Development and Implementation of a Climate Change and Health Curriculum Into Pediatric Residency Education Open Access

Climate change has been declared a health emergency by several prominent medical organizations.¹  Many physicians recognize the significance of climate change on health; however, they report feeling inadequately prepared to address it.^2,3  The American Medical Association recommended incorporating climate change and health (CCH) into medical education.⁴  A curricular framework was developed,⁵  but implementation details are sparse, particularly in pediatrics.

We developed and incorporated CCH material into a longitudinal curriculum for pediatric and combined internal medicine-pediatrics residents. This study aims to describe the development and feasibility of a formal CCH curriculum tailored to pediatric residents and evaluate residents’ knowledge and comfort throughout their training.

This curriculum began in May 2023 at the Jacobs School of Medicine and Biomedical Sciences in Buffalo, New York. The first year of a 3-year CCH curriculum was integrated within existing required didactic time in the pediatric residency program.

The total number of eligible residents at the start of data collection was 61. A programmatic and postgraduate year breakdown can be seen in the Table. All residents participated in the curriculum and were invited to complete the assessments.

We developed the curriculum using the conceptual framework put forth by Thomas et al.⁶  The 3-year longitudinal CCH curriculum provides residents with knowledge and skills to understand the negative impact of climate change on child health, and strategies to mitigate them. The curriculum development process included creation of a curriculum map as well as development of educational materials and assessment instruments.

The curriculum was developed, based on the framework of Philipsborn and colleagues.⁵  Objectives were mapped to the Accreditation Council for Graduate Medical Education’s pediatric Core Competencies. Educational and assessment strategies were assigned to each objective (online supplementary data 1).

Educational materials were developed for general pediatrics and subspecialty lectures. Four case-based discussions and 2 independent exercises were developed.

A set of assessment tools were developed to measure knowledge, attitudes, case-based learning, critical reflection, and clinical practice changes at multiple points throughout the 3-year curriculum. Knowledge questions (online supplementary data 2) reflect primary educational objectives and will be compared each year to assess for improvement. Attitude questions (online supplementary data 3) aim to measure the impact of the curriculum on overall attitude and self-reported comfort with the material. Case-based worksheets (online supplementary data 4) were designed to measure resident ability to recognize associations between climate change, environmental exposures, and associated health impacts as well as to assess resident skills in environmental health history-taking, anticipatory guidance, and patient education. Reflective essay prompts were distributed after completion of independent exercises to assess resident understanding of key objectives and how those concepts impact community health and well-being. Standardized rubrics were developed for faculty to use in grading worksheets and reflective essays (online supplementary data 5 and 6). A modified clinical evaluation exercise form was developed to enable faculty observers to measure practice changes during clinic encounters (online supplementary data 7).

Year one data from this ongoing study includes baseline pre-intervention data about resident knowledge and attitudes, and faculty assessment of group learning following case-based exercises. For the pre-intervention data, total correct responses (knowledge) and total responses to Likert items (attitudes) were collected. The only demographic information collected was residency training year. Descriptive statistics were used to analyze faculty assessments from standardized rubrics.

This study was reviewed by the University at Buffalo Institutional Review Board and was approved under exempt research determination.

Sixty-one residents were eligible to participate in the pre-intervention assessment of CCH knowledge and attitudes. Of those, 14 (23.0%) opted to complete the knowledge-based assessment and 12 (19.7%) opted to complete the attitudes-based assessment.

Online supplementary data Table 1 shows the complete results of the knowledge-based assessments. Respondents (10 of 14, 71.4%) strongly agreed that climate change is caused by human activities. Many respondents identified asthma exacerbations (12 of 14, 85.7%) as impacts of extreme heat exposure. Suicide (6 of 14, 42.9%) and congenital anomalies (2 of 14, 14.3%) were identified less so. Most residents were able to identify E. coli infections (12 of 14, 85.7%), as likely to increase. Fewer (6 of 14, 42.9%) identified hepatitis A.

Online supplementary data Table 2 summarizes questions specific to comfort discussing CCH with patients. Other data showed most respondents (11 of 12, 91.7%) agreed that climate change has direct impacts on health. All respondents felt climate change negatively impacts patients. Most respondents (11 of 12, 91.7%) felt incorporating CCH education into residency was important. Many respondents (9 of 12, 75.0%) did not discuss climate change and health with patients in the last year despite 7 of 12 (58.3%) feeling somewhat comfortable with advocacy engagement.

Feasibility estimates revealed no problems with institutional support, as department leadership was supportive. No faculty expressed opposition in initial discussions, and several agreed to incorporate material into their existing lectures. Together, these were used to determine acceptability. For more details regarding feasibility, refer to online supplementary data Table 3.

In the first year of CCH curriculum implementation, 5 foundational lectures and 1 case-based exercise took place. One case-based exercise was evaluated. Out of the 11 small groups in this exercise, 8 groups were scored as “not yet competent” in environmental health knowledge and patient care and 9 groups as “not yet competent” in advocacy (Figure).

Preliminary data reveals that this CCH curriculum is both feasible and necessary to ensure proficiency in this aspect of health care. Assessment results indicated that residents would be receptive to a CCH curriculum and had varying knowledge about CCH topics. When residents applied knowledge in a case-based exercise, most groups were graded as “not yet competent” in all categories, indicating need for continued education.

Most residents felt that climate change education is necessary and should be included in their education, which correlates with a prior study revealing that 76% of residents agreed to its importance.⁷  Social desirability bias may have contributed to the high percentage of support for the curriculum. We plan to account for this by analyzing longitudinal assessment data for consistency. Collection of direct patient care data will also assess this. Adaptation of patient care over time would be indicative of true acceptance of importance, less subject to bias.

The core components of the first year of this CCH curriculum were successfully integrated into pediatric resident training. Our findings demonstrate that existing proposed curricula⁵  can be easily adapted and feasibly implemented within preexisting educational frameworks. This curriculum could be replicated by other primary care specialties such as internal medicine and family medicine. Suggested adaptation of the cited curricula for internal medicine has been published elsewhere.⁸  With more substantiative adaptation, this curriculum could meet objectives for other specialties given the impact of climate change on many disease processes.

There are some limitations to this study. Participation in the knowledge- and attitudes-based assessments was low. This may be due to lack of motivation to complete, intimidation by content, or time limitations. Our assessments lack validity evidence, leading to potential differences in question interpretation. There are no available data for reflective essays or direct observation as these evaluations are still in the implementation phase.

Longitudinal data collection from all utilized assessment tools will allow us to assess the ability of this curriculum to improve knowledge and translation of knowledge into patient care. It will also identify areas of the curriculum that require modification or different educational approaches.

Our work demonstrates the feasibility and necessity of implementing a longitudinal CCH curriculum into pediatric residency education. We present a curricular framework that can be used and adapted by other residency programs, thus deepening and extending the body of proposed curricula published previously.

The authors would like to thank Bree Kramer, DO, and Jill Fennell, MD, for their support for project implementation, and Sofia Curdumi-Pendley, PhD, and Deborah Nagin for their guidance on evaluation development.

The online supplementary data contains further data from the study and the surveys used in the study.

This work was previously presented as an abstract at the MPPDA 2023 Annual Meeting at the Association of Pediatric Program Directors Annual Spring Meeting, March 28-31, 2023, Atlanta, Georgia, USA.

Funding: Time to develop and implement this project was afforded by the New York Children’s Environmental Health Centers.

Conflict of interest: The authors declare they have no competing interests.