Exploring UK medical students' views on the inclusion of healthcare and climate change within undergraduate medical education - a national survey

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This study aims to establish UK medical students’ opinions on climate change and health outcomes as well as their opinion on the respective medical school curricula inclusion of this topic. Methods An online survey consisting of multiple-choice, Likert-scale questions and free text questions was distributed nationally. Results 206 medical students responded. 173 (84%) and 188 (91.3%) were in agreement that climate change currently impacts health outcomes and it is important for healthcare professionals to be aware of this impact respectively. However, only 39 students were in agreement that they are confident discussing this topic with the patients, with only 38 students reporting environmental health teaching in their school and 15 students subjectively reporting this as adequate. Female students and students aged 40-44 were significantly more likely to agree that their medical school provides adequate education on climate change. 153 (74.3%) believe the inclusion of climate change related health topics should be mandatory during their training. Conclusions A majority of UK medical students surveyed, lack the confidence to counsel patients on climate change related health topics and perceive their respective medical school’s curricula coverage of this topic inadequate. This study demonstrates students’ demand and the gap in medical schools’ curricula on climate change related health topics across the UK. With an increasing health threat due to climate change, there is a need to update and evaluate the current medical school curricula. Climate Change Medical Education Medical student National survey Student perspective Figures Figure 1 Figure 2 Figure 3 Introduction In advance of the most recent United Nation Climate Change Conference (COP26) in 2021, the World Health Organisation (WHO) released a report on climate change and its associated health consequences proclaiming climate change to be ‘the single biggest health threat facing humanity’ (World Health Organizationc (WHO) 2021). The WHO estimates an additional 250 000 deaths per year to occur between the year 2030–2050 as a consequence of climate change (World Health Organization 2021 ). At a glance, the most recognisable adverse health effect is the mortality from extreme weathers and natural disasters such as droughts, floods and wildfires. Further consequences of climate change include an increase in the incidence of infectious diseases, cardiorespiratory conditions and undernutrition driven by food insecurity (Rocque et al. 2021 ). In addition to the adverse effects climate change has on physical health; deterioration in mental health has also been observed; including post-traumatic stress disorders or anxiety caused by natural disasters or the uncertainty of the future with the progression of global warming respectively (Berry et al. 2009 ). Consequently, this increase in prevalence of illnesses will increases the financial burden on the National Health Service (NHS), this being partially explained by the inevitable rise in hospital admissions (Corcuera Hotz and Hajat 2020 ) and ambulance call outs (Mahmood et al. 2017 ). As the NHS is a finite resource with limited funding, this rise in service demand without adequate service provision would further negatively impact patient care (Tennison et al. 2021 ) Healthcare professionals are seen as key advocates in driving the education and health policies needed to reduce the effect of climate change health care. Numerous studies in literature demonstrate that medical students and physicians globally are aware of climate change and its discernible health implications (Liao et al. 2019 ; Majra and Acharya 2009 ; Pandve and Raut 2011 ; Purcell and McGirr 2014 ; VILLELLA 2011 ) but concernedly there is a lack of preparation and knowledge in responding to climate change consequences (Hampshire et al. 2021 ; Liao et al. 2019 ; Majra and Acharya 2009 ). Previous studies in the United States (US) showed that a majority of medical students surveyed believe there is inadequate education on environmental health in undergraduate medical education (Finkel 2019 ), specifically climate change and its associated health effects (Hampshire et al. 2021 ). Thus, this study primarily aims to assess the awareness of climate change and its health implications amongst medical students in the United Kingdon (UK). Secondary aims of this study include: eliciting medical students’ opinions on their respective medical school incorporation of climate change into the curricula and the promotion of climate change related topics. This is the first known study performed in the UK to evaluate current medical students' opinions on the impact of climate change and the needs for such topics to be incorporated within the domestic medical school curriculum. Methods Ethical approval for this study was deemed not required by the use of the NHS Research Ethics Committee tool provided by the Medical Research Council. An online survey was developed and distributed to all year cohorts in the 37 medical schools across the UK. The survey consisted of 21 questions, modelled on previous US based studies, and aimed to obtain relevant student related factors that could influence likelihood of students’ pursuing medical school curricula change to incorporate climate change and its consequences (Hampshire et al. 2021) The survey consisted of a mixture of multiple-choice, 5-point Likert scale of agreeableness and free text questions in order to ascertain a comprehensive overview of medical students’ perspectives. Google Forms was utilised as online platform of choice to deliver the self-administered surveys. Google Forms requires participants to be signed-in to a Google account to complete the survey which prevented multiple entries from individual respondents. On 4 th January 2022, an invitation to participate in the survey was sent out to all medical students across the UK alongside an introductory message. The survey was distributed using medical school year social media groups. At the time of the survey being distributed, clear instruction was given to only participate if individuals were enrolled into a UK medical school only. Study participation was voluntary and no identifying information was collected. All statistical analysis was performed using R v3.6.1. Cronbach's alpha was used to measure internal consistency among items in the survey (ɑ = 0.852, Bootstrapped 95% CI [0.818,0.880]). Alpha shows reliable consistency among answering questions in the survey. Statistical significance was determined at p-value < 0.05. Likert-scale questions were converted to numeric values for analysis as follows: Strongly Disagree = 1; Disagree = 2; Neutral = 3; Agree = 4; Strongly Agree = 5. Results Demographics In total, 206 medical students, from 25 of the 37 UK medical schools, responded to our survey. The breakdown in responses per medical school is shown in Figure 1. 69.9% of medical students that responded fell within the 20-24 age group range (n=144), with the 25-29 (n=29) and 17-19 (n=28) age group ranges being the next populous. 71.4% of medical students identified themselves as female (n=147), with the remainder identifying themselves as male (n=56) and other (n=3). 87.9% entered medical school as an undergraduate (n=181), with the remainder having entered medical school as a post-graduate (n=25). 69.9% of medical students that responded were in the clinical phase of their medical school curricula (n=144), with the remainder in their pre-clinical phase (n=62) . 24.8% of medical students were engaged in climate change related projects prior to attending medical school (n=41). Medical students’ perspectives on climate change and its association with healthcare outcomes 97.6% of medical students surveyed were in agreement that climate change is happening at present (n=201). 46.6% of medical students agreed or strongly agreed on the statement that they are knowledgeable on the influence of climate change on healthcare and the NHS (n=96) with the remainder of students self-reporting a neutral stance (n=48) or disagreeing/strongly disagreeing to this statement (n=62). 84% (n=173) were in agreement that climate change affects health outcomes. The remainder of students had neutral stance (n=19) or disagreeing/strongly disagreeing to this statement (n=14). 74.8% (154) strongly agreed/agreed that this is a negative health effect and 89.9% (n=185) were in agreement that if climate change continues at the current rate, will harm patients' health outcome within the next 10 years. Participants were varied in deciding the single most important health consequence of climate change as seen in Table 1 . 38.8% of participants believed it was the prominence of health inequalities (n=80), with health consequences of natural disasters (n=30); increase in respiratory associated illness (n=27); increased infectious disease transmission (n=23) and undernutrition caused by food insecurity (n=22) being the next popular answers. Table 1: A breakdown of medical students' responses on the single most important health consequence of climate change Most important health consequences Number of responses Health inequalities becoming more prominent 80 health consequences of natural disasters 30 Increase in respiratory associated illness 27 Increased infectious disease transmission 23 Undernutrition caused by food insecurity 22 Worsening of cardiovascular health 8 Worsening of cancer related events 6 Worsening of mental health 6 Others 4 91.3% (n=188) of the responses were in agreement and 4.3% (n=9) in disagreement that medical students and doctors should be well-informed on climate change consequences on health. However, only 19% (n=37) of the students surveyed agreed or strongly agreed that they were confident in counselling patients on climate change related health topics. The remaining responses were in disagreement (62.1%, n= 128) or was neutral (18.9%, n= 39). The breakdown of the responses pertaining to climate change and its effects on health care are shown in figure 2. Medical students’ perspective on climate change and the medical school curricula Only 18.4% (n=38) of medical students reported receiving climate change and health teaching during medical school whilst 81.6% (n=168) reports no teaching on this topic. 77.2% (n=159) were in disagreement that their medical school provide an adequate education on this topic with 15.5% (n=32) taking a neutral view and the remainder of the responses were in agreement of the statement. Moreover, 80.6% were in agreement that the climate related health topics should be included in the core medical school curriculum. There was a mixed response regarding the incorporation of this topic into the curriculum, with 37.4% of medical students who believed this topic should be mandatory in both preclinical and clinical years, 31.1% who believed this topic should be mandatory only in preclinical years and the remainder of the responses were a combination of; mandatory in clinical years (5.8%), non-mandatory in preclinical years (8.3%), non-mandatory in clinical years (2.4%), non-mandatory in preclinical and clinical years (9.2%) and the topic should not be included in the curriculum at all (5.8%). Figure 3 shows a breakdown of medical students’ views on the medical schools’ response to climate change Participants were varied in reporting resources that would be helpful in educating medical students on climate change and its health effects. (n =62) was unsure. Example of other answers include; ‘Provide websites where students can look for more information on where they can make an impact and more information of the topic.’ ‘Links to statistics and journal articles illustrating the effect climate change has as well as the impact the NHS has in the environment.’ ‘Medicine-specific projects to get involved with to combat climate change’ ‘Workshops with the Centre for Sustainable Healthcare, incorporating sustainability and climate and health education in PBL sessions where relevant at medical schools, Health Care Without Harm’ ‘Green societies or events to bring awareness and encourage students to be involved in climate action’ ‘Talks from people in the community most affected / indigenous communities’ ‘Doctors and seniors should be actively advocating for it in their work’ ‘Conferences on climate change, more healthcare professional presence at climate change events eg COP’ ‘More widely available and tangible projects in the field that offer accreditation and teaching opportunities’ ‘Promoting outside organisations (especially initiatives students can engage in) via medical school communiques’ Factors affecting likelihood of medical students being satisfied with their medical school providing adequate education on climate change and its associated impacts The statistical breakdown used to create this multivariate analysis can be seen in Appendix 1. Participants studying at a medical school in Northern Ireland were significantly more likely to be satisfied with their medical school providing adequate education on climate change and its associated impacts (β=0.99, p=0.03). There was no significant difference noted with other medical schools. With regards to gender, females in our cohort were significantly dissatisfied with their medical school provisions on climate change education (β=-1.31, p=0.02) whereas males were non-significantly dissatisfied (β=-0.96, p=0.11). Participants in the 40-44 age demographic were significantly more satisfied with their medical school and their provision of adequate climate change education (β=2.50, p=0.02). No significant association was noted between participants’ medical school entry status (undergraduate vs graduate) or phase of medical school (clinical vs pre-clinical) and their satisfaction with their medical school’s provision of adequate education on climate change and its associated impacts. There was no significance noted between participants’ involvement in climate related projects prior to medical school and their current satisfaction with their medical school and provision of climate change education (β=-0.10, p=0.59). Participants that had strongly agreed (β=0.89, p=0.03), agreed (β=0.90, p=0.01) and remained neutral (β= 0.89, p=0.01) on the statement that they had thought greatly about the impact of climate change on patient’s health, were significantly more satisfied with their medical school and the climate change education it provides. For those that responded strongly agree to the statement that they were worried about the impact of climate change on patient’s health, there was a significant dissatisfaction associated with their medical school and its climate change education (β=-0.98, p=0.01). Factors affecting likelihood of medical students believing that climate change and its associated impacts should be incorporated within the core medical school curriculum There was no significant association between participants’ medical school, gender, age group, medical school entry, medical school phase with medical students’ beliefs that climate change and its associated impacts should be incorporated within the core medical school curriculum. Participant’s pre-survey thoughts on the impact of climate change on patient’s health had no significant impact on their belief that climate change education should be incorporated into medical school curricula. Those that agreed with the statement that they worried about the impact of climate change pre-survey were shown to be significantly likely in believing that climate change education should be incorporated within the core medical school curriculum (β=0.94, p=0.009). The statistical breakdown used to create this multivariate analysis can be seen in Appendix 2. Discussion The aims of this study are; firstly, to assess the awareness of climate change and its health implications amongst medical students in the UK and secondly to assess medical students’ opinion on how the medical schools promote this topic. This study found that a large majority of medical students are aware of the occurrence of climate change and are in agreement that climate change could affect patients’ health outcome, specifically the current patients and the NHS. Moreover, medical students are aware of the progression of climate change and its’ impending negative impact if no actions are taken to halt its progression. Although the majority of the responses were in agreement that physicians should be knowledgeable and play an active role in responding to climate change, the responses pertaining to the medical student's confidence in counselling patients on the effects of climate change on health outcomes are considerably reversed. More than half of the medical students reported to be unprepared to counsel patients regarding the health risks brought about by climate change. These results are mirrored in a similar US study where more than 90% of medical students surveyed, believed that climate change could result in adverse health outcomes but only 6.3% felt prepared to discuss the topic (Hampshire et al. 2021). This lack of confidence, although could be partially explained by the students’ reduced clinical exposure or communication skills development, points to a lack of knowledge as a significant cause. Anecdotally, the health community in the UK has voiced that climate change is not immersed in the medical education curriculum (Iacobucci 2022) and this study further validates this concern. A majority of medical students in this study reported no medical school curriculum coverage of health and climate change. This corresponds with the result of a 2020 survey performed by the International Federation of Medical Students’ Associations which revealed only 15% of 2817 global medical schools has climate change and health included in their curriculum (Omrani et al. 2020). Moreover, despite some medical students reported to be receiving climate change and environmental health teaching during medical school, only 7% (3/38) of these students were in agreement that this was adequate. This study did not explore the barriers in the incorporation of planetary health topics into the medical school curricular. However, literature have shown the omission of this topic in the medical school curricula to be due to a lack of knowledge and the lack of recognition of how the knowledge can be applied to clinical practice from the faculty personnel (Nordrum et al. 2022; Tun (May Sanyu Tun), SanYuMay et al. 2020; Walpole et al. 2019) Factors affecting medical students' perspective on with their medical school’s curricular inclusion of health-related climate change topic In this study, medical schools in Northen Ireland region, namely Queen's University Belfast Medical School, was more likely to be satisfied with the adequacy of climate change related health topics covered by their medical school curricula. A 2022 study on planetary health education in five medical schools in Ireland showed that a range of topics were taught, as per the curriculum learning objectives set by Planetary Health Report Card initiative (Nordrum et al. 2022). Although, Queen's University Belfast Medical School was not included in this study but it may be extrapolated that climate change topics are better covered in Irish medical schools. As there is currently no literature to compare the different UK medical school curricula on health and climate change, more research is needed to explain this finding. Female medical students were found to be significantly less satisfied whilst students aged 40-44 were significantly more satisfied with the medical school curriculum coverage. Literature suggests that females (Knight and Givens 2021; McCright and Xiao 2014) and younger generations (Milfont et al. 2021) especially gen Z and millennials (Funk 2021) are more concerned about climate change; this apprehension could provoke dissatisfaction if the curriculum does not meet ones’ expectation. This is also reflected in the results obtained from this study that medical students who are more worried about the impact of climate change pre-survey were shown to be significantly likely to believe that climate change education should be incorporated within the core medical school curriculum Medical students' opinions on extra-curricular support on climate change initiatives The study found variable responses in the ability for students to discuss climate friendly initiatives in medical school. Although the majority of the students reported neutral feeling or agreed that they can discuss climate friendly initiatives within the medical school, only a minority have been encouraged to play a role in responding to climate change and a minority still reported that they were engaged in climate change initiatives during their training. Moreover, although students with prior knowledge and exposure to climate change and its consequences may be more pro-active in discussing and advocating for climate friendly initiatives, this study found no association between students’ prior engagement in climate change related topic and their belief in the ease of discussion regarding climate change initiatives in medical school. This may demonstrate a lack of promotion and support from within the institution. Arguably, this may not necessarily reflect the insufficient promotion in the medical school as this does not account for the training demands medical students endure to meet the faculty standards. The high workload (Hill et al. 2018) presents a barrier to students taking on further roles in projects which may be important but does not necessarily obtain additional merits in regards to future career progression. This further highlights the need for global health topics to be included in the core curriculum to prevent it from being neglected. Some suggestions from medical students to improve education on climate change and its health effects include; health and climate change conferences, society events to raise awareness and the provision of online resources. The importance of medical school curricula inclusion of climate health Based on this evidence, as curriculum improvement is partially driven by students' feedback, this study highlights the need to improve and integrate more climate change and health education into the medical school curriculum. The importance of this being; clinically, future physicians will need to be able to recognise the risk factors, to prevent and treat patients with climate related health conditions. As these conditions can be multi-organ related and the increase in demand on the health service may cause doctors of all specialties to engage in climate related health education, it is vital that all doctors are aware of the pathophysiology, epidemiology and treatment of these climate change related diseases. From a public health perspective, physicians are important promoters of public health. They are a provider of digestible information, allowing the public to make an informed health decision. Moreover, physicians could use this knowledge to improve health services and contribute to the design of future health policies. As this study also found that in medical students' opinion, the single most important health consequence of climate change is the worsening in health inequalities, the knowledge on public health would concomitantly promote health equity. While the authors understand that the focus of the medical school curriculum should be around pathophysiology and patient care, the wider importance of socioeconomic and health factors should not be overlooked. Further studies are needed to design the specific details of the coverage of the curriculum. However, this study primarily showed that medical students believe the climate change topic should be a mandatory training which could be included in the pre-clinical or the clinical year. Currently, the estimated contribution of the NHS carbon footprint is around 4% of the total emission in England (NHS 2020). While parts of the health sector have responded to the increasing threats of global warming, for example the NHS delivering a ‘net zero’ service and the Royal society of medicine launching a health and climate change educational studies, there has not been enough responses from the UK medical schools to adapt the curriculum to the suit the growing threat. Arguably this is one of the most important responses as the future health workers will need to be well- informed to enable them to deliver the optimal care in the most sustainable fashion in the changing climate. As new doctors are entering into the workforce, they need to be aware of the targets and aims set up by the organisation. With a lack of education, it is likely the new incoming physicians are not aware of such strategies. The effort to mitigate the effects of climate change could lead to a reduction in costs for the health section as well as enhance patient care (Karliner et al. 2020; Watts et al. 2019). Limitations The authors acknowledge the sample size and the response rate of this study to be a limitation and acknowledge that this may not be wholly representative of the overall views exhibited by all medical students in the UK. Moreover, as there is a variation in responses across different medical school and the survey relied on voluntary completion, selection bias cannot be ruled out. The responses received included medical students in various stage of training, some of which have not completed the entire curriculum. Moreover, new curriculum content may have been introduced during a student’s time at medical school. As there was no formal verification with medical school performed, the responses regarding climate change teaching and students’ opinion on the adequacy of the curriculum may be biased. Declarations Acknowledgements The authors would like to thank all the medical students who participated in our nationwide survey. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflicts of Interest The authors declare that they do not have conflicts of interest to declare. This research did not receive any support from any organisation Ethics approval and consent to participate This study did not include experiments on animal or human subjects. Utilisation of the NHS Research Ethics Committee tool provided by the Medical Research Council determined that ethical approval was not required for this study. Consent was received from the participants in order to use information obtained for the purpose of this study. Consent for publication During the distribution of the national survey, participants were informed that by completing the survey they would be providing consent for their anonymised data to be used, analysed and potentially published. Consent was received from all participants for the publication of this manuscript. References Berry, H. L., Bowen, K. & Kjellstrom, T. (2009). Climate change and mental health: a causal pathways framework. International Journal of Public Health, 55, 123-132. 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Climate change and health , from https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health World Health Organization(WHO). COP26 Special report on climate change and health: The health argument for climate action Additional Declarations No competing interests reported. Supplementary Files AppendixforClimatechange.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-2046642","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":135587265,"identity":"574d8e3e-502e-46f5-a8c5-b91cbad25cd1","order_by":0,"name":"Kanapath Oungpasuk","email":"data:image/png;base64,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","orcid":"","institution":"Chelsea and Westminster Hospital NHS Foundation Trust","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Kanapath","middleName":"","lastName":"Oungpasuk","suffix":""},{"id":135587266,"identity":"99960308-d222-485a-9e92-bffbb05e28d8","order_by":1,"name":"Lavandan Jegatheeswaran","email":"","orcid":"","institution":"Norfolk and Norwich University Hospitals NHS Foundation Trust","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lavandan","middleName":"","lastName":"Jegatheeswaran","suffix":""},{"id":135587267,"identity":"10143f8c-0987-4935-8722-4eba51dea104","order_by":2,"name":"Maria Nakhoul","email":"","orcid":"","institution":"Dana-Farber Cancer Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Maria","middleName":"","lastName":"Nakhoul","suffix":""},{"id":135587268,"identity":"e9965e3e-db78-40ea-8a7f-20f63fb6d8fa","order_by":3,"name":"Byung Choi","email":"","orcid":"","institution":"Ashford and St Peter's Hospitals NHS Foundation Trust","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Byung","middleName":"","lastName":"Choi","suffix":""}],"badges":[],"createdAt":"2022-09-08 20:14:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2046642/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2046642/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":26417566,"identity":"121cc43d-c813-465a-ba79-b077ca4aaf7b","added_by":"auto","created_at":"2022-09-13 20:29:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":96785,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of responses per medical school\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2046642/v1/5f96bfae5cb2dd29c39a69a7.png"},{"id":26418490,"identity":"1b0fe4f8-c2c5-44b1-85e6-8fcd3ac70c75","added_by":"auto","created_at":"2022-09-13 20:39:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":171251,"visible":true,"origin":"","legend":"\u003cp\u003eA breakdown of medical students' responses on climate change and healthcare\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2046642/v1/846f54e43ce8d3bc27c02045.png"},{"id":26418205,"identity":"ae81a56b-5470-4421-aa4b-0b59473a7729","added_by":"auto","created_at":"2022-09-13 20:34:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":83814,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of medical students’ views on the medical schools’ response to climate change\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-2046642/v1/da794619bc398c7d96345891.png"},{"id":28686411,"identity":"20cd8db0-dde9-430e-99d6-2a20322c1894","added_by":"auto","created_at":"2022-11-04 22:44:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":722020,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2046642/v1/f39545c8-fddd-4498-9fc1-c472c4a6763c.pdf"},{"id":26418206,"identity":"1268e9f6-791a-4309-80b6-4dc63f52af77","added_by":"auto","created_at":"2022-09-13 20:34:23","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20917,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixforClimatechange.docx","url":"https://assets-eu.researchsquare.com/files/rs-2046642/v1/bb8d0d972653ad500b80516b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring UK medical students' views on the inclusion of healthcare and climate change within undergraduate medical education - a national survey","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn advance of the most recent United Nation Climate Change Conference (COP26) in 2021, the World Health Organisation (WHO) released a report on climate change and its associated health consequences proclaiming climate change to be \u0026lsquo;the single biggest health threat facing humanity\u0026rsquo; (World Health Organizationc (WHO) 2021). The WHO estimates an additional 250 000 deaths per year to occur between the year 2030\u0026ndash;2050 as a consequence of climate change (World Health Organization \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). At a glance, the most recognisable adverse health effect is the mortality from extreme weathers and natural disasters such as droughts, floods and wildfires. Further consequences of climate change include an increase in the incidence of infectious diseases, cardiorespiratory conditions and undernutrition driven by food insecurity (Rocque et al. \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In addition to the adverse effects climate change has on physical health; deterioration in mental health has also been observed; including post-traumatic stress disorders or anxiety caused by natural disasters or the uncertainty of the future with the progression of global warming respectively (Berry et al. \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Consequently, this increase in prevalence of illnesses will increases the financial burden on the National Health Service (NHS), this being partially explained by the inevitable rise in hospital admissions (Corcuera Hotz and Hajat \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and ambulance call outs (Mahmood et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). As the NHS is a finite resource with limited funding, this rise in service demand without adequate service provision would further negatively impact patient care (Tennison et al. \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eHealthcare professionals are seen as key advocates in driving the education and health policies needed to reduce the effect of climate change health care. Numerous studies in literature demonstrate that medical students and physicians globally are aware of climate change and its discernible health implications (Liao et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Majra and Acharya \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Pandve and Raut \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Purcell and McGirr \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; VILLELLA \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) but concernedly there is a lack of preparation and knowledge in responding to climate change consequences (Hampshire et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Liao et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Majra and Acharya \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Previous studies in the United States (US) showed that a majority of medical students surveyed believe there is inadequate education on environmental health in undergraduate medical education (Finkel \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), specifically climate change and its associated health effects (Hampshire et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThus, this study primarily aims to assess the awareness of climate change and its health implications amongst medical students in the United Kingdon (UK). Secondary aims of this study include: eliciting medical students\u0026rsquo; opinions on their respective medical school incorporation of climate change into the curricula and the promotion of climate change related topics. This is the first known study performed in the UK to evaluate current medical students' opinions on the impact of climate change and the needs for such topics to be incorporated within the domestic medical school curriculum.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eEthical approval for this study was deemed not required by the use of the NHS Research Ethics Committee tool provided by the Medical Research Council.\u003c/p\u003e\n\u003cp\u003eAn online survey was developed and distributed to all year cohorts in the 37 medical schools across the UK. The survey consisted of 21 questions, modelled on previous US based studies, and aimed to obtain relevant student related factors that could influence likelihood of students’ pursuing medical school curricula change to incorporate climate change and its consequences\u0026nbsp;(Hampshire et al. 2021)\u003c/p\u003e\n\u003cp\u003eThe survey consisted of a mixture of multiple-choice, 5-point Likert scale of agreeableness and free text questions in order to ascertain a comprehensive overview of medical students’ perspectives. Google Forms was utilised as online platform of choice to deliver the self-administered surveys. Google Forms requires participants to be signed-in to a Google account to complete the survey which prevented multiple entries from individual respondents. On 4\u003csup\u003eth\u003c/sup\u003e January 2022, an invitation to participate in the survey was sent out to all medical students across the UK alongside an introductory message. The survey was distributed using medical school year social media groups. At the time of the survey being distributed, clear instruction was given to only participate if individuals were enrolled into a UK medical school only. Study participation was voluntary and no identifying information was collected.\u003c/p\u003e\n\u003cp\u003eAll statistical analysis was performed using R v3.6.1. Cronbach's alpha was used to measure internal consistency among items in the survey (ɑ = 0.852, Bootstrapped 95% CI [0.818,0.880]). Alpha shows reliable consistency among answering questions in the survey. Statistical significance was determined at p-value \u0026lt; 0.05. Likert-scale questions were converted to numeric values for analysis as follows: Strongly Disagree = 1; Disagree = 2; Neutral = 3; Agree = 4; Strongly Agree = 5.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn total, 206 medical students, from 25 of the 37 UK medical schools, responded to our survey. The breakdown in responses per medical school is shown in Figure 1. 69.9% of medical students that responded fell within the 20-24 age group range (n=144), with the 25-29 (n=29) and 17-19 (n=28) age group ranges being the next populous. 71.4% of medical students identified themselves as female (n=147), with the remainder identifying themselves as male (n=56) and other (n=3). 87.9% entered medical school as an undergraduate (n=181), with the remainder having entered medical school as a post-graduate (n=25). 69.9% of medical students that responded were in the clinical phase of their medical school curricula (n=144), with the remainder in their pre-clinical phase (n=62)\u003cstrong\u003e.\u003c/strong\u003e 24.8% of medical students were engaged in climate change related projects prior to attending medical school (n=41).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMedical students\u0026rsquo; perspectives on climate change and its association with healthcare outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e97.6% of medical students surveyed were in agreement that climate change is happening at present (n=201). 46.6% of medical students agreed or strongly agreed on the statement that they are knowledgeable on the influence of climate change on healthcare and the NHS (n=96) with the remainder of students self-reporting a neutral stance (n=48) or disagreeing/strongly disagreeing to this statement (n=62).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e84% (n=173) were in agreement that climate change affects health outcomes. The remainder of students had neutral stance (n=19) or disagreeing/strongly disagreeing to this statement (n=14). 74.8% (154) strongly agreed/agreed that this is a negative health effect and 89.9% (n=185) were in agreement that if climate change continues at the current rate, will harm patients\u0026apos; health outcome within the next 10 years.\u003c/p\u003e\n\u003cp\u003eParticipants were varied in deciding the single most important health consequence of climate change as seen in Table 1\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e38.8% of participants believed it was the prominence of health inequalities (n=80), with health consequences of natural disasters (n=30); increase in respiratory associated illness (n=27); increased infectious disease transmission (n=23) and undernutrition caused by food insecurity (n=22) being the next popular answers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003eA breakdown of medical students\u0026apos; responses on the single most important health consequence of climate change\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"64.4524236983842%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMost important health consequences\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.5475763016158%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"64.4524236983842%\"\u003e\n \u003cp\u003eHealth inequalities becoming more prominent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.5475763016158%\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"64.4524236983842%\"\u003e\n \u003cp\u003ehealth consequences of natural disasters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.5475763016158%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"64.4524236983842%\"\u003e\n \u003cp\u003eIncrease in respiratory associated illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.5475763016158%\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"64.4524236983842%\"\u003e\n \u003cp\u003eIncreased infectious disease transmission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.5475763016158%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"64.4524236983842%\"\u003e\n \u003cp\u003eUndernutrition caused by food insecurity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.5475763016158%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"64.4524236983842%\"\u003e\n \u003cp\u003eWorsening of cardiovascular health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.5475763016158%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"64.4524236983842%\"\u003e\n \u003cp\u003eWorsening of cancer related events\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.5475763016158%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"64.4524236983842%\"\u003e\n \u003cp\u003eWorsening of mental health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.5475763016158%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"64.4524236983842%\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.5475763016158%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e91.3% (n=188) of the responses were in agreement and 4.3% (n=9) in disagreement that medical students and doctors should be well-informed on climate change consequences on health. However, only 19% (n=37) of the students surveyed agreed or strongly agreed that they were confident in counselling patients on climate change related health topics. The remaining responses were in disagreement (62.1%, n= 128) or was neutral (18.9%, n= 39). The breakdown of the responses pertaining to climate change and its effects on health care are shown in figure 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMedical students\u0026rsquo; perspective on climate change and the medical school curricula\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnly 18.4% (n=38) of medical students reported receiving climate change and health teaching during medical school whilst 81.6% (n=168) reports no teaching on this topic. 77.2% (n=159) were in disagreement that their medical school provide an adequate education on this topic with 15.5% (n=32) taking a neutral view and the remainder of the responses were in agreement of the statement. Moreover, 80.6% were in agreement that the climate related health topics should be included in the core medical school curriculum. There was a mixed response regarding the incorporation of this topic into the curriculum, with 37.4% of medical students who believed this topic should be mandatory in both preclinical and clinical years, 31.1% who believed this topic should be mandatory only in preclinical years and the remainder of the responses were a combination of; mandatory in clinical years (5.8%), non-mandatory in preclinical years (8.3%), non-mandatory in clinical years (2.4%), non-mandatory in preclinical and clinical years (9.2%) and the topic should not be included in the curriculum at all (5.8%). Figure 3 shows a breakdown of medical students\u0026rsquo; views on the medical schools\u0026rsquo; response to climate change\u003c/p\u003e\n\u003cp\u003eParticipants were varied in reporting resources that would be helpful in educating medical students on climate change and its health effects. (n =62) was unsure. Example of other answers include;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u0026lsquo;Provide websites where students can look for more information on where they can make an impact and more information of the topic.\u0026rsquo;\u003c/li\u003e\n \u003cli\u003e\u0026lsquo;Links to statistics and journal articles illustrating the effect climate change has as well as the impact the NHS has in the environment.\u0026rsquo;\u003c/li\u003e\n \u003cli\u003e\u0026lsquo;Medicine-specific projects to get involved with to combat climate change\u0026rsquo;\u003c/li\u003e\n \u003cli\u003e\u0026lsquo;Workshops with the Centre for Sustainable Healthcare, incorporating sustainability and climate and health education in PBL sessions where relevant at medical schools, Health Care Without Harm\u0026rsquo;\u003c/li\u003e\n \u003cli\u003e\u0026lsquo;Green societies or events to bring awareness and encourage students to be involved in climate action\u0026rsquo;\u003c/li\u003e\n \u003cli\u003e\u0026lsquo;Talks from people in the community most affected / indigenous communities\u0026rsquo;\u003c/li\u003e\n \u003cli\u003e\u0026lsquo;Doctors and seniors should be actively advocating for it in their work\u0026rsquo;\u003c/li\u003e\n \u003cli\u003e\u0026lsquo;Conferences on climate change, more healthcare professional presence at climate change events eg COP\u0026rsquo;\u003c/li\u003e\n \u003cli\u003e\u0026lsquo;More widely available and tangible projects in the field that offer accreditation and teaching opportunities\u0026rsquo;\u003c/li\u003e\n \u003cli\u003e\u0026lsquo;Promoting outside organisations (especially initiatives students can engage in) via medical school communiques\u0026rsquo;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eFactors affecting likelihood of medical students being satisfied with their medical school providing adequate education on climate change and its associated impacts\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe statistical breakdown used to create this multivariate analysis can be seen in Appendix 1. Participants studying at a medical school in Northern Ireland were significantly more likely to be satisfied with their medical school providing adequate education on climate change and its associated impacts (\u0026beta;=0.99, p=0.03). There was no significant difference noted with other medical schools. With regards to gender, females in our cohort were significantly dissatisfied with their medical school provisions on climate change education (\u0026beta;=-1.31, p=0.02) whereas males were non-significantly dissatisfied (\u0026beta;=-0.96, p=0.11). Participants in the 40-44 age demographic were significantly more satisfied with their medical school and their provision of adequate climate change education (\u0026beta;=2.50, p=0.02). No significant association was noted between participants\u0026rsquo; medical school entry status (undergraduate vs graduate) or phase of medical school (clinical vs pre-clinical) and their satisfaction with their medical school\u0026rsquo;s provision of adequate education on climate change and its associated impacts. There was no significance noted between participants\u0026rsquo; involvement in climate related projects prior to medical school and their current satisfaction with their medical school and provision of climate change education (\u0026beta;=-0.10, p=0.59).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants that had strongly agreed (\u0026beta;=0.89, p=0.03), agreed (\u0026beta;=0.90, p=0.01) and remained neutral (\u0026beta;= 0.89, p=0.01) on the statement that they had thought greatly about the impact of climate change on patient\u0026rsquo;s health, were significantly more satisfied with their medical school and the climate change education it provides. For those that responded strongly agree to the statement that they were worried about the impact of climate change on patient\u0026rsquo;s health, there was a significant dissatisfaction associated with their medical school and its climate change education (\u0026beta;=-0.98, p=0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors affecting likelihood of medical students believing that climate change and its associated impacts should be incorporated within the core medical school curriculum\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no significant association between participants\u0026rsquo; medical school, gender, age group, medical school entry, medical school phase with medical students\u0026rsquo; beliefs that climate change and its associated impacts should be incorporated within the core medical school curriculum.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003c/strong\u003eParticipant\u0026rsquo;s pre-survey thoughts on the impact of climate change on patient\u0026rsquo;s health had no significant impact on their belief that climate change education should be incorporated into medical school curricula. Those that agreed with the statement that they worried about the impact of climate change pre-survey were shown to be significantly likely in believing that climate change education should be incorporated within the core medical school curriculum (\u0026beta;=0.94, p=0.009). The statistical breakdown used to create this multivariate analysis can be seen in Appendix 2.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aims of this study are; firstly, to assess the awareness of climate change and its health implications amongst medical students in the UK and secondly to assess medical students’ opinion on how the medical schools promote this topic. This study found that a large majority of medical students are aware of the occurrence of climate change and are in agreement that climate change could affect patients’ health outcome, specifically the current patients and the NHS. Moreover, medical students are aware of the progression of climate change and its’ impending negative impact if no actions are taken to halt its progression. Although the majority of the responses were in agreement that physicians should be knowledgeable and play an active role in responding to climate change, the responses pertaining to the medical student's confidence in counselling patients on the effects of climate change on health outcomes are considerably reversed. More than half of the medical students reported to be unprepared to counsel patients regarding the health risks brought about by climate change. These results are mirrored in a similar US study where more than 90% of medical students surveyed, believed that climate change could result in adverse health outcomes but only 6.3% felt prepared to discuss the topic\u0026nbsp;(Hampshire et al. 2021).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis lack of confidence, although could be partially explained by the students’ reduced clinical exposure or communication skills development, points to a lack of knowledge as a significant cause. Anecdotally, the health community in the UK has voiced that climate change is not immersed in the medical education curriculum\u0026nbsp;(Iacobucci 2022)\u0026nbsp;and this study further validates this concern. A majority of medical students in this study reported no medical school curriculum coverage of health and climate change. This corresponds with the result of a 2020 survey performed by the International Federation of Medical Students’ Associations which revealed only 15% of 2817 global medical schools has climate change and health included in their curriculum\u0026nbsp;(Omrani et al. 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoreover, despite some medical students reported to be receiving climate change and environmental health teaching during medical school, only 7% (3/38) of these students were in agreement that this was adequate. This study did not explore the barriers in the incorporation of planetary health topics into the medical school curricular. However, literature have shown the omission of this topic in the medical school curricula to be due to a lack of knowledge and the lack of recognition of how the knowledge can be applied to clinical practice from the faculty personnel\u0026nbsp;(Nordrum et al. 2022; Tun (May Sanyu Tun), SanYuMay et al. 2020; Walpole et al. 2019)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors affecting medical students' perspective on with their medical school’s curricular inclusion of health-related climate change topic\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, medical schools in Northen Ireland region, namely Queen's University Belfast Medical School, was more likely to be satisfied with the adequacy of climate change related health topics covered by their medical school curricula. A 2022 study on planetary health education in five medical schools in Ireland showed that a range of topics were taught, as per the curriculum learning objectives set by Planetary Health Report Card initiative\u0026nbsp;(Nordrum et al. 2022). Although, Queen's University Belfast Medical School was not included in this study but it may be extrapolated that climate change topics are better covered in Irish medical schools. As there is currently no literature to compare the different UK medical school curricula on health and climate change, more research is needed to explain this finding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFemale medical students were found to be significantly less satisfied whilst students aged 40-44 were significantly more satisfied with the medical school curriculum coverage. Literature suggests that females\u0026nbsp;(Knight and Givens 2021; McCright and Xiao 2014)\u0026nbsp;and younger generations\u0026nbsp;(Milfont et al. 2021)\u0026nbsp;especially gen Z and millennials\u0026nbsp;(Funk 2021)\u0026nbsp;are more concerned about climate change; this apprehension could provoke dissatisfaction if the curriculum does not meet ones’ expectation. This is also reflected in the results obtained from this study that medical students who are more worried about the impact of climate change pre-survey were shown to be significantly likely to believe that climate change education should be incorporated within the core medical school curriculum\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMedical students' opinions on extra-curricular support on climate change initiatives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study found variable responses in the ability for students to discuss climate friendly initiatives in medical school. Although the majority of the students reported neutral feeling or agreed that they can discuss climate friendly initiatives within the medical school, only a minority have been encouraged to play a role in responding to climate change and a minority still reported that they were engaged in climate change initiatives during their training. Moreover, although students with prior knowledge and exposure to climate change and its consequences may be more pro-active in discussing and advocating for climate friendly initiatives, this study found no association between students’ prior engagement in climate change related topic and their belief in the ease of discussion regarding climate change initiatives in medical school. This may demonstrate a lack of promotion and support from within the institution. Arguably, this may not necessarily reflect the insufficient promotion in the medical school as this does not account for the training demands medical students endure to meet the faculty standards. The high workload\u0026nbsp;(Hill et al. 2018)\u0026nbsp;presents a barrier to students taking on further roles in projects which may be important but does not necessarily obtain additional merits in regards to future career progression. This further highlights the need for global health topics to be included in the core curriculum to prevent it from being neglected. Some suggestions from medical students to improve education on climate change and its health effects include; health and climate change conferences, society events to raise awareness and the provision of online resources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe importance of medical school curricula inclusion of climate health\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on this evidence, as curriculum improvement is partially driven by students' feedback, this study highlights the need to improve and integrate more climate change and health education into the medical school curriculum. The importance of this being; clinically, future physicians will need to be able to recognise the risk factors, to prevent and treat patients with climate related health conditions. As these conditions can be multi-organ related and the increase in demand on the health service may cause doctors of all specialties to engage in climate related health education, it is vital that all doctors are aware of the pathophysiology, epidemiology and treatment of these climate change related diseases. From a public health perspective,\u0026nbsp;physicians are important promoters of public health. They are a provider of digestible information, allowing the public to make an informed health decision. Moreover, physicians could use this knowledge to improve health services and contribute to the design of future health policies. As this study also found that in medical students' opinion, the single most important health consequence of climate change is the worsening in health inequalities, the knowledge on public health would concomitantly promote health equity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile the authors understand that the focus of the medical school curriculum should be around pathophysiology and patient care, the wider\u0026nbsp;importance of socioeconomic and health factors should not be overlooked. Further studies are needed to design the specific details of the coverage of the curriculum. However, this study primarily showed that medical students believe the climate change topic should be a mandatory training which could be included in the pre-clinical or the clinical year.\u003c/p\u003e\n\u003cp\u003eCurrently, the estimated contribution of the NHS carbon footprint is around 4% of the total emission in England\u0026nbsp;(NHS 2020). While parts of the health sector have responded to the increasing threats of global warming, for example the NHS delivering a ‘net zero’ service and the Royal society of medicine launching a health and climate change educational studies, there has not been enough responses from the UK medical schools to adapt the curriculum to the suit the growing threat. Arguably this is one of the most important responses as the future health workers will need to be well- informed to enable them to deliver the optimal care in the most sustainable fashion in the changing climate. As new doctors are entering into the workforce, they need to be aware of the targets and aims set up by the organisation. With a lack of education, it is likely the new incoming physicians are not aware of such strategies. The effort to mitigate the effects of climate change could lead to a reduction in costs for the health section as well as enhance patient care\u0026nbsp;(Karliner et al. 2020; Watts et al. 2019).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the sample size and the response rate of this study to be a limitation and acknowledge that this may not be wholly representative of the overall views exhibited by all medical students in the UK. Moreover, as there is a variation in responses across different medical school and the survey relied on voluntary completion, selection bias cannot be ruled out.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe responses received included medical students in various stage of training, some of which have not completed the entire curriculum. Moreover, new curriculum content may have been introduced during a student’s time at medical school. As there was no formal verification with medical school performed, the responses regarding climate change teaching and students’ opinion on the adequacy of the curriculum may be biased.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgements\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the medical students who participated in our nationwide survey.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they do not have conflicts of interest to declare. This research did not receive any support from any organisation\u003cbr\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not include experiments on animal or human subjects. Utilisation of the NHS Research Ethics Committee tool provided by the Medical Research Council determined that ethical approval was not required for this study. Consent was received from the participants in order to use information obtained for the purpose of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the distribution of the national survey, participants were informed that by completing the survey they would be providing consent for their anonymised data to be used, analysed and potentially published. Consent was received from all participants for the publication of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBerry, H. L., Bowen, K. \u0026amp; Kjellstrom, T. (2009). Climate change and mental health: a causal pathways framework. International Journal of Public Health, 55, 123-132. DOI 10.1007/s00038-009-0112-0\u003c/li\u003e\n \u003cli\u003eCorcuera Hotz, I. \u0026amp; Hajat, S. (2020). The Effects of Temperature on Accident and Emergency Department Attendances in London: A Time-Series Regression Analysis. International Journal of Environmental Research and Public Health, 17, 1957. DOI 10.3390/ijerph17061957\u003c/li\u003e\n \u003cli\u003eFinkel, M. L. (2019). A call for action: integrating climate change into the medical school curriculum. Perspectives on Medical Education, 8, 265-266. DOI 10.1007/s40037-019-00541-8\u003c/li\u003e\n \u003cli\u003eHampshire, K., Ndovu, A., Bhambhvani, H. \u0026amp; Iverson, N. (2021). Perspectives on climate change in medical school curricula\u0026mdash;A survey of U.S. medical students. The journal of climate change and health, 4, 100033. DOI 10.1016/j.joclim.2021.100033\u003c/li\u003e\n \u003cli\u003eHill, M. R., Goicochea, S. \u0026amp; Merlo, L. J. (2018). In their own words: stressors facing medical students in the millennial generation. Medical Education Online, 23, 1530558-10. DOI 10.1080/10872981.2018.1530558\u003c/li\u003e\n \u003cli\u003eIacobucci, G. (2022). Medical schools should include climate change in their curriculum, says report. BMJ (Online), 376, o845. DOI 10.1136/bmj.o845\u003c/li\u003e\n \u003cli\u003eKarliner, J., Slotterback, S., Boyd, R., Ashby, B., Steele, K. \u0026amp; Wang, J. (2020). Health care\u0026rsquo;s climate footprint: the health sector contribution and opportunities for action. European journal of public health, 30. DOI 10.1093/eurpub/ckaa165.843\u003c/li\u003e\n \u003cli\u003eKnight, K. W. \u0026amp; Givens, J. E. (2021). Gender and climate change views in context: a cross-national multilevel analysis. The Social science journal (Fort Collins), ahead-of-print, 1-18. DOI 10.1080/03623319.2021.1913041\u003c/li\u003e\n \u003cli\u003eLiao, W., Yang, L., Zhong, S., Hess, J. J., Wang, Q., Bao, J. \u0026amp; Huang, C. (2019). Preparing the next generation of health professionals to tackle climate change: Are China\u0026apos;s medical students ready?. Environmental research, 168, 270-277. DOI 10.1016/j.envres.2018.10.006\u003c/li\u003e\n \u003cli\u003eMahmood, M., Thornes, J., Pope, F., Fisher, P. \u0026amp; Vardoulakis, S. (2017). Impact of Air Temperature on London Ambulance Call-Out Incidents and Response Times. Climate, 5, 61. DOI 10.3390/cli5030061\u003c/li\u003e\n \u003cli\u003eMajra, J. P. \u0026amp; Acharya, D. (2009). Protecting health from climate change: preparedness of medical interns. Indian Journal of Community Medicine : Official Publication of Indian Association of Preventive \u0026amp; Social Medicine, 34, 317-320. DOI 10.4103/0970-0218.58390\u003c/li\u003e\n \u003cli\u003eMcCright, A. M. \u0026amp; Xiao, C. (2014). Gender and Environmental Concern: Insights from Recent Work and for Future Research. Society \u0026amp; natural resources, 27, 1109-1113. DOI 10.1080/08941920.2014.918235\u003c/li\u003e\n \u003cli\u003eMilfont, T. L., Zubielevitch, E., Milojev, P. \u0026amp; Sibley, C. G. (2021). Ten-year panel data confirm generation gap but climate beliefs increase at similar rates across ages. Nature communications, 12, 4038. DOI 10.1038/s41467-021-24245-y\u003c/li\u003e\n \u003cli\u003eNHS. Delivering a \u0026lsquo;Net Zero\u0026rsquo;\u003cbr\u003eNational Health Service, from https://www.england.nhs.uk/greenernhs/wp-content/uploads/sites/51/2020/10/delivering-a-net-zero-national-health-service.pdf\u003c/li\u003e\n \u003cli\u003eNordrum, O. L., Kirk, A., Lee, S. A., Haley, K., Killilea, D., Khalid, I., P\u0026eacute;rez, E. C., Waters, I., Yan, R., Zulfiqar, S. \u0026amp; Stanistreet, D. (2022). Planetary health education in medical curricula in the Republic of Ireland. Medical teacher, ahead-of-print, 1-7. DOI 10.1080/0142159X.2022.2072279\u003c/li\u003e\n \u003cli\u003eOmrani, O. E., Dafallah, A., Paniello Castillo, B., Amaro, Bianca Quintella Ribeiro Corr\u0026ecirc;a, Taneja, S., Amzil, M., Sajib, M. R. U. \u0026amp; Ezzine, T. (2020). Envisioning planetary health in every medical curriculum: An international medical student organization\u0026apos;s perspective. Medical teacher, 42, 1107-1111. DOI 10.1080/0142159X.2020.1796949\u003c/li\u003e\n \u003cli\u003ePandve, H. T. \u0026amp; Raut, A. (2011). Assessment of awareness regarding climate change and its health hazards among the medical students. Indian Journal of Occupational and Environmental Medicine, 15, 42-45. DOI 10.4103/0019-5278.82999\u003c/li\u003e\n \u003cli\u003ePurcell, R. \u0026amp; McGirr, J. (2014). Preparing rural general practitioners and health services for climate change and extreme weather. The Australian journal of rural health, 22, 8-14. DOI 10.1111/ajr.12075\u003c/li\u003e\n \u003cli\u003eRocque, R. J., Beaudoin, C., Ndjaboue, R., Cameron, L., Poirier-Bergeron, L., Poulin-Rheault, R., Fallon, C., Tricco, A. C. \u0026amp; Witteman, H. O. (2021). Health effects of climate change: an overview of systematic reviews. BMJ open, 11, e046333. DOI 10.1136/bmjopen-2020-046333\u003c/li\u003e\n \u003cli\u003eTennison, I., Roschnik, S., Ashby, B., Boyd, R., Hamilton, I., Oreszczyn, T., Owen, A., Romanello, M., Ruyssevelt, P., Sherman, J. D., Smith, A. Z. P., Steele, K., Watts, N. \u0026amp; Eckelman, M. J. (2021). Health care\u0026apos;s response to climate change: a carbon footprint assessment of the NHS in England. The Lancet. Planetary health, 5, e84-e92. DOI 10.1016/S2542-5196(20)30271-0\u003c/li\u003e\n \u003cli\u003eTun (May Sanyu Tun), SanYuMay, Wellbery, C. \u0026amp; Teherani, A. (2020). Faculty development and partnership with students to integrate sustainable healthcare into health professions education. Medical teacher, 42, 1112-1118. DOI 10.1080/0142159X.2020.1796950\u003c/li\u003e\n \u003cli\u003eVILLELLA, C. (2011) Climate change: what do doctors think? What can doctors do?: An international survey of general practitioners\u003c/li\u003e\n \u003cli\u003eWalpole, S. C., Barna, S., Richardson, J. \u0026amp; Rother, H. (2019). Sustainable healthcare education: integrating planetary health into clinical education. The Lancet. Planetary health, 3, e6-e7. DOI 10.1016/S2542-5196(18)30246-8\u003c/li\u003e\n \u003cli\u003eWatts, N., Amann, M., Arnell, N., Ayeb-Karlsson, S., Belesova, K., Boykoff, M., Byass, P., Cai, W., Campbell-Lendrum, D., Capstick, S., Chambers, J., Dalin, C., Daly, M., Dasandi, N., Davies, M., Drummond, P., Dubrow, R., Ebi, K. L., Eckelman, M., Ekins, P., Escobar, L. E., Fernandez Montoya, L., Georgeson, L., Graham, H., Haggar, P., Hamilton, I., Hartinger, S., Hess, J., Kelman, I., Kiesewetter, G., Kjellstrom, T., Kniveton, D., Lemke, B., Liu, Y., Lott, M., Lowe, R., Sewe, M. O., Martinez-Urtaza, J., Maslin, M., McAllister, L., McGushin, A., Jankin Mikhaylov, S., Milner, J., Moradi-Lakeh, M., Morrissey, K., Murray, K., Munzert, S., Nilsson, M., Neville, T., Oreszczyn, T., Owfi, F., Pearman, O., Pencheon, D., Phung, D., Pye, S., Quinn, R., Rabbaniha, M., Robinson, E., Rockl\u0026ouml;v, J., Semenza, J. C., Sherman, J., Shumake-Guillemot, J., Tabatabaei, M., Taylor, J., Trinanes, J., Wilkinson, P., Costello, A., Gong, P. \u0026amp; Montgomery, H. (2019). The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate. The Lancet (British edition), 394, 1836-1878. DOI 10.1016/S0140-6736(19)32596-6\u003c/li\u003e\n \u003cli\u003eWorld Health Organization (2021). Climate change and health\u003cbr\u003e, from https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health\u003c/li\u003e\n \u003cli\u003eWorld Health Organization(WHO). COP26 Special report on climate change\u003cbr\u003e\u0026nbsp;and health: The health argument for climate action\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":"Climate Change, Medical Education, Medical student, National survey, Student perspective","lastPublishedDoi":"10.21203/rs.3.rs-2046642/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2046642/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eClimate change is increasingly threatening human health. This study aims to establish UK medical students’ opinions on climate change and health outcomes as well as their opinion on the respective medical school curricula inclusion of this topic.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAn online survey consisting of multiple-choice, Likert-scale questions and free text questions was distributed nationally.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e206 medical students responded. 173 (84%) and 188 (91.3%) were in agreement that climate change currently impacts health outcomes and it is important for healthcare professionals to be aware of this impact respectively. However, only 39 students were in agreement that they are confident discussing this topic with the patients, with only 38 students reporting environmental health teaching in their school and 15 students subjectively reporting this as adequate. Female students and students aged 40-44 were significantly more likely to agree that their medical school provides adequate education on climate change. 153 (74.3%) believe the inclusion of climate change related health topics should be mandatory during their training.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eA majority of UK medical students surveyed, lack the confidence to counsel patients on climate change related health topics and perceive their respective medical school’s curricula coverage of this topic inadequate. This study demonstrates students’ demand and the gap in medical schools’ curricula on climate change related health topics across the UK. With an increasing health threat due to climate change, there is a need to update and evaluate the current medical school curricula.\u003c/p\u003e","manuscriptTitle":"Exploring UK medical students' views on the inclusion of healthcare and climate change within undergraduate medical education - a national survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-09-13 20:29:21","doi":"10.21203/rs.3.rs-2046642/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":"f0453893-e179-4dcd-975e-933f7b757176","owner":[],"postedDate":"September 13th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-11-04T22:44:10+00:00","versionOfRecord":[],"versionCreatedAt":"2022-09-13 20:29:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2046642","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2046642","identity":"rs-2046642","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}