A convergent parallel mixed methods design was used to collect both quantitative and qualitative data.

Figure 1²¹ shows the conceptual framework for the study. Climate change is seen as one ecological driver of the current crisis. These drivers have health and social effects via several pathways, such as air quality, food production, infectious disease exposures, access to fresh water and natural hazards, such as drought and extreme temperatures. These proximate causes lead to a wide variety of health effects, including malnutrition, infectious diseases, non-communicable diseases, mental health disorders, injury and trauma. These can be compounded by social effects such as conflict and displacement. The effects are mediated by factors such as the strength of the health system, wealth of the population, effective governance, available technology as well as local culture and belief systems.

The study took place in Isiolo County, which covers approximately 25 700 square kilometres. It is located in the Upper North Eastern Region of Kenya and has six sub-counties and two constituencies (see Figure 2). The population of the county is approximately 268 002 with a population density of 11 persons per square kilometre. The ethnic communities are mainly Maasai, Borana, Somali, Meru and Turkana. Their main economic activities include pastoralism, subsistence farming and small-scale trading within the urban centres. The study was mainly undertaken in Isiolo County Referral Hospital in Isiolo Town and Isiolo sub-county. This is one of the main government health facilities with a 154-bed capacity. It offers both primary and secondary healthcare including paediatric and child health services. Climate change has adversely affected healthcare service delivery; however, health facility preparedness and climate response programmes are inadequate. The hospital serves a population of approximately 121 000 who reside in both rural and urban areas of the county.

Ethical clearance to conduct this study was obtained from Stellenbosch University Health Research Ethics Committee (No. S23/08/183).

The parents noted that temperatures had been on the rise over the last several years. While the average temperatures recorded in the data showed little variation, there were days or weeks with very high temperatures. This was seen to interfere with food security as many of the animals and plants did not thrive. As a result, malnutrition was perceived to be increasing. The healthcare workers observed that effects such as hyperthermia and dehydration were also prevalent during the dry season:

The residents explained that Isiolo was affected by flash floods mainly in April 2023 and November 2023. This destroyed farms, crops and domestic animals, which were the primary source of livelihood for many of the inhabitants. Business premises, traditional houses called ‘manyattas’ were swept away, causing homelessness and loss of income:

Parents commented that the drought significantly reduced their access to water. This reduction in rainfall was mainly observed between 2021 and 2023. Many of them mentioned that they relied on rivers and streams for water for their daily use. However, the water was noted to be inadequate and contaminated by various pollutants. Low rainfall also affected food production as crops had lower yields and animals frequently lacked pasture and water to drink:

High out-of-pocket costs were emphasised as limiting access to healthcare. Despite public hospitals being affordable, a nurse reported that many families struggled with poverty and were not able to buy medication or seek laboratory services. Health insurance was seen to be inaccessible other than to those formally employed:

Climate change was strongly observed to have adversely affected the residents’ main source of income, which was pastoralism. Other sources of income, such as kiosks, transport services and farming were also reported to be affected because of flooding, drought and famine. Some caregivers also commented that their employment was jeopardised because of absenteeism from taking care of sick children. This resulted in the redirection of funds from other priorities, such as food and education, to cater for medical costs:

During the floods, it was noticed that health facilities and medical equipment were destroyed. Infrastructure, such as roads and bridges, was also swept away with only a few vehicles that could transport people to hospitals. A nurse felt that ambulance services were not able to access sick children in remote areas, which frequently led to premature deaths:

When outbreaks of illnesses occurred, it was observed that high admission rates led to overcrowding in the hospitals. This led to depletion of medical resources, healthcare worker shortages, burnout or mental health issues among medical staff, and extended stays of patients in the wards because of nosocomial infections. At the same time, attendance at maternal and child health (MCH) clinics for immunisations and wellness checks declined, as mothers were unable to physically or financially seek healthcare. Some of the healthcare workers noted that MCH attendance and vaccine coverage were particularly low during adverse weather events. Non Governmental Organisation (NGOs) and Faith Based Organisation (FBOs) were frequently relied on to supply medical care to remote areas during these times as a supplement to government-provided services:

It was noted that caregivers were aware of some effects of climate change on health. However, many of them still had limited knowledge on this intersection. Language barriers were a major obstacle to awareness as many of the members of the community do not speak any of the national languages. Others felt that the lack of technological devices, such as smartphones hindered them from acquiring information on climate and health. Local administration, religious leaders and healthcare workers were often relied on to fill this gap within the community:

Table 5 presents correlations between parameters and childhood illnesses. Spearman’s correlations indicated significant associations between food insecurity and both distance to water (r = 0.26, p = 0.048) and vegetation index (r = –0.52, p < 0.001). The greater the distance to water sources, the higher the prevalence of food insecurity. The higher the vegetation index, the lower the prevalence of food insecurity. Spearman’s correlations indicated no significant associations between climate change parameters and childhood conditions (p > 0.05) because of insufficient data.

There were several diseases reportedly associated with changing climatic conditions: Waterborne diseases such as cholera or diarrhoea and vector-borne diseases such as malaria or kala-azar were perceived to affect young children because of several factors such as stagnant water pools, flooding, rising temperatures and contaminated water. Infectious diseases spread by close contact, such as measles, chickenpox and mumps, were thought to spread within schools or through interactions in the community. Preventive measures, such as mosquito nets, vaccines, clean drinking water and appropriate shelter, were often limited:

Emphasis was put on food scarcity within the region. Many parents felt that because of famine, there was inadequate food to give to their children. Many of them agreed that because of the high cost of living, prioritising a balanced diet for their families was difficult, as most of the food was frequently bought, not grown. Healthcare workers perceived that malnutrition, micronutrient deficiency and stunted growth were among the most common illnesses experienced in the region. Fruits and vegetables were noted to be often missing from the children’s diet as many of the pastoralist communities relied on meat, milk and blood for food:

It was noticed by the parents that many of them had poor access to clean, uncontaminated water as they used the same water for various uses such as drinking, laundry and washing dishes, among others. They also reported that they lacked pit latrines or lavatories, and because of their nomadic lifestyle, relieved themselves near rivers or water pools. Some also noticed that industries, hotels and several institutions emitted their effluent into the same water sources. Healthcare workers saw a rise in cholera, dehydration and diarrhoea during the flooding season as most of the water consumed was not treated:

It was mentioned that the dust, extreme temperatures and poor air quality might have contributed to pneumonia and upper respiratory tract infections. Although very few caregivers thought their children had frequent asthma exacerbations, they reported that many had allergic reactions to the cold or dust. Moreover, some caregivers felt there was an association between floods, cold temperatures and pneumonia because of the frequency of infections during these climatic conditions:

Caregivers commented that stress, anxiety and depression were experienced among family members as a result of their children’s illnesses, prolonged admissions and the financial implications related to healthcare:

Displacement was expressed as a significant effect of the flooding in the region. Many families reported that they were rendered homeless and that they lost food, animals, property and businesses. It was also seen that access to hospitals and other social amenities was disrupted:

A few caregivers reported that their communities struggled with insecurity and loss of animals because of banditry. This led to displacement, hunger and poverty as many people relied on animals for food and income:

Caregivers noted with concern that some children were abandoned at home while their mother accompanied her sick child to the hospital. They often had to fend for their own food, take themselves to school and take care of themselves. Divorces were reported in a few families for various reasons, for example, if the father felt that the mother should have given more attention to her chronically ill child. It was seen that education was interrupted regularly because of either childhood illness or if finances were depleted from healthcare costs:

Some of the caregivers were initially reluctant to seek medical care in primary care facilities. Traditional healers and medicines were observed to be heavily relied on within the community. Prayers from religious leaders, such as Imams, were also reported to be utilised to treat ill children:

Figure 4 shows a summary of the key findings organised according to the conceptual framework into climate changes, proximate causes, mediating factors, as well as health and social effects.

According to the Kenya National Drought Management Authority, Isiolo County experienced reduced rainfall in 2021 and 2022, which significantly reduced the vegetation index, and increased food security and the distance travelled to water sources. This led to a drought alarm being issued by the authorities.²⁸ Similarly, the community’s experiences suggested that decreased rainfall had been observed throughout the region, leading to a predominantly hot and dry climate. In 2023, flash floods were experienced throughout the country, leading to the destruction of farms, animals and property. Temperature variation was not statistically significant within the study period.²³ However, the community’s experiences suggested increased temperatures during that period. There was non-concordance between reports of heat waves from the respondents and regional meteorological data. This could be because of the differences between human lived experiences and actual temperature measurements. Other reasons could be the existence of local microclimatic changes in areas with loss of vegetation or shade, and perception bias experienced when local socio-economic activities, such as pastoralism, are influenced by heat stress.

Health expenditure continued to impoverish families due to the high cost of medication, laboratory investigations, hospital admissions, loss of income and productivity. This is because many parents had been forced to buy prescription medicines or laboratory investigations from private institutions because of public facility shortages. This was similar to findings from 49 other African countries that showed climate change had impacted out-of-pocket health expenditure.²⁹ Social insurance had poor uptake within the communities because people prioritised their basic needs and could not afford to pay for insurance. This was similar to studies in Zambia, where only a small percentage of the population was willing to pay for social insurance.³⁰

Climate shocks and stressors compounded the existing shortages of medical resources, healthcare workers and equipment, thus further reducing the quality of healthcare services. This was because of the destruction of health facilities and their resources. Accessibility of hospitals and dispensaries in remote areas was also reduced by the destruction of roads and bridges by floods. Emergency services were affected, resulting in premature deaths in children.³¹ Furthermore, existing resources were stretched by overcrowding in hospitals, with some children having extended stays because of low immunity and nosocomial infections. Healthcare workers were often overwhelmed, resulting in burnout and loss of productivity. As with other physicians, psychosocial factors, such as work demands, available resources and work environments contributed to their reduced well-being.³² Interestingly, immunisation coverage and attendance at MCH clinics declined during adverse climate events. This effect of climate change on vaccines has also been recognised by the Global Alliance Vaccine Initiative especially in low-income countries.³³ Changes to vaccination planning had to be implemented to improve reach to remote areas.

The nexus of climate change and health was poorly understood by some members of the community. Similar to the general population in Egypt, where smartphones, TVs and radios were often used to gain knowledge, there was still a large gap in access to accurate and up-to-date information.³⁴ A large part of the community depended on cultural practices and traditional medicine for the treatment of their sick children. Local administration, religious leaders and healthcare workers were often called on to give health talks, especially during disease outbreaks. Healthcare workers and other stakeholders require training programmes to build their capacity on climate change. Similarly, in India, there was proven to be a perceived gap among key stakeholders on the knowledge, vulnerabilities and public health risks of climate change, necessitating a need for awareness programmes and policies.^35,36

The community experienced outbreaks of illnesses in their children, such as malaria, cholera and diarrhoeal diseases. Outbreaks of these diseases had not been experienced to this extent before and could be linked to the consequences of climate changes, such as flash floods. Outbreaks of diarrhoeal diseases such as cholera have also been observed in other low- and middle-income countries (LMICs), such as Malawi and Pakistan, following similar flooding.³⁷ Malnutrition and micronutrient deficiencies were more common during the dry season. Unpredictable rainfall led to food scarcity in other regions in Kenya, such as Kilifi County, where the unavailability of food and lack of food variety resulted in poor nutritional status in children.³⁸ Some of the parents reported their children were diagnosed with respiratory diseases, such as pneumonia and upper respiratory tract infections (URTIs). This was attributed to environmental influences and climate changes related to air quality and poor ventilation.³⁹ Mental health disorders among children and their caregivers were noted because of deteriorating health in the children or the lack of adequate resources to take care of their families. Previous studies have also demonstrated that climate change has had an effect on child and adolescent mental health.⁴⁰

Child neglect, threats of violence, family disruption, interruption of education and other social services for children were reported by some parents. This is similar to studies that have looked into the relationship between child abuse and climate change.⁴¹ Some of the parents commented that flash floods had left a trail of destruction to homes, businesses, farms and animals. Unfortunately, some people lost their lives during the floods in the region. Many other LMICs, such as India, China, Indonesia, the Philippines and Bangladesh, have also suffered effects such as deaths, displacement, destruction, separation of communities, and increased poverty as a result of flash floods.⁴² Political instability, banditry and crime increased in the region because of the loss of animals. This interruption in pastoralist activities in the region resulted in negative economic impacts because production of meat and milk had been adversely affected. Just as with rice production in Nigeria, political tension in rice farming regions reduced productivity as farmers would be attacked or intimidated during conflicts, keeping them away from their farming activities.⁴³

Quantitative data on climate change in the region were adequate; however, there was a significant lack of data on childhood diseases from the local health services and national databases. Data on climate parameters were available in months, but data on climate-sensitive diseases were available in years. This made it difficult to analyse trends and correlations between climate changes and climate-sensitive diseases. The qualitative data came from users of the government hospital. People using the private or mission hospitals may have had different views or experiences. Those dependent on the government hospital may come from lower socio-economic groups and be more engaged in the informal sector for employment. Transferability of the findings to all people in this region may therefore be limited. Reflexivity may have been affected by culture as many of the participants came from conservative ethnic backgrounds, which may have influenced their openness during the interviews.

Improving healthcare financing by providing affordable healthcare insurance as well as equipping public health facilities with resources would significantly reduce the financial burden on families. Increasing resilience in the healthcare systems by planning for adverse climates or investing in infrastructure could mitigate the impacts of climate on healthcare services. Closing gaps in information on climate and health among both healthcare workers and the community could be achieved by leveraging technology to disseminate knowledge. Strengthening data on climate-sensitive diseases from both local and national health information systems could significantly impact further quality research and development of effective policies based on community healthcare needs. Behaviour change can be promoted by engaging local leaders and communities to promote culturally acceptable programmes that would encourage modern healthcare practices. The Kenyan Ministry of Health has linked several adverse health outcomes, such as infectious disease risk and malnutrition, to climate stressors in the arid and semi-arid regions of the Country. To reduce these outcomes, there have been calls to enhance targeted interventions in health facilities to improve health system climate resilience and preparedness. Efforts to address health and social effects should focus on collaborations that will ensure food and water security. Addressing mental health challenges, homelessness, displacement and reduction of abuse among vulnerable populations, mainly children, can be integrated into adaptation policies.