Climate Change Impacts on Healthcare Infrastructure in Fiji: A Systematic Quantitative Literature Review

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Johnstone, Natalie A. Jones, Russell Richards, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5659753/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 Healthcare infrastructure in Fiji is undoubtedly vulnerable to climatic driver impacts. These impacts range from direct damages caused by extreme weather events to more diffuse impacts of changes in vector-borne diseases, causing pressure on local healthcare infrastructure. Climatic impacts also create vulnerabilities in infrastructure domains, such as human resources. This paper quantitatively and systematically reviews 25 empirical papers examining climate-induced risks, vulnerabilities, and impacts on the Fijian healthcare infrastructure and following PRISMA guidelines. Researchers published their findings in 21 journals, primarily in the fields of ecology and public health. A Systematic Quantitative Literature Review (SQLR) was conducted to assess the state of knowledge in the literature and address the research questions. The SQLR was chosen due to its rigorous and transparent approach, following PRISMA guidelines. A total of 457 studies were screened, and 25 studies were included in the review after exclusions and review. Nearly all articles (80%) were risk, vulnerability, or impact assessments, and the methods used were evenly distributed between quantitative and qualitative. Extreme weather events, including floods and tropical cyclones, were the focus of most papers (70%). In Fiji, coastal Viti Levu was the most studied location (56%). Most papers (68%) focus on climatic impacts on facilities and human resources. This review underscores the urgent need for additional research to enhance the resilience of Fiji's healthcare facilities. Based on the results of this systematic review, the scientific literature must test and review several climate resilience pathways. Healthcare Climate Change impacts Tropical Cyclone Fiji Figures Figure 1 Figure 2 Figure 3 Introduction Climate change poses a considerable threat to the Pacific Islands, with rising temperatures, rising sea levels, extreme weather events (EWE), and changes in disease vectors increasing the vulnerability of population health and the region's healthcare systems. 1 , 2 The Pacific Islands region is highly susceptible to the adverse effects of climate change due to its unique geographical and environmental characteristics. 3 Comprising thousands of low-lying atolls, volcanic islands, and diverse ecosystems, these nations face various climate-related challenges. In particular, climate change in the Pacific Islands has been associated with a multitude of health vulnerabilities. 4 Rising air temperatures can increase cases of heat-related illness. 5 Changes in precipitation patterns and warmer waters can alter disease vectors, increasing the prevalence of diseases such as dengue fever and malaria. 6 Additionally, extreme weather events such as cyclones and typhoons can disrupt healthcare services, damage medical infrastructure, and lead to injury and trauma. 7 Health systems in the Pacific Islands often face limited resources, insufficient and inadequate infrastructure, and shortages of medical human resources. 8 , 9 The additional burden of climate-related health problems exacerbates these challenges. 10 For example, the pressure on healthcare facilities during and after extreme weather events can overwhelm already fragile health systems in place. 11 Fiji is exceptionally prone to climate change impacts in the Pacific region, particularly its healthcare infrastructure. 8 The country faces tropical cyclones and floods that damage infrastructure and disrupt healthcare delivery, such as Tropical Cyclone Winston in 2016. 12 By being prone to climate change impacts, the Fijian healthcare infrastructure has been subject to several vulnerability and risk assessments, being the most researched location among the Pacific Islands Nations (PINs). This paper systematically analyses the literature to answer three research questions: 1: What empirical research has been completed on climate-driven hazards, exposure pathways, and vulnerabilities and their impacts on Fijian healthcare infrastructure? 2: According to the empirical research, what are the climate-driven hazards, exposure pathways, and vulnerabilities and their impacts on Fijian healthcare infrastructure? 3: What gaps exist in this empirical research? These research questions fill a gap in knowledge because no existing systematic review focuses on healthcare infrastructure and Climate Change in Fiji; current reviews have typically assessed climate impacts on healthcare in general and mention infrastructure in the process. This review aims to systematically examine specific empirical studies, such as those focused on risk, vulnerability, and impact assessments in the context of Fiji. Furthermore, this review responds to the WHO's call for more research on healthcare infrastructure in the Pacific, eventually leading to progress in building healthcare infrastructure capacity and climate resilience. 13 , 14 Indeed, by understanding climate change risks to healthcare infrastructure in Fiji, it is possible to enhance emergency preparedness and climate resilience locally and nationally, as well as in other locations that share similar characteristics. The paper begins by concisely defining the key terminology (‘Healthcare infrastructure, climate risks, vulnerability, exposure, and hazards') and then discusses the methods used in this study. The results of the systematic exploratory review of climate risks in healthcare infrastructure literature are then reported and discussed. Some suggestions are made for future research, and the paper concludes by identifying implications for healthcare resilience. Definition of key terms Healthcare Infrastructure Healthcare infrastructure encompasses the individuals, facilities, and structures necessary for delivering high-quality healthcare services. 14 , 15 , 16 , 17 , 18 , 19 This multifaceted concept includes the foundational elements of hospital operations, encompassing the physical structures and the ongoing maintenance needed to support healthcare delivery. 15 , 20 However, the interpretation of healthcare infrastructure often varies depending on the observer's perspective. 15 , 17 For instance, architects and engineers may view it primarily as the buildings and technical systems utilized in healthcare provision. In contrast, healthcare executives may emphasize the importance of the people and processes involved in delivering care. Ideally, healthcare infrastructure embodies a synthesis of these perspectives, drawing upon the expertise of diverse professionals and the effective coordination of facilities and support systems to ensure optimal healthcare delivery. 16 , 17 , 18 , 21 In this study, healthcare infrastructure is thus defined as the physical and organizational structures, facilities, and systems that collectively support the delivery of healthcare services. The infrastructure domains studied in this review are facilities, human resources, equipment and supplies, and community-based healthcare. Climate Change Risk, Vulnerability, Exposure, and Hazards. The IPCC concept of risk guidelines defines risk as: “ The potential for adverse consequences for human or ecological systems, recognizing the diversity of values and objectives associated with such systems. In the context of climate change, risks can arise from potential impacts of climate change and human responses to climate change. Relevant adverse consequences include those on lives, livelihoods, health and wellbeing, economic, social and cultural assets and investments, infrastructure, services (including ecosystem services), ecosystems and species ”. 22 According to the IPCC and the UNFCCC, vulnerability is “ the degree to which a system is susceptible to, or unable to cope with, adverse effects of climate change, including climate variability and extremes ”. 23 Exposure is defined in the same report as “ The nature and degree to which a system is exposed to significant climatic variations ”. 24 In the context of climate change impacts, risks result from dynamic interactions between climate-related hazards, such as extreme weather events, and the exposure and vulnerability of the affected human or ecological system to hazards. 22 , 25 In this review, the term risk will be used as recommended by the IPCC Working Group I. Therefore, in the context of climate change impacts, risk will be used as an umbrella term to represent the adverse consequences of climatic drivers on healthcare infrastructure. Healthcare infrastructure systems in Fiji face several climate-induced impacts that can significantly affect their operations, such as tropical cyclones, floods, or changes in disease vectors. These climatic driver impacts result from ongoing climate change impacts and can be grouped into three categories: direct, indirect, and diffuse. 13 , 26 , 27 Methods A Systematic Quantitative Literature Review (SQLR) was conducted to assess the state of knowledge in the literature and address the research questions. The SQLR was chosen due to its rigorous and transparent approach. 28 By quantitatively synthesizing data across studies, the SQLR systematically analyzes patterns, trends, and consistencies within the research topic and provides a comprehensive analysis across relevant disciplines, enhancing the credibility of the conclusions and contributing robust evidence to the research field. 28 The SQLR search strategy involved structuring the literature review using the three-circle diagram developed by Pickering. 29 This diagram was used to determine how this research’s broad discipline areas fit together to prioritize the relevance of papers to the research questions (Fig. 2 ). As shown in Fig. 1 , this systematic literature review will encompass a mix of two disciplines, climate change and public health, focusing on Fiji's geographical scope. Synthesizing these different research domains will highlight knowledge gaps in assessing climate risks to the Fijian healthcare infrastructure. The SQLR followed the protocols of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. 30 After 48 trial searches with different combinations of key search terms and databases, Scholarly electronic databases were searched to identify original research papers published in English journals. These databases included Scopus, PubMed, Science Direct, and Google Scholar. Databases were searched between October 2023 and May 2024. Keywords combined and used for the search included: ‘climatic impact drivers,’ ‘climate change,’ ‘climate risks,’ ‘climate vulnerability,’ ‘Extreme weather events,’ ‘Fiji,’ and ‘Pacific Islands.’ Other terms searched were ‘Healthcare impacts’ and ‘Healthcare infrastructure.’ Additional papers were identified from the reference list of those research papers found through the database search. Furthermore, the authors decided to remove all literature reviews from the screened record to focus on empirical research conducted to assess climate risks and impacts on healthcare infrastructure in Fiji. The articles were selected for their relevance and focus on Climate impacts in Fiji and healthcare infrastructure (Fig. 1 ). Articles discussing the same topic in a different country context were removed from the study, as well as articles discussing climate impact on healthcare in general and, therefore, not focusing on infrastructure. This selection process led to a shortlist of 25 papers, all fitting into the central category from the three-circle diagram (Fig. 1 ). Data from the selected papers was extracted and classified by themes through a coding process. 31 A comprehensive codebook was developed to support the coding and guide content analysis (Appendix A). This coding process identified categories representing key themes to be analysed using the study's findings. The categories were then input into the NVivo qualitative analysis software to code the final sample of papers. The codebook categories were then continuously updated through the coding process. This included revising and expanding/merging categories to capture patterns and nuances in the data and ensure the relevance and adaptability of the codebook. From each original research paper, the following ten items of information were recorded in a Microsoft Excel spreadsheet: (i) author(s), (ii) journal, (iii) year of publication, (iv) study location, (v) Geographical origin of the study, (vi) Disciplines, (vii) research methodology, (viii) Type of climatic driver impacts studied, (ix) Healthcare domains and (x) Location of the impacts in Fiji. Each paper was classified based on the research methods used. These included quantitative methods (e.g., surveys and modeling), social science methods (e.g., interviews, questionnaires, focus groups, and ethnographic methods), and mixed methods (e.g., a combination of experiments, interviews, questionnaires, and surveys). Information on Climate change impacts on Fijian healthcare infrastructure was extracted from each paper and assigned to relevant categories and sub-categories. For direct impacts, the sub-categories were related to Sea level rise, extreme weather events, and heat-related diseases. For indirect impacts, the sub-categories were related to precipitation variability, change in disease vectors, and disruption of food and water resources. Each sub-category was also coded depending on the impacts on relevant health infrastructure components: facilities, human resources, equipment and supplies, and community-based healthcare. Results A total of 25 original, peer-reviewed research papers on Climate risks to healthcare infrastructure in Fiji were identified (Fig. 2 ). Reflecting the trans-disciplinary interest in this topic, papers were published in 22 journals spanning a small range of disciplines (Table 1 ). Two dominant fields were climate change/environment and public health. Just over 52% of the papers were published in Climate Change/Environment journals, with 6 (24%) published in Public Health journals. Four different publishers published five book chapters. The books are all related to environmental sciences but are not accounted for in the results as this only looks at scientific journal disciplines. One article only was published in a medicine/epidemiology journal. Table 1 Discipline of the 25 research papers assessed in this study. Discipline Journal titles n of Papers Environment and Ecology (13) Climate and Development 1 Climatic Change 2 Environment and Urbanization 1 Environmental Health Perspectives 2 Extreme Weather Events and Human Health 1 Frontiers Climate 1 Nature Climate Change 1 Population and Environment 1 Regional Environmental Change 1 Sustainability 1 Wildlife Conservation Society 1 Public Health (6) Fiji Journal of Public Health 1 Globalization and Health 1 Health Services Insights 1 Human Resources for Health 1 International Journal of Environmental Research and Public Health 1 International Journal of Health Policy and Management 1 Epidemiology (1) Prehospital and Disaster Medicine 1 Other (Book publishers) (5) Gottingen University Press 1 Springer editions 2 Taylor & Francis 1 World Resources Institute 1 The earliest research paper selected in the screening process was published in Prehospital and disaster medicine. Since 2016, research on Climate risks to health infrastructure in Fiji has progressed, with 32% of papers published between 2016 and 2019 and 48% from 2019 to 2024 (Fig. 3 ). From 2020 to 2021 alone, nine papers were published (36%). This number coincides with several relevant recommendations, action plans, and frameworks from the Fijian government and international institutions (WHO) on the impacts of climate change on healthcare infrastructure and the need for resilience and emergency preparedness. 13 , 18 , 25 , 32 , 33 Geographic distribution of studies Climate change impacts in Fiji have attracted diverse scholarly interest from different geographic locations. Research has predominantly originated from Australia (56% of papers) and Fiji (24% of papers). Four other countries account for 20% of the papers. Regarding locations studied, 21 articles (84%) specifically studied the climate risks for healthcare infrastructure in Fiji. Four articles (16%) focused on Pacific Island Nations in general, including Fiji. Methods used A wide range of methods have been used to assess climate risks on Fijian healthcare infrastructure. The review only focuses on empirical research methods and has excluded reviews. Seven articles conducted Risk assessments, seven conducted vulnerability assessments, six papers developed impact assessments, and four developed climate-related frameworks (Table 2 ). Table 2 Approaches used in the 25 research papers examined in this study. Approaches n of papers Risk assessments 7 Vulnerability assessments 7 Impact assessments 6 Frameworks 4 Other 1 Total 25 By mainly using interviews and focus groups, 16 papers chose qualitative data collection tools to create qualitative assessments of risks and vulnerabilities or frameworks (Table 3 ). Modeling and GIS were also commonly used in assessments, often combined with qualitative methods (Table 3 ). In total, 12 articles employed qualitative methods, eight only used quantitative methods, and five used mixed methods. Traditional research methods, such as Talanoa, are underrepresented in the literature, comprising only 12% of the reviewed papers. Table 3 Details of research methods used in the 25 research papers examined in this study[1] . Details of the methods n Interviews / Focus groups 14 Modeling 8 GIS / Mapping 7 Questionnaires 3 Economic analysis 1 Decision Space Analysis 1 Ethnographic 1 [1] The number of methods used doesn’t add to the number of paper (25) because mixed methods were used, 8 articles reviewed employed interviews as well as GIS or modelling. Types of Climatic Driver Impacts to Healthcare Infrastructure in Fiji Extreme Weather Events had the highest representation (40%), including floods, tropical cyclones, sea level rise, and storm surges (Table 4 ). In addition, seven papers discussed a range of climatic driver impacts but prioritized extreme weather events. Two articles focused on floods, and two on rising sea levels and tropical cyclones (Table 4 ). Of the 25 articles, only two (8%) did not include Extreme weather events, instead focussing on vector-borne diseases and water stress. This shows the predominance of research conducted on direct impacts such as cyclones and floods, which is particularly relevant in the Fijian context, where the impacts of extreme weather events are consequent. Nevertheless, empirical research about indirect or diffuse climate impacts such as vector-borne diseases is lacking. Table 4 Types of climatic drivers assessed in the 25 research papers examined in this study. Type of climatic driver n of papers n (%) Extreme weather events 10 40.0 All 7 28.0 Floods 2 8.0 Sea level rise 2 8.0 Tropical cyclones 2 8.0 Water stress 1 4.0 Vector-borne diseases 1 4.0 Total 25 Healthcare infrastructure domains impacted by climatic driver impacts Most papers examined risks to infrastructure without clearly defining infrastructure domains. Several domains emerged from the literature. Facilities were present in 17 papers, followed by HR (16 papers), which were inseparable from facilities according to the literature (Table 5 ). Equipment and supplies were assessed regarding damages related to EWE and pressures on drug and water supplies. Community-based healthcare is an essential component of the healthcare infrastructure in Fiji and is specifically impacted by climate change. However, only ten articles mentioned it, with only four solely focusing on it. In conclusion, most articles focused on Extreme Weather Events' impacts on facilities and humans. This follows the recommendations from international institutions such as the WHO and the local reality of climate change impacts on Fijian healthcare infrastructure. Table 5 Health infrastructure domains studied in the 25 research papers examined in this study. Infrastructure domain studied n of papers Facilities 17 Human resources 16 Equipment and supplies 10 Community-based healthcare 10 Locating risks in Fiji Fiji's cyclone and flood risk hotspots are mainly found in coastal and island regions and lowlands. Viti Levu is the central Island and gathers 75% of Fiji’s population. 4 About 14 papers (56%) focused on coastal Viti Levu, with an essential concentration of papers studying multiple coastal locations (28%) and four papers focusing on Suva, the capital city. Seven papers (28%) researched national climate risks to healthcare infrastructure (Table 7 ), but the articles all prioritize coastal areas and low-lying islands in their assessment. Only three articles (Table 6 ) discussed climate impacts on healthcare infrastructure in remote or inland areas. Only one paper focused on research outside of Viti Levu's main island. Table 6 Locating climatic impacts on healthcare infrastructure in Fiji. Location Precisions n of papers Coastal Viti Levu (14) Nadi (1) 1 Multiple coastal locations in Viti Levu (7) 7 Ba (1) 1 Suva and Rewa Delta (4) 4 Lautoka - west Fiji (1) 1 Vunidogoloa - North (1) 1 All Fiji (7) Papers examining risks nationally 7 Inland Viti Levu (3) Remote and Inland Viti Levu 3 Taveuni Island (1) Coastal - not in Viti Levu 1 Definition and usage of the term ‘risk’ in the literature In total, 22 papers discussed climate risks to health— 3 did not because they solely focused on vulnerabilities or impacts to specific infrastructure domains. The IPCC, per their guidance on climate risk for authors, describes two ways to appropriately use the term risk and three incorrect uses of the term risk (“Some DOs and DONTs”). 22 Eleven articles followed the first DO correctly, and eleven did not (Table 7 ). For criteria 2, 14 papers (56%) accurately followed the IPCC recommendation, and eight did not. In terms of ‘DONTs,’ 12 papers correctly followed the first recommendation. In comparison, ten articles did not. 14 papers respected the second recommendation not to use risk to describe hazards, but eight did not (Table 7 ). The most respected guideline was the last recommendation not to use risk as a generic term for anything bad happening in the future (76%). By looking into how the authors described, defined, and used the term risk in the literature, seven papers (28%) followed the IPCC definitions and recommendations, and only these seven papers defined the term risk. Five papers did not follow the IPCC risk guide but used the term correctly and did not use it interchangeably. Finally, ten papers did not follow the IPCC risk guide, did not define risk, and used risk incorrectly and interchangeably. Table 7 IPCC risk guidance for authors' criteria following rate in the 25 papers reviewed. 22 n of papers following the 5 IPCC ‘DOs and DON’Ts’ on using Risk Do use risk where you are explicitly considering potential adverse consequences and the uncertainty relating to those consequences Do use risk to improve the ability for decision-makers to understand and manage risk Don’t use risk as a simple substitute for probability/chance Don’t use risk to describe physical hazards Don’t use risk as a generic term for ‘anything bad that may happen in future’ aligns with 11 14 12 14 19 Does not align with 11 8 10 8 3 NA 3 3 3 3 3 Table 8 Climate Change exposure pathways, impacts, and risks to healthcare infrastructure in Fiji. Healthcare Infrastructure Exposure pathways Healthcare infrastructure impact and risks Facilities Sea level rise Damage to facilities, interruption of health services Extreme weather events Damage to facilities, interruption of health services Human Resources Extreme weather events Hospital pressure, interruption of health services, mobility disruption Change in disease vectors Hospital pressure Increased extreme heat and heat-related illnesses Hospital pressure, disruption of food and water resources Equipment & Supplies Extreme weather events Disruption of the pharmaceutical supply chain, destruction of equipment Extreme heat Drug and vaccine storage disruption Discussion A limited geographical scope This study systematically reviews the literature on climate impacts on the Fijian healthcare infrastructure and emphasizes the need for more localized case studies. Over 70% of the papers examined focus on Viti Levu, which is understandable given its concentration of risk factors, including a dense population, significant vulnerability to extreme weather events, and the highest proportion of infrastructure. 34 However, other areas, such as Vanua Levu and Kadavu Island, are even more susceptible to climate change, with minimal capacity for local infrastructure development. 35 , 36 This dominating focus on coastal and central areas can be explained by the fact that it is more accessible and relevant regarding risks, infrastructure domains, and population impacts. 37 , 38 , 39 The literature also indicates that the two main areas of concern include coastal and low-lying islands, which are highly vulnerable to cyclones and flooding, and densely populated coastal regions, such as the Suva-Nausori region on the island of Viti Levu, which are particularly at risk from cyclones and flooding. 39 , 40 , 41 Storms and flooding often affect these areas during the cyclone season. 27 , 33 The WHO recommends that research on risks, vulnerabilities, and impacts on healthcare infrastructure should address these other critical locations in Fiji to build climate-resilient healthcare systems. 42 , 43 , 44 Community-based research and traditional research methods Community-based studies are challenging to implement in Fiji but could provide essential insights. 45 , 46 Traditional research methods, such as Talanoa, are underrepresented in the literature, comprising only 12% of the reviewed papers. Notably, 60% of the articles originate from Australia, the closest central research hub to Fiji. The small number of traditional research methods present in the research surrounding climate-induced impacts on Fijian healthcare is concerning. Indeed, the research could lack community-based results, leading to Fijian stakeholders' and participants' mistrust in a country where foreign researchers are sometimes seen as outsiders. 46 , 47 , 48 , 49 , 50 Research methods and conceptual approaches Most papers rely on qualitative methods to gather information from local stakeholders about their climate vulnerabilities, risks, or impacts. There is an opportunity to model vulnerabilities, impacts, and solutions such as mitigation or adaptation strategies. 25 , 51 , 52 , 53 Literature reviews on this topic tend to be too broadly framed regarding geographical scope—often investigating global or regional contexts—and focus on studying healthcare systems rather than explicitly addressing infrastructure. As a result, this study excluded literature reviews from the analysis and concentrated on empirical case studies. Limits in the diversity of disciplines studying impacts and risks of Fijian healthcare. Additionally, various disciplines need to engage in researching this topic. Climate change affects a broad spectrum of areas, including medical issues such as changes in vector-borne diseases, heat waves, and mosquito-borne illnesses. 7 , 54 Only one reviewed article thoroughly examined changes in disease patterns affecting infrastructure. Greater attention must be directed towards understanding the impacts of climate hazard exposure on healthcare infrastructure in Fiji from a medical perspective. 14 , 27 , 55 , 56 Moreover, climate change has financial implications for healthcare infrastructure, causing damage to facilities and equipment and disrupting supplies and medical activities. 57 , 58 Despite this, only one economic analysis was found in the reviewed articles. Considering financial climate risks presents opportunities such as enhancing capacity building, implementing nature-based solutions, and mitigating climate change, often accompanied by valuable co-benefits; there is an opportunity for positive, impactful research. 59 , 60 Non-climatic exposure pathways Most of the literature studied did not research non-climatic exposure pathways; nevertheless, a lot of non-climatic risks for healthcare infrastructure in Fiji can be increased by Climate Change or could become barriers when trying to build resilience. 61 , 62 In Fiji, one of the main issues with healthcare infrastructure is the lack of capacity building. 63 , 64 At least six non-climatic triggers limit capacity building in the healthcare infrastructure in Fiji. Financial constraints, including limited funding, restrict the healthcare system’s ability to invest in infrastructure, equipment, and personnel. 65 , 66 Much of the healthcare funding comes from international aid and donations, which can be unpredictable and not always aligned with local priorities. 8 , 65 Geographical challenges also play a significant role. Fiji consists of over 300 islands, many remote and hard to reach. This geographical spread complicates the delivery of healthcare services and the construction of healthcare facilities. 8 , 67 Human resources issues include a significant shortage of trained healthcare professionals, such as doctors, nurses, and specialists. 68 , 69 This shortage is exacerbated by the migration of skilled workers to countries with better opportunities and working conditions. 9 Limited local training facilities and programs contribute to the shortage, and the healthcare system struggles to retain trained professionals due to inadequate salaries and working conditions. 8 , 69 Policy and governance issues also contribute to the lack of capacity building. There is often a lack of comprehensive long-term planning and effective policy implementation to address the population's healthcare needs, leading to misallocation of resources and insufficient attention to preventive care. 64 , 70 Technological and infrastructure deficits are another significant factor. Many healthcare facilities are outdated and lack modern medical equipment. Due to financial constraints, the maintenance and upgrade of these facilities are often neglected. 71 , 72 , 73 Socioeconomic factors, including high levels of poverty and inequality, impact the population's health outcomes and place additional burdens on the healthcare system. 8 , 74 , 75 These non-climatic exposure pathways must be more present in the scientific literature, especially in vulnerability and risk assessments. The distinction between the different types of climate-induced impacts and the need to follow consensual definitions One of the challenges in the scientific literature is that climate-induced impacts on healthcare infrastructure are often indirect consequences of exposure to climate hazards on health. 1 , 21 , 76 , 77 Some studies focus on the direct impacts of cyclones and floods on facilities, equipment, and human resources. In contrast, others examine the indirect pressure on non-resilient infrastructure resulting from climate impacts on health. 78 , 79 There is a need to quantify and model this distinction and to find innovative solutions. 57 , 80 , 81 Moreover, the definitions of climate impacts/risks and healthcare infrastructure are inconsistent. Most papers use internationally recognized definitions, but some still need to be more specific. 22 The IPCC has asked the scientific community to follow its guidelines and definitions on using the terms risk, vulnerability, or impact; it must be said that a minority of papers reviewed wholly followed these guidelines. 3 , 22 , 24 Therefore, it adds to the confusion in the area, creating multiple notions and definitions of risks that do not have a consensus. This creates several problems, such as the low quantity and quality of systematic reviews in the field, the confusion of empirical research on the terms used, and the difficulty of adequately scanning the scientific literature on the subject. This could also impact inter-disciplinary collaboration. The need for healthcare infrastructure resilience Finally, international institutions, such as the UNDRR or the WHO, as well as the governments of Fiji and many other PINs, have called for more research on building resilience pathways to healthcare infrastructure. Analysing and modelling vulnerabilities, exposure, and upstream determinants of climate change impacts and risks to healthcare infrastructure are essential to developing research and precise solutions to this problem. 81 , 82 , 83 , 84 , 85 The literature also points out the importance of healthcare resilience in the light of planned relocation in Fiji. 86 , 87 , 88 Conclusions This review highlights the substantial vulnerabilities and risks that climate change poses to Fiji's healthcare infrastructure, particularly due to extreme weather events like floods and tropical cyclones. The findings emphasize the predominance of research on direct impacts, such as damage to facilities and human resources, with coastal Viti Levu being the most frequently studied location. However, there is a critical need for more localized studies, especially in less-researched areas like Vanua Levu and Kadavu Island, to build comprehensive climate resilience. Future research should also engage a broader range of disciplines, including epidemiology and economics, to address the diverse impacts of climate change on healthcare systems. Strengthening Fiji's healthcare infrastructure against climate risks is essential for ensuring the health and well-being of its population in the face of ongoing climate challenges. Declarations Acknowledgments The authors’ contributions to this work were as follows. TD., conceptualization, methodology, data curation, formal analysis, investigation, data curation, writing – original draft, writing – review and editing, and visualization. KJ., supervision, writing, review, and editing. NJ., supervision, writing, review, and editing. RR., supervision, writing, review, and editing. PD., conceptualization, and supervision. This research was supported by The University of Queensland. 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International journal of environmental research and public health, 11(12), 13097–13116. https://pubmed.ncbi.nlm.nih.gov/25522050/ DOI: 10.3390/ijerph111213097 McMichael, Celia, and Teresia Powell. "Planned relocation and health: a case study from Fiji." International Journal of Environmental Research and Public Health 18.8 (2021): 4355. https://pubmed.ncbi.nlm.nih.gov/33923978/ DOI: 10.3390/ijerph18084355 McNamara, K. E., & Prasad, S. S. (2014). Coping with extreme weather: communities in Fiji and Vanuatu share their experiences and knowledge. Climatic change, 123, 121–132. https://www.researchgate.net/publication/272018933_Coping_with_extreme_weather_Communities_in_Fiji _and_Vanuatu_share_their_experiences_and_knowledge DOI: 10.1007/s10584-013-1047-2 Oakes, R. (2019). Culture, climate change and mobility decisions in Pacific Small Island Developing States. Population and Environment, 40, 480–503. https://www.researchgate.net/publication/333164475_Culture_climate_change_and_mobility_decisions_in_ Pacific_Small_Island_Developing_States DOI: 10.1007/s11111-019-00321-w Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5659753","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":391964840,"identity":"52a96a82-13b5-4c70-9ef2-6db9a4cd2170","order_by":0,"name":"Tom Deweerdt","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYHACAwh1gPkAiGJsIKSeB67lGFsCyVp4DIjTYs/AvPExT4VNPt/9nm8SbxhsZDccYH4mgd8WtmJjnjNpljOP8W6TnMOQZrzhAJsZAS08ZtK5bYcNDIBapHkYDiduOMBAUIv579x//4FaeJ4BtfwHamH/RtAW5tyGAyAtbEAtB4BaeAjYcpitWPrPsWQDyWNpxpZzDJKNZx7mKbbAp4W9vXnjxxk1dgZ8hw8/vPGmwk6273j7xhv4tDAwo9hpgC5CEPCQpHoUjIJRMApGCgAAsVBDhflpW80AAAAASUVORK5CYII=","orcid":"","institution":"University of Queensland","correspondingAuthor":true,"prefix":"","firstName":"Tom","middleName":"","lastName":"Deweerdt","suffix":""},{"id":391964841,"identity":"20d833ae-885d-4061-bde3-b220288e5fb9","order_by":1,"name":"Kelly R. Johnstone","email":"","orcid":"","institution":"University of Queensland","correspondingAuthor":false,"prefix":"","firstName":"Kelly","middleName":"R.","lastName":"Johnstone","suffix":""},{"id":391964842,"identity":"4e20f5d8-9f30-4388-b375-839f3657763d","order_by":2,"name":"Natalie A. Jones","email":"","orcid":"","institution":"University of Queensland","correspondingAuthor":false,"prefix":"","firstName":"Natalie","middleName":"A.","lastName":"Jones","suffix":""},{"id":391964844,"identity":"795b04db-79c4-4e29-a3e4-560b309f1096","order_by":3,"name":"Russell Richards","email":"","orcid":"","institution":"University of Queensland","correspondingAuthor":false,"prefix":"","firstName":"Russell","middleName":"","lastName":"Richards","suffix":""},{"id":391964845,"identity":"5fe1d718-8489-43dc-8ad9-88f349510e15","order_by":4,"name":"Paul Dargusch","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"","lastName":"Dargusch","suffix":""}],"badges":[],"createdAt":"2024-12-17 08:23:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5659753/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5659753/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":72037204,"identity":"4c533590-debf-4bb5-9bd0-8a1103f391db","added_by":"auto","created_at":"2024-12-21 00:14:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":345792,"visible":true,"origin":"","legend":"\u003cp\u003eThree-circles diagram for the SQLR search strategy\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5659753/v1/3fc2ac08b6685038b5f02920.png"},{"id":72037217,"identity":"fd4524a1-ac02-4404-a597-e711fa30f8a6","added_by":"auto","created_at":"2024-12-21 00:14:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":286257,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flow diagram\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5659753/v1/78acfacb08c65802533f4317.png"},{"id":72037208,"identity":"8a778ed6-a167-494e-8c65-e975d4f90097","added_by":"auto","created_at":"2024-12-21 00:14:07","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":37048,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of papers per year of publication.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5659753/v1/fff153df1bb19cb64d09be97.png"},{"id":72617213,"identity":"01e5f681-8bb4-4f5f-b5b5-7ac7f08700ae","added_by":"auto","created_at":"2024-12-30 11:38:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1582128,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5659753/v1/909ef9af-6e10-4027-8885-609a76debdeb.pdf"},{"id":72037205,"identity":"3d37b210-8ae9-4fe3-95d0-2cb2f07f8d7b","added_by":"auto","created_at":"2024-12-21 00:14:07","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":28777,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-5659753/v1/982295c9ed68e73f289415b2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Climate Change Impacts on Healthcare Infrastructure in Fiji: A Systematic Quantitative Literature Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eClimate change poses a considerable threat to the Pacific Islands, with rising temperatures, rising sea levels, extreme weather events (EWE), and changes in disease vectors increasing the vulnerability of population health and the region's healthcare systems.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The Pacific Islands region is highly susceptible to the adverse effects of climate change due to its unique geographical and environmental characteristics.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Comprising thousands of low-lying atolls, volcanic islands, and diverse ecosystems, these nations face various climate-related challenges. In particular, climate change in the Pacific Islands has been associated with a multitude of health vulnerabilities.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Rising air temperatures can increase cases of heat-related illness.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Changes in precipitation patterns and warmer waters can alter disease vectors, increasing the prevalence of diseases such as dengue fever and malaria.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Additionally, extreme weather events such as cyclones and typhoons can disrupt healthcare services, damage medical infrastructure, and lead to injury and trauma.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHealth systems in the Pacific Islands often face limited resources, insufficient and inadequate infrastructure, and shortages of medical human resources.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e The additional burden of climate-related health problems exacerbates these challenges.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e For example, the pressure on healthcare facilities during and after extreme weather events can overwhelm already fragile health systems in place.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Fiji is exceptionally prone to climate change impacts in the Pacific region, particularly its healthcare infrastructure.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e The country faces tropical cyclones and floods that damage infrastructure and disrupt healthcare delivery, such as Tropical Cyclone Winston in 2016.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e By being prone to climate change impacts, the Fijian healthcare infrastructure has been subject to several vulnerability and risk assessments, being the most researched location among the Pacific Islands Nations (PINs).\u003c/p\u003e \u003cp\u003eThis paper systematically analyses the literature to answer three research questions:\u003c/p\u003e \u003cp\u003e1: What empirical research has been completed on climate-driven hazards, exposure pathways, and vulnerabilities and their impacts on Fijian healthcare infrastructure?\u003c/p\u003e \u003cp\u003e2: According to the empirical research, what are the climate-driven hazards, exposure pathways, and vulnerabilities and their impacts on Fijian healthcare infrastructure?\u003c/p\u003e \u003cp\u003e3: What gaps exist in this empirical research?\u003c/p\u003e \u003cp\u003eThese research questions fill a gap in knowledge because no existing systematic review focuses on healthcare infrastructure and Climate Change in Fiji; current reviews have typically assessed climate impacts on healthcare in general and mention infrastructure in the process. This review aims to systematically examine specific empirical studies, such as those focused on risk, vulnerability, and impact assessments in the context of Fiji. Furthermore, this review responds to the WHO's call for more research on healthcare infrastructure in the Pacific, eventually leading to progress in building healthcare infrastructure capacity and climate resilience.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Indeed, by understanding climate change risks to healthcare infrastructure in Fiji, it is possible to enhance emergency preparedness and climate resilience locally and nationally, as well as in other locations that share similar characteristics.\u003c/p\u003e \u003cp\u003eThe paper begins by concisely defining the key terminology (‘Healthcare infrastructure, climate risks, vulnerability, exposure, and hazards') and then discusses the methods used in this study. The results of the systematic exploratory review of climate risks in healthcare infrastructure literature are then reported and discussed. Some suggestions are made for future research, and the paper concludes by identifying implications for healthcare resilience.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Definition of key terms","content":"\u003cp\u003eHealthcare Infrastructure\u003c/p\u003e\u003cp\u003eHealthcare infrastructure encompasses the individuals, facilities, and structures necessary for delivering high-quality healthcare services.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e This multifaceted concept includes the foundational elements of hospital operations, encompassing the physical structures and the ongoing maintenance needed to support healthcare delivery.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e However, the interpretation of healthcare infrastructure often varies depending on the observer's perspective.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e For instance, architects and engineers may view it primarily as the buildings and technical systems utilized in healthcare provision. In contrast, healthcare executives may emphasize the importance of the people and processes involved in delivering care. Ideally, healthcare infrastructure embodies a synthesis of these perspectives, drawing upon the expertise of diverse professionals and the effective coordination of facilities and support systems to ensure optimal healthcare delivery.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e In this study, healthcare infrastructure is thus defined as the physical and organizational structures, facilities, and systems that collectively support the delivery of healthcare services. The infrastructure domains studied in this review are facilities, human resources, equipment and supplies, and community-based healthcare.\u003c/p\u003e\u003cp\u003eClimate Change Risk, Vulnerability, Exposure, and Hazards.\u003c/p\u003e\u003cp\u003eThe IPCC concept of risk guidelines defines risk as: “\u003cem\u003eThe potential for adverse consequences for human or ecological systems, recognizing the diversity of values and objectives associated with such systems. In the context of climate change, risks can arise from potential impacts of climate change and human responses to climate change. Relevant adverse consequences include those on lives, livelihoods, health and wellbeing, economic, social and cultural assets and investments, infrastructure, services (including ecosystem services), ecosystems and species\u003c/em\u003e”.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAccording to the IPCC and the UNFCCC, vulnerability is “\u003cem\u003ethe degree to which a system is susceptible to, or unable to cope with, adverse effects of climate change, including climate variability and extremes\u003c/em\u003e”.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Exposure is defined in the same report as “\u003cem\u003eThe nature and degree to which a system is exposed to significant climatic variations\u003c/em\u003e”.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn the context of climate change impacts, risks result from dynamic interactions between climate-related hazards, such as extreme weather events, and the exposure and vulnerability of the affected human or ecological system to hazards.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn this review, the term risk will be used as recommended by the IPCC Working Group I. Therefore, in the context of climate change impacts, risk will be used as an umbrella term to represent the adverse consequences of climatic drivers on healthcare infrastructure.\u003c/p\u003e\u003cp\u003eHealthcare infrastructure systems in Fiji face several climate-induced impacts that can significantly affect their operations, such as tropical cyclones, floods, or changes in disease vectors. These climatic driver impacts result from ongoing climate change impacts and can be grouped into three categories: direct, indirect, and diffuse.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA Systematic Quantitative Literature Review (SQLR) was conducted to assess the state of knowledge in the literature and address the research questions. The SQLR was chosen due to its rigorous and transparent approach.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e By quantitatively synthesizing data across studies, the SQLR systematically analyzes patterns, trends, and consistencies within the research topic and provides a comprehensive analysis across relevant disciplines, enhancing the credibility of the conclusions and contributing robust evidence to the research field.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e The SQLR search strategy involved structuring the literature review using the three-circle diagram developed by Pickering.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e This diagram was used to determine how this research’s broad discipline areas fit together to prioritize the relevance of papers to the research questions (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e, this systematic literature review will encompass a mix of two disciplines, climate change and public health, focusing on Fiji's geographical scope. Synthesizing these different research domains will highlight knowledge gaps in assessing climate risks to the Fijian healthcare infrastructure.\u003c/p\u003e\u003cp\u003eThe SQLR followed the protocols of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e After 48 trial searches with different combinations of key search terms and databases, Scholarly electronic databases were searched to identify original research papers published in English journals. These databases included Scopus, PubMed, Science Direct, and Google Scholar. Databases were searched between October 2023 and May 2024. Keywords combined and used for the search included: ‘climatic impact drivers,’ ‘climate change,’ ‘climate risks,’ ‘climate vulnerability,’ ‘Extreme weather events,’ ‘Fiji,’ and ‘Pacific Islands.’ Other terms searched were ‘Healthcare impacts’ and ‘Healthcare infrastructure.’ Additional papers were identified from the reference list of those research papers found through the database search.\u003c/p\u003e\u003cp\u003eFurthermore, the authors decided to remove all literature reviews from the screened record to focus on empirical research conducted to assess climate risks and impacts on healthcare infrastructure in Fiji. The articles were selected for their relevance and focus on Climate impacts in Fiji and healthcare infrastructure (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Articles discussing the same topic in a different country context were removed from the study, as well as articles discussing climate impact on healthcare in general and, therefore, not focusing on infrastructure. This selection process led to a shortlist of 25 papers, all fitting into the central category from the three-circle diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eData from the selected papers was extracted and classified by themes through a coding process.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e A comprehensive codebook was developed to support the coding and guide content analysis (Appendix A). This coding process identified categories representing key themes to be analysed using the study's findings. The categories were then input into the NVivo qualitative analysis software to code the final sample of papers. The codebook categories were then continuously updated through the coding process. This included revising and expanding/merging categories to capture patterns and nuances in the data and ensure the relevance and adaptability of the codebook.\u003c/p\u003e\u003cp\u003eFrom each original research paper, the following ten items of information were recorded in a Microsoft Excel spreadsheet: (i) author(s), (ii) journal, (iii) year of publication, (iv) study location, (v) Geographical origin of the study, (vi) Disciplines, (vii) research methodology, (viii) Type of climatic driver impacts studied, (ix) Healthcare domains and (x) Location of the impacts in Fiji.\u003c/p\u003e\u003cp\u003eEach paper was classified based on the research methods used. These included quantitative methods (e.g., surveys and modeling), social science methods (e.g., interviews, questionnaires, focus groups, and ethnographic methods), and mixed methods (e.g., a combination of experiments, interviews, questionnaires, and surveys).\u003c/p\u003e\u003cp\u003eInformation on Climate change impacts on Fijian healthcare infrastructure was extracted from each paper and assigned to relevant categories and sub-categories. For direct impacts, the sub-categories were related to Sea level rise, extreme weather events, and heat-related diseases. For indirect impacts, the sub-categories were related to precipitation variability, change in disease vectors, and disruption of food and water resources. Each sub-category was also coded depending on the impacts on relevant health infrastructure components: facilities, human resources, equipment and supplies, and community-based healthcare.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 25 original, peer-reviewed research papers on Climate risks to healthcare infrastructure in Fiji were identified (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Reflecting the trans-disciplinary interest in this topic, papers were published in 22 journals spanning a small range of disciplines (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Two dominant fields were climate change/environment and public health. Just over 52% of the papers were published in Climate Change/Environment journals, with 6 (24%) published in Public Health journals. Four different publishers published five book chapters. The books are all related to environmental sciences but are not accounted for in the results as this only looks at scientific journal disciplines. One article only was published in a medicine/epidemiology journal.\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\u003eDiscipline of the 25 research papers assessed in this study.\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscipline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJournal titles\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e of Papers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnvironment and Ecology (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClimate and Development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eClimatic Change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \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\u003eEnvironment and Urbanization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eEnvironmental Health Perspectives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \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\u003eExtreme Weather Events and Human Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eFrontiers Climate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eNature Climate Change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003ePopulation and Environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eRegional Environmental Change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eSustainability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eWildlife Conservation Society\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic Health (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFiji Journal of Public Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eGlobalization and Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eHealth Services Insights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eHuman Resources for Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eInternational Journal of Environmental Research and Public Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eInternational Journal of Health Policy and Management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpidemiology (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrehospital and Disaster Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther (Book publishers) (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGottingen University Press\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eSpringer editions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \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\u003eTaylor \u0026amp; Francis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eWorld Resources Institute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\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\u003eThe earliest research paper selected in the screening process was published in Prehospital and disaster medicine. Since 2016, research on Climate risks to health infrastructure in Fiji has progressed, with 32% of papers published between 2016 and 2019 and 48% from 2019 to 2024 (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e). From 2020 to 2021 alone, nine papers were published (36%). This number coincides with several relevant recommendations, action plans, and frameworks from the Fijian government and international institutions (WHO) on the impacts of climate change on healthcare infrastructure and the need for resilience and emergency preparedness. \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eGeographic distribution of studies\u003c/h2\u003e \u003cp\u003eClimate change impacts in Fiji have attracted diverse scholarly interest from different geographic locations. Research has predominantly originated from Australia (56% of papers) and Fiji (24% of papers). Four other countries account for 20% of the papers.\u003c/p\u003e \u003cp\u003eRegarding locations studied, 21 articles (84%) specifically studied the climate risks for healthcare infrastructure in Fiji. Four articles (16%) focused on Pacific Island Nations in general, including Fiji.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMethods used\u003c/h3\u003e\n\u003cp\u003eA wide range of methods have been used to assess climate risks on Fijian healthcare infrastructure. The review only focuses on empirical research methods and has excluded reviews. Seven articles conducted Risk assessments, seven conducted vulnerability assessments, six papers developed impact assessments, and four developed climate-related frameworks (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\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\u003eApproaches used in the 25 research papers examined in this study.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApproaches\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en of papers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk assessments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVulnerability assessments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpact assessments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrameworks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\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\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\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\u003eBy mainly using interviews and focus groups, 16 papers chose qualitative data collection tools to create qualitative assessments of risks and vulnerabilities or frameworks (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Modeling and GIS were also commonly used in assessments, often combined with qualitative methods (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In total, 12 articles employed qualitative methods, eight only used quantitative methods, and five used mixed methods. Traditional research methods, such as Talanoa, are underrepresented in the literature, comprising only 12% of the reviewed papers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDetails of research methods used in the 25 research papers examined in this study[1]\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDetails of the methods\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterviews / Focus groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModeling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGIS / Mapping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestionnaires\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEconomic analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecision Space Analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnographic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\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\u003csup\u003e\u003csup\u003e[1]\u003c/sup\u003e\u003c/sup\u003e The number of methods used doesn\u0026rsquo;t add to the number of paper (25) because mixed methods were used, 8 articles reviewed employed interviews as well as GIS or modelling.\u0026nbsp;\u003c/p\u003e\n\n\u003ch3\u003eTypes of Climatic Driver Impacts to Healthcare Infrastructure in Fiji\u003c/h3\u003e\n\u003cp\u003eExtreme Weather Events had the highest representation (40%), including floods, tropical cyclones, sea level rise, and storm surges (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). In addition, seven papers discussed a range of climatic driver impacts but prioritized extreme weather events. Two articles focused on floods, and two on rising sea levels and tropical cyclones (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Of the 25 articles, only two (8%) did not include Extreme weather events, instead focussing on vector-borne diseases and water stress. This shows the predominance of research conducted on direct impacts such as cyclones and floods, which is particularly relevant in the Fijian context, where the impacts of extreme weather events are consequent. Nevertheless, empirical research about indirect or diffuse climate impacts such as vector-borne diseases is lacking.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTypes of climatic drivers assessed in the 25 research papers examined in this study.\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=\"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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eType of climatic driver\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003en\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eof papers\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003en\u003c/span\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\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eExtreme weather events\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAll\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFloods\u003c/span\u003e\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\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSea level rise\u003c/span\u003e\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\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTropical cyclones\u003c/span\u003e\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\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eWater stress\u003c/span\u003e\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\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eVector-borne diseases\u003c/span\u003e\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\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eHealthcare infrastructure domains impacted by climatic driver impacts\u003c/h3\u003e\n\u003cp\u003eMost papers examined risks to infrastructure without clearly defining infrastructure domains. Several domains emerged from the literature. Facilities were present in 17 papers, followed by HR (16 papers), which were inseparable from facilities according to the literature (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Equipment and supplies were assessed regarding damages related to EWE and pressures on drug and water supplies. Community-based healthcare is an essential component of the healthcare infrastructure in Fiji and is specifically impacted by climate change. However, only ten articles mentioned it, with only four solely focusing on it.\u003c/p\u003e \u003cp\u003eIn conclusion, most articles focused on Extreme Weather Events' impacts on facilities and humans. This follows the recommendations from international institutions such as the WHO and the local reality of climate change impacts on Fijian healthcare infrastructure.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHealth infrastructure domains studied in the 25 research papers examined in this study.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eInfrastructure domain studied\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003en\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eof papers\u003c/span\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\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFacilities\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eHuman resources\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEquipment and supplies\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCommunity-based healthcare\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eLocating risks in Fiji\u003c/h3\u003e\n\u003cp\u003eFiji's cyclone and flood risk hotspots are mainly found in coastal and island regions and lowlands. Viti Levu is the central Island and gathers 75% of Fiji\u0026rsquo;s population.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e About 14 papers (56%) focused on coastal Viti Levu, with an essential concentration of papers studying multiple coastal locations (28%) and four papers focusing on Suva, the capital city. Seven papers (28%) researched national climate risks to healthcare infrastructure (Table \u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e), but the articles all prioritize coastal areas and low-lying islands in their assessment. Only three articles (Table \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e) discussed climate impacts on healthcare infrastructure in remote or inland areas. Only one paper focused on research outside of Viti Levu's main island.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLocating climatic impacts on healthcare infrastructure in Fiji.\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eLocation\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePrecisions\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan type=\"ItalicSmallCaps\" class=\"ItalicSmallCaps\" name=\"Emphasis\"\u003en\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eof papers\u003c/span\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\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCoastal Viti Levu\u003c/span\u003e (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNadi (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eMultiple coastal locations in Viti Levu (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \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\u003eBa (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eSuva and Rewa Delta (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \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\u003eLautoka - west Fiji (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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\u003eVunidogoloa - North (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAll Fiji (7)\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePapers examining risks nationally\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eInland Viti Levu\u003c/span\u003e (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRemote and Inland Viti Levu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTaveuni Island\u003c/span\u003e (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoastal - not in Viti Levu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDefinition and usage of the term \u0026lsquo;risk\u0026rsquo; in the literature\u003c/h2\u003e \u003cp\u003eIn total, 22 papers discussed climate risks to health\u0026mdash; 3 did not because they solely focused on vulnerabilities or impacts to specific infrastructure domains.\u003c/p\u003e \u003cp\u003eThe IPCC, per their guidance on climate risk for authors, describes two ways to appropriately use the term risk and three incorrect uses of the term risk (\u0026ldquo;Some DOs and DONTs\u0026rdquo;).\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Eleven articles followed the first DO correctly, and eleven did not (Table \u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). For criteria 2, 14 papers (56%) accurately followed the IPCC recommendation, and eight did not. In terms of \u0026lsquo;DONTs,\u0026rsquo; 12 papers correctly followed the first recommendation. In comparison, ten articles did not. 14 papers respected the second recommendation not to use risk to describe hazards, but eight did not (Table \u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). The most respected guideline was the last recommendation not to use risk as a generic term for anything bad happening in the future (76%).\u003c/p\u003e \u003cp\u003eBy looking into how the authors described, defined, and used the term risk in the literature, seven papers (28%) followed the IPCC definitions and recommendations, and only these seven papers defined the term risk. Five papers did not follow the IPCC risk guide but used the term correctly and did not use it interchangeably. Finally, ten papers did not follow the IPCC risk guide, did not define risk, and used risk incorrectly and interchangeably.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIPCC risk guidance for authors' criteria following rate in the 25 papers reviewed.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"char\" char=\".\" 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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e of papers following the 5 IPCC \u0026lsquo;DOs and DON\u0026rsquo;Ts\u0026rsquo; on using Risk\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo use risk where you are explicitly considering potential adverse consequences and the uncertainty relating to those consequences\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDo use risk to improve the ability for decision-makers to understand and manage risk\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDon\u0026rsquo;t use risk as a simple substitute for probability/chance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDon\u0026rsquo;t use risk to describe physical hazards\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDon\u0026rsquo;t use risk as a generic term for \u0026lsquo;anything bad that may happen in future\u0026rsquo;\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ealigns with\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes not align with\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\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\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\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\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\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 \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClimate Change exposure pathways, impacts, and risks to healthcare infrastructure in Fiji.\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\u003eHealthcare Infrastructure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExposure pathways\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealthcare infrastructure impact and risks\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFacilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSea level rise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDamage to facilities, interruption of health services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExtreme weather events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDamage to facilities, interruption of health services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eHuman Resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExtreme weather events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital pressure, interruption of health services, mobility disruption\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChange in disease vectors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital pressure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncreased extreme heat and heat-related illnesses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital pressure, disruption of food and water resources\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEquipment \u0026amp; Supplies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExtreme weather events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDisruption of the pharmaceutical supply chain, destruction of equipment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExtreme heat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDrug and vaccine storage disruption\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eA limited geographical scope\u003c/h2\u003e \u003cp\u003eThis study systematically reviews the literature on climate impacts on the Fijian healthcare infrastructure and emphasizes the need for more localized case studies. Over 70% of the papers examined focus on Viti Levu, which is understandable given its concentration of risk factors, including a dense population, significant vulnerability to extreme weather events, and the highest proportion of infrastructure.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e However, other areas, such as Vanua Levu and Kadavu Island, are even more susceptible to climate change, with minimal capacity for local infrastructure development.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e This dominating focus on coastal and central areas can be explained by the fact that it is more accessible and relevant regarding risks, infrastructure domains, and population impacts.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e The literature also indicates that the two main areas of concern include coastal and low-lying islands, which are highly vulnerable to cyclones and flooding, and densely populated coastal regions, such as the Suva-Nausori region on the island of Viti Levu, which are particularly at risk from cyclones and flooding.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e,\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e Storms and flooding often affect these areas during the cyclone season.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e The WHO recommends that research on risks, vulnerabilities, and impacts on healthcare infrastructure should address these other critical locations in Fiji to build climate-resilient healthcare systems.\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e,\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e,\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCommunity-based research and traditional research methods\u003c/h2\u003e \u003cp\u003eCommunity-based studies are challenging to implement in Fiji but could provide essential insights.\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e,\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e Traditional research methods, such as Talanoa, are underrepresented in the literature, comprising only 12% of the reviewed papers. Notably, 60% of the articles originate from Australia, the closest central research hub to Fiji. The small number of traditional research methods present in the research surrounding climate-induced impacts on Fijian healthcare is concerning. Indeed, the research could lack community-based results, leading to Fijian stakeholders' and participants' mistrust in a country where foreign researchers are sometimes seen as outsiders.\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e,\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e,\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e,\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eResearch methods and conceptual approaches\u003c/h2\u003e \u003cp\u003eMost papers rely on qualitative methods to gather information from local stakeholders about their climate vulnerabilities, risks, or impacts. There is an opportunity to model vulnerabilities, impacts, and solutions such as mitigation or adaptation strategies.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e,\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e,\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e Literature reviews on this topic tend to be too broadly framed regarding geographical scope\u0026mdash;often investigating global or regional contexts\u0026mdash;and focus on studying healthcare systems rather than explicitly addressing infrastructure. As a result, this study excluded literature reviews from the analysis and concentrated on empirical case studies.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimits in the diversity of disciplines studying impacts and risks of Fijian healthcare.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAdditionally, various disciplines need to engage in researching this topic. Climate change affects a broad spectrum of areas, including medical issues such as changes in vector-borne diseases, heat waves, and mosquito-borne illnesses.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e Only one reviewed article thoroughly examined changes in disease patterns affecting infrastructure. Greater attention must be directed towards understanding the impacts of climate hazard exposure on healthcare infrastructure in Fiji from a medical perspective.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e,\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e Moreover, climate change has financial implications for healthcare infrastructure, causing damage to facilities and equipment and disrupting supplies and medical activities.\u003csup\u003e\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e,\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e Despite this, only one economic analysis was found in the reviewed articles. Considering financial climate risks presents opportunities such as enhancing capacity building, implementing nature-based solutions, and mitigating climate change, often accompanied by valuable co-benefits; there is an opportunity for positive, impactful research.\u003csup\u003e\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e,\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eNon-climatic exposure pathways\u003c/h2\u003e \u003cp\u003eMost of the literature studied did not research non-climatic exposure pathways; nevertheless, a lot of non-climatic risks for healthcare infrastructure in Fiji can be increased by Climate Change or could become barriers when trying to build resilience.\u003csup\u003e\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e,\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e In Fiji, one of the main issues with healthcare infrastructure is the lack of capacity building.\u003csup\u003e\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e,\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e At least six non-climatic triggers limit capacity building in the healthcare infrastructure in Fiji. Financial constraints, including limited funding, restrict the healthcare system\u0026rsquo;s ability to invest in infrastructure, equipment, and personnel.\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e Much of the healthcare funding comes from international aid and donations, which can be unpredictable and not always aligned with local priorities.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e Geographical challenges also play a significant role. Fiji consists of over 300 islands, many remote and hard to reach. This geographical spread complicates the delivery of healthcare services and the construction of healthcare facilities.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHuman resources issues include a significant shortage of trained healthcare professionals, such as doctors, nurses, and specialists.\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e This shortage is exacerbated by the migration of skilled workers to countries with better opportunities and working conditions.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Limited local training facilities and programs contribute to the shortage, and the healthcare system struggles to retain trained professionals due to inadequate salaries and working conditions.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e Policy and governance issues also contribute to the lack of capacity building. There is often a lack of comprehensive long-term planning and effective policy implementation to address the population's healthcare needs, leading to misallocation of resources and insufficient attention to preventive care.\u003csup\u003e\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e,\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTechnological and infrastructure deficits are another significant factor. Many healthcare facilities are outdated and lack modern medical equipment. Due to financial constraints, the maintenance and upgrade of these facilities are often neglected.\u003csup\u003e\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e Socioeconomic factors, including high levels of poverty and inequality, impact the population's health outcomes and place additional burdens on the healthcare system.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e,\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThese non-climatic exposure pathways must be more present in the scientific literature, especially in vulnerability and risk assessments.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe distinction between the different types of climate-induced impacts and the need to follow consensual definitions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOne of the challenges in the scientific literature is that climate-induced impacts on healthcare infrastructure are often indirect consequences of exposure to climate hazards on health.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e\u003c/sup\u003e Some studies focus on the direct impacts of cyclones and floods on facilities, equipment, and human resources. In contrast, others examine the indirect pressure on non-resilient infrastructure resulting from climate impacts on health.\u003csup\u003e\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u003c/sup\u003e There is a need to quantify and model this distinction and to find innovative solutions.\u003csup\u003e\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMoreover, the definitions of climate impacts/risks and healthcare infrastructure are inconsistent. Most papers use internationally recognized definitions, but some still need to be more specific.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e The IPCC has asked the scientific community to follow its guidelines and definitions on using the terms risk, vulnerability, or impact; it must be said that a minority of papers reviewed wholly followed these guidelines.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Therefore, it adds to the confusion in the area, creating multiple notions and definitions of risks that do not have a consensus. This creates several problems, such as the low quantity and quality of systematic reviews in the field, the confusion of empirical research on the terms used, and the difficulty of adequately scanning the scientific literature on the subject. This could also impact inter-disciplinary collaboration.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eThe need for healthcare infrastructure resilience\u003c/h2\u003e \u003cp\u003eFinally, international institutions, such as the UNDRR or the WHO, as well as the governments of Fiji and many other PINs, have called for more research on building resilience pathways to healthcare infrastructure. Analysing and modelling vulnerabilities, exposure, and upstream determinants of climate change impacts and risks to healthcare infrastructure are essential to developing research and precise solutions to this problem.\u003csup\u003e\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e,\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e,\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e,\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e,\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe literature also points out the importance of healthcare resilience in the light of planned relocation in Fiji.\u003csup\u003e\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e,\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e,\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis review highlights the substantial vulnerabilities and risks that climate change poses to Fiji's healthcare infrastructure, particularly due to extreme weather events like floods and tropical cyclones. The findings emphasize the predominance of research on direct impacts, such as damage to facilities and human resources, with coastal Viti Levu being the most frequently studied location. However, there is a critical need for more localized studies, especially in less-researched areas like Vanua Levu and Kadavu Island, to build comprehensive climate resilience. Future research should also engage a broader range of disciplines, including epidemiology and economics, to address the diverse impacts of climate change on healthcare systems. Strengthening Fiji's healthcare infrastructure against climate risks is essential for ensuring the health and well-being of its population in the face of ongoing climate challenges.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eThe authors\u0026rsquo; contributions to this work were as follows. TD., conceptualization, methodology, data curation, formal analysis, investigation, data curation, writing \u0026ndash; original draft, writing \u0026ndash; review and editing, and visualization. KJ., supervision, writing, review, and editing. NJ., supervision, writing, review, and editing. RR., supervision, writing, review, and editing. PD., conceptualization, and supervision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research was supported by The University of Queensland. Any opinions, findings, conclusions, or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the University of Queensland.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u003cspan\u003eBarnett, J., \u0026amp; Waters, E. (2016). Rethinking the vulnerability of small island states: climate change and development in the Pacific Islands. 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T. T., Bertram, M., Brindley, C., Meshreky,A., \u0026hellip; Soucat, A. (2017).\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e Financing transformative health systems towards achievement of the health Sustainable Development Goals:\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e a model for projected resource needs in 67 low-income and middle-income countries. The Lancet Global\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e Health, 5(9), e875-e887.https://pubmed.ncbi.nlm.nih.gov/28728918/ DOI: 10.1016/S2214-109X(17)30263-2\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan\u003ePrasad, R. R., Alam, M. A., \u0026amp; Kundra, S. (2022). Climate Change Adaptation On Small Islands: Towards An\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e Effective And Sustainable Fijian Approach. 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(2019). Extreme weather events in Small Island Developing States: Barriers to climate change adaptation among coastal communities in a remote island of Fiji. Dealing with Climate Change on Small Islands: Towards Effective and Sutainable Adaptation, 217\u0026ndash;247. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/338070431_Extreme_weather_events_in_Small_Island_Developing\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e_States_barriers_to_climate_change_adaptation_among_coastal_communities_in_a_remote_island_of_Fiji\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.17875/gup2019-1218\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan\u003eNelson, S., Abimbola, S., Jenkins, A., Naivalu, K., \u0026amp; Negin, J. (2022). Information sharing, collaboration, and decision-making during disease outbreaks: the experience of Fiji. Journal of Decision Systems, \u003cem\u003e31\u003c/em\u003e(1\u0026ndash;2), 171\u0026ndash;188. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/351563338_Information_sharing_collaboration_and_decision-making_during_disease_outbreaks_the_experience_of_Fiji\u003c/span\u003e\u003c/span\u003e DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/12460125.2021.1927486\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan\u003eSabūnas, A., Mori, N., Fukui, N., Miyashita, T., \u0026amp; Shimura, T. (2020). Impact assessment of climate change on storm surge and sea level rise around Viti Levu, Fiji. Frontiers in Climate, 2, 579715. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/356102106_Impact_Assessment_of_Storm_Surge_and_Climate_Change-Enhanced_Sea_Level_Rise_on_Atoll_Nations_A_Case_Study_of_the_Tarawa_Atoll_Kiribati\u003c/span\u003e\u003c/span\u003e DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fbuil.2021.752599\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan\u003eTye, S., \u0026amp; Waslander, J. (2021). Mainstreaming Climate Adaptation Planning and Action into Health Systems in Fiji, Ghana, and Benin.\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/350746024_Mainstreaming_Climate_Adaptation_Planning_and_A\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ection_into_Health_Systems_in_Fiji_Ghana_and_Benin\u003c/span\u003e\u003c/span\u003e DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.46830/wriwp.19.00119\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan\u003ePearce, T., Currenti, R., Mateiwai, A., \u0026amp; Doran, B. (2018). Adaptation to climate change and freshwater resources in Vusama village, Viti Levu, Fiji. Regional environmental change, 18, 501\u0026ndash;510.\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/319904192_Adaptation_to_climate_change_and\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e_freshwater_resources_in_Vusama_village_Viti_Levu_Fiji\u003c/span\u003e\u003c/span\u003e DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10113-017-1222-5\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan\u003eHashim, J. H., \u0026amp; Hashim, Z. (2016). Climate change, extreme weather events, and human health implications in the Asia Pacific region. Asia Pacific Journal of Public Health, 28(2_suppl), 8S-14S. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/26377857/\u003c/span\u003e\u003c/span\u003e DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1010539515599030\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan\u003eChandra, A., \u0026amp; Gaganis, P. (2016). Deconstructing vulnerability and adaptation in a coastal river basin ecosystem: a participatory analysis of flood risk in Nadi, Fiji Islands. Climate and Development, 8(3), 256\u0026ndash;269.\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/275037520_Deconstructing_vulnerability_and_adaptation_in_a_co\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eastal_river_basin_ecosystem_a_participatory_analysis_of_flood_risk_in_Nadi_Fiji_Islands\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/17565529.2015.1016884\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan\u003eSingh, P., Schulman, D., Charan, D., Reyes-Garc\u0026iacute;a, V., Schlingmann, A., Singh, A. A., \u0026amp; Railoa, K. (2023). 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Climate and Development, 1\u0026ndash;15.\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/370062152_Human_health_and_climate_change_in_the_Pacific_a\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e_review_of_current_knowledge\u003c/span\u003e\u003c/span\u003e DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/17565529.2023.2185479\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan\u003eGuihenneuc, J., Ayraud-Thevenot, S., Roschnik, S., Dupuis, A., \u0026amp; Migeot, V. (2023). Climate change and health care facilities: A risk analysis framework through a mapping review. Environmental Research, 216, 114709. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/36343709/\u003c/span\u003e\u003c/span\u003e DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.envres.2022.114709\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan\u003eBiddle, L., Wahedi, K., \u0026amp; Bozorgmehr, K. (2020). Health system resilience: a literature review of empirical research. 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International journal of environmental research and public health, 11(12), 13097\u0026ndash;13116. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/25522050/\u003c/span\u003e\u003c/span\u003e DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph111213097\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan\u003eMcMichael, Celia, and Teresia Powell. \u0026quot;Planned relocation and health: a case study from Fiji.\u0026quot; International Journal of Environmental Research and Public Health 18.8 (2021): 4355. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/33923978/\u003c/span\u003e\u003c/span\u003e DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph18084355\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan\u003eMcNamara, K. E., \u0026amp; Prasad, S. S. (2014). Coping with extreme weather: communities in Fiji and Vanuatu share their experiences and knowledge. Climatic change, 123, 121\u0026ndash;132.\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/272018933_Coping_with_extreme_weather_Communities_in_Fiji\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e_and_Vanuatu_share_their_experiences_and_knowledge\u003c/span\u003e\u003c/span\u003e DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10584-013-1047-2\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan\u003eOakes, R. (2019). Culture, climate change and mobility decisions in Pacific Small Island Developing States. Population and Environment, 40, 480\u0026ndash;503.\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/333164475_Culture_climate_change_and_mobility_decisions_in_\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003cbr\u003e\u003cspan\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ePacific_Small_Island_Developing_States\u003c/span\u003e\u003c/span\u003e DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11111-019-00321-w\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\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":"Healthcare, Climate Change impacts, Tropical Cyclone, Fiji","lastPublishedDoi":"10.21203/rs.3.rs-5659753/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5659753/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHealthcare infrastructure in Fiji is undoubtedly vulnerable to climatic driver impacts. These impacts range from direct damages caused by extreme weather events to more diffuse impacts of changes in vector-borne diseases, causing pressure on local healthcare infrastructure. Climatic impacts also create vulnerabilities in infrastructure domains, such as human resources. This paper quantitatively and systematically reviews 25 empirical papers examining climate-induced risks, vulnerabilities, and impacts on the Fijian healthcare infrastructure and following PRISMA guidelines. Researchers published their findings in 21 journals, primarily in the fields of ecology and public health. A Systematic Quantitative Literature Review (SQLR) was conducted to assess the state of knowledge in the literature and address the research questions. The SQLR was chosen due to its rigorous and transparent approach, following PRISMA guidelines. A total of 457 studies were screened, and 25 studies were included in the review after exclusions and review. Nearly all articles (80%) were risk, vulnerability, or impact assessments, and the methods used were evenly distributed between quantitative and qualitative. Extreme weather events, including floods and tropical cyclones, were the focus of most papers (70%). In Fiji, coastal Viti Levu was the most studied location (56%). Most papers (68%) focus on climatic impacts on facilities and human resources. This review underscores the urgent need for additional research to enhance the resilience of Fiji's healthcare facilities. Based on the results of this systematic review, the scientific literature must test and review several climate resilience pathways.\u003c/p\u003e","manuscriptTitle":"Climate Change Impacts on Healthcare Infrastructure in Fiji: A Systematic Quantitative Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-21 00:14:00","doi":"10.21203/rs.3.rs-5659753/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","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}}],"origin":"","ownerIdentity":"4bf51e13-30f5-4d08-9a33-ca84daf22548","owner":[],"postedDate":"December 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-21T00:14:03+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-21 00:14:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5659753","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5659753","identity":"rs-5659753","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}