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Climate Change AND Health Equity​

​Guide to Health Equity-Centered Local Heat Planning 

Revised April 23, 2025. Guidance subject to change.
Original Interim Guide released September 29, 2023.

​*Note: The California Department of Public Health looks forward to feedback from local jurisdictions and other partners on this guide.​ To submit feedback or questions about this guide, email climatechange@cdph.ca.gov​.


Key Updates As of October 29, 2024:

Contents:

    • ​Step 6: Evaluate plan​​

I. How to Us​e This Guide​

This guide is intended to assist local jurisdictions with incorporating health equity​ into new or existing heat action and planning efforts. Creation of heat plans and use of this guide are not mandatory but are recommended. This guide can be used by land use planning and community development agencies, emergency management planners, public health partners including local health jurisdictions and Tribal governments, as well as community members and advocates supporting or engaged in these efforts. Strategies or elements from this guide can comprise a new or updated stand-alone heat plan or be incorporated into Local Hazard Mitigation Plan updates, Climate Action and​ Adaptation Plans, General Plan Safety Elements or Public Health Emergency Preparedness Plans. 

This guide was developed based on a review of more than 40 local and regional extreme heat plans, guides for creating heat plans and other best practices for creating plans and strategies that center or work to address health equity. A selected bibliography is included in Appendix 1​ (PDF) ​for reference. 

This guide is intended as a resource for local jurisdictions to help with protecting the entire community from extreme heat regardless of residents' background and access to resources and particularly those with the least opportunity for good health. This resource can help facilitate partnerships between local health departments, offices of emergency services and other local agencies.

It is recommended that this guide be reviewed in full prior to initiating any planning efforts, to incorporate a health equity approach throughout the entire process. However, if planning has already begun, you may review the recommendations that apply to your specific phase of planning and seek opportunities to incorporate strategies that may have been missed in previous steps of the planning process where feasible. 

Organization

This guide is organized according to steps, categories and phases:

Steps: The steps indicated below outline each stage of a process for developing or updating a health-equity centered local heat plan, starting with engaging with the priority populations and partner organizations in your jurisdiction, identifying the heat risks to priority populations, establishing thresholds for determining an extreme heat event and taking actions, selecting your plan's actions and finally evaluating the success of the plan. ā€‹

Categories: Step 4 (ā€œSelect Heat Plan Actionsā€) allows you to ​​select from a number of categories of actions—actions grouped together according to a specific topi​c. Categories can be thought of as areas in which to intervene to protect health. The categories are as follows:

  • Category 1: Communications and Engagement

  • Category 2: Data, Surveillance and Situational Awareness

  • Category 3: Cooling Centers and Other Cool Spaces

  • Category 4: Homes

  • Category 5: Workplaces

  • Category 6: Schools and Childcare Facilities

  • Category 7: Built and Natural Environment

  • Category 8: Transit

  • Category 9: Assisted Living and Skilled Nursing Facilities

  • Category 10: Local Detention Facilities

  • Category 11: Shelters and Encampments

  • Category 12: Ensuring Continuous Power and Affordable Energy

  • Category 13: Institutionalizing Extreme Heat Work​

Phases: Within each category, actions are organized by phases of implementation:

  • Long-term planning and policy actions to reduce exposure to heat and build resilience

  • Heat season (pre, during and post)

  • Heat event (pre, during and post)

​II. Heat in ​​the Context of Climate Change

Climate change is considered the greatest public health threat of this century.¹​ The health impacts of the climate crisis are already being felt by Californians, with negative health effects projected to only worsen in the coming years.²​​ Many populations in California also currently face health inequities, unfair and unjust health differences between population groups that are systemic and avoidable.³​ People facing the greatest health inequities include populations with low income, older adults, children, communities of color, people with disabilities, people experiencing homelessness, immigrants, Tribal communities and people who have been marginalized or discriminated against based on gender, race/ethnicity or sexual orientation.⁓ Climate change disproportionately impacts these same populations.⁵​ 

The Health Impacts of Heat 

Heat is already the deadliest of all types of weather events in the United States and with climate change, increasing heat across California is projected to cause two to three times more heat-related deaths by mid-century. Exposure to high temperatures can cause negative health impacts, such as heat-related illnesses, which include heat cramps, heat rashes, heat exhaustion, heatstroke and death. Other health impacts include:

  • Worsening of existing medical conditions: Heat events are associated with increases in emergency department visits for acute renal failure, kidney disease, diabetes and cardiovascular diseases. 

  • Adverse birth outcomes as a result of extreme heat exposure during pregnancy, including increased risk of congenital heart disease, pre-term delivery, low birthweight and stillbirth. 

  • Mental health impacts, with research showing a link between higher temperatures and suicide rates. 

  • Indirect health impacts, such as through

    • increases in work-related injuries such as falls;

    • health harms from disruption of life-sustaining medical equipment during public safety power shutoffs, rolling blackouts or electrical outages;

    • disruption or delay in medical services due to many people needing care at the same time when it’s hot;

    • drowning or injury while swimming in bodies of water to cool off; and

    • ​injury or death due to increased interpersonal violence and aggression. 

Heat Has Inequitable Health Impacts

While higher average temperatures and more frequent and severe heatwaves are and will continue to be experienced across all of California, the negative health impacts of heat are not distributed equitably across all populations. Numerous communities and populations face a disproportionate risk of experiencing heat-related health impacts because of greater exposure to heat, greater sensitivity to higher temperatures and/or reduced adaptive capacity (the ability, through resources such as financial, political and social capital, to reduce or avoid the negative impacts of climate change) resulting from historic and continuing systemic marginalization. For example, workers outdoors or in non-air-conditioned spaces, people currently unhoused, people who are incarcerated and people living within an urban heat ​island experience above average, continuous or prolonged exposure to heat, increasing their risk of health impacts. Additionally, communities with low income, low social cohesion or that have been historically and presently marginalized and underinvested in may face worse living conditions, have limited access to decision-making processes, power and resources, in turn limiting adaptive capacity prior to, during and after an extreme heat event. Finally, older adults, children, people who are pregnant, people with pre-existing health conditions and people taking prescription medications or substances are more sensitive to changes in temperature and heat, increasing their susceptibility to heat-related health impacts.

​Compounding Impacts​

​​Factors creating disproportionate risk may overlap with each other, as well as with other existing health, social, economic or environmental injustices creating a compound or cumulative impact within a population or community, further exacerbating risk of experiencing heat-related health impacts. For example, outdoor workers may experience direct exposure to heat during the workday and may not be able to afford to turn on air conditioning at home due to costs (or may not have access to air conditioning at all), extending their exposure to heat and eliminating any opportunity for reprieve and recuperation, thus increasing their risk of heat illness. Fear of job loss, eviction, deportation or incarceration may also hinder community members from accessing government-funded support programs, such as weatherization or utility bill subsidies. This same community may have low tree canopy coverage or may be located in a rural, unincorporated area with limited access to resources, limiting collective adaptive capacity.

​​

The Importance of an E​​quity Focus in Heat Planning

Given the inequitable distribution of heat-related health impacts, local heat mitigation, adaptation, response and recovery efforts must apply a health equity lens when developing, implementing, evaluating and prioritizing strategies. A health equity frame for heat planning and action is necessary to ensure that those experiencing limited adaptive capacity and the greatest exposure, sensitivity and impact are prioritized and benefit from focused efforts to achieve positive health outcomes in the face of heat events.

Considering Concurrent Events

​​Extreme heat can lead to worsening air pollution, wildfires (and wildfire smoke) and drought. In recent years, jurisdictions across California have experienced concurrent record-breaking extreme heat events at the same time as major smoke events due to wildfires. These concurrent events can challenge preparedness and response activities. For example, recommendations to cope with extreme heat (such as opening windows at night to bring in cooler air) conflict with recommendations to protect from poor air quality (to keep doors and windows closed). Efforts to prepare and respond, therefore, cannot be siloed and must account for the likelihood of concurrent climate-related emergencies.

III. A Health Equity-Centered Local Heat Plan

We recommend following the below steps in developing or updating your jurisdiction's health equity-centered heat plan. 

Steps:

  1. Engage with priority populations and partner organizations in jurisdiction
  2. Identify heat risks to priority populations
  3. Set thresholds for declaring an extreme heat event
  4. Select heat plan actions
  5. Finalize plan for implementation
  6. Evaluate plan​

Step 1: Engage with priority populations and partner organizations in jurisdiction

Extreme heat disproportionately affects certain populations. The key to developing or updating a heat plan is identifying priority populations who may be most impacted by extreme heat events and engaging with these populations and the organizations that serve them. It is critical to engage with community members and partner organizations throughout the process of developing the plan and as your jurisdiction implements the plan to protect the public from the health impacts of heat. 

1. Identify priority populations. We use the term ā€œpriority populations" here to indicate groups of people who are disproportionately impacted by extreme heat. We recommend considering the following groups or individuals as priority populations: 

  • Renters

  • Unhoused populations

  • Incarcerated individuals

  • Older adults

  • Women, children and pregnant people

  • Individuals taking medications or using substances

  • Low-income individuals and households

  • People living in urban heat islands (UHI)

  • People with health conditions such as respiratory or cardiovascular diseases​ or diabetes

  • People with mental health conditions

  • People with mental or physical disability

  • People with electricity-dependent medical equipment

  • Socially or geographically isolated populations

  • Some racial and ethnic groups, particularly Black or African American, American Indian or Alaska Native and Latine/x

  • Outdoor workers and workers in non-air-conditioned environments

  • People who are active outdoors

  • Overburdened and under-resourced populations²​​

  • Immigrants and refugees

  • Individuals who are limited English proficient (LEP)

  • Emergency responders​

Overburdened and under-resources populations

​​Overburdened and under-resourced populations include people or communities that experience disparate exposure, risk or negative outcomes, such as environmental injustices resulting in health inequities, due to systematic oppression through discriminatory policies, plans, and procedures, including limiting access to cash, capital or other financial resources. These populations may overlap with or include many of the other populations or groups listed, as well as additional populations; this is intentional to encourage the use of an intersectional approach (PDF, 1.9 MB)  to identify priority populations within your jurisdiction.


2. Identify partner organizations or lead organizations within a jurisdiction and establish roles and responsibilities. Consider including both traditional and non-traditional planning and community development partner organizations, with a focus on any and all internal and external partners that engage with and serve priority populations. Examples include:

  • ​Public Officials (e.g., Mayor's Office, Board of Supervisors and appointed committee members)

  • Emergency Management Agencies

  • Healthcare Providers and Facilities

  • Agencies Operating Cooling Center and Other Cool Spaces (e.g., parks and libraries)

  • Agencies Serving At-Risk Populations (e.g., serving unhoused people and older adults)

  • Agencies that Support Critical Resources (e.g., food banks, water utilities, energy utilities and nonprofits that provide utility assistance)

  • Planning and Public Works Agencies

  • National Weather Service (PDF)

  • Tribal Governments

  • Community-Based Organizations

  • Mutual Aid Groups (in which groups of community members work together voluntarily to meet vital community needs such as food, housing or disaster relief)

  • Occupational Safety and Health Organizations

  • Schools and School Districts

  • Academic Institutions

  • Businesses

  • Voluntary Organizations (such as Voluntary Organizations Active in Disaster)

3. Participate in engagement activities and needs assessment with community members and partner organizations regarding extreme heat planning, particularly with respect to priority populations. For more information on how to conduct meaningful community engagement, refer to the resources provided in Appendix​​ 1 (PDF)​ under the ā€œCommunity Engagement" section.

4. Collaborate with community-based organizations (CBOs) and partner organizations to involve them in plan development, implementation and evaluation.​

Step 2: Identify heat risks to priority populations​

After identifying and engaging with priority populations and organizations that serve them, it is critical to gain a better understanding of where priority populations reside in your jurisdiction and what factors increase their risk to extreme heat. We recommend using the following tools to identify heat risks to priority populations:

  1. Utilize Tracking California Heat-Related Illness Sum​​mary Tables ā€‹to identify the age, race and ethnicity and gender of people experiencing most heat-related illness in your jurisdiction

  2. Utilize the California Healthy Place​s Index: Extreme Heat Edition to generate maps of priority areas.

  3. Utilize California Heat Assessment Tool (CHAT) to map the projected number of heat-health events in your jurisdiction in the periods 2031-2050 and/or 2041-2060.

  4. Utilize the UCLA Heat Maps Tool to understand where excess emergency department visits are occurring in your jurisdiction on extreme heat days.

  5. Utilize the Heat and Health Tracker Heat Health​ Index to identify communities where people are most likely to feel the effects of heat on their health.​​

​See Appendix ​​2 (P​DF)​ for detailed step-by-step instructions on how to use these tools to complete the above steps.​

Step 3: Establish thresholds for declaring heat events and taking actions​

In different jurisdictions, different agencies (such as the local health department or the local office of emergency services) may be responsible for determining when to declare a heat event locally. Local emergency man​agers may already have these protocols established. The California Department of Public Health recommends utilizing the National Weather Service (N​​WS) HeatRisk Tool as part of this process. The NWS itself issues advisories, watches and warnings based on this tool as interpreted by their staff's experience and expertise. Local jurisdictions may choose to adopt and amplify warnings from the NWS, and plan what actions will be taken at which alert level from the NWS. We recommend the NWS Heat Risk Tool because it incorporates health data into its calculations to forecast risk of heat-related impacts to occur over a 7-day period. More information on interpreting HeatRisk Levels can be found in CDPH's HeatR​isk ​Gri​d (PDF).​

Pursuant to AB 2238 (Rivas, Chapter 264 of the Public Resources Code, Statutes of 2022), the California Environmental Protection Agency, in coordination with the Integrated Climate Adaptation and Resiliency Program (ICARP), the California Department of Public Health and the Department of Insurance, has developed a statewide extreme heat ranking system called CalHeatSc​​​ore that will:

  1. Map heat risk across California communities with an interactive online interface.​

  2. Update daily with temperature forecasts for early warning of heat waves.

  3. Set local health-protective thresholds of extreme heat by accounting for factors like:

    • Regional and local climates.

    • Duration of extreme heat, minimum nighttime temperatures and seasonality.

    • Where people most vulnerable to heat reside, such as children and elderly people or people with certain health conditions.

    • ​Local health effects of heat, including heat-related illnesses.

  4. Connect people with locally relevant resources, such as nearby cooling centers and community pools.

  5. Use high-quality, publicly available data and be fully transparent, with all data, models and methodology published online.

The CalHeatScore Proto​type is now available and will continuously be updated. Other heat risk tools like the National Weather Service's (NWS) HeatRisk Tool will be helpful to Californians, especially as CalHeatScore is updated. To stay up to date on CalHeatScore and its further development subscribe to the OEHHA's lis​tserv

Step 4: Identify heat risks to priority populations

Once you have worked to identify and engage priority populations and partner organizations, understand the risks to priority populations and set thresholds for declaring an extreme heat event and taking actions, the next step is to select actions to include in your jurisdiction's heat plan. Ensure that you are centering the priority populations and partner organizations in decision-making around how to prioritize actions and which actions to select.

Actions are organized according to 13 categories. Within each, there are long-term planning and policy actions, actions to implement before, during and after each heat season, and actions to implement before, during and after a heat event. ā€‹

Step 5: Finalize plan for implementation

​Once your jurisdiction, partner organizations, priority populations and community members have selected the heat actions to include in your jurisdiction's heat plan, collaboration should continue as you work to clarify operational details and establish a clear path to move towards implementation of heat actions. Implementation details regarding roles and responsibilities, timelines, costs, funding and prioritization of actions should be included within your heat plan or as a publicly accessible supplementary document, to ensure transparency and accountability.

Define Roles and Responsibilities

Your jurisdiction and partner organizations should review the heat actions included in your heat plan and determine which entity will take the lead in implementing each action and which entities will provide support or will need to be engaged throughout implementation. The lead organization will take primary responsibility for coordinating further development of the action, as well as activation, implementation and monitoring the heat action impacts. Lead organization roles may align with the mandated responsibilities and related jurisdiction of a specific department, agency, office or organization. Additionally, you will need to consider which populations, neighborhoods or communities will be most impacted by heat actions and include community-based organizations as well as other priority population representatives in lead or supporting roles for relevant heat actions to ensure implementation is community-driven. Establishing and integrating roles and responsibilities for partner organizations, departments or offices within your jurisdiction and specific community groups within your heat plan will provide clarity, focus and transparency for implementing entities as well as the community at large.

Timeline for Implementation

A timeline for implementation of heat actions should be developed and incorporated into your heat plan. Lead and supporting entities should work together to approximate the time they will need to conduct additional planning, analysis and community engagement; secure funds; and operationalize each heat action across your jurisdiction or within specific priority communities (based on populations identified in St​ep 1​). Implementation timelines should be developed for near- and long-term heat actions to ensure immediate relief is provided to community members who need it most, while also committing to implementation of actions that provide policy, systemic or environmental changes which can relieve heat-related health disparities and inequities overall. Integrating a timeline for implementation within your heat plan will allow for greater transparency, accountability and collective understanding of the time it will take to achieve near- and long-term goals. Include timelines to share updates on progress, challenges and roadblocks, as well as create opportunities for community members to provide feedback on progress made or changes and improvements that are needed.

Cost Estimates and Funding Sources

Finally, estimated cost and potential funding sources should be calculated, identified and listed for each heat action within your heat plan. Costs such as new staff, resources, training, equipment and fees should be factored in, as well as the scale of implementation (e.g., pilot project vs. county-wide implementation). Proposed or potential funding sources should be listed as well; consider collaborating with partner organizations and community members to identify potential funding constraints as well as innovative solutions. Incorporating associated costs and opportunities for funding within your heat plan will allow for transparency on the scope and scale of each heat action, as well as around current financial constraints and barriers. It will also allow community to track progress in applying for or securing funding and identify or share additional opportunities for potential funding. Additionally, it may allow community members and organizations to garner community support and overcome existing financial constraints by advocating for organizations or agencies to allocate funds for implementation of community-driven heat actions. Funding and financing ideas and resources can be found on the Arsht-Rockefeller Foundation Resilience ​Center's Heat Action Platform. Additional funding resources can be found in Appendix 1 (PDF).

Step 6: Evaluate plan​​

​A critical component of any plan is continual monitoring and evaluation to ensure planned actions achieve their intended impact and have not resulted in unintended consequences. In order to successfully track the progress and impact of your heat action plan, monitoring and evaluation activities should be integrated within your plan and aligned with heat action steps, so your jurisdiction and implementation partners have the tools, resources and capacity to collect data and feedback before, during and/or immediately following implementation of a heat action strategy. Recommended monitoring and evaluation strategies have been incorporated throughout each category in the guide to demonstrate key points when data, feedback or other information can be collected and analyzed to evaluate the results and impact of your heat action plan. If feasible, set aside a portion of the budget for evaluation.

On a regular basis, your jurisdiction, implementation partners and community members should review heat plan activities and related outputs (e.g., the number of people served) and outcomes (e.g., changes in heat-related health outcomes or community perceptions and experiences) to determine what worked, what didn't, what lessons were learned and what changes are needed to improve the utility and impact of your heat actions. This process should be community-driven and fully integrate the voice, perspective and experiences of priority populations within the community to ensure that heat actions are benefiting these populations and advancing health equity as intended. Upon completing an evaluation, priority populations within the community should also be informed of evaluation results to ensure that your jurisdiction's interpretation of community input and feedback is accurate and representative of community members' lived experience, as well as to maintain transparency and knowledge sharing. Finally, community should also be engaged in the process of revising heat actions to ensure that the updated actions meet the needs of the community members most impacted. Iterative, community-engaged monitoring and evaluation will enable your jurisdiction, implementation partners and community members to track, assess, course correct as needed, and eventually demonstrate the progress that has been made towards equitable heat resilience, response, preparedness and recovery as a result of heat action plan implementation.​

Further guidance and resources can be found within the Center for Disease Control and Prevention's ​​(C​DC) Enhanced Evaluation Framework​. Additionally, your local health jurisdiction, academic institution or other public health entities within your community or region may be able to provide guidance and support on monitoring and evaluation best practices and/or assist in establishing a clear monitoring and evaluation plan for your heat action plan.

References​ 

  1. Romanello M, McGushin A, Napoli CD, et al. The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future. The Lancet. 2021;398(10311). (doi.org/10.1016/S0140-6736(21)01787-6)

  2. U.S. Global Change Research Program. Fourth National Climate Assessment. 2017;2(4):1-470. (nca2018.globalchange.gov/  

  3. Whitehead M. The concepts and principles of equity and health. International journal of health services : planning, administration, evaluation. 1992;22(3):429-445. (doi.org/10.2190/986L-LHQ6-2VTE-YRRN) 

  4. California Department of Public Health - Office of Health Equity. Portrait of Promise: The California Statewide Plan to Promote Health and Mental Health Equity (PDF, 3.4 MB)​. A Report to the Legislature and the People of California by the Office of Health Equity. 2015. (www.cdph.ca.gov/Programs/OHE/CDPH%20Document%20Library/Accessible-CDPH_OHE_Disparity_Report_Race_Equity.pdf)

  5. Romanello M, Napoli CD, Drummond P, et al. The 2022 report of the Lancet Countdown on health and climate change: health at the mercy of fossil fuels. The Lancet. 2022;400(10363):1619-1654. (doi.org/10.1016/S0140-6736(22)01540-9)

  6. Lee J, Blaeser J, and Small C. Extreme heat will take an unequal toll on tribal jails. Grist. (grist.org/indigenous/tribal-jail-climate-change-extreme-heat/). Published May 10, 2023.

  7. Skarha J, Peterson M, Rich JD, Dosa D. An Overlooked Crisis: Extreme Temperature Exposures in Incarceration Settings. American Journal of Public Health. 2020;110(S1):S41-S42. (doi.org/10.2105/ajph.2019.305453)

  8. American Public Health Association. Advancing Public Health Interventions to Address the Harms of the Carceral System​. www.apha.org. 2021;202117. (www.apha.org/Policies-and-Advocacy/Public-Health-Policy-Statements/Policy-Database/2022/01/07/Advancing-Public-Health-Interventions-to-Address-the-Harms-of-the-Carceral-System)

  9. Holt DWE. Heat in US Prisons and Jails: Corrections and the Challenge of Climate Change. SSRN Electronic Journal. Published online 2015. (doi.org/10.2139/ssrn.2667260)​​​


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