The role of the public health service in the implementation of heat health action plans for climate change adaptation in Germany: A qualitative study.

Background: In response to climate change-induced increases in heat periods, the WHO recommends the implementation of heat health action plans (HHAPs). In Germany, HHAPs are implemented neither comprehensively nor nationwide. Several recommendations have identified the public health service (PHS) at municipal and federal state levels as a key actor regarding to heat and health. Therefore, this study aimed at assessing the role of the PHS in implementing HHAPs at municipal and federal state levels in Germany.

Methods: We conducted a policy document analysis to assess the legal basis for the work of the PHS in the 16 federal states in Germany. Furthermore, we conducted semi-structured interviews with 16 experts from within and outside the PHS to explore their perceptions of the PHS in the implementation of HHAPs. The interviews were analysed using reflective thematic analysis.

Results: The policy document analysis revealed that heat is not mentioned in any of the federal states' regulatory frameworks for the PHS, while tasks related to environment and health are addressed, but tend to remain vague. The interviews confirmed that there is currently no clearly defined role for the PHS in implementing HHAPs in Germany and that the actual role primarily depends on the local setting. Main barriers and facilitators could be assigned to three levels (individual, organizational and political), and two overarching contextual factors (awareness of the need for adaptation and existence of other public health emergencies) influenced the implementation of HHAPs across all levels. At the individual level, motivation, knowledge and competencies, and previous experience were possible barriers or enablers. At the organizational level, administrative structures, financial and human resources, leadership and networks were barriers or facilitators, while at the political level they included legislation and political decisions.

Conclusions: The PHS could and should be a relevant actor for implementing measures addressing health and climate change locally, in particular because of its focus on vulnerable populations. However, our findings suggest that the legal basis in the federal states of Germany is insufficient. Tailored approaches are needed to overcome barriers such as rigid, non-agile administrative structures and competing priorities, while taking advantage of facilitators such as awareness of relevant actors.