“You don't know what to do with your body”: Perceptions of extreme heat in northern Ghana

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Amoore, Sophia E. A. Kpebu, Bruce A. Abugri, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7199748/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract In northern Ghana, extreme heat, exacerbated by climate change, threatens livelihoods, worsens poverty, increases social disparities, and can adversely impact population health. However, specific health and social impacts of extreme heat are still relatively unknown. This study explored public perceptions of extreme heat, climate change, and their associated health and social risks through 12 semi-structured interviews and 4 focus group discussions conducted among urban and peri-urban adults living in the Tamale Metropolis. Nearly all participants expressed awareness of climate change, predominantly in the form of extreme heat, and its perceived associated poor health outcomes. Participants reported feeling increasing uncertainty and helplessness due to climate change-related economic difficulties, food insecurity, and water scarcity. The study highlights the interconnectedness of climate change with social determinants of health in northern Ghana and the importance of addressing the complexity of these relationships while implementing climate change mitigation and adaptation measures. Figures Figure 1 Figure 2 Figure 3 Introduction Climate change substantially affects the health of people from all walks of life, race, gender, geography, and health systems. 1 Climate change-related extreme weather events are global phenomena that manifest locally in the form of drought, heatwaves, and rainwater flooding. 2 These climate change-related health hazards are estimated to increase mortality and morbidity, as well as exert a cost of $ 2–4 billion USD per year by 2030. 3 Among the most pressing climate change-related hazards is extreme heat, with increasing frequency, intensity, and duration of hot weather events, associated with increases in both mortality and morbidity. 4,5 The consequences of extreme heat are disproportionately felt by populations in low-and-middle-income countries (LMICs) already susceptible to the health risks of poverty, inadequate water, and poor sanitation infrastructure. 6 In addition, intensifying occupational heat exposure decreases labor productivity, with a projected 43.8% productivity loss in West Africa by 2050. 7 These indicators are projected to worsen with the current trend of global warming and its related morbidity and mortality. 8–14 In Ghana, the impacts of extreme heat are expected directly in the form of drought, heatwaves, and erratic rainfall, and indirectly through poor agricultural yield, loss of employment, and poverty. 15,16 The repercussions of these exposures include additional strain on an already taxed health system characterized by water insecurity, food insecurity, and reduced availability of and access to electricity. 8,17,18 In particular, Northern Ghana has been identified as the most vulnerable and sensitive to extreme heat across the country, with the highest projected increase in mean minimum and maximum ambient temperature, upwards of 3.5°C and 3.9°C, respectively, by 2080. 19,20 The existing literature focuses predominantly on the agricultural repercussions of climate change and extreme heat, with relatively few studies exploring the health consequences. 21,22 We therefore sought to understand the public perception of the health and social risks of extreme heat in northern Ghana to guide future development of appropriate and impactful adaptation and mitigation strategies to improve population health. Methods Setting. This study evolved from an academic global health partnership between University for Development Studies and NYU Grossman School of Medicine representing the Academic Model Providing Access to Healthcare (AMPATH) Consortium. The study included three peri-urban communities (Kpalsi, Zujung, and Dohini-Kukuo) and three urban neighborhoods (Hausa Zongo, Lamashigu, Moshie Zongo) in the Tamale Metropolis (Fig. 1 ), located in Ghana’s Northern Region. All six communities were identified to be resource poor, with suboptimal or inconsistent housing infrastructure (lacking in water piping, ventilation, or electricity supply). The residents of these communities subsist on less diversified and unstable sources of income and are therefore potentially more vulnerable to the health risks of extreme heat and climate change. 16,23 Study Design. This study utilized a qualitative approach consisting of 12 semi-structured interviews (SSIs) and 4 focus group discussions (FGDs) with 4 participants in each, allowing researchers to gain in-depth understanding of community perceptions and experiences of extreme heat. The research team developed a structured question guide that included items related to manifestations of climate change and extreme heat, awareness of climate change, experiences with extreme heat, social determinants of health, and health outcomes (Appendix A). Participants and Recruitment. Research team members identified potential participants within the six communities at their residences, provided them with a general summary of the study aims and objectives, then subsequently invited them to participate. Interested individuals were provided detailed information regarding the study procedures, voluntary participation, and assurances for confidentiality in English or Dagbani. Written informed consent was obtained, unless the individual was not literate, in which case verbal consent was obtained. A total of 28 individuals from the Tamale municipality were invited to participate, with 100% consent rate. An equal proportion of urban and peri-urban residents were recruited overall, with all participants aged ≥ 18 years at the time of consent. Ten urban and two peri-urban residents participated in the SSIs. Four urban and 12 peri-urban residents participated in the FGDs, clustered by their respective community. The study was approved by the University for Development Studies Institutional Review Board. Data Collection and Analysis. Data collection occurred in December 2022. The SSIs were less than 35 minutes and the FGDs were less than 75 minutes. All SSIs and FGDs were digitally recorded, transcribed, translated into English if conducted in Dagbani, and pseudonymized by participant number. All 16 transcripts from the SSIs and FGDs were reviewed by four research team members (BA, SK, VM, RS). Content and thematic analysis of the data were conducted to identify a priori themes (intersection of extreme heat with social determinants of health, gender-specific impacts, and health impacts) as well as emerging themes. The analysis followed an iterative process, including data familiarization, coding, preliminary theme generation, and theme review and refinement. An initial codebook structure was developed by consensus by two research team members (BA, SK), with further refinement and additional coding done after reanalysis of transcripts by the other two team members (VM, RS). The four research team members met to discuss the analysis and came to a consensus on the final version of the codebook. Consistent review of themes throughout analysis ensured cohesive, consensus accounts of participant perceptions. Results Table 1 summarizes the demographic characteristics of the 28 study participants according to urban vs. peri-urban location. The gender distribution (slightly more male) was the same in the urban and peri-urban settings. The mean age of participants was 36.1 years (SD = 14.3), and urban participants were younger in general. A greater proportion of urban participants were Muslim compared to peri-urban participants, and a greater proportion of peri-urban participants reported to belong to the traditional-Islam religion (i.e., practitioners of both the African tradition and Islam religion at the same time). A greater proportion of urban participants were found to have any formal education compared to peri-urban participants. However, among those who had attended formal schooling, a greater proportion of peri-urban participants were found to have tertiary education compared to the urban participants. Table 1 Demographic characteristics of participants. Baseline characteristic Peri-urban (n = 14) Urban (n = 14) Total (n = 28) n % n % n % Gender Female 6 42.9 6 42.9 12 42.9 Male 8 57.1 8 57.1 16 57.1 Age 20–29 4 28.6 9 64.3 13 46.4 30–39 4 28.6 4 28.6 8 28.6 40–49 3 21.4 0 0.0 3 10.7 50+ 3 21.4 1 7.1 4 14.3 Ethnicity Mole Dagbani 12 85.7 10 57.1 22 78.6 Gurunsi 0 0 3 21.4 3 10.7 Other 2 14.3 1 7.1 3 10.7 Religion Islam 9 64.3 13 92.9 22 78.6 Islam-Traditional (African faith) 4 28.6 0 0.0 4 14.3 Christianity 1 7.1 1 7.1 2 7.1 Highest educational level None 4 28.6 1 7.1 5 17.9 Primary (up to JHS) 2 14.3 2 14.3 4 14.3 Secondary (up to SHS) 2 14.3 7 50.0 9 32.1 Tertiary (college and above) 6 42.9 4 28.6 10 35.7 Employment Unemployed/Not working 3 21.4 0 0.0 3 10.7 Student 1 7.1 5 35.7 6 21.4 Professional 3 21.4 4 28.6 7 25.0 Farmer 2 14.3 0 0.0 2 7.1 Artisan 2 14.3 2 14.3 4 14.3 Vendor 3 21.4 3 21.4 3 10.7 Perceptions of climate change Table 2 contains representative participant quotations on the manifestations, causes, and outcomes of climate change and extreme heat. We found that virtually all participants were aware of climate change, having heard about it from the television, friends, and family, and/or social media. Climate change was most often defined and described as “heat” or “extreme heat” across all participants. However, peri-urban residents described their climate change experience as also including drought and erratic rainfall, whereas urban residents more frequently mentioned harmattan/dust and erosion. Table 2 Participant quotes on the manifestations, causes, and outcomes of climate change and extreme heat. Dimension Supporting quote Manifestations of Climate Change Heat “ Just the heat, extreme heat”. (Female, aged 20–29, urban resident) “It’s as if they are pouring something very hot on you, especially at night. Even when you put on the fan, it’s full of heat. And when you go outside you don’t even feel the wind blowing. You feel the sun very hot and it will be burning you”. (F emale, aged 30–39, peri-urban resident) Causes of Climate Change Deforestation “Cutting down of trees. Because, if the trees were to be plenty, the way the sun rays hit the earth, it wouldn’t have been that much. Because we have been cutting down trees it allows the sun rays to get to us”. (Male, aged 20–29 years, urban resident) God “There is nothing we can do to stop the storms and heat except to suffer and pray for the mercies of God”. (Male, aged 50 + years, peri-urban resident). Health outcomes of climate change and extreme heat Malaria “You know when, the weather is hot it is often difficult for one to sleep, and it is also the time mosquitoes are able to do their work”. (Female, aged 40–49, peri-urban resident) Hypertension “[Climate change and extreme heat] I think you may not take me very serious because I may not know very much about what I am saying, but I believe that something like hypertension it contributes to it. Because when they take your temperature, and it is high it definitely talks about something heat or some pressure somewhere”. (Male, aged 40–49 years, urban resident) Work productivity “For myself, it has affected the output I used to get from the farm, we get tired easily because of the heat, you work small you are tired you have to rest”. (Male, aged 20–29 years, peri-urban resident) Stress “The temperature is making us feel sick and stressful”. (Female, aged 20–29 years, urban resident). Uncertainty, insecurity, and helplessness due to climate change and extreme heat Livelihood Drought is what I meant by saying disappointment of the rains, we follow the pattern as we know it in the past and it does not come that way, only your crops to fail because of inadequate water or unpredictable rainfalls”. (Male, aged 40–49 years, urban resident) Food insecurity “[Extreme heat and climate change] has increased the prices of goods. A bag of maize is now sold at Gh¢600.00. But we used not to buy it even at Gh¢200.00”. (Female, aged 30–39 years, peri-urban resident) Water insecurity “ Due to the discovery of guinea worm infestation from drinking from the dam, pipes were laid in the area to supply us with pipe borne water, but up to date these pipes are still dry without water, and people continue to drink from the dam. So, what happens when the dam dries up? What will be our next option of drinking water? Because it is a small dam, and the population of the community outnumber its supply capacity”. (Male, aged 40–49 years, peri-urban resident) Uncertainty “You don't know what to do with your body because today there's heat tomorrow there will be cold. Now a days, they put off the lights almost all the time and then if you are to sleep outside mosquitoes are biting which causes malaria”. (Female, aged 50 + years, peri-urban resident) Housing “I would say that the way we build our houses, we don’t provide more space for ventilation”. ( Male, aged 20–29 years, urban resident) “Sleeping in a room without a window is just like being in the grave. No one will wish to sleep in such a room.” ( Female, aged 30–39, peri-urban resident) Intersection with social determinants of health Extreme heat comes with so many challenges, for example diseases like malaria, headaches, “punidotti” and the likes affects us and our children. It brings calamities to our households. So, if you are not financially sound at this period of the year, how will you manage to solve these health problems? So, it is a very huge challenge to our source of livelihood, because we are constantly caught in the circle of household food shortages and health related problems, therefore leaving you with almost nothing to be able to finance the health care of your family. So, we are typically helpless people in this period of the year”. (Male , aged 40–49 years, peri-urban resident) Most participants stated that their communities contribute to the ongoing incidence of climate change, specifically in the form of deforestation, through felling of trees for construction and building purposes, and subsequent burning, for refuse management or cultural bush burning. A substantial proportion of peri-urban participants also held a strong belief that climate change is caused by God or a divine force (Fig. 2 ). Many asserted that extreme heat is the will of God and a sign of “His displeasure for the transgressions of humanity”, and only through faith, kindness, and community will God end the punishment. Perceptions of climate change outcomes Consequences of climate change and extreme heat on health Almost all the participants reported that extreme heat is associated with adverse health conditions, with cases of malaria, boils, skin rashes, cerebrospinal meningitis, headaches and fever increasing during the period of extreme heat. Peri-urban residents expressed more concern for the health impacts of extreme heat compared to their urban counterparts, and more frequently mentioned general malaise, hypertension/stroke, and skin diseases (Fig. 3 ). Unbearable indoor temperatures compel many residents to sleep or sit outdoor throughout the night, leaving them vulnerable to mosquito bites, leading to increased incidence of diseases such as malaria, and greater health-related expenditures. Participants generally reported that children and the elderly are the most vulnerable and affected persons due to extreme heat exposure. They recounted that individuals in those age groups are the most hospitalized during the period of extreme heat. Respondents working within the healthcare field noted that extreme heat leads to increased fatigue and irritability for both providers and patients. Participants felt that pregnant women develop higher risk for hypertension and assisted delivery due to extreme heat exposure. Additionally, the heat exhaustion and psychological stress of managing the unbearable indoor temperatures can also negatively affect individuals managing existing chronic health conditions like hypertension. Uncertainty, insecurity, and helplessness Nearly all the participants expressed concerns about the unpredictable nature of the weather. Both urban and peri-urban participants described climate change as a source of uncertainty and helplessness, arising from irregular climate patterns. Those reliant on agriculture as a source of income, especially in peri-urban areas, noted that extreme heat, increased droughts, and erratic rainfall (including long periods without rain, unexpected heavy downpours, and abrupt short showers) lead to low or failed crop yields, resulting in financial insecurity, worsening poverty, regional food shortages, and inflated cost of available food. Some urban residents highlighted that extreme heat negatively impacts work, productivity, and economic security. They expressed that they easily get exhausted while working under the hot sun, leading to decreased working hours due to increased frequency of breaks to cool down or rest. In addition, participants who were more reliant on trade as their primary source of income felt that extreme heat was linked to low sales and poor customer turnout. All of this was felt to contribute to economic fragility and associated feelings of helplessness. Prolonged duration of extreme heat was also felt to exacerbate water insecurity that individuals and communities already experience in northern Ghana. This would force residents to rely on expensive or unsanitary sources of water. Participants in urban Tamale reported using dam water strictly for washing purposes, while those in the peri-urban areas reported the use of dam water for both drinking and washing—a practice participants believed led to widespread guinea worm infestations in their communities in the recent past. Both urban and peri-urban participants expressed the belief that overcrowding of buildings is a major contributor to indoor extreme heat. Deficient size, number, and location of windows within the household were felt to cause suboptimal ventilation, contributing to excessive indoor heat exposure. Participants who reported having no windows or ventilation expressed increased stress and restlessness. Additionally, sleeping quarters shared with multiple household members as well as inadequate or unavailable circulation from fans or air conditioners were compounding factors for increased distress from rising indoor extreme heat. Extreme heat was described as a major source of helplessness, uncertainty, and insecurity for nearly every household. For instance, increased prevalence of diseases due to extreme heat was generally perceived to be associated with increased household healthcare expenditure, contributing to the already existing financial and food insecurity experienced by most households. Discussion In this qualitative study, we sought to assess perceptions of climate change, extreme heat, and health and social risks, among peri-urban and urban residents in northern Ghana. Extreme heat was the primary perceived manifestation of climate change in this setting. Though human activity was felt to be a contributor to climate change, peri-urban residents more heavily cited God and divine forces as a primary cause of climate change. Climate change was felt to contribute to poor health outcomes, and also to intersect with and exacerbate social determinants of health, including poverty, food insecurity, and water insecurity, collectively leading to feelings of helplessness and uncertainty. We observed high awareness of climate change but lower concurrence regarding anthropogenic causes and adaptation strategies for climate change. While the majority of our respondents acknowledged that deforestation within their communities contributed to climate change and increased extreme heat due to reduced available shade cover, this was not universally expressed by all study participants. Notably, peri-urban residents more commonly expressed belief in God or a divine force as the cause of climate change. Studies conducted in other populations have reported similar findings regarding differential perspectives regarding the causes of climate change. 24–26 The existing literature from Ghana also cites traditional land management practices, low acuity to ecological repercussions, and lack of government conservation policy or enforcement as factors contributing to continued forest degradation and deforestation and, in turn, increased heat perception. 27,28 Implementing climate change education within both formal and informal settings has proven to foster better climate literacy and risk perceptions, making education a vital strategy to improving adaptive capacity against growing climate change-related hazards. 29–31 Previous research in Ghana has documented the feasibility and effectiveness of climate change curriculum across all levels of education. These curricular efforts have expanded beyond an agricultural focus to improve overall awareness and understanding of climate change and health, as well as attitudes, behaviors, and involvement regarding climate mitigation and adaptation. 32–35 The perception of extreme heat as a primary manifestation of climate change is consistent with prior literature from other countries in West Africa. 36–38 Farmers living in several countries in West Africa have reported a perceived increase in temperature and frequency of hot days, alongside changes in rainfall, as the primary experience of climate change. 39,40 Similarly, a case study of climate change and variability experienced by residents in Accra identified floods and excessive heat as the primary climate-related stressors. 41 Indeed, in Ghana, annual and maximum temperatures increased all agroecological zones between 1985 and 2021. 42,43 Correspondingly, mean land surface temperature n Tamale rose from 45.7°C in 2003 to 62.9°C in 2023. 44,45 Clearly, the community perceptions in our study reflect lived experiences of extreme heat. The inclusion of both urban and peri-urban communities within our study improves generalizability of findings for similar urbanizing cities, while also highlighting differences in perceived risks, outcomes, and priorities unique to each population. The peri-urban experience of drought and erratic rainfall is also similar to what has been reported from rural agricultural communities in northern Ghana. 36,46–49 This contrast with their urban counterparts, who cited harmattan/dust and erosion as a more commonly perceived manifestation of climate change, may be attributable, in part, to the agrarian livelihoods of peri-urban and rural populations that are more reliant on weather forecasting for crop cultivation. In addition to the belief that God or a divine force was the primary cause of climate change, peri-urban residents also felt that the solution to climate change would require divine intervention, asserting that there are limited human-led adaptation or mitigation strategies that would reduce climate change outcomes. A “divine cause” of climate change has been reported from several parts of Africa and has been reported to serve as a barrier to successful implementation of climate change adaptation and mitigation strategies. 50–52 Participants also expressed a strong perceived association between extreme heat exposure and frequency of malaria, skin conditions, and headaches. 1,53–55 Peri-urban residents in particular referred to increased heart disease and hypertension resulting from extreme heat anxiety and socioeconomic stressors. This perception is consistent with epidemiological data linking heat exposure with cardiovascular disease outcomes. 56 In the context of preexisting challenges with health care accessibility and insufficient health system capacity, the health impacts of climate change are more difficult for already vulnerable populations. 53 The perceived risk groups in our study, including children, people of advanced age, and pregnant women, have been reported to experience increased morbidity and mortality resulting from climate change, including increases in hospitalization among these populations during extreme heat seasons. 57–60 Current evidence supports the association between increased exposure to climate change-related hazards and poor health outcomes, loss of productive hours, and reduced work capacity. 7,8,13,61 The participants in our study described the impact of increase temperatures on their ability and capacity to work, either directly, by reducing tolerable hours to perform manual labor in extreme heat, or indirectly, through productive hours lost to sickness and hospitalization. Increasing capital spent on climate-related health hazards coupled with decreasing earnings due to climate-related labor reduction translates to compounding financial insecurity. 62–64 Northern Ghana is already experiencing a double burden of food and water insecurity, which is exacerbated by extreme heat events that further reduce availability and accessibility of food and water. 65,66 Our study’s peri-urban residents in particular reported food insecurity resulting from poor crop yields and post-harvest losses. Without the ability to produce enough crops to consume and trade, agrarian livelihoods are threatened, leading to mounting physical and mental health consequences. 49,65 In addition, unavailability of potable water, which is exacerbated by climate change-related hazards such as drought and erratic rainfall, leads to increased reliance on contaminated water sources. This is particularly problematic for poor and peri-urban residents, increasing the spread of water-borne and diarrheal diseases. 67,68 Women in northern Ghana are especially at risk of water and food insecurity in light of gendered domestic responsibilities, with household chores such as fetching water, cooking, and washing predominantly allocated to wives and daughters. 69,70 Community perceptions and empirical data demonstrate the disproportionate adverse effects of extreme heat for women, often exacerbating pre-existing gender inequalities like access to education or social marginalization and immobility. 71,72 Strategies that provide women with healthier options and choices, within the constraints of their daily lived experiences, can have beneficial impact. For example, less-polluting cookstoves and fuels, as well efforts to enhance female access to capital such as increased participation in agriculture or education, can contribute to both climate change adaptation, gender equality, and improved health. 71,73 The intersection and exacerbation of adverse social determinants of health, such as water scarcity, food insecurity, poverty, and financial insecurity, intersected with the challenging experiences of climate change-related hazards, leading to feelings of uncertainty and helplessness expressed by the study participants. The challenge, therefore, for policymakers and program planners is to develop and implement innovative strategies to mitigate and adapt to the impacts of climate change while also providing a substrate for hope and reassurance. Such innovations could include, but are not limited to, climate-smart urban and peri-urban agriculture, climate-resilient health systems strengthening, local ecological conservation, and socio-economic development initiatives. 74–80 We acknowledge the following limitations of our study: We recognize that the sample size of the study was small; however, we did successfully gather input and perceptions from a diverse array of stakeholders in both urban and peri-urban Tamale, northern Ghana. We are planning for complementary larger-scale quantitative assessments of this issue in the future. In addition, we recognize that generalizability may be limited. However, we also feel that the challenges described by our study, including the intersection of extreme heat with other social determinants of health, is relevant to low-resource communities worldwide. Conclusion Our study highlights the interconnectedness of climate change and extreme heat with social determinants of health in northern Ghana, a population that faces multiple social, economic, and health challenges. Extreme heat is perceived to contribute to a loss of livelihood and life, with disproportionate impact on women, children, and the elderly. While helplessness and uncertainty can result from the intersection of these challenges, there remain opportunities to engage in effective and acceptable mitigation and adaptation efforts. This study forms a foundation for future efforts to enhance resilience of communities and individuals in the face of the ongoing and growing challenges of climate change and extreme heat. Declarations Ethical Statement This study was conducted in accordance in full conformity with the Regulations for the Protection of Human Subjects of Research codified in 45 CFR Part 46; Declaration of Helsinki; the Council for International Organizations of Medical Sciences (CIOMS) International Ethical Guidelines for Health-related Research Involving Humans (2002); and the ethical principles and protocols for research set by Ghana Health Service (GHS), the Ghana Ministry of Health, and the Government of Ghana. The study was approved by the Institutional Review Board (IRB) of the University for Development Studies (reference number UDS/IRB/106/22). Informed consent was obtained from all participants prior to their participation in the study, and all data was handled in accordance with privacy and confidentiality guidelines. Competing Interests The authors declare no competing interests. Funding Statement The authors wish to thank the American Red Cross Global Disaster Preparedness Center and The Leona M. and Harry B. Helmsley Charitable Trust for funding to support the conduct of this research. Author Contribution Data collection and transcription was conducted by BYA, SK, and BAA. Data cleaning was done by BYA, BA, and SK under the supervision of VM. The analytical plan was developed by RV with support of VM. Coding was initially done by VM with the support of BYA, RS, and SK. Subsequently, the codebook was developed by BYA, RS, SK, and VM. Manuscript was primarily drafted by BYA and RS, with input from SK. Guidance and mentorship across all components was provided by VM and RV. SDZ provided guidance and review contribution during data collection, transcription, and initial coding. All authors reviewed and approved the final version of the manuscript. Acknowledgement The authors extend sincere gratitude to the research participants for their time and contributions. Data Availability The datasets supporting the conclusions of this article are available in the Open Science Framework (OSF) repository, https://osf.io/dg2z6/?view_only=a3313c356c6b417fb6f15bf93978b636. References Opoku SK, Leal Filho W, Hubert F, Adejumo O. Climate Change and Health Preparedness in Africa: Analysing Trends in Six African Countries. Int J Environ Res Public Health 2021;18(9) (In eng). DOI: 10.3390/ijerph18094672. Organization WH. Climate change. World Health Organization. (https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health). Odonkor ST, Sallar AM. An Assessment of Public Knowledge and Potential Health Impacts of Global Warming in Ghana. BioMed Research International 2020;2020:1-10. DOI: 10.1155/2020/7804692. Lüthi S, Fairless C, Fischer EM, et al. Rapid increase in the risk of heat-related mortality. Nature Communications 2023;14(1):4894. DOI: 10.1038/s41467-023-40599-x. Bell ML, Gasparrini A, Benjamin GC. Climate Change, Extreme Heat, and Health. New England Journal of Medicine 2024;390(19):1793-1801. DOI: doi:10.1056/NEJMra2210769. Watts N, Amann M, Arnell N, et al. The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises. The Lancet 2021;397(10269):129-170. DOI: https://doi.org/10.1016/S0140-6736(20)32290-X. Kjellstrom T, Kovats RS, Lloyd SJ, Holt T, Tol RSJ. The Direct Impact of Climate Change on Regional Labor Productivity. Archives of Environmental & Occupational Health 2009;64(4):217-227. DOI: 10.1080/19338240903352776. Hughes L, Hanna E, Fenwick J. The silent killer: climate change and the health impacts of extreme heat: Climate Council of Australia, 2016. Joshua O, MAJEKODUNMI AS. Climate change impact on workers’ health, safety and productivity. Climate Change 2020;6(21):156-167. Kiefer M, Rodríguez-Guzmán J, Watson J, van Wendel de Joode B, Mergler D, da Silva AS. Worker health and safety and climate change in the Americas: issues and research needs. Rev Panam Salud Publica 2016;40(3):192-197. (In eng). Marchetti E, Capone P, Freda D. Climate change impact on microclimate of work environment related to occupational health and productivity. Ann Ist Super Sanita 2016;52(3):338-342. (In eng). DOI: 10.4415/ann_16_03_05. Schulte PA, Jacklitsch BL, Bhattacharya A, et al. Updated assessment of occupational safety and health hazards of climate change. Journal of Occupational and Environmental Hygiene 2023;20(5-6):183-206. DOI: 10.1080/15459624.2023.2205468. Hanna EG, Spickett JT. Climate Change and Human Health: Building Australia’s Adaptation Capacity. Asia Pacific Journal of Public Health 2011;23(2_suppl):7S-13S. DOI: 10.1177/1010539510391775. Kjellstrom T, Lemke B, Otto M. Mapping occupational heat exposure and effects in South-East Asia: ongoing time trends 1980-2011 and future estimates to 2050. Ind Health 2013;51(1):56-67. (In eng). DOI: 10.2486/indhealth.2012-0174. Sraku-Lartey M, Buor D, Adjei PO-W, Foli EG. Perceptions and knowledge on climate change in local communities in the Offinso Municipality, Ghana. Information Development 2020;36(1):16-35. DOI: 10.1177/0266666918811391. Dumenu WK, Obeng EA. Climate change and rural communities in Ghana: Social vulnerability, impacts, adaptations and policy implications. Environmental Science & Policy 2016;55:208-217. DOI: https://doi.org/10.1016/j.envsci.2015.10.010. Bell JE, Brown CL, Conlon K, et al. Changes in extreme events and the potential impacts on human health. Journal of the Air & Waste Management Association 2018;68(4):265-287. DOI: 10.1080/10962247.2017.1401017. Chavaillaz Y, Roy P, Partanen A-I, et al. Exposure to excessive heat and impacts on labour productivity linked to cumulative CO2 emissions. Scientific Reports 2019;9(1). DOI: 10.1038/s41598-019-50047-w. Klutse NAB, Owusu K, Boafo YA. Projected temperature increases over northern Ghana. SN Applied Sciences 2020;2(8):1339. DOI: 10.1007/s42452-020-3095-3. Ghana Ministry of Environment S, Technology, and Innovation (MESTI); Environmental Protection Agency (EPA). 2015 Climate Change Report. National Communication Report. UNFCCC, 2015. Nti AAA, Takyi SA, Kwarteng L, Acquah AA, Arko-Mensah J, Fobil JN. CLIMATE CHANGE AND HEALTH IN GHANA: A SYSTEMATIC REVIEW. Climate Change in Ghana 2019:6. Diko SK, Okyere SA, Opoku Mensah S, Ahmed A, Yamoah O, Kita M. Are local development plans mainstreaming climate-smart agriculture? A mixed-content analysis of medium-term development plans in semi-arid Ghana. Socioecol Pract Res 2021;3(2):185-206. (In eng). DOI: 10.1007/s42532-021-00079-2. Damte E, Manteaw BO, Wrigley-Asante C. Urbanization, climate change and health vulnerabilities in slum communities in Ghana. The Journal of Climate Change and Health 2023;10:100189. DOI: https://doi.org/10.1016/j.joclim.2022.100189. Armah FA, T. YG, Mengieng U, Isaac L, Ratana C, and Campbell G. The unusual suspects? Perception of underlying causes of anthropogenic climate change in coastal communities in Cambodia and Tanzania. Journal of Environmental Planning and Management 2017;60(12):2150-2173. DOI: 10.1080/09640568.2017.1281797. Ugwoke F, Nnadi F, Anaeto C, Aja O, Nwakwasi R. Crop farmers’ perception of and adaptation to climate change in Orlu agricultural zone of Imo state, Nigeria. Journal of Agricultural Extension 2012;16(2):212-223. Lee TM, Markowitz EM, Howe PD, Ko C-Y, Leiserowitz AA. Predictors of public climate change awareness and risk perception around the world. Nature Climate Change 2015;5(11):1014-1020. DOI: 10.1038/nclimate2728. Appiah M, Blay D, Damnyag L, Dwomoh FK, Pappinen A, Luukkanen O. Dependence on forest resources and tropical deforestation in Ghana. Environment, Development and Sustainability 2009;11:471-487. Asante MS. Deforestation in Ghana: Explaining the chronic failure of forest preservation policies in a developing country: University Press of America, 2005. Rousell D, Cutter-Mackenzie-Knowles A. A systematic review of climate change education: giving children and young people a ‘voice’ and a ‘hand’ in redressing climate change. Children's Geographies 2020;18(2):191-208. DOI: 10.1080/14733285.2019.1614532. Ofori BY, Ameade EPK, Ohemeng F, Musah Y, Quartey JK, Owusu EH. Climate change knowledge, attitude and perception of undergraduate students in Ghana. PLOS Climate 2023;2(6):e0000215. DOI: 10.1371/journal.pclm.0000215. Feinstein NW, Mach KJ. Three roles for education in climate change adaptation. Climate Policy 2020;20(3):317-322. DOI: 10.1080/14693062.2019.1701975. Mantey PPK, Afutu-Kotey RL, Tagoe MA, Attiogbe E. Climate change knowledge, attitudes and adaptation among households in three major agro-ecological zones of Ghana: Implications for climate change education and sustainable development. Sustainable Community Development in Ghana: Routledge; 2024:177-203. Boateng C. Tertiary Institutions in Ghana Curriculum Coverage on Climate Change: Implications for Climate Change Awareness. Journal of Education and Practice 2015;6(12):99-106. Boakye C. Climate Change Education:The Role of Pre-Tertiary Science Curricula in Ghana. SAGE Open 2015;5(4):2158244015614611. DOI: 10.1177/2158244015614611. Laube W. Climate Change Adaptation, Education, and Rural Transformation in Northern Ghana. Moving Beyond an Agricultural Focus. In: Yaro JA, Hesselberg J, eds. Adaptation to Climate Change and Variability in Rural West Africa. Cham: Springer International Publishing; 2016:121-145. Callo-Concha D. Farmer Perceptions and Climate Change Adaptation in the West Africa Sudan Savannah: Reality Check in Dassari, Benin, and Dano, Burkina Faso. Climate 2018;6(2):44. (https://www.mdpi.com/2225-1154/6/2/44). Mouhamed L, Traore SB, Alhassane A, Sarr B. Evolution of some observed climate extremes in the West African Sahel. Weather and Climate Extremes 2013;1:19-25. DOI: https://doi.org/10.1016/j.wace.2013.07.005. Ringard J, Dieppois B, Rome S, et al. The intensification of thermal extremes in west Africa. Global and Planetary Change 2016;139:66-77. Akponikpè PI, Johnston P, Agbossou EK. Farmers’ perception of climate change and adaptation strategies in Sub-Saharan West-Africa. 2nd International Conference: Climate, Sustainability and Development in Semi-arid Regions August2010:134147. Montcho M, Padonou EA, Montcho M, Mutua MN, Sinsin B. Perception and adaptation strategies of dairy farmers towards climate variability and change in West Africa. Climatic Change 2022;170(3):38. DOI: 10.1007/s10584-022-03311-4. Codjoe SNA, Owusu G, Burkett V. Perception, experience, and indigenous knowledge of climate change and variability: the case of Accra, a sub-Saharan African city. Regional Environmental Change 2014;14(1):369-383. DOI: 10.1007/s10113-013-0500-0. Asare-Nuamah P, Botchway E. Understanding climate variability and change: analysis of temperature and rainfall across agroecological zones in Ghana. Heliyon 2019;5(10). DOI: 10.1016/j.heliyon.2019.e02654. Oduro C, Lim Kam Sian KTC, Hagan DFT, et al. The influence of land surface temperature on Ghana’s climate variability and implications for sustainable development. Scientific Reports 2025;15(1):2595. DOI: 10.1038/s41598-025-86585-9. Kwofie S, Nyamekye C, Appiah Boamah L, Owusu Adjei F, Arthur R, Agyapong E. Urban growth nexus to land surface temperature in Ghana. Cogent Engineering 2022;9(1):2143045. DOI: 10.1080/23311916.2022.2143045. Kotir C, Amponsah O, Anbazu J, Takyi SA, Blija DK, Frempong F. Unveiling Ghana's urban tapestry: satellite-based analysis of Tamale city's spatial expansion and land surface temperature (LST) dynamics. GeoJournal 2024;89(6):242. DOI: 10.1007/s10708-024-11243-y. Teye JK, Yaro JA, Bawakyillenuo S. Local farmers’ experiences and perceptions of climate change in the Northern Savannah zone of Ghana. International Journal of Climate Change Strategies and Management 2015;7(3):327-347. Kemausuor F, Dwamena E, Bart-Plange A, Kyei-Baffour N. Farmers’ perception of climate change in the Ejura-Sekyedumase district of Ghana. 2011. Asare-Nuamah P, Botchway E. Comparing smallholder farmers’ climate change perception with climate data: the case of Adansi North District of Ghana. Heliyon 2019;5(12). Asante F, Guodaar L, Arimiyaw S. Climate change and variability awareness and livelihood adaptive strategies among smallholder farmers in semi-arid northern Ghana. Environmental Development 2021;39:100629. DOI: https://doi.org/10.1016/j.envdev.2021.100629. Benebere P, Asante F, Odame Appiah D. Hindrances to adaptation to water insecurity under climate variability in peri-urban Ghana. Cogent Social Sciences 2017;3(1):1394786. DOI: 10.1080/23311886.2017.1394786. Wolf J, Moser SC. Individual understandings, perceptions, and engagement with climate change: insights from in-depth studies across the world. WIREs Climate Change 2011;2(4):547-569. DOI: https://doi.org/10.1002/wcc.120. Hussey LK, Arku G. Conceptualizations of climate-related health risks among health experts and the public in Ghana. Social Science & Medicine 2019;223:40-50. DOI: https://doi.org/10.1016/j.socscimed.2019.01.026. Coates SJ, Enbiale W, Davis MDP, Andersen LK. The effects of climate change on human health in Africa, a dermatologic perspective: a report from the International Society of Dermatology Climate Change Committee. International Journal of Dermatology 2020;59(3):265-278. DOI: https://doi.org/10.1111/ijd.14759. Serdeczny O, Adams S, Baarsch F, et al. Climate change impacts in Sub-Saharan Africa: from physical changes to their social repercussions. Regional Environmental Change 2017;17(6):1585-1600. DOI: 10.1007/s10113-015-0910-2. Campbell-Lendrum D, Manga L, Bagayoko M, Sommerfeld J. Climate change and vector-borne diseases: what are the implications for public health research and policy? Philosophical Transactions of the Royal Society B: Biological Sciences 2015;370(1665):20130552. DOI: 10.1098/rstb.2013.0552. Liu J, Varghese BM, Hansen A, et al. Heat exposure and cardiovascular health outcomes: a systematic review and meta-analysis. The Lancet Planetary Health 2022;6(6):e484-e495. DOI: 10.1016/S2542-5196(22)00117-6. Akerlof K, Debono R, Berry P, et al. Public Perceptions of Climate Change as a Human Health Risk: Surveys of the United States, Canada and Malta. International Journal of Environmental Research and Public Health 2010;7(6):2559-2606. DOI: 10.3390/ijerph7062559. Cianconi P, Betrò S, Janiri L. The Impact of Climate Change on Mental Health: A Systematic Descriptive Review. Frontiers in Psychiatry 2020;11. DOI: 10.3389/fpsyt.2020.00074. Ebi KL, Capon A, Berry P, et al. Hot weather and heat extremes: health risks. The Lancet 2021;398(10301):698-708. DOI: https://doi.org/10.1016/S0140-6736(21)01208-3. Tay S, Danuor S, Mensah D, Acheampong G, Badu K. Climate variability and malaria incidence in peri-urban, urban and rural communities around Kumasi, Ghana: a case study at three health facilities; Emena, Atonsu and Akropong. 2012. Kjellstrom T, Holmer I, Lemke B. Workplace heat stress, health and productivity – an increasing challenge for low and middle-income countries during climate change. Global Health Action 2009;2(1):2047. DOI: 10.3402/gha.v2i0.2047. Wondmagegn BY, Xiang J, Williams S, Pisaniello D, Bi P. What do we know about the healthcare costs of extreme heat exposure? A comprehensive literature review. Science of The Total Environment 2019;657:608-618. DOI: https://doi.org/10.1016/j.scitotenv.2018.11.479. Levi M, Kjellstrom T, Baldasseroni A. Impact of climate change on occupational health and productivity: a systematic literature review focusing on workplace heat. Med Lav 2018;109(3):163-79. (In eng). DOI: 10.23749/mdl.v109i3.6851. Leap SR, Soled DR, Sampath V, Nadeau KC. Effects of extreme weather on health in underserved communities. Annals of Allergy, Asthma & Immunology 2024;133(1):20-27. DOI: https://doi.org/10.1016/j.anai.2024.04.018. Akudugu MA, Alhassan A-R. The Climate Change Menace, Food Security, Livelihoods and Social Safety in Northern Ghana. International Journal of Sustainable Development & World Policy 2012;1(3):80-95. (https://EconPapers.repec.org/RePEc:pkp:ijsdwp:v:1:y:2012:i:3:p:80-95:id:2019). Wessells KR, Kumordzie S, Becher E, et al. Household Water Insecurity Is Associated With Food Insecurity in 2 Districts in the Northern Region of Ghana. Current Developments in Nutrition 2024;8. DOI: 10.1016/j.cdnut.2024.102997. Pare S, Bonzi-Coulibaly LY. Water quality issues in West and Central Africa: present status and future challenges. IAHS Publ 2013;361:87-95. Ntouda J, Sikodf F, Ibrahim M, Abba I. Access to drinking water and health of populations in Sub-Saharan Africa. Comptes Rendus Biologies 2013;336(5-6):305-309. Botreau H, Cohen MJ. Chapter Two - Gender inequality and food insecurity: A dozen years after the food price crisis, rural women still bear the brunt of poverty and hunger. In: Cohen MJ, ed. Advances in Food Security and Sustainability: Elsevier; 2020:53-117. Jeil EB, Abass K, Ganle JK. “We are free when water is available”: gendered livelihood implications of sporadic water supply in Northern Ghana. Local Environment 2020;25(4):320-335. DOI: 10.1080/13549839.2020.1744118. Aryal JP, Sapkota TB, Rahut DB, Gartaula HN, Stirling C. Gender and climate change adaptation: A case of Ethiopian farmers. Natural Resources Forum 2022;46(3):263-288. DOI: https://doi.org/10.1111/1477-8947.12259. Senja O. Gender and Climate Change: Challenges and Opportunities. HAPSc Policy Briefs Series 2021;2(2):85-93. DOI: 10.12681/hapscpbs.29494. Adeola O, Evans O, Ngare I. Gender and Climate Issues in Africa. Gender Equality, Climate Action, and Technological Innovation for Sustainable Development in Africa. Cham: Springer International Publishing; 2024:35-58. Chagomoka T, Drescher A, Glaser R, et al. Urban and peri-urban agriculture and its implication on food and nutrition insecurity in northern Ghana: a socio-spatial analysis along the urban–rural continuum. Population and Environment 2018;40(1):27-46. DOI: 10.1007/s11111-018-0301-y. Gyasi E, Fosu M, Kranjac-Berisavljevic G, et al. Building urban resilience: Assessing urban and peri-urban agriculture in Tamale, Ghana.[Padgham, J. and J. Jabbour. United Nations Environment Programme (UNEP), Nairobi, Kenya 2014:50. Padgham J, Jabbour J, Dietrich K. Managing change and building resilience: A multi-stressor analysis of urban and peri-urban agriculture in Africa and Asia. Urban Climate 2015;12:183-204. Organization WH. Operational framework for building climate resilient health systems: World Health Organization, 2015. Mosadeghrad AM, Isfahani P, Eslambolchi L, Zahmatkesh M, Afshari M. Strategies to strengthen a climate-resilient health system: a scoping review. Globalization and Health 2023;19(1):62. DOI: 10.1186/s12992-023-00965-2. Matocha J, Schroth G, Hills T, Hole D. Integrating Climate Change Adaptation and Mitigation Through Agroforestry and Ecosystem Conservation. In: Nair PKR, Garrity D, eds. Agroforestry - The Future of Global Land Use. Dordrecht: Springer Netherlands; 2012:105-126. Milder JC, Majanen T, Scherr SJ. Performance and potential of conservation agriculture for climate change adaptation and mitigation in Sub-Saharan Africa. 2011. Additional Declarations No competing interests reported. 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21:23:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7199748/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7199748/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89065900,"identity":"ba629351-8461-44db-a498-d681aea022bc","added_by":"auto","created_at":"2025-08-14 10:42:24","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":316409,"visible":true,"origin":"","legend":"\u003cp\u003eLocation of participating communities in the Tamale metropolis, with urban communities (Moshi Zongo, Lamashigu, Hausa Zongo) in red and peri-urban communities (Kpalsi, Zujung, and Dohini Kukuo) in blue.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7199748/v1/3cc3d598e4cb370b127f5e1c.jpeg"},{"id":89065958,"identity":"3d674187-1e19-492c-aaa7-fc9679dbfb6d","added_by":"auto","created_at":"2025-08-14 10:42:27","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":119062,"visible":true,"origin":"","legend":"\u003cp\u003eCauses of climate change, as represented by a word cloud comparing peri-urban vs urban residents.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7199748/v1/e2ed8a498300de1e06c4402b.jpg"},{"id":89066582,"identity":"c45d54f3-5295-4550-a50c-390bd12f2ff0","added_by":"auto","created_at":"2025-08-14 10:42:44","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":359676,"visible":true,"origin":"","legend":"\u003cp\u003ePerceived health effects of climate change, as reported by urban and peri-urban residents.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7199748/v1/319e4f7f257e7cadd29f6596.jpeg"},{"id":98427773,"identity":"50d3e43e-8a8e-42ed-b315-153712136adf","added_by":"auto","created_at":"2025-12-17 16:41:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1622155,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7199748/v1/e74cf186-bdc8-4a8b-b374-cf0b575e6b13.pdf"},{"id":89066086,"identity":"4953a46a-8a35-4eda-8f98-1a5711e80519","added_by":"auto","created_at":"2025-08-14 10:42:33","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":28763,"visible":true,"origin":"","legend":"","description":"","filename":"ExtremeHeatManuscriptSupplementalInformation20250402RS.docx","url":"https://assets-eu.researchsquare.com/files/rs-7199748/v1/ad53dd0727a23d56b138a294.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"“You don't know what to do with your body”: Perceptions of extreme heat in northern Ghana","fulltext":[{"header":"Introduction","content":"\u003cp\u003eClimate change substantially affects the health of people from all walks of life, race, gender, geography, and health systems.\u003csup\u003e1\u003c/sup\u003e Climate change-related extreme weather events are global phenomena that manifest locally in the form of drought, heatwaves, and rainwater flooding.\u003csup\u003e2\u003c/sup\u003e These climate change-related health hazards are estimated to increase mortality and morbidity, as well as exert a cost of \u003cspan\u003e$\u003c/span\u003e2\u0026ndash;4\u0026nbsp;billion USD per year by 2030.\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAmong the most pressing climate change-related hazards is extreme heat, with increasing frequency, intensity, and duration of hot weather events, associated with increases in both mortality and morbidity.\u003csup\u003e4,5\u003c/sup\u003e The consequences of extreme heat are disproportionately felt by populations in low-and-middle-income countries (LMICs) already susceptible to the health risks of poverty, inadequate water, and poor sanitation infrastructure.\u003csup\u003e6\u003c/sup\u003e In addition, intensifying occupational heat exposure decreases labor productivity, with a projected 43.8% productivity loss in West Africa by 2050.\u003csup\u003e7\u003c/sup\u003e These indicators are projected to worsen with the current trend of global warming and its related morbidity and mortality.\u003csup\u003e8\u0026ndash;14\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn Ghana, the impacts of extreme heat are expected directly in the form of drought, heatwaves, and erratic rainfall, and indirectly through poor agricultural yield, loss of employment, and poverty.\u003csup\u003e15,16\u003c/sup\u003e The repercussions of these exposures include additional strain on an already taxed health system characterized by water insecurity, food insecurity, and reduced availability of and access to electricity.\u003csup\u003e8,17,18\u003c/sup\u003e In particular, Northern Ghana has been identified as the most vulnerable and sensitive to extreme heat across the country, with the highest projected increase in mean minimum and maximum ambient temperature, upwards of 3.5\u0026deg;C and 3.9\u0026deg;C, respectively, by 2080.\u003csup\u003e19,20\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe existing literature focuses predominantly on the agricultural repercussions of climate change and extreme heat, with relatively few studies exploring the health consequences.\u003csup\u003e21,22\u003c/sup\u003e We therefore sought to understand the public perception of the health and social risks of extreme heat in northern Ghana to guide future development of appropriate and impactful adaptation and mitigation strategies to improve population health.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eSetting.\u003c/em\u003e This study evolved from an academic global health partnership between University for Development Studies and NYU Grossman School of Medicine representing the Academic Model Providing Access to Healthcare (AMPATH) Consortium. The study included three peri-urban communities (Kpalsi, Zujung, and Dohini-Kukuo) and three urban neighborhoods (Hausa Zongo, Lamashigu, Moshie Zongo) in the Tamale Metropolis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), located in Ghana\u0026rsquo;s Northern Region. All six communities were identified to be resource poor, with suboptimal or inconsistent housing infrastructure (lacking in water piping, ventilation, or electricity supply). The residents of these communities subsist on less diversified and unstable sources of income and are therefore potentially more vulnerable to the health risks of extreme heat and climate change.\u003csup\u003e16,23\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eStudy Design.\u003c/em\u003e This study utilized a qualitative approach consisting of 12 semi-structured interviews (SSIs) and 4 focus group discussions (FGDs) with 4 participants in each, allowing researchers to gain in-depth understanding of community perceptions and experiences of extreme heat. The research team developed a structured question guide that included items related to manifestations of climate change and extreme heat, awareness of climate change, experiences with extreme heat, social determinants of health, and health outcomes (Appendix A).\u003c/p\u003e\u003cp\u003e\u003cem\u003eParticipants and Recruitment.\u003c/em\u003e Research team members identified potential participants within the six communities at their residences, provided them with a general summary of the study aims and objectives, then subsequently invited them to participate. Interested individuals were provided detailed information regarding the study procedures, voluntary participation, and assurances for confidentiality in English or Dagbani. Written informed consent was obtained, unless the individual was not literate, in which case verbal consent was obtained.\u003c/p\u003e\u003cp\u003eA total of 28 individuals from the Tamale municipality were invited to participate, with 100% consent rate. An equal proportion of urban and peri-urban residents were recruited overall, with all participants aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years at the time of consent. Ten urban and two peri-urban residents participated in the SSIs. Four urban and 12 peri-urban residents participated in the FGDs, clustered by their respective community. The study was approved by the University for Development Studies Institutional Review Board.\u003c/p\u003e\u003cp\u003e\u003cem\u003eData Collection and Analysis.\u003c/em\u003e Data collection occurred in December 2022. The SSIs were less than 35 minutes and the FGDs were less than 75 minutes. All SSIs and FGDs were digitally recorded, transcribed, translated into English if conducted in Dagbani, and pseudonymized by participant number.\u003c/p\u003e\u003cp\u003eAll 16 transcripts from the SSIs and FGDs were reviewed by four research team members (BA, SK, VM, RS). Content and thematic analysis of the data were conducted to identify a priori themes (intersection of extreme heat with social determinants of health, gender-specific impacts, and health impacts) as well as emerging themes. The analysis followed an iterative process, including data familiarization, coding, preliminary theme generation, and theme review and refinement. An initial codebook structure was developed by consensus by two research team members (BA, SK), with further refinement and additional coding done after reanalysis of transcripts by the other two team members (VM, RS). The four research team members met to discuss the analysis and came to a consensus on the final version of the codebook. Consistent review of themes throughout analysis ensured cohesive, consensus accounts of participant perceptions.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the demographic characteristics of the 28 study participants according to urban vs. peri-urban location. The gender distribution (slightly more male) was the same in the urban and peri-urban settings. The mean age of participants was 36.1 years (SD\u0026thinsp;=\u0026thinsp;14.3), and urban participants were younger in general. A greater proportion of urban participants were Muslim compared to peri-urban participants, and a greater proportion of peri-urban participants reported to belong to the traditional-Islam religion (i.e., practitioners of both the African tradition and Islam religion at the same time). A greater proportion of urban participants were found to have any formal education compared to peri-urban participants. However, among those who had attended formal schooling, a greater proportion of peri-urban participants were found to have tertiary education compared to the urban participants.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of participants.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBaseline characteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003ePeri-urban (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eUrban (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e57.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e57.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u0026ndash;29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e46.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30\u0026ndash;39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40\u0026ndash;49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e10.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e50+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMole Dagbani\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e57.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e78.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGurunsi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e10.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e10.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIslam\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e92.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e78.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIslam-Traditional (African faith)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChristianity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHighest educational level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e17.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary (up to JHS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary (up to SHS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e50.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e32.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary (college and above)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e35.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEmployment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnemployed/Not working\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e10.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e35.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e25.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFarmer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eArtisan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVendor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e10.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePerceptions of climate change\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e contains representative participant quotations on the manifestations, causes, and outcomes of climate change and extreme heat. We found that virtually all participants were aware of climate change, having heard about it from the television, friends, and family, and/or social media. Climate change was most often defined and described as \u0026ldquo;heat\u0026rdquo; or \u0026ldquo;extreme heat\u0026rdquo; across all participants. However, peri-urban residents described their climate change experience as also including drought and erratic rainfall, whereas urban residents more frequently mentioned harmattan/dust and erosion.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant quotes on the manifestations, causes, and outcomes of climate change and extreme heat.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDimension\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSupporting quote\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eManifestations of Climate Change\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeat\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eJust the heat, extreme heat\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e(Female, aged 20\u0026ndash;29, urban resident)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s as if they are pouring something very hot on you, especially at night. Even when you put on the fan, it\u0026rsquo;s full of heat. And when you go outside you don\u0026rsquo;t even feel the wind blowing. You feel the sun very hot and it will be burning you\u0026rdquo;. \u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e(F\u003c/em\u003eemale, aged 30\u0026ndash;39, peri-urban resident)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCauses of Climate Change\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeforestation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Cutting down of trees. Because, if the trees were to be plenty, the way the sun rays hit the earth, it wouldn\u0026rsquo;t have been that much. Because we have been cutting down trees it allows the sun rays to get to us\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e(Male, aged 20\u0026ndash;29 years, urban resident)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGod\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There is nothing we can do to stop the storms and heat except to suffer and pray for the mercies of God\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e(Male, aged 50\u0026thinsp;+\u0026thinsp;years, peri-urban resident).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHealth outcomes of climate change and extreme heat\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMalaria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You know when, the weather is hot it is often difficult for one to sleep, and it is also the time mosquitoes are able to do their work\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e(Female, aged 40\u0026ndash;49, peri-urban resident)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[Climate change and extreme heat] I think you may not take me very serious because I may not know very much about what I am saying, but I believe that something like hypertension it contributes to it. Because when they take your temperature, and it is high it definitely talks about something heat or some pressure somewhere\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e(Male, aged 40\u0026ndash;49 years, urban resident)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWork productivity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;For myself, it has affected the output I used to get from the farm, we get tired easily because of the heat, you work small you are tired you have to rest\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e(Male, aged 20\u0026ndash;29 years, peri-urban resident)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The temperature is making us feel sick and stressful\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e(Female, aged 20\u0026ndash;29 years, urban resident).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUncertainty, insecurity, and helplessness due to climate change and extreme heat\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLivelihood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cem\u003eDrought is what I meant by saying disappointment of the rains, we follow the pattern as we know it in the past and it does not come that way, only your crops to fail because of inadequate water or unpredictable rainfalls\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e(Male, aged 40\u0026ndash;49 years, urban resident)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFood insecurity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[Extreme heat and climate change] has increased the prices of goods. A bag of maize is now sold at Gh\u0026cent;600.00. But we used not to buy it even at Gh\u0026cent;200.00\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e(Female, aged 30\u0026ndash;39 years, peri-urban resident)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWater insecurity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eDue to the discovery of guinea worm infestation from drinking from the dam, pipes were laid in the area to supply us with pipe borne water, but up to date these pipes are still dry without water, and people continue to drink from the dam. So, what happens when the dam dries up? What will be our next option of drinking water? Because it is a small dam, and the population of the community outnumber its supply capacity\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e(Male, aged 40\u0026ndash;49 years, peri-urban resident)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUncertainty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You don't know what to do with your body because today there's heat tomorrow there will be cold. Now a days, they put off the lights almost all the time and then if you are to sleep outside mosquitoes are biting which causes malaria\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e(Female, aged 50\u0026thinsp;+\u0026thinsp;years, peri-urban resident)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHousing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I would say that the way we build our houses, we don\u0026rsquo;t provide more space for ventilation\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e(\u003c/em\u003eMale, \u003cem\u003eaged 20\u0026ndash;29 years, urban resident)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Sleeping in a room without a window is just like being in the grave. No one will wish to sleep in such a room.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e(\u003cem\u003eFemale, aged 30\u0026ndash;39, peri-urban resident)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntersection with social determinants of health\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cem\u003eExtreme heat comes with so many challenges, for example diseases like malaria, headaches, \u0026ldquo;punidotti\u0026rdquo; and the likes affects us and our children. It brings calamities to our households. So, if you are not financially sound at this period of the year, how will you manage to solve these health problems? So, it is a very huge challenge to our source of livelihood, because we are constantly caught in the circle of household food shortages and health related problems, therefore leaving you with almost nothing to be able to finance the health care of your family. So, we are typically helpless people in this period of the year\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e(Male\u003c/em\u003e, aged 40\u0026ndash;49 years, peri-urban resident)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMost participants stated that their communities contribute to the ongoing incidence of climate change, specifically in the form of deforestation, through felling of trees for construction and building purposes, and subsequent burning, for refuse management or cultural bush burning. A substantial proportion of peri-urban participants also held a strong belief that climate change is caused by God or a divine force (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Many asserted that extreme heat is the will of God and a sign of \u0026ldquo;His displeasure for the transgressions of humanity\u0026rdquo;, and only through faith, kindness, and community will God end the punishment.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePerceptions of climate change outcomes\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eConsequences of climate change and extreme heat on health\u003c/span\u003e\u003c/p\u003e\u003cp\u003eAlmost all the participants reported that extreme heat is associated with adverse health conditions, with cases of malaria, boils, skin rashes, cerebrospinal meningitis, headaches and fever increasing during the period of extreme heat. Peri-urban residents expressed more concern for the health impacts of extreme heat compared to their urban counterparts, and more frequently mentioned general malaise, hypertension/stroke, and skin diseases (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Unbearable indoor temperatures compel many residents to sleep or sit outdoor throughout the night, leaving them vulnerable to mosquito bites, leading to increased incidence of diseases such as malaria, and greater health-related expenditures. Participants generally reported that children and the elderly are the most vulnerable and affected persons due to extreme heat exposure. They recounted that individuals in those age groups are the most hospitalized during the period of extreme heat. Respondents working within the healthcare field noted that extreme heat leads to increased fatigue and irritability for both providers and patients. Participants felt that pregnant women develop higher risk for hypertension and assisted delivery due to extreme heat exposure. Additionally, the heat exhaustion and psychological stress of managing the unbearable indoor temperatures can also negatively affect individuals managing existing chronic health conditions like hypertension.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eUncertainty, insecurity, and helplessness\u003c/span\u003e\u003c/p\u003e\u003cp\u003eNearly all the participants expressed concerns about the unpredictable nature of the weather. Both urban and peri-urban participants described climate change as a source of uncertainty and helplessness, arising from irregular climate patterns. Those reliant on agriculture as a source of income, especially in peri-urban areas, noted that extreme heat, increased droughts, and erratic rainfall (including long periods without rain, unexpected heavy downpours, and abrupt short showers) lead to low or failed crop yields, resulting in financial insecurity, worsening poverty, regional food shortages, and inflated cost of available food.\u003c/p\u003e\u003cp\u003eSome urban residents highlighted that extreme heat negatively impacts work, productivity, and economic security. They expressed that they easily get exhausted while working under the hot sun, leading to decreased working hours due to increased frequency of breaks to cool down or rest. In addition, participants who were more reliant on trade as their primary source of income felt that extreme heat was linked to low sales and poor customer turnout. All of this was felt to contribute to economic fragility and associated feelings of helplessness.\u003c/p\u003e\u003cp\u003eProlonged duration of extreme heat was also felt to exacerbate water insecurity that individuals and communities already experience in northern Ghana. This would force residents to rely on expensive or unsanitary sources of water. Participants in urban Tamale reported using dam water strictly for washing purposes, while those in the peri-urban areas reported the use of dam water for both drinking and washing\u0026mdash;a practice participants believed led to widespread guinea worm infestations in their communities in the recent past.\u003c/p\u003e\u003cp\u003eBoth urban and peri-urban participants expressed the belief that overcrowding of buildings is a major contributor to indoor extreme heat. Deficient size, number, and location of windows within the household were felt to cause suboptimal ventilation, contributing to excessive indoor heat exposure. Participants who reported having no windows or ventilation expressed increased stress and restlessness. Additionally, sleeping quarters shared with multiple household members as well as inadequate or unavailable circulation from fans or air conditioners were compounding factors for increased distress from rising indoor extreme heat.\u003c/p\u003e\u003cp\u003eExtreme heat was described as a major source of helplessness, uncertainty, and insecurity for nearly every household. For instance, increased prevalence of diseases due to extreme heat was generally perceived to be associated with increased household healthcare expenditure, contributing to the already existing financial and food insecurity experienced by most households.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this qualitative study, we sought to assess perceptions of climate change, extreme heat, and health and social risks, among peri-urban and urban residents in northern Ghana. Extreme heat was the primary perceived manifestation of climate change in this setting. Though human activity was felt to be a contributor to climate change, peri-urban residents more heavily cited God and divine forces as a primary cause of climate change. Climate change was felt to contribute to poor health outcomes, and also to intersect with and exacerbate social determinants of health, including poverty, food insecurity, and water insecurity, collectively leading to feelings of helplessness and uncertainty.\u003c/p\u003e\u003cp\u003eWe observed high awareness of climate change but lower concurrence regarding anthropogenic causes and adaptation strategies for climate change. While the majority of our respondents acknowledged that deforestation within their communities contributed to climate change and increased extreme heat due to reduced available shade cover, this was not universally expressed by all study participants. Notably, peri-urban residents more commonly expressed belief in God or a divine force as the cause of climate change. Studies conducted in other populations have reported similar findings regarding differential perspectives regarding the causes of climate change.\u003csup\u003e24\u0026ndash;26\u003c/sup\u003e The existing literature from Ghana also cites traditional land management practices, low acuity to ecological repercussions, and lack of government conservation policy or enforcement as factors contributing to continued forest degradation and deforestation and, in turn, increased heat perception.\u003csup\u003e27,28\u003c/sup\u003e Implementing climate change education within both formal and informal settings has proven to foster better climate literacy and risk perceptions, making education a vital strategy to improving adaptive capacity against growing climate change-related hazards.\u003csup\u003e29\u0026ndash;31\u003c/sup\u003e Previous research in Ghana has documented the feasibility and effectiveness of climate change curriculum across all levels of education. These curricular efforts have expanded beyond an agricultural focus to improve overall awareness and understanding of climate change and health, as well as attitudes, behaviors, and involvement regarding climate mitigation and adaptation.\u003csup\u003e32\u0026ndash;35\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe perception of extreme heat as a primary manifestation of climate change is consistent with prior literature from other countries in West Africa.\u003csup\u003e36\u0026ndash;38\u003c/sup\u003e Farmers living in several countries in West Africa have reported a perceived increase in temperature and frequency of hot days, alongside changes in rainfall, as the primary experience of climate change.\u003csup\u003e39,40\u003c/sup\u003e Similarly, a case study of climate change and variability experienced by residents in Accra identified floods and excessive heat as the primary climate-related stressors.\u003csup\u003e41\u003c/sup\u003e Indeed, in Ghana, annual and maximum temperatures increased all agroecological zones between 1985 and 2021.\u003csup\u003e42,43\u003c/sup\u003e Correspondingly, mean land surface temperature n Tamale rose from 45.7\u0026deg;C in 2003 to 62.9\u0026deg;C in 2023.\u003csup\u003e44,45\u003c/sup\u003e Clearly, the community perceptions in our study reflect lived experiences of extreme heat.\u003c/p\u003e\u003cp\u003eThe inclusion of both urban and peri-urban communities within our study improves generalizability of findings for similar urbanizing cities, while also highlighting differences in perceived risks, outcomes, and priorities unique to each population. The peri-urban experience of drought and erratic rainfall is also similar to what has been reported from rural agricultural communities in northern Ghana.\u003csup\u003e36,46\u0026ndash;49\u003c/sup\u003e This contrast with their urban counterparts, who cited harmattan/dust and erosion as a more commonly perceived manifestation of climate change, may be attributable, in part, to the agrarian livelihoods of peri-urban and rural populations that are more reliant on weather forecasting for crop cultivation. In addition to the belief that God or a divine force was the primary cause of climate change, peri-urban residents also felt that the solution to climate change would require divine intervention, asserting that there are limited human-led adaptation or mitigation strategies that would reduce climate change outcomes. A \u0026ldquo;divine cause\u0026rdquo; of climate change has been reported from several parts of Africa and has been reported to serve as a barrier to successful implementation of climate change adaptation and mitigation strategies.\u003csup\u003e50\u0026ndash;52\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eParticipants also expressed a strong perceived association between extreme heat exposure and frequency of malaria, skin conditions, and headaches.\u003csup\u003e1,53\u0026ndash;55\u003c/sup\u003e Peri-urban residents in particular referred to increased heart disease and hypertension resulting from extreme heat anxiety and socioeconomic stressors. This perception is consistent with epidemiological data linking heat exposure with cardiovascular disease outcomes.\u003csup\u003e56\u003c/sup\u003e In the context of preexisting challenges with health care accessibility and insufficient health system capacity, the health impacts of climate change are more difficult for already vulnerable populations.\u003csup\u003e53\u003c/sup\u003e The perceived risk groups in our study, including children, people of advanced age, and pregnant women, have been reported to experience increased morbidity and mortality resulting from climate change, including increases in hospitalization among these populations during extreme heat seasons.\u003csup\u003e57\u0026ndash;60\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eCurrent evidence supports the association between increased exposure to climate change-related hazards and poor health outcomes, loss of productive hours, and reduced work capacity.\u003csup\u003e7,8,13,61\u003c/sup\u003e The participants in our study described the impact of increase temperatures on their ability and capacity to work, either directly, by reducing tolerable hours to perform manual labor in extreme heat, or indirectly, through productive hours lost to sickness and hospitalization. Increasing capital spent on climate-related health hazards coupled with decreasing earnings due to climate-related labor reduction translates to compounding financial insecurity.\u003csup\u003e62\u0026ndash;64\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eNorthern Ghana is already experiencing a double burden of food and water insecurity, which is exacerbated by extreme heat events that further reduce availability and accessibility of food and water.\u003csup\u003e65,66\u003c/sup\u003e Our study\u0026rsquo;s peri-urban residents in particular reported food insecurity resulting from poor crop yields and post-harvest losses. Without the ability to produce enough crops to consume and trade, agrarian livelihoods are threatened, leading to mounting physical and mental health consequences.\u003csup\u003e49,65\u003c/sup\u003e In addition, unavailability of potable water, which is exacerbated by climate change-related hazards such as drought and erratic rainfall, leads to increased reliance on contaminated water sources. This is particularly problematic for poor and peri-urban residents, increasing the spread of water-borne and diarrheal diseases.\u003csup\u003e67,68\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eWomen in northern Ghana are especially at risk of water and food insecurity in light of gendered domestic responsibilities, with household chores such as fetching water, cooking, and washing predominantly allocated to wives and daughters.\u003csup\u003e69,70\u003c/sup\u003e Community perceptions and empirical data demonstrate the disproportionate adverse effects of extreme heat for women, often exacerbating pre-existing gender inequalities like access to education or social marginalization and immobility.\u003csup\u003e71,72\u003c/sup\u003e Strategies that provide women with healthier options and choices, within the constraints of their daily lived experiences, can have beneficial impact. For example, less-polluting cookstoves and fuels, as well efforts to enhance female access to capital such as increased participation in agriculture or education, can contribute to both climate change adaptation, gender equality, and improved health.\u003csup\u003e71,73\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe intersection and exacerbation of adverse social determinants of health, such as water scarcity, food insecurity, poverty, and financial insecurity, intersected with the challenging experiences of climate change-related hazards, leading to feelings of uncertainty and helplessness expressed by the study participants. The challenge, therefore, for policymakers and program planners is to develop and implement innovative strategies to mitigate and adapt to the impacts of climate change while also providing a substrate for hope and reassurance. Such innovations could include, but are not limited to, climate-smart urban and peri-urban agriculture, climate-resilient health systems strengthening, local ecological conservation, and socio-economic development initiatives.\u003csup\u003e74\u0026ndash;80\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eWe acknowledge the following limitations of our study: We recognize that the sample size of the study was small; however, we did successfully gather input and perceptions from a diverse array of stakeholders in both urban and peri-urban Tamale, northern Ghana. We are planning for complementary larger-scale quantitative assessments of this issue in the future. In addition, we recognize that generalizability may be limited. However, we also feel that the challenges described by our study, including the intersection of extreme heat with other social determinants of health, is relevant to low-resource communities worldwide.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study highlights the interconnectedness of climate change and extreme heat with social determinants of health in northern Ghana, a population that faces multiple social, economic, and health challenges. Extreme heat is perceived to contribute to a loss of livelihood and life, with disproportionate impact on women, children, and the elderly. While helplessness and uncertainty can result from the intersection of these challenges, there remain opportunities to engage in effective and acceptable mitigation and adaptation efforts. This study forms a foundation for future efforts to enhance resilience of communities and individuals in the face of the ongoing and growing challenges of climate change and extreme heat.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthical Statement\u003c/h2\u003e\u003cp\u003e This study was conducted in accordance in full conformity with the Regulations for the Protection of Human Subjects of Research codified in 45 CFR Part 46; Declaration of Helsinki; the Council for International Organizations of Medical Sciences (CIOMS) International Ethical Guidelines for Health-related Research Involving Humans (2002); and the ethical principles and protocols for research set by Ghana Health Service (GHS), the Ghana Ministry of Health, and the Government of Ghana. The study was approved by the Institutional Review Board (IRB) of the University for Development Studies (reference number UDS/IRB/106/22). Informed consent was obtained from all participants prior to their participation in the study, and all data was handled in accordance with privacy and confidentiality guidelines.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding Statement\u003c/h2\u003e\u003cp\u003eThe authors wish to thank the American Red Cross Global Disaster Preparedness Center and The Leona M. and Harry B. Helmsley Charitable Trust for funding to support the conduct of this research.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eData collection and transcription was conducted by BYA, SK, and BAA. Data cleaning was done by BYA, BA, and SK under the supervision of VM. The analytical plan was developed by RV with support of VM. Coding was initially done by VM with the support of BYA, RS, and SK. Subsequently, the codebook was developed by BYA, RS, SK, and VM. Manuscript was primarily drafted by BYA and RS, with input from SK. Guidance and mentorship across all components was provided by VM and RV. SDZ provided guidance and review contribution during data collection, transcription, and initial coding. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors extend sincere gratitude to the research participants for their time and contributions.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets supporting the conclusions of this article are available in the Open Science Framework (OSF) repository, https://osf.io/dg2z6/?view_only=a3313c356c6b417fb6f15bf93978b636.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOpoku SK, Leal Filho W, Hubert F, Adejumo O. Climate Change and Health Preparedness in Africa: Analysing Trends in Six African Countries. Int J Environ Res Public Health 2021;18(9) (In eng). DOI: 10.3390/ijerph18094672.\u003c/li\u003e\n\u003cli\u003eOrganization WH. Climate change. World Health Organization. (https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health).\u003c/li\u003e\n\u003cli\u003eOdonkor ST, Sallar AM. An Assessment of Public Knowledge and Potential Health Impacts of Global Warming in Ghana. BioMed Research International 2020;2020:1-10. DOI: 10.1155/2020/7804692.\u003c/li\u003e\n\u003cli\u003eL\u0026uuml;thi S, Fairless C, Fischer EM, et al. Rapid increase in the risk of heat-related mortality. Nature Communications 2023;14(1):4894. DOI: 10.1038/s41467-023-40599-x.\u003c/li\u003e\n\u003cli\u003eBell ML, Gasparrini A, Benjamin GC. Climate Change, Extreme Heat, and Health. New England Journal of Medicine 2024;390(19):1793-1801. DOI: doi:10.1056/NEJMra2210769.\u003c/li\u003e\n\u003cli\u003eWatts N, Amann M, Arnell N, et al. The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises. The Lancet 2021;397(10269):129-170. DOI: https://doi.org/10.1016/S0140-6736(20)32290-X.\u003c/li\u003e\n\u003cli\u003eKjellstrom T, Kovats RS, Lloyd SJ, Holt T, Tol RSJ. The Direct Impact of Climate Change on Regional Labor Productivity. Archives of Environmental \u0026amp; Occupational Health 2009;64(4):217-227. DOI: 10.1080/19338240903352776.\u003c/li\u003e\n\u003cli\u003eHughes L, Hanna E, Fenwick J. The silent killer: climate change and the health impacts of extreme heat: Climate Council of Australia, 2016.\u003c/li\u003e\n\u003cli\u003eJoshua O, MAJEKODUNMI AS. Climate change impact on workers\u0026rsquo; health, safety and productivity. Climate Change 2020;6(21):156-167.\u003c/li\u003e\n\u003cli\u003eKiefer M, Rodr\u0026iacute;guez-Guzm\u0026aacute;n J, Watson J, van Wendel de Joode B, Mergler D, da Silva AS. Worker health and safety and climate change in the Americas: issues and research needs. Rev Panam Salud Publica 2016;40(3):192-197. (In eng).\u003c/li\u003e\n\u003cli\u003eMarchetti E, Capone P, Freda D. Climate change impact on microclimate of work environment related to occupational health and productivity. Ann Ist Super Sanita 2016;52(3):338-342. (In eng). DOI: 10.4415/ann_16_03_05.\u003c/li\u003e\n\u003cli\u003eSchulte PA, Jacklitsch BL, Bhattacharya A, et al. Updated assessment of occupational safety and health hazards of climate change. Journal of Occupational and Environmental Hygiene 2023;20(5-6):183-206. DOI: 10.1080/15459624.2023.2205468.\u003c/li\u003e\n\u003cli\u003eHanna EG, Spickett JT. Climate Change and Human Health: Building Australia\u0026rsquo;s Adaptation Capacity. Asia Pacific Journal of Public Health 2011;23(2_suppl):7S-13S. DOI: 10.1177/1010539510391775.\u003c/li\u003e\n\u003cli\u003eKjellstrom T, Lemke B, Otto M. Mapping occupational heat exposure and effects in South-East Asia: ongoing time trends 1980-2011 and future estimates to 2050. Ind Health 2013;51(1):56-67. (In eng). DOI: 10.2486/indhealth.2012-0174.\u003c/li\u003e\n\u003cli\u003eSraku-Lartey M, Buor D, Adjei PO-W, Foli EG. Perceptions and knowledge on climate change in local communities in the Offinso Municipality, Ghana. Information Development 2020;36(1):16-35. DOI: 10.1177/0266666918811391.\u003c/li\u003e\n\u003cli\u003eDumenu WK, Obeng EA. Climate change and rural communities in Ghana: Social vulnerability, impacts, adaptations and policy implications. Environmental Science \u0026amp; Policy 2016;55:208-217. DOI: https://doi.org/10.1016/j.envsci.2015.10.010.\u003c/li\u003e\n\u003cli\u003eBell JE, Brown CL, Conlon K, et al. Changes in extreme events and the potential impacts on human health. Journal of the Air \u0026amp; Waste Management Association 2018;68(4):265-287. DOI: 10.1080/10962247.2017.1401017.\u003c/li\u003e\n\u003cli\u003eChavaillaz Y, Roy P, Partanen A-I, et al. Exposure to excessive heat and impacts on labour productivity linked to cumulative CO2 emissions. Scientific Reports 2019;9(1). DOI: 10.1038/s41598-019-50047-w.\u003c/li\u003e\n\u003cli\u003eKlutse NAB, Owusu K, Boafo YA. Projected temperature increases over northern Ghana. SN Applied Sciences 2020;2(8):1339. DOI: 10.1007/s42452-020-3095-3.\u003c/li\u003e\n\u003cli\u003eGhana Ministry of Environment S, Technology, and Innovation (MESTI); Environmental Protection Agency (EPA). 2015 Climate Change Report. National Communication Report. UNFCCC, 2015.\u003c/li\u003e\n\u003cli\u003eNti AAA, Takyi SA, Kwarteng L, Acquah AA, Arko-Mensah J, Fobil JN. CLIMATE CHANGE AND HEALTH IN GHANA: A SYSTEMATIC REVIEW. Climate Change in Ghana 2019:6.\u003c/li\u003e\n\u003cli\u003eDiko SK, Okyere SA, Opoku Mensah S, Ahmed A, Yamoah O, Kita M. Are local development plans mainstreaming climate-smart agriculture? A mixed-content analysis of medium-term development plans in semi-arid Ghana. Socioecol Pract Res 2021;3(2):185-206. (In eng). DOI: 10.1007/s42532-021-00079-2.\u003c/li\u003e\n\u003cli\u003eDamte E, Manteaw BO, Wrigley-Asante C. Urbanization, climate change and health vulnerabilities in slum communities in Ghana. The Journal of Climate Change and Health 2023;10:100189. DOI: https://doi.org/10.1016/j.joclim.2022.100189.\u003c/li\u003e\n\u003cli\u003eArmah FA, T. YG, Mengieng U, Isaac L, Ratana C, and Campbell G. The unusual suspects? Perception of underlying causes of anthropogenic climate change in coastal communities in Cambodia and Tanzania. Journal of Environmental Planning and Management 2017;60(12):2150-2173. DOI: 10.1080/09640568.2017.1281797.\u003c/li\u003e\n\u003cli\u003eUgwoke F, Nnadi F, Anaeto C, Aja O, Nwakwasi R. Crop farmers\u0026rsquo; perception of and adaptation to climate change in Orlu agricultural zone of Imo state, Nigeria. Journal of Agricultural Extension 2012;16(2):212-223.\u003c/li\u003e\n\u003cli\u003eLee TM, Markowitz EM, Howe PD, Ko C-Y, Leiserowitz AA. Predictors of public climate change awareness and risk perception around the world. Nature Climate Change 2015;5(11):1014-1020. DOI: 10.1038/nclimate2728.\u003c/li\u003e\n\u003cli\u003eAppiah M, Blay D, Damnyag L, Dwomoh FK, Pappinen A, Luukkanen O. Dependence on forest resources and tropical deforestation in Ghana. Environment, Development and Sustainability 2009;11:471-487.\u003c/li\u003e\n\u003cli\u003eAsante MS. Deforestation in Ghana: Explaining the chronic failure of forest preservation policies in a developing country: University Press of America, 2005.\u003c/li\u003e\n\u003cli\u003eRousell D, Cutter-Mackenzie-Knowles A. A systematic review of climate change education: giving children and young people a \u0026lsquo;voice\u0026rsquo; and a \u0026lsquo;hand\u0026rsquo; in redressing climate change. Children\u0026apos;s Geographies 2020;18(2):191-208. DOI: 10.1080/14733285.2019.1614532.\u003c/li\u003e\n\u003cli\u003eOfori BY, Ameade EPK, Ohemeng F, Musah Y, Quartey JK, Owusu EH. Climate change knowledge, attitude and perception of undergraduate students in Ghana. PLOS Climate 2023;2(6):e0000215. DOI: 10.1371/journal.pclm.0000215.\u003c/li\u003e\n\u003cli\u003eFeinstein NW, Mach KJ. Three roles for education in climate change adaptation. Climate Policy 2020;20(3):317-322. DOI: 10.1080/14693062.2019.1701975.\u003c/li\u003e\n\u003cli\u003eMantey PPK, Afutu-Kotey RL, Tagoe MA, Attiogbe E. Climate change knowledge, attitudes and adaptation among households in three major agro-ecological zones of Ghana: Implications for climate change education and sustainable development. Sustainable Community Development in Ghana: Routledge; 2024:177-203.\u003c/li\u003e\n\u003cli\u003eBoateng C. Tertiary Institutions in Ghana Curriculum Coverage on Climate Change: Implications for Climate Change Awareness. Journal of Education and Practice 2015;6(12):99-106.\u003c/li\u003e\n\u003cli\u003eBoakye C. Climate Change Education:The Role of Pre-Tertiary Science Curricula in Ghana. SAGE Open 2015;5(4):2158244015614611. DOI: 10.1177/2158244015614611.\u003c/li\u003e\n\u003cli\u003eLaube W. Climate Change Adaptation, Education, and Rural Transformation in Northern Ghana. Moving Beyond an Agricultural Focus. In: Yaro JA, Hesselberg J, eds. Adaptation to Climate Change and Variability in Rural West Africa. Cham: Springer International Publishing; 2016:121-145.\u003c/li\u003e\n\u003cli\u003eCallo-Concha D. Farmer Perceptions and Climate Change Adaptation in the West Africa Sudan Savannah: Reality Check in Dassari, Benin, and Dano, Burkina Faso. Climate 2018;6(2):44. (https://www.mdpi.com/2225-1154/6/2/44).\u003c/li\u003e\n\u003cli\u003eMouhamed L, Traore SB, Alhassane A, Sarr B. Evolution of some observed climate extremes in the West African Sahel. Weather and Climate Extremes 2013;1:19-25. DOI: https://doi.org/10.1016/j.wace.2013.07.005.\u003c/li\u003e\n\u003cli\u003eRingard J, Dieppois B, Rome S, et al. The intensification of thermal extremes in west Africa. Global and Planetary Change 2016;139:66-77.\u003c/li\u003e\n\u003cli\u003eAkponikp\u0026egrave; PI, Johnston P, Agbossou EK. Farmers\u0026rsquo; perception of climate change and adaptation strategies in Sub-Saharan West-Africa. 2nd International Conference: Climate, Sustainability and Development in Semi-arid Regions August2010:134147.\u003c/li\u003e\n\u003cli\u003eMontcho M, Padonou EA, Montcho M, Mutua MN, Sinsin B. Perception and adaptation strategies of dairy farmers towards climate variability and change in West Africa. Climatic Change 2022;170(3):38. DOI: 10.1007/s10584-022-03311-4.\u003c/li\u003e\n\u003cli\u003eCodjoe SNA, Owusu G, Burkett V. Perception, experience, and indigenous knowledge of climate change and variability: the case of Accra, a sub-Saharan African city. Regional Environmental Change 2014;14(1):369-383. DOI: 10.1007/s10113-013-0500-0.\u003c/li\u003e\n\u003cli\u003eAsare-Nuamah P, Botchway E. Understanding climate variability and change: analysis of temperature and rainfall across agroecological zones in Ghana. Heliyon 2019;5(10). DOI: 10.1016/j.heliyon.2019.e02654.\u003c/li\u003e\n\u003cli\u003eOduro C, Lim Kam Sian KTC, Hagan DFT, et al. The influence of land surface temperature on Ghana\u0026rsquo;s climate variability and implications for sustainable development. Scientific Reports 2025;15(1):2595. DOI: 10.1038/s41598-025-86585-9.\u003c/li\u003e\n\u003cli\u003eKwofie S, Nyamekye C, Appiah Boamah L, Owusu Adjei F, Arthur R, Agyapong E. Urban growth nexus to land surface temperature in Ghana. Cogent Engineering 2022;9(1):2143045. DOI: 10.1080/23311916.2022.2143045.\u003c/li\u003e\n\u003cli\u003eKotir C, Amponsah O, Anbazu J, Takyi SA, Blija DK, Frempong F. Unveiling Ghana\u0026apos;s urban tapestry: satellite-based analysis of Tamale city\u0026apos;s spatial expansion and land surface temperature (LST) dynamics. GeoJournal 2024;89(6):242. DOI: 10.1007/s10708-024-11243-y.\u003c/li\u003e\n\u003cli\u003eTeye JK, Yaro JA, Bawakyillenuo S. Local farmers\u0026rsquo; experiences and perceptions of climate change in the Northern Savannah zone of Ghana. International Journal of Climate Change Strategies and Management 2015;7(3):327-347.\u003c/li\u003e\n\u003cli\u003eKemausuor F, Dwamena E, Bart-Plange A, Kyei-Baffour N. Farmers\u0026rsquo; perception of climate change in the Ejura-Sekyedumase district of Ghana. 2011.\u003c/li\u003e\n\u003cli\u003eAsare-Nuamah P, Botchway E. Comparing smallholder farmers\u0026rsquo; climate change perception with climate data: the case of Adansi North District of Ghana. Heliyon 2019;5(12).\u003c/li\u003e\n\u003cli\u003eAsante F, Guodaar L, Arimiyaw S. Climate change and variability awareness and livelihood adaptive strategies among smallholder farmers in semi-arid northern Ghana. Environmental Development 2021;39:100629. DOI: https://doi.org/10.1016/j.envdev.2021.100629.\u003c/li\u003e\n\u003cli\u003eBenebere P, Asante F, Odame Appiah D. Hindrances to adaptation to water insecurity under climate variability in peri-urban Ghana. Cogent Social Sciences 2017;3(1):1394786. DOI: 10.1080/23311886.2017.1394786.\u003c/li\u003e\n\u003cli\u003eWolf J, Moser SC. Individual understandings, perceptions, and engagement with climate change: insights from in-depth studies across the world. WIREs Climate Change 2011;2(4):547-569. DOI: https://doi.org/10.1002/wcc.120.\u003c/li\u003e\n\u003cli\u003eHussey LK, Arku G. Conceptualizations of climate-related health risks among health experts and the public in Ghana. Social Science \u0026amp; Medicine 2019;223:40-50. DOI: https://doi.org/10.1016/j.socscimed.2019.01.026.\u003c/li\u003e\n\u003cli\u003eCoates SJ, Enbiale W, Davis MDP, Andersen LK. The effects of climate change on human health in Africa, a dermatologic perspective: a report from the International Society of Dermatology Climate Change Committee. International Journal of Dermatology 2020;59(3):265-278. DOI: https://doi.org/10.1111/ijd.14759.\u003c/li\u003e\n\u003cli\u003eSerdeczny O, Adams S, Baarsch F, et al. Climate change impacts in Sub-Saharan Africa: from physical changes to their social repercussions. Regional Environmental Change 2017;17(6):1585-1600. DOI: 10.1007/s10113-015-0910-2.\u003c/li\u003e\n\u003cli\u003eCampbell-Lendrum D, Manga L, Bagayoko M, Sommerfeld J. Climate change and vector-borne diseases: what are the implications for public health research and policy? Philosophical Transactions of the Royal Society B: Biological Sciences 2015;370(1665):20130552. DOI: 10.1098/rstb.2013.0552.\u003c/li\u003e\n\u003cli\u003eLiu J, Varghese BM, Hansen A, et al. Heat exposure and cardiovascular health outcomes: a systematic review and meta-analysis. The Lancet Planetary Health 2022;6(6):e484-e495. DOI: 10.1016/S2542-5196(22)00117-6.\u003c/li\u003e\n\u003cli\u003eAkerlof K, Debono R, Berry P, et al. Public Perceptions of Climate Change as a Human Health Risk: Surveys of the United States, Canada and Malta. International Journal of Environmental Research and Public Health 2010;7(6):2559-2606. DOI: 10.3390/ijerph7062559.\u003c/li\u003e\n\u003cli\u003eCianconi P, Betr\u0026ograve; S, Janiri L. The Impact of Climate Change on Mental Health: A Systematic Descriptive Review. Frontiers in Psychiatry 2020;11. DOI: 10.3389/fpsyt.2020.00074.\u003c/li\u003e\n\u003cli\u003eEbi KL, Capon A, Berry P, et al. Hot weather and heat extremes: health risks. The Lancet 2021;398(10301):698-708. DOI: https://doi.org/10.1016/S0140-6736(21)01208-3.\u003c/li\u003e\n\u003cli\u003eTay S, Danuor S, Mensah D, Acheampong G, Badu K. Climate variability and malaria incidence in peri-urban, urban and rural communities around Kumasi, Ghana: a case study at three health facilities; Emena, Atonsu and Akropong. 2012.\u003c/li\u003e\n\u003cli\u003eKjellstrom T, Holmer I, Lemke B. Workplace heat stress, health and productivity \u0026ndash; an increasing challenge for low and middle-income countries during climate change. Global Health Action 2009;2(1):2047. DOI: 10.3402/gha.v2i0.2047.\u003c/li\u003e\n\u003cli\u003eWondmagegn BY, Xiang J, Williams S, Pisaniello D, Bi P. What do we know about the healthcare costs of extreme heat exposure? A comprehensive literature review. Science of The Total Environment 2019;657:608-618. DOI: https://doi.org/10.1016/j.scitotenv.2018.11.479.\u003c/li\u003e\n\u003cli\u003eLevi M, Kjellstrom T, Baldasseroni A. Impact of climate change on occupational health and productivity: a systematic literature review focusing on workplace heat. Med Lav 2018;109(3):163-79. (In eng). DOI: 10.23749/mdl.v109i3.6851.\u003c/li\u003e\n\u003cli\u003eLeap SR, Soled DR, Sampath V, Nadeau KC. Effects of extreme weather on health in underserved communities. Annals of Allergy, Asthma \u0026amp; Immunology 2024;133(1):20-27. DOI: https://doi.org/10.1016/j.anai.2024.04.018.\u003c/li\u003e\n\u003cli\u003eAkudugu MA, Alhassan A-R. The Climate Change Menace, Food Security, Livelihoods and Social Safety in Northern Ghana. International Journal of Sustainable Development \u0026amp;amp; World Policy 2012;1(3):80-95. (https://EconPapers.repec.org/RePEc:pkp:ijsdwp:v:1:y:2012:i:3:p:80-95:id:2019).\u003c/li\u003e\n\u003cli\u003eWessells KR, Kumordzie S, Becher E, et al. Household Water Insecurity Is Associated With Food Insecurity in 2 Districts in the Northern Region of Ghana. Current Developments in Nutrition 2024;8. DOI: 10.1016/j.cdnut.2024.102997.\u003c/li\u003e\n\u003cli\u003ePare S, Bonzi-Coulibaly LY. Water quality issues in West and Central Africa: present status and future challenges. IAHS Publ 2013;361:87-95.\u003c/li\u003e\n\u003cli\u003eNtouda J, Sikodf F, Ibrahim M, Abba I. Access to drinking water and health of populations in Sub-Saharan Africa. Comptes Rendus Biologies 2013;336(5-6):305-309.\u003c/li\u003e\n\u003cli\u003eBotreau H, Cohen MJ. Chapter Two - Gender inequality and food insecurity: A dozen years after the food price crisis, rural women still bear the brunt of poverty and hunger. In: Cohen MJ, ed. Advances in Food Security and Sustainability: Elsevier; 2020:53-117.\u003c/li\u003e\n\u003cli\u003eJeil EB, Abass K, Ganle JK. \u0026ldquo;We are free when water is available\u0026rdquo;: gendered livelihood implications of sporadic water supply in Northern Ghana. Local Environment 2020;25(4):320-335. DOI: 10.1080/13549839.2020.1744118.\u003c/li\u003e\n\u003cli\u003eAryal JP, Sapkota TB, Rahut DB, Gartaula HN, Stirling C. Gender and climate change adaptation: A case of Ethiopian farmers. Natural Resources Forum 2022;46(3):263-288. DOI: https://doi.org/10.1111/1477-8947.12259.\u003c/li\u003e\n\u003cli\u003eSenja O. Gender and Climate Change: Challenges and Opportunities. HAPSc Policy Briefs Series 2021;2(2):85-93. DOI: 10.12681/hapscpbs.29494.\u003c/li\u003e\n\u003cli\u003eAdeola O, Evans O, Ngare I. Gender and Climate Issues in Africa. Gender Equality, Climate Action, and Technological Innovation for Sustainable Development in Africa. Cham: Springer International Publishing; 2024:35-58.\u003c/li\u003e\n\u003cli\u003eChagomoka T, Drescher A, Glaser R, et al. Urban and peri-urban agriculture and its implication on food and nutrition insecurity in northern Ghana: a socio-spatial analysis along the urban\u0026ndash;rural continuum. Population and Environment 2018;40(1):27-46. DOI: 10.1007/s11111-018-0301-y.\u003c/li\u003e\n\u003cli\u003eGyasi E, Fosu M, Kranjac-Berisavljevic G, et al. Building urban resilience: Assessing urban and peri-urban agriculture in Tamale, Ghana.[Padgham, J. and J. Jabbour. United Nations Environment Programme (UNEP), Nairobi, Kenya 2014:50.\u003c/li\u003e\n\u003cli\u003ePadgham J, Jabbour J, Dietrich K. Managing change and building resilience: A multi-stressor analysis of urban and peri-urban agriculture in Africa and Asia. Urban Climate 2015;12:183-204.\u003c/li\u003e\n\u003cli\u003eOrganization WH. Operational framework for building climate resilient health systems: World Health Organization, 2015.\u003c/li\u003e\n\u003cli\u003eMosadeghrad AM, Isfahani P, Eslambolchi L, Zahmatkesh M, Afshari M. Strategies to strengthen a climate-resilient health system: a scoping review. Globalization and Health 2023;19(1):62. DOI: 10.1186/s12992-023-00965-2.\u003c/li\u003e\n\u003cli\u003eMatocha J, Schroth G, Hills T, Hole D. Integrating Climate Change Adaptation and Mitigation Through Agroforestry and Ecosystem Conservation. In: Nair PKR, Garrity D, eds. Agroforestry - The Future of Global Land Use. Dordrecht: Springer Netherlands; 2012:105-126.\u003c/li\u003e\n\u003cli\u003eMilder JC, Majanen T, Scherr SJ. Performance and potential of conservation agriculture for climate change adaptation and mitigation in Sub-Saharan Africa. 2011.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7199748/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7199748/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIn northern Ghana, extreme heat, exacerbated by climate change, threatens livelihoods, worsens poverty, increases social disparities, and can adversely impact population health. However, specific health and social impacts of extreme heat are still relatively unknown. This study explored public perceptions of extreme heat, climate change, and their associated health and social risks through 12 semi-structured interviews and 4 focus group discussions conducted among urban and peri-urban adults living in the Tamale Metropolis. Nearly all participants expressed awareness of climate change, predominantly in the form of extreme heat, and its perceived associated poor health outcomes. Participants reported feeling increasing uncertainty and helplessness due to climate change-related economic difficulties, food insecurity, and water scarcity. 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