Heat, maternal health, and community action: a realist study in Senegal

Background

Extreme heat is a growing public health concern, particularly in low- and middle-income countries where vulnerability is high. While epidemiological studies link heat exposure to adverse maternal and neonatal outcomes, including preterm birth and mental health disorders, little is known about the mechanisms involved or how interventions can mitigate these effects. This gap is especially marked for maternal mental health and context-sensitive strategies.

Methods

This study is embedded in an intervention research programme in Senegal and adopts a realist evaluation approach to examine how, for whom, and under what conditions community-based interventions influence adaptive behaviours among pregnant and breastfeeding women. We reconstructed the intervention theory through a literature review, document analysis, and initial interviews, and refined it through a second round of data collection.

Results

Findings reveal multiple barriers to exclusive breastfeeding under extreme heat, including beliefs that infants need water, maternal fatigue, and strong influence of family decision-makers. Women’s limited autonomy and insufficient information further constrain behaviour change. Mental health issues, linked to economic stress, social tensions, workload, and heat, remain stigmatized and poorly addressed. Interventions appear to act through several mechanisms: strengthening knowledge to challenge beliefs, shifting social norms through collective discussions and role models, and creating spaces for expressing distress. Combining multiple channels (community dialogues, home visits, theatre, social media) is key to reaching both women and influential family members.

Conclusions

Effectiveness depends on engaging social norms, power dynamics, and structural constraints. A realist approach helps explain how behavioural change emerges from interactions between intervention resources and local contexts, informing more effective and equitable climate-health strategies.

Key messages

• Interventions must target not only mothers but also influential family members to effectively shift breastfeeding practices in contexts of extreme heat.

• Integrating mental health into existing community channels can improve early identification and support, but requires stronger health system linkages.