Of the 17 key informants, 12 were state health officials, 2 were local health officials, 2 were tribal representatives, and 1 was a consultant. Several of the 11 interviews included more than 1 informant, yielding a total of 17 participants.

Informants noted that, although the draft activities (Table B) adequately captured existing and future climate change adaptation work in health agencies, they suggested several changes to make indicators more specific and actionable. Several informants noted that, although certain indicators would be appropriate for local health departments, tracking the full set is likely beyond their capacity and would need to be deferred to a larger organization with more resources. Most informants noted that, for Oregon and Washington, it would be most appropriate for the indicators to be tracked at the state level.

In addition to comments on the draft activities and indicators, informants highlighted opportunities and challenges (Table C, available as a supplement to the online version of this article at http://www.ajph.org) regarding adaptation and engagement with climate change at different administrative levels. We organized these by major theme.

Collaboration and partnerships.

A recurring theme across the interviews was the need for more collaboration and partnerships. Several benefits were advanced: to share expertise and activities, to extend activities into local communities more effectively, and to more effectively embed or mainstream climate change adaptation into existing work streams and programs. Informants from local health departments and tribal communities identified the lack of capacity in their organizations to work on adaptation, pointing to partnerships with state health, decision-makers, local organizations, and other nontraditional partners as a way to make progress at the local level. These informants also highlighted the need for guidance on how to seek partnerships and on the role of different administrative levels within public health.

Communication.

Nearly all informants identified a need for more communication within, between, and across sectors with respect to adaptation and climate-related hazards. A couple of state-level informants noted that there is inadequate funding for communication, particularly at the local level. Furthermore, several informants noted the need for guidance on outreach and community engagement and in creating culturally and linguistically appropriate and politically sensitive messaging. A handful of informants noted that political feasibility of measuring or operationalizing particular indicators and the most appropriate language to use depends on the audience and local community, and they highlighted the challenges of matching language to community priorities and perceptions. Respondents reported that a communications approach focused on weather-related hazards instead of climate change was often more successful. All informants highlighted the importance of communicating and engaging with local communities, but they noted the many challenges in doing so successfully.

Equity.

Several informants highlighted the challenges they had in cross-cultural collaboration and communication. A couple of informants noted that tribal communities, in particular, lack the capacity to engage in adaptation on their own and must rely on external partnerships. However, this coordination is often difficult because of issues of tribal sovereignty and other cross-cultural differences.

Resources, capacity, and authority.

One of the most prominent themes throughout the interviews, mentioned by all informants, was the overwhelming lack of resources and capacity, particularly in rural and tribal communities. Informants identified this as a major barrier in adaptation implementation, and they suggested ways the proposed activities and indicators could be integrated into existing programs and plans, given capacity constraints. Furthermore, several informants noted they could benefit from guidance on partnerships, nontraditional funding opportunities, engaging with the community, and general guidance on how to become a climate-prepared health agency. Finally, a few informants noted their state health department’s lack of regulatory authority as a major barrier to enforcing adaptation-oriented plans and policies.

Using emergency preparedness and response capacity.

Several informants highlighted the opportunity to build on existing response capacity in emergency preparedness divisions and departments, while also discussing the general lack of response capacity in public health agencies. Many informants mentioned the need for more holistic approaches, rather than relying only on siloed, hazard-specific, or event-based responses. Informants noted that both event-based and all-hazards preparedness approaches across agencies are needed both to respond to events as needed and for longer-term planning and capacity building.

Training.

A final theme was the need for more training of the public health workforce on public health’s role in climate change preparedness and response. Approximately one third of informants noted a need for guidance on the role of public health and how the workforce should be trained to collaborate across sectors and approach climate change response holistically, rather than via event- and hazard-based responses.

Final Framework

Table 1 lists several activities and indicator examples organized by essential service from the TES framework. It broadly describes representative programming in each service category and is generally applicable across regions. It provides examples of quantifiable indicators related to activities that can be used to track readiness, engagement, and ongoing progress in the relevant activity and is more specific to the hazards and challenges in the Pacific Northwest. The framework is meant to be a guide that can serve as a point of entry for agencies to use in developing their adaptation plans, modifying as necessary to reflect local vulnerabilities, dynamics, and activities. Table D (available as a supplement to the online version of this article at http://www.ajph.org) provides more guidance on suggested effective use of the framework.

TABLE 1—

Climate Change Adaptation Activities and Indicators

Public Health Service	Activities	Indicator Examples
1. Monitor climate-related health threats	1. Monitors influence of weather and climate on health outcomes	Annual report of rates of hazardous events (e.g., floods, droughts, wildfires, extreme heat events, other extreme weather events, ecological events like wildlife disease outbreaks; no./yr)
	a. Collaborates with other agencies for data and monitoring efforts	Annual reporting of above items with exposures and outcomes stratified by vulnerability factors (no./population)
	b. Conducts vulnerability and adaptation assessments	State conducts continual monitoring for new and emerging threats (e.g., vector-borne disease, increasing extreme heat) through monitoring hazard rates and emerging impacts (e.g., through syndromic surveillance; Y/N; updates monitoring/tracking system)
	2. Develops, implements, and updates early warning systems, as appropriate	Conducts surveillance of weather-related morbidity and mortality, including cold- and heat-related illness and mortality, asthma exacerbations, and other respiratory hospitalizations related to wildfire events, shellfish poisoning outbreaks, utilization of mental health services, etc. (Y/N; rates)
	3. Partners with meteorological agencies to monitor for potential new climate- or weather-related threats in the region	State tracks and aggregates data on local health department activities regarding monitoring and surveillance for climate-sensitive hazards, exposures, and health outcomes (Y/N, updated annually)
	4. Ensures clear and regular communication between state and local health departments regarding monitoring and surveillance of climate-sensitive hazardous exposures and adverse health outcomes
2. Diagnose and investigate climate-related health threats	1. Investigates health outcomes associated with climate- and weather-related events equitably across populations, with attention to population vulnerability	Partners with meteorological service agencies to report proportion of identified emerging threats investigated for likelihood of regional impact in the next decade (%)
		Employs early detection methods to facilitate surveillance and identify changing incidence (proportion of indicator health outcomes with early detection methods)
		Tracks geographic and temporal distributions of health risks, outcomes, and relevant trends over time (Y/N)
3. Inform, educate, and empower regarding climate-related health outcomes	1. Conducts outreach to community partners and members regarding weather- and climate-related risks and expected changes in those risks	Proportion of prevalent hazards for which information for reducing risks is communicated to the public (%)
	2. Carries out education and communication campaigns using evidence-based public health methodology	Communicates (e.g., e-mails/calls/meetings) in advance and during extreme weather events between state and local health agencies (no./yr)
	3. Communicates between state and local health and across states regarding information and education on extreme events	State conducts annual needs assessment with local health departments and with affected populations regarding informational, educational, and other resource needs during extreme events (Y/N; frequency)
		Conducts evaluation of communication and education efforts (frequency)
4. Mobilize community partnerships regarding the response to extreme weather and climate events	1. Engages with community members and community partners on effects of climate- and weather-related events in their communities	Develops and maintains partnerships with cross-sector work groups/committees for decision-making and enhanced response capacity (e.g., ability to respond to early warnings) related to climate-sensitive exposures and health outcomes (includes county/city government, health department, health care providers, nonprofits, industry, meteorological services, etc.; no./y)
	2. Communicates and shares information with other agencies and nongovernmental partners, both before and during events	Establishes and maintains regular communication (e.g., e-mails/meetings/calls) with community organizations for disaster response (e.g., Red Cross/Red Crescent; Y/N; frequency of communication)
	3. Coordinates with other agencies and partners on the health response to hazardous weather and climate-sensitive hazards	Maintains regular interagency communication or meetings regarding overlapping activities and shared interests (Y/N; frequency)
		Participates in vulnerability and adaptation assessments on request from partners (Y/N)
		Works with industry, community boards, and other agencies on rule making and reviews regularly (e.g., every 5 y) to incorporate changing hazard landscape (periodic review of stakeholder engagement related to policy to assess breadth, depth, and frequency of activities)
		Maintains partnerships and supports other agency/organization efforts on climate change adaptation (description of active partnerships and engagements, updated annually)
5. Develop policies on weather and climate preparedness and climate change response	1. Adds and maintains climate change response plans and protocols in existing processes (i.e., strategic plans), which include specific plans for vulnerable populations, defined by issue/hazard	Proportion of extreme weather events and climate-sensitive environmental hazards experienced (e.g., wildfires, harmful algal blooms) for which a plan was developed and tested for response to the hazard (%)
	2. Sends agency representatives to climate policy and decision-making meetings, state or locally	Allocates resources for local and state health departments to help nearby areas respond to weather- and climate-related hazards, including disasters (Y/N; tracking of investments by category)
	3. Allocates funding for weather- and climate-sensitive hazard preparedness	Evaluates efficacy of climate change response plans (frequency)
	4. Participates in state and federal disaster planning	Periodically (e.g., every 10 y) assesses weather- and climate-related risks to health facilities and health-related infrastructure (e.g., water and sanitation; Y/N; date of last assessment)
	5. Collaborates with sister agencies on policy and rule-making development and updates to accommodate changing hazard landscape	Develops and regularly updates (e.g., every 5 y) guidance regarding siting and construction of health facilities and health-related infrastructure (e.g., water and sanitation; Y/N; date of last update)
		Periodically (e.g., every 10 y) reviews and updates regulations related to key environmental media (air, water, food, soil, housing, waste) and hazards in light of current and expected climatic conditions (Y/N; date of last update)
		Includes climate change mitigation and adaptation considerations in health impact assessments of policies and programs in health and other sectors (Y/N)
		Periodically (e.g., every 10 y) assess exposure of critical health infrastructure to physical damage from extreme weather and climate events against insurance coverage (Y/N; date of last assessment)
6. Enforce laws relevant to climate change response efforts	1. Regularly updates protocols and regulation regarding agency climate change response efforts	If applicable, periodically (e.g., every 10 y) inventories public health enforcement activities with climate-sensitive elements (Y/N; date of last inventory)
		If applicable, periodically (e.g., every 10 y) inventories sister agencies’ enforcement activities with climate-sensitive elements with health sector relevance (Y/N; date of last inventory)
		If applicable, has a system in place to track enforcement activities related to environmental hazards or partners with an agency (e.g., private well use during periods of water stress, prescribed burns to reduce wildland fuel load, monitoring of chemical and biological hazards in locally produced foods; Y/N; frequency of use)
		Identifies target expenditures for weather- and climate-sensitive hazard regulation, if applicable, and identifies possible funding sources (Y/N)
		If applicable, periodically (e.g., every 5 y) inventories greenhouse gas emissions and mitigation targets for facilities in health sector and report mitigation progress relative to goals (Y/N; date of last inventory)
7. Link to/provide health care for climate-related health outcomes	1. Provides information regarding common symptoms, health outcomes, and treatments associated with climate- and weather-related exposures and events	Inventories and periodically updates (e.g., every 5 y) emergency response plans for major health facilities (e.g., hospitals, assisted living and long-term care facilities, dialysis centers) and reviews plans for attention to current and expected climate conditions (Y/N; date of last update)
		Develops and updates (e.g., every 10 y) contingency plans for risk reduction and maintenance of operations in extreme weather events (Y/N; date of last update)
8. Ensure competent workforce	1. Provides workforce training on climate-related risk and vulnerability and adaptation assessment	Periodically inventories (e.g., every 5 y) workforce needs related to activities captured in other indicators, including stakeholder engagement, risk assessment and mapping, surveillance, disaster risk reduction and planning, health impact assessment, and provides trainings to fill gaps (Y/N; date of last inventory)
	2. Ensures staff have access to updated information and research regarding climate threats and response efforts	Holds regular trainings on using environmental and weather data and climate outlooks for the state and region (Y/N; frequency of trainings)
		Proportion of staff who participate in disaster planning, training, and exercises, such as disaster drills (proportion in each category)
9. Evaluate climate change preparedness and response efforts	1. Conducts regular evaluations of agency monitoring of and surveillance systems for weather- and climate-related hazards and events	Conducts annual evaluations of systems for monitoring climate- and weather-sensitive hazards and exposures (Y/N; date of last evaluation)
	2. Tracks programs and projects related to climate change response efforts	Conducts evaluations (e.g., every 5 y) to track progress toward longer-term resilience (Y/N; date of last evaluation)
		System in place to track project-specific milestones and updates progress annually (Y/N; results over time; date of last progress update)
		System in place to track employee use of environmental data and number and nature of applications in products, publications, and communications per y (Y/N; frequency)
		Periodically (e.g., every 5 y) assess the adequacy of investments for climate change adaptation in health sector (Y/N; date of last assessment)
		Conducts a hazard risk assessment of jurisdiction public health facilities to ensure facilities will be operational in the event of a climate- or weather-related event (Y/N; date of last assessment)
10. Research	1. Partners or supports research related to climate change preparedness and response efforts or the health impacts of climate- and weather-related events	Actively seeks partnerships with universities with respect to research on climate response efforts or related health impacts; incorporates university input and recommendations into programming (Y/N)
	2. Gathers information and scientific literature on health impacts of climate- and weather-related events	Conducts literature reviews of new and relevant climate and weather-related literature or partners with local authorities (e.g., universities, NOAA Regional Integrated Science and Assessments programs, state climatologists) to keep up to date on literature (Y/N)
	3. Solicits feedback from community members and diverse stakeholder populations regarding community needs with respect to climate change response and potential areas of research	Convene dedicated community group from beginning of research process when new research efforts are started, if applicable (Y/N; frequency of meetings)

Note. NOAA = National Oceanic and Atmospheric Administration; Y/N = yes or no.

DISCUSSION

The literature on climate change adaptation in the health sector continues to evolve.^{8,15,23,24,26} There is a need for guidance at the state and local levels,^8,9 where most climate change adaptation takes place. We aimed to develop a preliminary set of indicators, based on best practices for indicator development,^28–30 for state and local adaptation in the United States, based on guidance for national actors,¹⁵ using existing climate change indicators,^8–14 and situated within the context of the TES framework. Our research demonstrated that national-level guidance has relevance for local agencies,^15,23,24 but needs to allow variable organizational structures, a wide range of different climate-sensitive hazards, resource limitations, and different approaches to engaging climate-sensitive health concerns, including the need to use ongoing activities, mainstream into existing activities and programs, and expand link within health programs and between health and other sectors.

To properly capture the trajectory of emerging adaptation activities and monitoring and evaluation efforts, suggested activities and indicators need to recognize the importance of existing programming and data streams for capturing adaptation activities and tracking adaptation engagement, which has been built around existing, hazard-specific programming and funding streams. Even in settings with high awareness of climate change health impacts and the need for adaptation, practitioners perceive a large gap between needs, as we discussed in the findings from key informant interviews, and available resources. They perceive that this gap hinders a comprehensive approach to health adaptation, connection with stakeholders, and coordination with other sectors.

Several informants noted that the lack of clarity regarding the role of public health in climate change has led to inadequate resource and capacity allocation. Washington and Oregon rank 22nd and 30th, respectively, in the United States for per capita public health spending,³² indicating that resource concerns may be applicable to many US state public health agencies. Given resource and capacity constraints, informants emphasized a need to integrate climate adaptation into existing work streams. By using the TES framework, we propose ways that activities and resources can be used to help agencies build and track additional capacity for climate-specific hazards. Yet, given the climate-related health impacts that communities are likely to face in the coming years,^1,2 additional resources will ultimately be necessary to meet the demands placed on public health. Early implementation of effective adaptation would reduce the magnitude of future risks. Therefore, tribal, state, and local health agencies can use these activities and indicators to capture and communicate the important roles they play in climate response and to work with decision-makers in their communities and at the federal level to garner the necessary support for their work.

Another notable theme was the need for more and stronger partnerships and collaborations between state and local health, county and city government, community groups and nonprofits, and other agencies to take a holistic, cross-sector approach to use capacity in other sectors, as well as hone existing relationships. Our informants emphasized that this reflects the larger role of stakeholder engagement in local public health activities, an important dynamic that should be tracked. Public health practitioners require tools and resources to facilitate their ability to advocate the integration of public health considerations into adaptation decisions made by actors not in the health sector, such as utilities, natural resources, urban planning, and transit. For example, templates and guidance on conducting health impact assessments of common adaptation strategies and customized communication tools may facilitate their ability to coordinate with other sectors, resulting in a more substantive impact on community-level adaptation strategies.

Informants also called for additional training to support the ability of the public health workforce to meaningfully engage in climate adaptation activities. To support this goal, continuing education curriculum and professional development opportunities should be developed and offered to members of the public health workforce, such as through the CDC’s BRACE framework program, which supports ongoing training and education opportunities to grantees.³³ However, the CDC’s BRACE framework program is small; supports a minority of states, tribes, and territories; and represents a small fraction of the workforce of interest. In addition, guidance and tools for staff on communication within and across sectors, partnership development, and linguistically and culturally appropriate communication about climate change should be considered. Schools of public health may consider the development and integration into existing curriculum of coursework and experiential learning on climate change adaptation and the roles of public health agencies.

Limitations

These activities and indicators have limitations that can be improved with additional feedback and application in other settings. First, although the breadth of this pilot framework allows flexibility, we obtained feedback only from public health officials in 2 states in 1 region, so feedback may not include all stakeholders or generalize to other settings. In particular, the indicators reflect the specific challenges and hazards experienced in these 2 states, which are not generalizable to all settings in the United States, potentially limiting the application of these specific indicators to other settings. However, the activities are more broadly relevant across regions.

Second, not all activities listed under each service are applicable to each agency or tribe but, rather, represent the full suite of potential activities. The indicators are most relevant to the functions of state agencies, as organized in Washington and Oregon, which may or may not be the case in other settings, depending on the size and jurisdiction of each state and local health agency. Furthermore, because the activities and indicators do not enumerate every possible climate- or weather-related hazard, agencies and tribes will need to identify hazards specific to their region or climate zone that need to be addressed to ensure readiness. To better characterize the limitations of these activities and indicators in other settings, additional research needs to test the utility of the activities and indicators in other geographic areas and agencies, and a broader audience of stakeholders should be engaged.

Lastly, the indicators as developed do not focus significantly on tracking resources and investments relevant to adaptation. This likely relates to the emphasis on mainstreaming and the difficulty of disaggregating funding streams focused on particular hazards. Funding to support environmental public health activity may be a reasonable proxy, but additional research is needed before this can be proposed as a valid indicator.

Another limitation is the reliance of the activities and indicators on the TES. We chose the TES because of its comprehensiveness and wide acceptance in the United States, but it does not address specific capabilities such as emergency preparedness; therefore, many state and local health departments have turned to other frameworks, such as the Foundational Public Health Services³⁴ framework, to organize their work. Although this framework is built around the TES, opportunities to crosswalk this framework with the framework or other frameworks may prove more useful for some agencies and has the potential to increase the utility and applicability of this framework to other settings.

Public Health Implications

This work begins to address a critical need for indicators to describe and track state and local health agency adaptation activities in the United States. Through a narrative literature review and key informant interviews with state, tribal, and local health officials in Washington and Oregon, activities and indicators were proposed and refined to guide state and local health agencies and tribes in tracking and building capacity in preparing and adapting to climate- and weather-related events. The activities and indicators are not meant to be comprehensive for all hazards and scenarios; instead, they are a guide to aid agencies, departments, and tribes in considering what steps they need to take and what areas they need to invest to become more climate-prepared organizations. This is a pilot framework that proposes broadly applicable activities and regionally specific indicators that need refinement in other communities.