Climate stress as a caregiving crisis for mothers of children with disabilities in Tamil Nadu, India

1 Introduction: climate-health has a household blind spot

A flood can close a therapy center, block transport, cut electricity, damage assistive equipment, and disrupt a child's daily routine. For a mother caring for a child with a disability, each disruption creates more work at home. She may need to replace lost services, manage changes in the child's behavior or health, and make decisions with little formal support. Low-income households have fewer resources to absorb these shocks.

Climate-health research often measures individual exposure, illness, death, infrastructure damage, and disruption of health services. It pays less attention to the unpaid care that follows when these systems fail. This Perspective argues that the caregiving household is an important unit of analysis for climate-health equity. It examines how climate hazards may increase unpaid care demands and affect the mental health of mothers caring for children with disabilities.

Climate change affects health through extreme heat, floods, droughts, air pollution, food and water insecurity, displacement, and disruption of essential services. The World Health Organization (WHO) describes climate change as a fundamental threat to human health because it affects physical environments, social and economic conditions, and health systems (1). The 2023 Lancet Countdown documented growing exposure to heat, food insecurity, and pressure on health systems. People with fewer social and economic resources face greater risks from these changes (2).

Tamil Nadu faces high temperatures, humid conditions, cyclones, intense rainfall, and urban flooding. These hazards interact with poverty, inadequate housing, and uneven access to services. Research among women aged 40–79 in rural Tamil Nadu found substantial variation in personal heat exposure, including sharp increases that may relate to domestic activities such as cooking with solid fuels (3). Flooding creates different pressures. It can damage homes and equipment, interrupt transport and rehabilitation, and remove children from familiar routines and settings.

Evidence from Chennai shows how these disruptions reach caregiving households. Recent qualitative evidence from South India further supports this pattern, drawing on interviews with 14 caregivers of children with disabilities from neighborhoods affected by the December 2023 floods (4). The sample included nine mothers, four fathers, and one grandmother. Caregivers reported interruptions to therapy, schooling, medication access, sleep, feeding, and daily routines. They also described fatigue, anxiety, role strain, and limited formal assistance. The study provides local evidence of how flooding can increase care demands in households already managing disability-related needs.

Climate hazards can also affect mental health. Research on acute disasters and long-term environmental stress identifies several recurring pathways: direct exposure to danger, loss and displacement, interruption of healthcare, financial insecurity, sleep disturbance, and existing social inequality (5, 6). Researchers have also examined links between climate-related exposures and perinatal mood and anxiety disorders, although findings vary by exposure, outcome, population, and study design (7). Women in low- and middle-income countries may face additional risks because they often have less control over resources and carry a larger share of unpaid care (8). This literature rarely examines mothers caring for children with disabilities as a distinct group.

Research on disability caregiving in India has also documented substantial caregiving burden and depressive symptoms among caregivers of children with intellectual disabilities (9). In a community-based study of 205 primary caregivers in Chennai, most of whom were mothers, assessed quality of life, coping, and depressive symptoms. The study identified limitations across several quality-of-life domains, and 33.2% of caregivers screened positive for depression (10).

Current research has examined climate exposure, disability caregiving, unpaid care, and maternal mental health mainly as separate issues. This separation creates a household blind spot. When electricity, transport, medication supplies, rehabilitation, education, or social support fail, families must often replace them with unpaid work. Climate-health research rarely measures this transfer of responsibility or its effects on caregivers.

This Perspective develops a household-centered framework through a narrative conceptual synthesis of four intersecting bodies of evidence: climate-related health and service disruption, disability vulnerability and continuity of care, unpaid and gendered caregiving, and maternal and caregiver mental health. It proposes that climate-related stressors may deepen maternal mental health inequities by increasing unpaid care demands in households already affected by disability, poverty, stigma, inadequate infrastructure, and fragmented services. The framework is intended to organize plausible relationships and guide empirical testing; it is neither a systematic review nor an established causal model. Household-level research must test these relationships across different disabilities, family structures, hazards, and service environments and examine how caregiving demands and mental health change over time. Climate stress should therefore be examined not only as an environmental exposure or health-system disruption, but also as a potential caregiving crisis in households where care responsibilities are unequally distributed.

2 Why mothers of children with disabilities face compounded climate risk

In this Perspective, compounded climate risk refers to the interaction of four conditions: exposure to a climate hazard, disability-related support requirements, limited household and institutional resources, and gendered responsibility for care. These conditions do not operate separately. A climate hazard may interrupt several forms of support while also reducing the resources that a family can use to respond.

Some children with disabilities need regular medication, rehabilitation, assistive devices, personal assistance, accessible transport, temperature control, or predictable routines. A power failure may affect cooling, communication devices, refrigeration of medicines, or electrically powered equipment. A flood may block transport, close schools and therapy centers, or damage assistive devices. Extreme heat may make travel and waiting at health facilities more difficult. When these supports fail, families must reorganize care at home.

To illustrate this interaction, consider a low-income household during a prolonged heatwave and power failure. A child may require cooling, temperature-sensitive medication, an electrically powered assistive device, or a stable daily routine. The family may lack backup electricity, private transport, or alternative care. If the mother provides most daily care, she must manage the child's needs while also securing medicines, water, food, and transport. Evidence from Chennai shows that climate-related disruption can interrupt medication access, therapy, and established routines, while research from South Korea shows that disability, age, and income can combine to shape heat-related health risks (4, 11). This example shows why heat exposure alone cannot capture the household burden.

The household's resources shape what happens next. Families with secure housing, savings, flexible employment, reliable transport, and strong social networks may find alternatives. Families without these resources have fewer options. They may delay healthcare, miss therapy, reduce paid work, borrow money, or depend on one family member to provide more care. Poverty therefore affects both exposure to climate hazards and the ability to respond.

Many caregivers already face substantial demands before a climate-related disruption occurs. In a study of 100 Indian mothers of children with specific learning disabilities, affiliate stigma predicted poorer psychological well-being. Subjective caregiving burden partly explained this relationship (12). A scoping review of 35 studies from 15 low- and middle-income countries identified psychological distress, financial strain, family disruption, stigma, and unmet service needs among caregivers of children with mental health or neurodevelopmental conditions (13). Most studies came from Africa, but the findings show how limited services and weak social protection can shift responsibility to families.

Public systems can either reduce or increase this burden. Warning messages may not use accessible formats. Evacuation vehicles and shelters may not accommodate mobility, sensory, communication, or behavioral needs. Emergency plans may overlook medication, rehabilitation, assistive equipment, personal assistance, and continuity of care. A systematic review found that personal, social, economic, environmental, and institutional factors shape both climate vulnerability and the capacity of people with disabilities to adapt (14). The review identified limited government support, inaccessible services, evacuation barriers, low income, and difficulty replacing adaptive equipment as important sources of risk. Disability alone does not create climate vulnerability. Inaccessible systems and unequal access to resources produce much of it.

Heat exposure shows how these conditions can combine. A study using healthcare data collected between 2010 and 2022 across seven South Korean cities examined the relationship between heat exposure and health outcomes (11). Heat-related health risks varied according to disability, age, and income. The effects of combined vulnerabilities also differed between outpatient visits and emergency admissions. Although the setting differs from Tamil Nadu, the study shows why climate-health research should examine overlapping health and socioeconomic conditions rather than treat disability, poverty, and heat exposure as separate risks.

Gender shapes who performs the additional work. In a study of 205 caregivers, women accounted for 85.9% of participants, while mothers comprised 80% of the sample (10). This pattern sits within a wider unequal distribution of unpaid care. Using data from 125 countries, the International Labour Organization estimated that 708 million women were outside the labor force because of care responsibilities in 2023, compared with 40 million men (15). UN Women has also described how climate-related changes in health, water, food, energy, migration, and livelihoods can increase women's and girls’ unpaid care, domestic, and communal work (16).

Fathers, grandparents, siblings, and other relatives may also provide care. However, when mothers already perform most daily care, they are likely to manage much of the added work created by service failure, unsafe travel, school closure, or disruption of a child's routine. This work may increase time pressure, physical fatigue, worry, lost income, and social isolation. It may also leave less time for sleep, healthcare, and recovery.

Compounded climate risk therefore arises from the interaction between a hazard and the organization of care around it. Research must ask more than whether a mother or child experienced a flood or heatwave. It must also ask which services failed, what new tasks appeared, who performed those tasks, what resources the household could use, and how these changes affected health over time. This household-level approach provides the basis for examining the climate–caregiving–mental health pathway.

3 From climate-related disruption to maternal psychological strain

Climate-related hazards can reach the household through several routes. Heat may make daily care harder. Air pollution may worsen a child's respiratory symptoms. Flooding may interrupt transport, therapy, medication, electricity, and schooling. Water shortages and rising food costs may place further pressure on household resources. Although these exposures differ, they can produce the same practical result: more care must be provided at home.

The proposed pathway has three linked stages. First, a climate-related event disrupts a child's health, routine, services, or essential household resources. Second, the mother takes on additional work to maintain care. Third, repeated demands contribute to worry, sleep loss, exhaustion, anxiety, depressive symptoms, and isolation. These effects may weaken the household's capacity to manage the next disruption.

This pathway is plausible but has not been established as a causal model. Most studies examine climate exposure, caregiving, disability, or maternal mental health separately. Evidence that follows mothers of children with disabilities through repeated climate events remains limited, particularly in Tamil Nadu.

3.1 Extreme heat

High temperatures and heatwaves have been associated with adverse mental-health outcomes. The strength of the association varies by population, exposure measure, outcome, and study design (5, 17). Heat can also disturb sleep, increase fatigue, and worsen existing health conditions.

In a household caring for a child with a disability, these effects can create additional work. A mother may need to monitor symptoms, maintain hydration, change meals or medication schedules, find a cooler space, or decide whether travel to a clinic is safe. Heat may also make feeding, bathing, lifting, and calming a distressed child more difficult.

A power failure can compound these demands. The household may lose access to fans, refrigeration, communication devices, or electrically powered medical equipment. Families with limited income may be unable to purchase backup power, travel to a cooler location, or increase their use of electricity. The relevant exposure is therefore not only the temperature. It is also the work and worry involved in keeping the child safe when cooling, electricity, transport, and clinical support are unreliable.

3.2 Air pollution

Air pollution is associated with asthma, respiratory infections, reduced lung function, and other respiratory problems in children (18). Children with existing respiratory conditions, limited mobility, or difficulty communicating symptoms may require closer observation during periods of poor air quality.

For mothers, this may mean monitoring breathing, administering medication, arranging clinical care, or keeping the child home from school or therapy. Staying indoors may provide limited protection in crowded housing with poor ventilation or household air pollution. Closing windows to reduce outdoor exposure may also make indoor heat harder to manage.

Research has identified possible associations between air pollution and perinatal mental-health outcomes, although the evidence remains heterogeneous (19). In disability-caregiving households, the likely pathway is indirect. Concern about the child's health, repeated monitoring, restricted activity, disrupted routines, and the cost of treatment may together increase psychological strain.

3.3 Food insecurity and income loss

Climate-related events can damage livelihoods, interrupt employment, reduce household income, and increase food prices. These pressures may force families to reduce the amount, quality, or variety of food they purchase.

Evidence from low- and middle-income settings links household food insecurity with maternal psychological distress. In a community-based study of 497 mothers in rural Egypt, symptoms of anxiety and depression were more common among women living in food-insecure households. Severe food insecurity was associated with substantially greater odds of maternal distress (20). A longitudinal study of 371 pregnant and postpartum women in Kenya also found that severe food insecurity was associated with higher depressive-symptom scores and greater odds of probable depression (21).

For a mother caring for a child with a disability, food insecurity may present specific problems. The child may need a particular food texture, feeding schedule, nutritional supplement, or diet related to a medical condition. These needs can become difficult to meet when prices rise or income falls. Mothers may have to choose among food, medication, transport, therapy, electricity, and other essential expenses.

The psychological burden extends beyond hunger. It includes the continuing responsibility to meet a child's needs when the household lacks the necessary resources. That pressure may become more severe when disability-related expenses already consume a substantial share of household income.

3.4 Water insecurity and hygiene

Water insecurity affects drinking, cooking, bathing, cleaning, toileting, and infection prevention. A review of studies from low- and middle-income countries linked inadequate water and sanitation with worry, shame, anxiety, conflict, and other forms of psychosocial distress (22).

Children who need help with feeding, toileting, bathing, wound care, or mobility may require more water and direct assistance. When water becomes scarce or contaminated, mothers may spend additional time collecting, storing, rationing, or treating it. They may also need to manage diarrhea, skin problems, urinary infections, or difficulties cleaning assistive equipment.

Water insecurity can therefore increase both the physical work of caregiving and the fear that basic care cannot be maintained safely. The burden may intensify during floods when water is present in abundance but is contaminated, inaccessible, or unsafe for household use.

3.5 Disruption of health, rehabilitation, and education services

Floods, cyclones, heatwaves, and other climate-related events can interrupt transport, medication supplies, primary care, rehabilitation, therapy, schooling, and social support. These services may be essential to a child's health, communication, mobility, learning, and daily routine.

Evidence from the December 2023 Chennai floods shows how these disruptions entered caregiving households. In an exploratory qualitative study of 14 caregivers of children with disabilities—nine mothers, four fathers, and one grandmother, documented interruptions to therapy, schooling, medication access, sleep, feeding, and established routines (4). Caregivers described anxiety, fatigue, role strain, overload, and difficulty obtaining formal assistance or respite. The small, non-probability sample does not support population estimates, but it provides direct evidence from flood-affected communities in Tamil Nadu.

When formal services stop, care does not stop. Mothers may provide exercises normally delivered by therapists, manage behavioral distress caused by disrupted routines, search for medication, arrange alternative transport, or postpone their own work and healthcare. A short interruption can have effects that continue after the immediate event, especially when the child loses developmental progress or must wait for services to resume.

3.6 Cumulative psychological strain

These pathways rarely occur alone. A flood may interrupt therapy and income while contaminating water and increasing food costs. A heatwave may coincide with a power failure and poor air quality. Each disruption creates new tasks, but their combined effect may be greater than the sum of the individual demands.

The likely mental-health consequence is not simply a brief episode of stress. It is the cumulative strain of maintaining care under unstable conditions. This strain may appear as persistent worry, sleep loss, irritability, anxiety, depressive symptoms, exhaustion, or social isolation. It may become more severe when the mother provides most daily care, has little respite, and must repeatedly compensate for failures in infrastructure and public services.

This framing does not treat maternal distress as a failure to cope. It places that distress within the conditions under which care is provided. Repeated climate-related disruptions may increase care demands while reducing the time, income, rest, and support available to meet them. Research should test this pathway through longitudinal and household-level studies that connect climate exposure, changes in caregiving demands, and maternal mental-health outcomes. Figure 1 summarizes the proposed pathway and the factors that may modify relationships across it. The next section considers why current adaptation policy often fails to recognize this transfer of work.

4 Why climate-health policy misses unpaid care

The pathway described in Section 3 leads to a policy question: when climate-related disruption creates more care inside the home, do adaptation plans recognize that work?.

Climate-health plans commonly focus on early-warning systems, disease surveillance, emergency response, resilient health facilities, and secure supply chains. These measures are essential, but they provide an incomplete account of adaptation if they stop at the boundary of the health system. A service may remain available while transport, cost, unsafe conditions, or inaccessible communication prevents a family from using it. System readiness does not always mean that care remains accessible.

4.1 What current assessments overlook

The World Health Organization's guidance on climate-change and health vulnerability assessments asks countries to identify exposed populations, health risks, institutional weaknesses, and adaptation options. It also recognizes that social conditions influence vulnerability and the capacity to respond (23). The framework is broad enough to include caregiving, but it does not make unpaid care a standard part of assessment.

Most assessments classify vulnerability by geography, age, income, occupation, health condition, or exposure. These categories may identify a child with a disability as vulnerable and a mother as economically or psychologically at risk. They may not capture how their risks are connected through daily care.

That relationship matters. A child's health may depend on continuous medication, rehabilitation, cooling, feeding assistance, mobility support, electricity, or a stable routine. The mother's health and economic security may depend on the time, money, sleep, and physical effort required to maintain those supports. Assessing them separately can therefore miss the mechanism that links their risks.

Disability also remains weakly represented in climate policy. A review of policies from all 195 parties to the Paris Agreement found that only 41 parties referred to people with disabilities in their nationally determined contributions, while 75 included them in adaptation policies (24). These references often lacked clear provisions for participation, implementation, funding, or accountability.

Identifying people with disabilities as a vulnerable group is only a first step. Policy must also ask whether warnings are accessible, evacuation is possible, essential equipment can be protected, and daily care can continue. It must identify who provides that care and what help is available to them.

Recent evidence from Nepal shows the practical importance of this gap. Among 280 caregivers of children with physical disabilities, 95.7% had no household emergency plan and 95% had never received disaster-preparedness training. Climate knowledge differed significantly by gender, education, and location (25). Because the study was cross-sectional and conducted in Nepal, its findings cannot be applied directly to Tamil Nadu. It nevertheless shows the risk of placing responsibility on caregivers without providing training or practical support.

4.2 The uncounted cost of access failure

Climate policy often treats service availability as the main outcome. A more useful assessment would distinguish among three questions: i) Is the service operating? ii) Can the family reach and use it? And iii) What additional work or expense falls on the family when access fails? The third question is often missing. A response may therefore appear successful even when mothers lose income, rest, or access to their own healthcare while maintaining a child's care.

Research on the climate-care nexus identifies the same gap. Climate hazards and environmental degradation can increase women's domestic, caregiving, and community work, yet unpaid care remains weakly represented in climate plans, budgets, and monitoring systems (16).

This omission makes household adaptation appear less costly than it is. Families may absorb the cost through additional time, physical effort, lost earnings, delayed treatment, or psychological strain. When these consequences remain unmeasured, policy may overstate household resilience while overlooking the work required to sustain it.

4.3 Adding the caregiving household to climate-health assessment

The caregiving household should be added as a unit of assessment, alongside existing individual, geographic, and health-system measures. Its purpose is to connect the child's support needs with the caregiver's time, health, income, and access to assistance.

Assessments should establish whether climate-related events interrupt medication, rehabilitation, education, transport, or social support. They should also record dependence on electricity, cooling, water, assistive equipment, and specialized food. At the household level, relevant indicators include additional caregiving time, out-of-pocket spending, missed employment, availability of another caregiver, caregiver sleep and psychological well-being, and the time required to restore the child's usual care.

These indicators would show whether an intervention protects continuity of care or leaves families to compensate for gaps in public services. They would also guide practical responses, including accessible warnings, household emergency planning, backup medication, transport assistance, respite care, and income protection.

Mothers already adapt under difficult conditions. Climate-health policy should reduce the work and risk they carry rather than assume that families can continue absorbing both.

5 A household-centered framework for climate-health equity

Table 1 translates five priorities into proposed actions, delivery platforms, and indicators: identifying essential care needs, protecting service continuity, connecting caregivers with mental health care, reducing additional care work, and financing household support.

Table 1. Proposed household-centered framework for climate-health equity.

These actions and indicators are proposed components of a conceptual framework, not validated standards. Delivery arrangements should be adapted and tested locally.

The household is the unit of action because this is where service failures are often absorbed. This does not shift further responsibility to families. It makes visible the responsibilities that health, disability, and emergency systems already leave to caregivers.

5.1 Record essential care needs

Once caregiving households are included in climate-health assessments, existing primary care, disability, maternal and child health, school, and social protection systems can record the support that must continue during a climate event. This may include medication, rehabilitation, assistive technology, cooling, accessible transport, feeding support, or close supervision.

Participation should be voluntary. Systems should collect only the information needed to organize support and restrict access to authorized personnel. The aim is not to classify every household caring for a child with a disability as equally vulnerable. It is to identify the specific support a household may require during heat, flooding, or another service disruption.

5.2 Protect essential services

Climate preparedness should treat medication, rehabilitation, assistive technology, transport, and disability support as essential services. A short continuity plan, developed with the family and relevant providers, can identify what must continue and what alternatives are available when regular services fail.

The response will differ by hazard. Extreme heat may require cooling, safe medication storage, or flexible appointment times. Flooding may require accessible evacuation, replacement of damaged equipment, transport, or temporary rehabilitation support. The World Health Organization recommends integrating rehabilitation into emergency preparedness and response rather than postponing it until recovery begins (26).

Continuity must be judged from the household's position. A service is not accessible simply because a facility remains open. The child must also be able to reach and use it safely.

5.3 Link mental health screening to care

Support for caregiving households should include a clear mental health pathway. Primary care teams, disability services, maternal and child health programs, and trained community health workers can provide initial assessment and screening. Screening is useful only when treatment, referral, crisis support, and follow-up are available.

Indian studies show that some mental health services can be delivered by trained non-specialists. In Goa, the Healthy Activity Program improved depression outcomes when lay counselors delivered a brief psychological treatment through primary care (27). A multicenter Indian trial protocol also describes a model for nurses to deliver and evaluate a brief intervention for depression during pregnancy (28).

These studies support task-shared mental health delivery in Indian health settings. They do not establish that the same interventions will address climate-related distress among mothers of children with disabilities. Any adapted model requires development and evaluation with this population.

Mental health care must also be linked to practical assistance. Counseling cannot restore medication, repair assistive equipment, replace lost income, or provide respite. Treating distress without addressing the disruption that produces it would leave the main source of strain unchanged.

5.4 Reduce and redistribute additional care work

Household support should target the disruption creating additional work. Depending on need, this may include transport, medication delivery, cooling, food assistance, equipment repair, respite, or temporary home- and community-based services.

The support itself should not create another administrative burden. Repeated applications, extensive documentation, and travel between offices can add to the caregiver's workload. Simple enrollment, accessible communication, and a clear point of contact can make assistance easier to use.

Care should not automatically default to the mother. Where appropriate and safe, fathers, relatives, schools, community health workers, peer groups, and local organizations can share defined tasks. Not every mother has a reliable partner or family network, and the framework should not assume otherwise. Its purpose is to reduce the additional work created by climate disruption and distribute essential responsibilities more fairly.

5.5 Finance and test the framework in Tamil Nadu

Household support requires funding that can be released before or during a climate emergency. Public health, disability services, social protection, disaster management, and local government may each hold part of the required resources. Linking these systems could allow practical support to reach households when defined heat or flood thresholds are met. Social protection can help families manage climate-related shocks, but it remains poorly integrated with climate policy in many settings (29).

India offers one example of trigger-based assistance. The Extreme Heat Protection Initiative, developed with the Self-Employed Women's Association, enrolls women working in the informal economy before the heat season and links financial assistance to specified temperature conditions (30). The program does not address disability caregiving or maternal mental health. Its relevance is limited to one operational principle: climate thresholds can activate pre-arranged support.

Tamil Nadu could test the household framework in one flood-prone urban district and one heat-exposed rural district. An initial pilot could combine household identification, continuity planning, a local point of contact, and rapid assistance during a defined climate event. Evaluation should examine whether the model preserves access to medication and rehabilitation, limits additional caregiving work, reduces household costs, and protects caregiver well-being. It should also examine reach, equity, implementation cost, stigma, unwanted disclosure, and exclusion from support.

Caregivers, people with disabilities, community health workers, rehabilitation providers, and local officials should participate in the design and interpretation of the pilot. Their involvement would help determine whether the proposed model is acceptable, useful, and workable within local services.

6 Implications for Tamil Nadu and other low- and middle-income country settings

Tamil Nadu provides a relevant setting for this Perspective because climate exposure intersects with gendered care responsibilities and unequal access to services. Research in rural Tamil Nadu has documented substantial personal heat exposure among women, including during domestic activities (3). A qualitative study of women's use of publicly funded health insurance in the state identified unpaid care, financial dependence, mobility restrictions, and gender norms as barriers to healthcare access (31). Evidence from flood-affected neighborhoods in Chennai has also shown how disruption can affect medication, therapy, schooling, and daily care routines for children with disabilities (4).

These studies do not establish the full pathway proposed in this article. They examine different populations, exposures, and outcomes. Taken together, however, they show that its main elements are present in Tamil Nadu: climate hazards, disability-related service disruption, gendered care responsibilities, and barriers to healthcare access. This Perspective brings those elements together in a testable account of how climate stress may affect maternal mental health through additional caregiving work.

Several existing programs provide settings in which parts of this pathway could be examined. Future implementation research could assess whether maternal and child health services can identify intensive disability-related caregiving without adding workload or stigma. Disability services provide one setting in which the effects of heat, flooding, power loss, and transport disruption on continuity of care could be measured. Mental health services could examine whether caregiver distress is associated with unmet practical needs. Disaster preparedness programs could assess whether warning, evacuation, transport, and recovery plans meet the needs of households that depend on medication, assistive equipment, accessible transport, or continuous supervision. These questions follow from the framework in Section 5 but require separate evaluation.

The underlying pathway may also be relevant in other low- and middle-income countries (LMICs) where families provide much of the daily support for children with disabilities and formal services remain limited or fragmented. A review of climate-related disasters and disability in developing countries found evidence of physical and mental health effects, service disruption, barriers to inclusive planning, and major gaps in the available research (32). These findings support wider study of caregiving households, but they do not justify applying one intervention model across settings.

What may transfer is the analytical approach: identify the climate hazard, determine which service or household resource it disrupts, measure the care transferred to the family, and assess the effects on caregivers and children. The response must reflect local conditions. Rural and urban households may face different hazards, transport systems, family structures, service networks, social protection programs, and forms of gender inequality. Mothers may provide most daily care in one setting, while fathers, grandparents, siblings, or other relatives may hold that role elsewhere.

Tamil Nadu should therefore be treated as the setting in which this framework is grounded, not as evidence that the pathway has already been established. Research in Tamil Nadu and other LMIC settings can determine which relationships recur, which depend on local conditions, and whether household-centered support improves continuity of care without adding further work, stigma, or exclusion.

6.1 Limitations and research priorities

This Perspective draws on a narrative synthesis of studies across different populations, hazards, disabilities, and outcomes. Direct evidence linking climate disruption, increased caregiving demands, and maternal mental health remains limited, particularly in Tamil Nadu. The proposed pathway therefore requires empirical testing and should not be interpreted as causal or universally applicable.

Future studies should measure climate exposure, service disruption, caregiving time, household costs, social support, and maternal mental health over time. Participatory and implementation research should also test whether household support protects continuity of care without increasing caregiver workload, stigma, or exclusion.

7 Conclusion: the household is part of the climate-health system

Climate-health research usually locates vulnerability in individuals, communities, infrastructure, or health facilities. This Perspective adds another unit of analysis: the caregiving household. When climate hazards interrupt transport, electricity, medication, rehabilitation, or other essential services, the unmet need does not disappear. It returns as additional care within the household, where mothers often absorb it.

This framing does not establish a causal relationship between climate exposure, caregiving burden, and maternal mental health. Instead, it defines a pathway for empirical testing. Grounded in Tamil Nadu, the framework may offer a useful analytical starting point for comparable resource-constrained settings, but its relationships and implementation strategies require local testing. Climate adaptation cannot be assessed only by whether facilities remain open or services resume. It must also examine what households are required to do when formal support fails. A system that maintains continuity by transferring disruption to unpaid caregivers has not removed the burden; it has moved the point of failure into the home.

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Footnotes

Edited by: Lutchmie Narine, Syracuse University, United States

Reviewed by: Anne-Lise Boyer, UMR5600 Environnement, Ville, Societe (EVS), France

Nycil Thomas, Rajagiri School of Social Work, India

Pramod Kumar, National Centre for Polar and Ocean Research (NCPOR), India