The Effect of Screening Training for Diseases Caused by Environmental and Industrial Pollutants on the Evaluation Scores of Medical Clerkship and Internship

The Effect of Screening Training for Diseases Caused by Environmental and Industrial Pollutants on the Evaluation Scores of Medical Clerkship and Internship | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effect of Screening Training for Diseases Caused by Environmental and Industrial Pollutants on the Evaluation Scores of Medical Clerkship and Internship Javad Javaheri, Mina Asgari, Pegah Mohaghegh, Mohammad Javad Ghanadzadeh, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8344207/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Routine monitoring, identification, early diagnosis and screening of diseases caused by environmental and industrial pollutants by all physicians who will practice in large and polluted cities or areas affected, must be integrated into the theoretical and practical curriculum. Thus, the present study was designed and executed to operationalize and assess the feasibility of this important issue. Methods: The current study employed a single-group pretest-posttest design, and was conducted at Arak Medical school, Iran. Over a period of six months, this study was implemented on 131 community medical clerks and 60 community medical interns during their respective one-month rotations. The study was implemented in four phases: Phase 1, the production of educational content, contains identifying various environmental and industrial pollutants, how these substances cause disease, and the recognition and screening methods for various pollution-related diseases. Phase 2, the production of measurement and evaluation tools. Questionnaires derived from the produced educational contents were designed and constructed in three domains: Knowledge, Attitude, and Practice. Phase 3, Educational interventions for the medical clerks and interns were measured using pretests and posttests administered through questionnaires specific to each group. Following the pretests, at the end of the one-month intervention period, a posttest was administered. Phase 4, the analysis of data was statistically analyzed in two stages, the pretest and the posttest, using the SPSS software version 26. Results: The mean posttest scores of medical clerks compared to their pretest demonstrates a significant increase (P < 0.0001). The comparison of the percentages of correct responses given by medical clerks between the pretest and posttest shows a statistical significance increase (P < 0.0001). The mean posttest scores of medical interns compared to their pretest demonstrates a significant increase (P < 0.0001). The comparison of the percentage of correct responses given by medical interns between the pretest and posttest is statistically significant (P < 0.0001). Conclusions: The necessity of possessing knowledge, skills, and familiarity with the topics related to environmental and industrial pollutants, is felt for future physicians. It is suggested that these topics be included in the medical students' curriculum in a structured and goal-oriented manner. Training Environmental and industrial pollutants Screening Medical student Clerkship Internship Evaluation Background Air pollution is a dangerous environmental risk factor and a major cause of chronic, non-communicable diseases (NCDs). Air pollution contributes to global greenhouse gas (GHG) emissions through the combustion of fossil fuels for energy, industry, and transportation, which are the most important causes of climate change. The combustion of these fuels, along with other vapors and vehicle exhaust, releases a wide range of pollutants into the atmosphere, including nitrogen oxides (NOx​), carbon monoxide (CO), black carbon, sulfur dioxide (SO2​), ozone (O3​), methane (CH4​), and particulate matter (PM) ( 3 ). Air pollution, through ultrafine particles entering the bloodstream, causes detrimental health effects on individual organ systems. The table and figure below summarize air pollution-related diseases, categorized by organ. Brain (stroke, dementia, Parkinson's disease, and reduced mental health); e yes (conjunctivitis, dry eye, blepharitis, and cataract); n ose (allergic rhinitis); heart (ischemic heart disease, hypertension, arrhythmia, and congestive heart diseases); lungs (chronic obstructive pulmonary disease, asthma, lung cancer, chronic laryngitis, and acute and chronic bronchitis); gastrointestinal tract (gastric cancer, colorectal cancer, inflammatory bowel diseases, Crohn's disease, and appendicitis); skin (eczema and allergic skin diseases, acne, dry skin, itching, skin aging, dermatographism, and seborrhea); blood (leukemia, thrombosis [clot formation], anemia, sickle cell anemia attacks, and obesity-related metabolic syndrome); liver (fatty liver disease and hepatocellular carcinoma); pancreas (type 1 and type 2 diabetes); urogenital tract (bladder and kidney cancers and prostate hyperplasia); bones (osteoporosis and bone fracture). Joints Rheumatic diseases ( 4 ) The Institute for Health Metrics and Evaluation (IHME) classifies air pollution into three categories: 1. Environmental pollution caused by O3 2. Environmental pollution caused by PM 3. Household pollution caused by the use of solid fuels. The sources that impair air quality include gas emissions from motor vehicles, energy production related to smelting and metal processing, and combustion of waste, etc. ( 6 ). A study published in 2019 estimated the massive economic burden stemming from NCDs associated with air pollution in China. The study estimated that the lost cost due to air pollution-related NCDs amounted to $ 137 trillion (in 2010 U.S. dollars) over the period from 1990 to 2030, and $ 499 trillion (in 2010 U.S. dollars) over the period from 2015 to 2030. Cardiovascular diseases had the highest burden, followed by chronic respiratory diseases, diabetes, and cancer. The calculated treatment costs for air pollution-related chronic diseases accounted for approximately 30% of the total treatment costs for these diseases. This study also found that the economic burden share related to diabetes treatment costs was the highest of all, and this is fundamentally due to the fact that, on a case-by-case basis, diabetes has a lower health burden than other pollution-related diseases ( 7 ). Air pollution is a global issue that affects people all over the world. According to a World Health Organization (WHO) report, approximately 24% of the burden of diseases and 23% of total deaths worldwide can be attributed to environmental factors. Research has demonstrated that air pollution is associated with respiratory diseases and mortality from lung cancer, with women being more susceptible to these issues ( 8 ). Substantial documentation has demonstrated an association between exposure to various air pollutants and brain health, including an increased prevalence of neuropsychiatric disorders, such as cognitive decline, dementia, anxiety, depression, and suicide. Experimental studies have shown that PM and O3, two common pollutants that exhibit distinct characteristics and reactions, can activate the hypothalamic-pituitary-adrenal (HPA) axis, leading to the release of glucocorticoid hormones (including cortisol), which is part of the neuroendocrine system's response to stress. Chronic stress and the hormones released due to the hyperactivity of the HPA axis can induce significant structural and biochemical changes in the brain. Therefore, air pollution, like other stress-inducing factors, can be considered a modifiable risk factor for neurodegenerative and psychiatric disorders ( 9 ). Medical schools in the United States and the United Kingdom have placed greater emphasis on teaching clinical prevention and health promotion ( 10 , 11 ). The need to dedicate a specific curriculum to aspects of the healthcare system’s way of functioning and the physician’s role within it has recently raised by the American Medical Association’s (AMA) consortium, which published a book on health systems science in medical education, calling for this to be established as the “third pillar,” which, until now, has been “part of the hidden curriculum in medical education,” integrating into the two other (traditional) pillars: Basic sciences and clinical sciences ( 12 ). Preventive medicine, which is often the most cost-effective medical approach, has become imperative to curb the rising costs of chronic disease care. For years, public health has been marginalized in medical education as an area receiving scant attention ( 13 ). Although environmental factors contribute to over 25% of global diseases, and toxic agents ranked fifth among the underlying causes of death in the United States in 2000, environmental medicine education remains largely omitted in continuous medical education in the United States. The scarcity of trained professionals in environmental medicine (i.e., occupational medicine and other preventive medicine specialties and subspecialties), coupled with insufficient general medical education on how to prevent, diagnose, refer, or treat patients exposed to hazardous environmental agents (pollutants), contributes to missed opportunities for primary prevention and early intervention to mitigate or minimize the burden of environmentally related diseases. Survey findings of graduating medical students over the past few years have identified environmental health as a medical school’s topic area that can be improved. A variety of educational strategies, models, and resources have been presented that illustrate how the recommended competence-based environmental health content can be integrated into medical education to prepare or facilitate medical students and physicians without specialized expertise in environmental medicine to provide environmental preventive or curative patient care ( 14 ). The consideration of the significance and risks caused by environmental pollutants by healthcare providers (especially general practitioners) on public health, and the institutionalization of methods for preventing diseases resulting from this pollution, particularly primary and secondary prevention in the care of patients and healthy visitors by the healthcare team, specifically general practitioners, is necessary. Therefore, routine monitoring, identification, and early diagnosis (screening) of diseases caused by environmental and industrial pollutants by all physicians (especially young general medicine graduates) who will practice in large and polluted cities or areas affected by these pollutants must be integrated into the theoretical and practical curriculum. Thus, the present study was designed and executed to operationalize and assess the feasibility of this important issue. Methods The current study employed a single-group pretest-posttest design based on reference textbooks and was conducted at the School of Medicine, the Department of Community Medicine, and urban and rural comprehensive health training centers in Arak, Iran, as the educational field. Over a period of six months, from June 2024 to December 2024, this study was implemented on 131 community medicine clerks and 60 community medicine interns during their community medicine one-month rotations. The study was designed and executed in four phases. The study was implemented in four phases. Phase 1 (production of educational content) : During this phase, educational contents on identifying various environmental and industrial pollutants, how these substances cause disease, and the recognition and screening methods for various pollution-related diseases were developed as separate educational files (electronic file and handbook) specifically for medical students in their clerkship and internship periods by professors of the Department of Community Medicine, in consultation with the Department of Internal Medicine and the Department of Environmental Health at the School of Health. Phase 2 (production of measurement and evaluation tools) : During this phase, questionnaires derived from the produced educational contents (an educational booklet specifically for medical clerks and interns), along with the intended headings of pollutants, their pathogenicity, the types of diseases caused by pollutants, and their screening methods, were designed and constructed in three domains: Knowledge, Attitude, and Practice (KAP). Their validity was established based on the opinions of experts in the fields of environmental health, internal medicine, and community medicine, and their reliability was determined using the test-retest method on 5 medical clerks and 5 medical interns, which was found to be acceptable (Cronbach’s alpha > 0.7). Samples of these questionnaires are available in Appendix 1 and Appendix 2. Phase 3 (implementation of interventions and the measurement of their effects): The implementation of interventions commenced for a period of six months, starting in June 2024 until the end of December 2024 . Six groups of medical clerks and interns participated in pretests and posttests administered through questionnaires specific to each group until the end of December 2024. Immediately following the pretests, which implemented at the beginning of the one-month period, educational booklets relevant to each group (clerk or intern) were handed over to them. Concurrently, a two-hour training session was held by the supervising professors regarding the importance and method of studying the educational booklet related to pollutants, and addressing students' ambiguities and questions. At the end of the one-month intervention period, a posttest was administered. Additionally, to assess the extent and manner of exposure to pollutants among clients visiting educational healthcare centers, specific forms regarding exposure to the pollutants’ risk factor were provided to the medical interns, and they were asked to complete these forms for 3–5 of the clients visiting the centers and submit them to the project’s executive manager at the end of their internship period. Regarding the results obtained from these evaluation forms on the amount of exposure, it should be noted that the initial goal was for the interns to become familiar with how to assess risk and exposure to signs and symptoms resulting from pollutants in patients visiting healthcare centers, and to learn which systematic and regular questions to ask, and concerning which substances or pollutants. That is, the objective was training, and this goal was truly achieved. A sample of the completed forms by the interns is available in Appendix 3. Phase 4: ( analysis of data and presentation of the project’s final report ) : Data pertaining to the clerkship and internship questionnaires were statistically analyzed in two phases, the pretest and the posttest, and entered the SPSS software version 26 by an operator. The data were then subjected to statistical analysis by one of the collaborating professors on this project. Ultimately, the final report was prepared, the details of which will be presented in the following. Statement on Ethics Approval: The project was found to be in accordance to the ethical principles and the national norms and standards for conducting Medical Research in Iran. The certification was issued by Research Ethics Committees of National Agency for Strategic Research in Medical Education. Approval ID; IR.NASRME.REC.1402.082 Approval Date;2023-03-07. Our study was adhered to the Declaration of Helsinki in relevant GENERAL PRINCIPLES. Each student completed and signed an informed consent form. Results Complete Results Pertaining to the Medical Clerks: Descriptive statistics, including measures of range, mean, and standard deviation, were used to examine the descriptive status of the scores obtained by community medicine clerks from the pollutant questionnaire during the pretest and posttest phases. The results are presented in Table- 1. Table 1 The mean scores obtained by clerks in the pretest and posttest phases Variable Number Minimum Maximum SD Mean Pretest 128 5 22 3.77 13.50 Posttest 130 13 37 2.96 26.33 SD: Standard deviation Assessing the distribution of medical clerks’ pretest and posttest scores using the Kolmogorov-Smirnov test determined that the data distribution was not normal. Consequently, the non-parametric Wilcoxon test was employed to compare the mean scores obtained. Table- 2 presents the results of this comparison. Table 2 Comparison of the mean scores obtained by clerks following the interventions Comparison Rank Sign Number Mean Rank Sum of Rank Z-Value P-Value* Pretest-posttest scores Negative 1 10 10 -9.76 0.0001 Positive 126 64.43 8118 * Wilcoxon signed-rank test The analysis and comparison results of this test demonstrate a significant increase in the mean posttest scores of community medicine clerks compared to their pretest scores (P < 0.0001). Regarding the analysis of the number of correct responses given to the pollutant questionnaire items, the frequency percentage of medical clerkship students who provided a correct response at each stage was calculated, the results of which are presented in Table- 3. A comparison of the number of correct responses in the pretest and posttest (i.e., after educational interventions) phases was performed using the Wilcoxon signed-rank test. As shown in Table- 3, this analysis indicated that the increase in the number of correct responses was statistically significant and substantial (P < 0.0001). Table 3 The frequency percentage of correct responses given by clerks in the pretest and posttest phases Variable Number Minimum Maximum SD Mean Frequency Percentage of Correct Responses P-Value* Pretest 128 17.24 75.86 16.02 46.55 0.0001 Posttest 130 44.83 37 2.96 90.55 SD: Standard deviation * Wilcoxon signed-rank test Concerning the status to respond to the survey attitude-assessment question, “In your opinion, to what extent does a physician need to acquire scientific information regarding environmental and industrial pollutants?” in Table- 4, a comparison between the frequency percentages of responses given by medical clerks in the posttest phase (i.e., after the training) and those in the pretest phase suggests that the students’ attitudes toward training on pollutant-related topics did not change significantly. This is evident from the results in Table- 4, showing that the options “moderate” and “low” slightly increased, while the options “high” and “no need” decreased. Table 4 Frequency percentage of clerks’ responses in the pretest and posttest phases to the question* Variable Low (Generalities) Moderate (Basic Information) High (Generalities, Basic, and Specialized Information) No Need No Response Pretest 12.2 45.8 26.7 9.2 6.1 Posttest 14.5 55 21.4 4.6 4.6 * “In your opinion, to what extent does a physician need to acquire scientific information regarding environmental and industrial pollutants?” Additionally, the status to respond to another survey attitude-assessment question “To what extent is your personal interest as a medical student in learning and acquiring scientific information about environmental and industrial pollutants and their resultant health-related consequences?” in Table- 5, a comparison between the frequency percentages of responses given in the posttest phase (i.e., after the training) and those in the pretest phase suggests that, apparently, the medical clerks’ personal attitudes toward training on pollutant-related topics have undergone a relatively positive change , as the response “low” has decreased , while the responses “moderate” and “high” have increased . However, the option “very high” shows a slight decrease in the posttest. Table 5 Frequency percentage of clerks’ responses in the pretest and posttest phases to the question* Variable Low Moderate High Very High No Response Pretest 25.2 32.8 16.8 16.7 8.4 Posttest 7.6 42 19.8 15.3 15.3 * “To what extent is your personal interest as a medical student in learning and acquiring scientific information about environmental and industrial pollutants and their resultant health-related consequences?” Complete Results Pertaining to the Medical Interns: Descriptive statistics, including measures of range, mean, and standard deviation, were used to examine the descriptive status of the scores obtained by community medicine interns from the pollutant questionnaire during the pretest and posttest phases. The results are presented in Table- 6. Table 6 The mean scores obtained by interns in the pretest and posttest phases Variable Number Minimum Maximum SD Mean Pretest 58 5 22 3.97 14.96 Posttest 57 8 29 4.14 29 SD: Standard deviation Based on assessing the data distribution of medical clerks’ pretest and posttest scores using the Kolmogorov-Smirnov test, it was determined that the data distribution was not normal. Therefore, the non-parametric Wilcoxon signed-rank test was employed to compare the mean scores. Table- 7 presents the results of this comparison. Table 7 Comparison of the mean scores obtained by interns following the implementation of educational interventions Comparison Rank Sign Number Mean Rank Sum of Rank Z-Value P-Value* Pretest-posttest scores Negative 3 25.5 76.50 -5.66 0.0001 Positive 50 27.09 1354.50 * Wilcoxon signed-rank test The analysis and comparison results of this test demonstrate a significant increase in the mean posttest scores of community medicine interns compared to their pretest scores (P < 0.0001). Regarding the analysis of the number of correct responses given to the pollutant questionnaire items, the frequency percentage of the intern students who provided the correct response in each stage was calculated, the results of which are presented in Table- 8. As shown in Table- 8, the comparison of the rate of correct responses between the pretest and posttest (i.e., after the educational interventions) phases using the Wilcoxon signed-rank test demonstrate that this increase in correct responses is statistically significant and substantial (P < 0.0001). Table 8 The frequency percentage of correct responses given by interns in the pretest and posttest phases Variable Number Minimum Maximum SD Mean Frequency Percentage of Correct Responses P-Value* Pretest 58 17.24 86.21 13.71 51.60 0.0001 Posttest 57 27.59 100 14.30 82.39 SD: Standard deviation * Wilcoxon signed-rank test Concerning the status to respond to the survey attitude-assessment question, “In your opinion, to what extent does a physician need to acquire scientific information regarding environmental and industrial pollutants?” in Table 4 , a comparison between the frequency percentages of responses given by medical interns in the posttest phase (i.e., after the training) and those in the pretest phase suggests that medical intern students’ attitudes toward training on pollutant-related topics have had a positive change. This is evident from the results in Table- 9, showing that the options “moderate” and “low” have decreased, while the option “high” has increased in the posttest (more than 2.5 times). It should, however, be noted that the rate of “no response” has increased. Table 9 Frequency percentage of community medicine interns’ responses in the pretest and posttest phases to the question: “In your opinion, to what extent does a physician need to acquire scientific information regarding environmental and industrial pollutants?” Variable Low (Generalities) Moderate (Basic Information) High (Generalities, Basic, and Specialized Information) No Need No Response Pretest 31.7 36.7 15 11.7 5 Posttest 11.7 20 41.7 3.3 23.3 Additionally, the status to respond to another survey attitude-assessment question “To what extent is your personal interest as a medical student in learning and acquiring scientific information about environmental and industrial pollutants and their resultant health-related consequences?” in Table-10, a comparison between the frequency percentages of responses given in the posttest phase (i.e., after the training) and those in the pretest phase suggests that, apparently, the medical interns’ personal attitudes toward training on pollutant-related topics have undergone a relatively positive change, as the responses “low” and “moderate” have decreased , while the option “high” has increased . However, the option “very high” shows a slight decrease in the posttest. Table 10 Frequency percentage of community medicine interns’ responses in the pretest and posttest phases to the question * Variable Low Moderate High Very High No Response Pretest 38.3 31.7 13.3 5.1 10 Posttest 15 26.7 20 3.3 35 *“To what extent is your personal interest as a medical student in learning and acquiring scientific information about environmental and industrial pollutants and their resultant health-related consequences?” Discussion The comparison of results and statistical analyses demonstrates a significant increase in the mean posttest scores of community medicine clerks compared to their pretest scores (P < 0.0001). (Changed awareness and knowledge) The comparison of results and statistical analyses demonstrates a significant increase in the mean posttest scores of community medicine interns compared to their pretest scores (P < 0.0001). (Changed awareness and knowledge) A comparison of the percentages of correct responses given by medical clerks to the pollutant questionnaire items between the pretest and posttest (i.e., after the training) phases shows a statistical significance and is substantial (P < 0.0001). (Changed awareness and knowledge) A comparison of the rate of correct responses given by medical interns to the pollutant questionnaire items between the pretest and posttest (i.e., after the educational interventions) phases reveals that the increase in correct responses is statistically significant and substantial (P < 0.0001). (Changed awareness and knowledge) A comparison between the frequency percentages of responses given by the medical clerks in the posttest phase (i.e., after the training) and the corresponding responses in the pretest phase for the first attitude-assessment question indicates that the medical clerks’ attitudes toward training on pollutant-related topics have not changed significantly . A comparison between the frequency percentages of responses given in the posttest phase (i.e., after the training) to the second attitude-assessment question and the comparable cases in the pretest phase suggests that medical clerk students’ personal attitudes toward training on pollutant-related topics have undergone a relatively positive change . (Changed tendency and attitude) A comparison between the frequency percentages of responses given by medical interns in the posttest phase (i.e., after the training) and the corresponding responses in the pretest phase for the first attitude-assessment question indicates that the medical interns’ attitudes toward training on pollutant-related topics shows a positive change . A comparison between the frequency percentages of responses given in the posttest phase (i.e., after the training) to the second attitude-assessment question and the comparable cases in the pretest phase suggests that medical intern students’ personal attitudes toward training on pollutant-related topics have undergone a relatively positive change . (Changed tendency and attitude) Overall, the findings reveal that the student clerks’ awareness, knowledge, and attitudes have significantly and positively changed compared to before the training (interventions). Finally, the changes related to the student interns’ awareness and KAP exhibit to become significant and positive compared to before the training (interventions). Our complementary investigations in this study included evaluating the extent and manner of exposure to pollutants among clients using specific forms regarding exposure to the pollutants’ risk factor provided to the medical interns, and they were asked to complete these forms for 3–5 of the clients visiting the centers and submit them to the project’s executive manager at the end of their internship period. Regarding the results obtained from these evaluation forms on the amount of exposure, it should be noted that the initial goal was for the interns to become familiar with how to assess risk and exposure to signs and symptoms resulting from pollutants in patients visiting healthcare centers, and to learn which systematic and regular questions to ask, and concerning which substances or pollutants. That is, the objective was training, and this goal was truly achieved. A sample of the completed forms by the interns is available in Appendix 5. Conclusion The results reveal a positive and significant change in medical intern students’ awareness, knowledge, and attitudes compared to before the training (interventions). Moreover, the changes related to medical interns’ awareness and KAP have also been positive and significant compared to before the training (interventions). Hence, considering the necessity of acquiring knowledge and skills and becoming familiar with topics related to environmental and industrial pollutants, including the stages of identifying them as causes and risks for disease occurrence, their pathogenesis, the signs and symptoms of associated illnesses, and the manner of screening and diagnosing their consequences, for future physicians, it is suggested that these topics be included in the medical students' curriculum in a structured and goal-oriented manner. Declarations •Ethics approval and consent to participate The Certification File uploaded in submission •Consent for publication “Not applicable” •Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. •Competing interests The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. •Funding “This project was funded by the National Agency for Strategic Research in Medical Sciences Education. Tehran. Iran. Grant No.4000565” •Authors' contributions "J. J. conceived and designed the research and drafted the manuscript. M.A. participated in designing and implementation of the evaluation (pretest, posttest). P.M performed parts of the statistical analysis and helped to edit the manuscript. M. J.G involved in developing educational documents, also in educating students during intervention. M.G. helped in revising educational documents and students training on clinical aspects of exposure forms data gathering. All authors reviewed the manuscript" •Acknowledgements We would like to thanks the National Agency for Strategic Research in Medical Sciences Education for funding this project. Medical Students of Arak University of Medical Sciences(AUMS) who generously participated in this study. The authors would like to acknowledge Mrs. Dr. Nahid Sharahei, for organizing and coordination of educational sessions and evaluation exams. References Dr. Mansour Ghiyath-eddin, Dr. Mehrnoush Abtahi, Air Pollution and Its Effects, Comprehensive Book of Public Health, Chapter 4, Section 5 - Tehran 2019 National document on the prevention and control of non-communicable diseases and related risk factors in the Islamic Republic of Iran for the period 1394 to 1404. 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Public health education for medical students: reflections over the last two decades. J Public Health (Bangkok). 2009;32(1):132–3. Kimberly S.GehleMD, MPHJewel L.CrawfordMDMichael T. HatcherDrPH. Integrating Environmental Health into Medical Education. American Journal of Preventive Medicine. Volume 41, Issue 4, Supplement 3, October 2011, Pages S296-S301. Additional Declarations No competing interests reported. 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. 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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-8344207","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":591604252,"identity":"e71cf82d-c1a0-445e-9d05-0e7ab1456c9b","order_by":0,"name":"Javad Javaheri","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIiWNgGAWjYDCCAwwMBkAqgYGBsfEBA4QDAhJEaWk2IFoLA0QLA5sEkhbcgO/2AYaCn212efzSh9sqfu6xM9adkcD44QeDRT4uLZLnEhgMe9uSiyX7Ettu9jxLNjO7kcAs2cMgYdmAQ4vBGSDmOcOcuOEMY9sNngPMNkAtDNJAv+B0IUiL4Z8z9Yn7gVoK/xyoB2lh/k1IizFPxeHEDTyMbcw8Bw6DHMaG1xbJM4wNxjIVxxNnnGFslpY5cNzY7MzDNsseA9xa+M4wHzN8Y1Cd2N/D/vDjmwPVhtuOJx++8aOiDk9oM7ahSzI2EIoe5gd4pUfBKBgFo2AUAACV0lSkhJ7AZgAAAABJRU5ErkJggg==","orcid":"","institution":"Arak University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Javad","middleName":"","lastName":"Javaheri","suffix":""},{"id":591604256,"identity":"6d93ef12-0770-41ab-944a-fc2eb9079d83","order_by":1,"name":"Mina Asgari","email":"","orcid":"","institution":"Arak University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mina","middleName":"","lastName":"Asgari","suffix":""},{"id":591604260,"identity":"dc4981ec-4019-498c-a164-34de0ba69e79","order_by":2,"name":"Pegah Mohaghegh","email":"","orcid":"","institution":"Arak University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Pegah","middleName":"","lastName":"Mohaghegh","suffix":""},{"id":591604261,"identity":"be4d9387-8bf1-4381-aba3-79acd472cc5d","order_by":3,"name":"Mohammad Javad Ghanadzadeh","email":"","orcid":"","institution":"Arak University of Medical Sciences Arak","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Javad","lastName":"Ghanadzadeh","suffix":""},{"id":591604262,"identity":"3f7dda97-f68b-4fc9-9384-77b19b5b079f","order_by":4,"name":"Mohammadreza Gholami","email":"","orcid":"","institution":"Arak University of Medical Sciences Arak","correspondingAuthor":false,"prefix":"","firstName":"Mohammadreza","middleName":"","lastName":"Gholami","suffix":""}],"badges":[],"createdAt":"2025-12-12 09:38:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8344207/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8344207/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104265347,"identity":"1ab824d3-8623-4667-a04f-52e071736de3","added_by":"auto","created_at":"2026-03-09 19:54:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1691813,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8344207/v1/a3eabf0b-c003-45a9-ae76-2ca4c543d84e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effect of Screening Training for Diseases Caused by Environmental and Industrial Pollutants on the Evaluation Scores of Medical Clerkship and Internship","fulltext":[{"header":"Background","content":"\u003cp\u003eAir pollution is a dangerous environmental risk factor and a major cause of chronic, non-communicable diseases (NCDs). Air pollution contributes to global greenhouse gas (GHG) emissions through the combustion of fossil fuels for energy, industry, and transportation, which are the most important causes of climate change.\u003c/p\u003e \u003cp\u003eThe combustion of these fuels, along with other vapors and vehicle exhaust, releases a wide range of pollutants into the atmosphere, including nitrogen oxides (NOx​), carbon monoxide (CO), black carbon, sulfur dioxide (SO2​), ozone (O3​), methane (CH4​), and particulate matter (PM) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAir pollution, through ultrafine particles entering the bloodstream, causes detrimental health effects on individual organ systems. The table and figure below summarize air pollution-related diseases, categorized by organ.\u003c/p\u003e \u003cp\u003e \u003cb\u003eBrain\u003c/b\u003e (stroke, dementia, Parkinson's disease, and reduced mental health); e\u003cb\u003eyes\u003c/b\u003e (conjunctivitis, dry eye, blepharitis, and cataract); n\u003cb\u003eose\u003c/b\u003e (allergic rhinitis); \u003cb\u003eheart\u003c/b\u003e (ischemic heart disease, hypertension, arrhythmia, and congestive heart diseases); \u003cb\u003elungs\u003c/b\u003e (chronic obstructive pulmonary disease, asthma, lung cancer, chronic laryngitis, and acute and chronic bronchitis); \u003cb\u003egastrointestinal tract\u003c/b\u003e (gastric cancer, colorectal cancer, inflammatory bowel diseases, Crohn's disease, and appendicitis); \u003cb\u003eskin\u003c/b\u003e (eczema and allergic skin diseases, acne, dry skin, itching, skin aging, dermatographism, and seborrhea); \u003cb\u003eblood\u003c/b\u003e (leukemia, thrombosis [clot formation], anemia, sickle cell anemia attacks, and obesity-related metabolic syndrome); \u003cb\u003eliver\u003c/b\u003e (fatty liver disease and hepatocellular carcinoma); \u003cb\u003epancreas\u003c/b\u003e (type 1 and type 2 diabetes); \u003cb\u003eurogenital tract\u003c/b\u003e (bladder and kidney cancers and prostate hyperplasia); \u003cb\u003ebones\u003c/b\u003e (osteoporosis and bone fracture).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eJoints\u003c/strong\u003e \u003cp\u003eRheumatic diseases (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe Institute for Health Metrics and Evaluation (IHME) classifies air pollution into three categories:\u003c/p\u003e \u003cp\u003e1. Environmental pollution caused by O3\u003c/p\u003e\n\u003cp\u003e2. Environmental pollution caused by PM\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e3. Household pollution caused by the use of solid fuels.\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eThe sources that impair air quality include gas emissions from motor vehicles, energy production related to smelting and metal processing, and combustion of waste, etc. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA study published in 2019 estimated the massive economic burden stemming from NCDs associated with air pollution in China. The study estimated that the lost cost due to air pollution-related NCDs amounted to \u003cspan\u003e$\u003c/span\u003e137 trillion (in 2010 U.S. dollars) over the period from 1990 to 2030, and \u003cspan\u003e$\u003c/span\u003e499 trillion (in 2010 U.S. dollars) over the period from 2015 to 2030. Cardiovascular diseases had the highest burden, followed by chronic respiratory diseases, diabetes, and cancer. The calculated treatment costs for air pollution-related chronic diseases accounted for approximately 30% of the total treatment costs for these diseases. This study also found that the economic burden share related to diabetes treatment costs was the highest of all, and this is fundamentally due to the fact that, on a case-by-case basis, diabetes has a lower health burden than other pollution-related diseases (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAir pollution is a global issue that affects people all over the world. According to a World Health Organization (WHO) report, approximately 24% of the burden of diseases and 23% of total deaths worldwide can be attributed to environmental factors. Research has demonstrated that air pollution is associated with respiratory diseases and mortality from lung cancer, with women being more susceptible to these issues (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSubstantial documentation has demonstrated an association between exposure to various air pollutants and brain health, including an increased prevalence of neuropsychiatric disorders, such as cognitive decline, dementia, anxiety, depression, and suicide. Experimental studies have shown that PM and O3, two common pollutants that exhibit distinct characteristics and reactions, can activate the hypothalamic-pituitary-adrenal (HPA) axis, leading to the release of glucocorticoid hormones (including cortisol), which is part of the neuroendocrine system's response to stress. Chronic stress and the hormones released due to the hyperactivity of the HPA axis can induce significant structural and biochemical changes in the brain. Therefore, air pollution, like other stress-inducing factors, can be considered a modifiable risk factor for neurodegenerative and psychiatric disorders (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMedical schools in the United States and the United Kingdom have placed greater emphasis on teaching clinical prevention and health promotion (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The need to dedicate a specific curriculum to aspects of the healthcare system\u0026rsquo;s way of functioning and the physician\u0026rsquo;s role within it has recently raised by the American Medical Association\u0026rsquo;s (AMA) consortium, which published a book on health systems science in medical education, calling for this to be established as the \u0026ldquo;third pillar,\u0026rdquo; which, until now, has been \u0026ldquo;part of the hidden curriculum in medical education,\u0026rdquo; integrating into the two other (traditional) pillars: Basic sciences and clinical sciences (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Preventive medicine, which is often the most cost-effective medical approach, has become imperative to curb the rising costs of chronic disease care. For years, public health has been marginalized in medical education as an area receiving scant attention (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough environmental factors contribute to over 25% of global diseases, and toxic agents ranked fifth among the underlying causes of death in the United States in 2000, environmental medicine education remains largely omitted in continuous medical education in the United States. The scarcity of trained professionals in environmental medicine (i.e., occupational medicine and other preventive medicine specialties and subspecialties), coupled with insufficient general medical education on how to prevent, diagnose, refer, or treat patients exposed to hazardous environmental agents (pollutants), contributes to missed opportunities for primary prevention and early intervention to mitigate or minimize the burden of environmentally related diseases. Survey findings of graduating medical students over the past few years have identified environmental health as a medical school\u0026rsquo;s topic area that can be improved. A variety of educational strategies, models, and resources have been presented that illustrate how the recommended competence-based environmental health content can be integrated into medical education to prepare or facilitate medical students and physicians without specialized expertise in environmental medicine to provide environmental preventive or curative patient care (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe consideration of the significance and risks caused by environmental pollutants by healthcare providers (especially general practitioners) on public health, and the institutionalization of methods for preventing diseases resulting from this pollution, particularly primary and secondary prevention in the care of patients and healthy visitors by the healthcare team, specifically general practitioners, is necessary. Therefore, routine monitoring, identification, and early diagnosis (screening) of diseases caused by environmental and industrial pollutants by all physicians (especially young general medicine graduates) who will practice in large and polluted cities or areas affected by these pollutants must be integrated into the theoretical and practical curriculum. Thus, the present study was designed and executed to operationalize and assess the feasibility of this important issue.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe current study employed a single-group pretest-posttest design based on reference textbooks and was conducted at the School of Medicine, the Department of Community Medicine, and urban and rural comprehensive health training centers in Arak, Iran, as the educational field. Over a period of six months, from June 2024 to December 2024, this study was implemented on 131 community medicine clerks and 60 community medicine interns during their community medicine one-month rotations. The study was designed and executed in four phases. The study was implemented in four phases.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase 1 (production of educational content)\u003c/b\u003e: During this phase, educational contents on identifying various environmental and industrial pollutants, how these substances cause disease, and the recognition and screening methods for various pollution-related diseases were developed as separate educational files (electronic file and handbook) specifically for medical students in their clerkship and internship periods by professors of the Department of Community Medicine, in consultation with the Department of Internal Medicine and the Department of Environmental Health at the School of Health. \u003cb\u003ePhase 2 (production of measurement and evaluation tools)\u003c/b\u003e: During this phase, questionnaires derived from the produced educational contents (an educational booklet specifically for medical clerks and interns), along with the intended headings of pollutants, their pathogenicity, the types of diseases caused by pollutants, and their screening methods, were designed and constructed in three domains: Knowledge, Attitude, and Practice (KAP). Their validity was established based on the opinions of experts in the fields of environmental health, internal medicine, and community medicine, and their reliability was determined using the test-retest method on 5 medical clerks and 5 medical interns, which was found to be acceptable (Cronbach\u0026rsquo;s alpha\u0026thinsp;\u0026gt;\u0026thinsp;0.7). Samples of these questionnaires are available in Appendix 1 and Appendix 2.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase 3 (implementation of interventions and the measurement of their effects): The implementation of interventions commenced for a period of six months, starting in June 2024 until the end of December 2024\u003c/b\u003e. Six groups of medical clerks and interns participated in pretests and posttests administered through questionnaires specific to each group until the end of December 2024. Immediately following the pretests, which implemented at the beginning of the one-month period, educational booklets relevant to each group (clerk or intern) were handed over to them. Concurrently, \u003cb\u003ea two-hour training session\u003c/b\u003e was held by the supervising professors regarding the importance and method of studying the educational booklet related to pollutants, and addressing students' ambiguities and questions. At the end of the one-month intervention period, a posttest was administered. Additionally, to assess the extent and manner of exposure to pollutants among clients visiting educational healthcare centers, specific forms regarding exposure to the pollutants\u0026rsquo; risk factor were provided to the medical interns, and they were asked to complete these forms for 3\u0026ndash;5 of the clients visiting the centers and submit them to the project\u0026rsquo;s executive manager at the end of their internship period. Regarding the results obtained from these evaluation forms on the amount of exposure, it should be noted that the initial goal was for the interns to become familiar with how to assess risk and exposure to signs and symptoms resulting from pollutants in patients visiting healthcare centers, and to learn which systematic and regular questions to ask, and concerning which substances or pollutants. That is, the objective was training, and this goal was truly achieved. A sample of the completed forms by the interns is available in Appendix 3.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase 4: (\u003c/b\u003eanalysis of data and presentation of the project\u0026rsquo;s final report\u003cb\u003e)\u003c/b\u003e: Data pertaining to the clerkship and internship questionnaires were statistically analyzed in two phases, the pretest and the posttest, and entered the SPSS software version 26 by an operator. The data were then subjected to statistical analysis by one of the collaborating professors on this project. Ultimately, the final report was prepared, the details of which will be presented in the following.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatement on Ethics Approval:\u003c/h2\u003e \u003cp\u003eThe project was found to be in accordance to the ethical principles and the national norms and standards for conducting Medical Research in Iran. The certification was issued by Research Ethics Committees of National Agency for Strategic Research in Medical Education. Approval ID; IR.NASRME.REC.1402.082 Approval Date;2023-03-07.\u003c/p\u003e \u003cp\u003eOur study was adhered to the Declaration of Helsinki in relevant GENERAL PRINCIPLES.\u003c/p\u003e \u003cp\u003eEach student completed and signed an informed consent form.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eComplete Results Pertaining to the Medical Clerks:\u003c/p\u003e \u003cp\u003eDescriptive statistics, including measures of range, mean, and standard deviation, were used to examine the descriptive status of the scores obtained by community medicine clerks from the pollutant questionnaire during the pretest and posttest phases. The results are presented in Table- 1.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe mean scores obtained by clerks in the pretest and posttest phases\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePretest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosttest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eSD: Standard deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAssessing the distribution of medical clerks\u0026rsquo; pretest and posttest scores using the Kolmogorov-Smirnov test determined that the data distribution was not normal. Consequently, the non-parametric Wilcoxon test was employed to compare the mean scores obtained. Table- 2 presents the results of this comparison.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the mean scores obtained by clerks following the interventions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRank Sign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean Rank\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSum of Rank\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eZ-Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-Value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePretest-posttest scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-9.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8118\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* Wilcoxon signed-rank test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe analysis and comparison results of this test demonstrate a significant increase in the mean posttest scores of community medicine clerks compared to their pretest scores (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003eRegarding the analysis of the number of correct responses given to the pollutant questionnaire items, the frequency percentage of medical clerkship students who provided a correct response at each stage was calculated, the results of which are presented in Table- 3. A comparison of the number of correct responses in the pretest and posttest (i.e., after educational interventions) phases was performed using the Wilcoxon signed-rank test. As shown in Table- 3, this analysis indicated that the increase in the number of correct responses was statistically significant and substantial (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe frequency percentage of correct responses given by clerks in the pretest and posttest phases\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean Frequency Percentage of Correct Responses\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-Value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePretest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e46.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosttest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e90.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eSD: Standard deviation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* Wilcoxon signed-rank test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eConcerning the status to respond to the survey attitude-assessment question, \u003cb\u003e\u0026ldquo;In your opinion, to what extent does a physician need to acquire scientific information regarding environmental and industrial pollutants?\u0026rdquo;\u003c/b\u003e in Table- 4, a comparison between the frequency percentages of responses given by medical clerks in the posttest phase (i.e., after the training) and those in the pretest phase suggests that the students\u0026rsquo; attitudes toward training on pollutant-related topics did not change significantly. This is evident from the results in Table- 4, showing that the options \u003cem\u003e\u0026ldquo;moderate\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;low\u0026rdquo;\u003c/em\u003e slightly increased, while the options \u003cem\u003e\u0026ldquo;high\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;no need\u0026rdquo;\u003c/em\u003e decreased.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency percentage of clerks\u0026rsquo; responses in the pretest and posttest phases to the question*\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003cp\u003e(Generalities)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003cp\u003e(Basic Information)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003cp\u003e(Generalities, Basic, and Specialized Information)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo Need\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo Response\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePretest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosttest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e* \u003cem\u003e\u0026ldquo;In your opinion, to what extent does a physician need to acquire scientific information regarding environmental and industrial pollutants?\u0026rdquo;\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAdditionally, the status to respond to another survey attitude-assessment question \u003cb\u003e\u0026ldquo;To what extent is your personal interest as a medical student in learning and acquiring scientific information about environmental and industrial pollutants and their resultant health-related consequences?\u0026rdquo;\u003c/b\u003e in Table- 5, a comparison between the frequency percentages of responses given in the posttest phase (i.e., after the training) and those in the pretest phase suggests that, apparently, \u003cb\u003ethe medical clerks\u0026rsquo; personal attitudes toward training on pollutant-related topics have undergone a relatively positive change\u003c/b\u003e, as the response \u003cem\u003e\u0026ldquo;low\u0026rdquo; has decreased\u003c/em\u003e, while the responses \u003cem\u003e\u0026ldquo;moderate\u0026rdquo; and \u0026ldquo;high\u0026rdquo; have increased\u003c/em\u003e. However, the option \u003cem\u003e\u0026ldquo;very high\u0026rdquo; shows a slight decrease\u003c/em\u003e in the posttest.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency percentage of clerks\u0026rsquo; responses in the pretest and posttest phases to the question*\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVery High\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo Response\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePretest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosttest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e* \u003cem\u003e\u0026ldquo;To what extent is your personal interest as a medical student in learning and acquiring scientific information about environmental and industrial pollutants and their resultant health-related consequences?\u0026rdquo;\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eComplete Results Pertaining to the Medical Interns:\u003c/h3\u003e\n\u003cp\u003eDescriptive statistics, including measures of range, mean, and standard deviation, were used to examine the descriptive status of the scores obtained by community medicine interns from the pollutant questionnaire during the pretest and posttest phases. The results are presented in Table- 6.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe mean scores obtained by interns in the pretest and posttest phases\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePretest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosttest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eSD: Standard deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBased on assessing the data distribution of medical clerks\u0026rsquo; pretest and posttest scores using the Kolmogorov-Smirnov test, it was determined that the data distribution was not normal. Therefore, the non-parametric Wilcoxon signed-rank test was employed to compare the mean scores. Table- 7 presents the results of this comparison.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the mean scores obtained by interns following the implementation of educational interventions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRank Sign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean Rank\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSum of Rank\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eZ-Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-Value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePretest-posttest scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e76.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-5.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1354.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* Wilcoxon signed-rank test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe analysis and comparison results of this test demonstrate a significant increase in the mean posttest scores of community medicine interns compared to their pretest scores (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003eRegarding the analysis of the number of correct responses given to the pollutant questionnaire items, the frequency percentage of the intern students who provided the correct response in each stage was calculated, the results of which are presented in Table- 8.\u003c/p\u003e \u003cp\u003eAs shown in Table- 8, the comparison of the rate of correct responses between the pretest and posttest (i.e., after the educational interventions) phases using the Wilcoxon signed-rank test demonstrate that this increase in correct responses is statistically significant and substantial (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe frequency percentage of correct responses given by interns in the pretest and posttest phases\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean Frequency Percentage of Correct Responses\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-Value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePretest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e51.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosttest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e82.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eSD: Standard deviation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* Wilcoxon signed-rank test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eConcerning the status to respond to the survey attitude-assessment question, \u003cb\u003e\u0026ldquo;In your opinion, to what extent does a physician need to acquire scientific information regarding environmental and industrial pollutants?\u0026rdquo;\u003c/b\u003e in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, a comparison between the frequency percentages of responses given by medical interns in the posttest phase (i.e., after the training) and those in the pretest phase suggests that medical intern students\u0026rsquo; attitudes toward training on pollutant-related topics have had a positive change. This is evident from the results in Table- 9, showing that the options \u003cem\u003e\u0026ldquo;moderate\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;low\u0026rdquo;\u003c/em\u003e have decreased, while the option \u003cem\u003e\u0026ldquo;high\u0026rdquo;\u003c/em\u003e has increased in the posttest (more than 2.5 times). It should, however, be noted that the rate of \u0026ldquo;no response\u0026rdquo; has increased.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency percentage of community medicine interns\u0026rsquo; responses in the pretest and posttest phases to the question: \u003cem\u003e\u0026ldquo;In your opinion, to what extent does a physician need to acquire scientific information regarding environmental and industrial pollutants?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003cp\u003e(Generalities)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003cp\u003e(Basic Information)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003cp\u003e(Generalities, Basic, and Specialized Information)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo Need\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo Response\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePretest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosttest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAdditionally, the status to respond to another survey attitude-assessment question \u003cb\u003e\u0026ldquo;To what extent is your personal interest as a medical student in learning and acquiring scientific information about environmental and industrial pollutants and their resultant health-related consequences?\u0026rdquo;\u003c/b\u003e in Table-10, a comparison between the frequency percentages of responses given in the posttest phase (i.e., after the training) and those in the pretest phase suggests that, apparently, \u003cb\u003ethe medical interns\u0026rsquo; personal attitudes\u003c/b\u003e toward training on pollutant-related topics have undergone a relatively positive change, as the responses \u003cem\u003e\u0026ldquo;low\u0026rdquo; and \u0026ldquo;moderate\u0026rdquo; have decreased\u003c/em\u003e, while the option \u003cem\u003e\u0026ldquo;high\u0026rdquo; has increased\u003c/em\u003e. However, the option \u003cem\u003e\u0026ldquo;very high\u0026rdquo; shows a slight decrease\u003c/em\u003e in the posttest.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab10\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 10\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency percentage of community medicine interns\u0026rsquo; responses in the pretest and posttest phases to the question\u003cem\u003e*\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVery High\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo Response\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePretest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosttest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003e*\u0026ldquo;To what extent is your personal interest as a medical student in learning and acquiring scientific information about environmental and industrial pollutants and their resultant health-related consequences?\u0026rdquo;\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe comparison of results and statistical analyses demonstrates a significant increase in the mean posttest scores of \u003cb\u003ecommunity medicine clerks\u003c/b\u003e compared to their pretest scores (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). \u003cb\u003e(Changed awareness and knowledge)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe comparison of results and statistical analyses demonstrates a significant increase in the mean posttest scores of \u003cb\u003ecommunity medicine interns\u003c/b\u003e compared to their pretest scores (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). \u003cb\u003e(Changed awareness and knowledge)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA comparison of the percentages of correct responses given by \u003cb\u003emedical clerks\u003c/b\u003e to the pollutant questionnaire items between the pretest and posttest (i.e., after the training) phases shows a statistical significance and is substantial (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). \u003cb\u003e(Changed awareness and knowledge)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA comparison of the rate of correct responses given by \u003cb\u003emedical interns\u003c/b\u003e to the pollutant questionnaire items between the pretest and posttest (i.e., after the educational interventions) phases reveals that the increase in correct responses is statistically significant and substantial (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). \u003cb\u003e(Changed awareness and knowledge)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA comparison between the frequency percentages of responses given by the medical clerks in the posttest phase (i.e., after the training) and the corresponding responses in the pretest phase for \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ethe first attitude-assessment question\u003c/span\u003e indicates that \u003cb\u003ethe medical clerks\u0026rsquo; attitudes\u003c/b\u003e toward training on pollutant-related topics \u003cb\u003ehave not changed significantly\u003c/b\u003e. A comparison between the frequency percentages of responses given in the posttest phase (i.e., after the training) to \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ethe second attitude-assessment question\u003c/span\u003e and the comparable cases in the pretest phase suggests that \u003cb\u003emedical clerk students\u0026rsquo; personal attitudes toward training on pollutant-related topics have undergone a relatively positive change\u003c/b\u003e. \u003cb\u003e(Changed tendency and attitude)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA comparison between the frequency percentages of responses given by medical interns in the posttest phase (i.e., after the training) and the corresponding responses in the pretest phase for \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ethe first attitude-assessment question\u003c/span\u003e indicates that \u003cb\u003ethe medical interns\u0026rsquo; attitudes\u003c/b\u003e toward training on pollutant-related topics \u003cb\u003eshows a positive change\u003c/b\u003e. A comparison between the frequency percentages of responses given in the posttest phase (i.e., after the training) to \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ethe second attitude-assessment question\u003c/span\u003e and the comparable cases in the pretest phase suggests that \u003cb\u003emedical intern students\u0026rsquo; personal attitudes toward training on pollutant-related topics have undergone a relatively positive change\u003c/b\u003e. \u003cb\u003e(Changed tendency and attitude)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOverall, the findings reveal that the student clerks\u0026rsquo; awareness, knowledge, and attitudes have significantly and positively changed compared to before the training (interventions). Finally, the changes related to the student interns\u0026rsquo; awareness and KAP exhibit to become significant and positive compared to before the training (interventions).\u003c/p\u003e \u003cp\u003eOur complementary investigations in this study included evaluating the extent and manner of exposure to pollutants among clients using specific forms regarding exposure to the pollutants\u0026rsquo; risk factor provided to the medical interns, and they were asked to complete these forms for 3\u0026ndash;5 of the clients visiting the centers and submit them to the project\u0026rsquo;s executive manager at the end of their internship period. Regarding the results obtained from these evaluation forms on the amount of exposure, it should be noted that the initial goal was for the interns to become familiar with how to assess risk and exposure to signs and symptoms resulting from pollutants in patients visiting healthcare centers, and to learn which systematic and regular questions to ask, and concerning which substances or pollutants. That is, the objective was training, and this goal was truly achieved. A sample of the completed forms by the interns is available in Appendix 5.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results reveal a positive and significant change in medical intern students\u0026rsquo; awareness, knowledge, and attitudes compared to before the training (interventions). Moreover, the changes related to medical interns\u0026rsquo; awareness and KAP have also been positive and significant compared to before the training (interventions). Hence, considering the necessity of acquiring knowledge and skills and becoming familiar with topics related to environmental and industrial pollutants, including the stages of identifying them as causes and risks for disease occurrence, their pathogenesis, the signs and symptoms of associated illnesses, and the manner of screening and diagnosing their consequences, for future physicians, it is suggested that these topics be included in the medical students' curriculum in a structured and goal-oriented manner.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u0026bull;Ethics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Certification File uploaded in submission\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026bull;Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Not applicable\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026bull;Availability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026bull;Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026bull;Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;This project was funded by the National Agency for Strategic Research in Medical Sciences Education. Tehran. Iran. Grant No.4000565\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026bull;Authors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026quot;J. J. conceived and designed the research and drafted the manuscript. \u0026nbsp;M.A. participated in designing and implementation of the evaluation (pretest, posttest). \u0026nbsp;P.M performed parts of the statistical analysis and helped to edit the manuscript. \u0026nbsp; M. J.G involved in developing educational documents, also in educating students during intervention. \u0026nbsp;M.G. \u0026nbsp;helped in revising educational documents and students training on clinical aspects of exposure forms data gathering. \u0026nbsp;All authors reviewed the manuscript\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026bull;Acknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thanks the National Agency for Strategic Research in Medical Sciences Education for funding this project. Medical Students of Arak University of Medical Sciences(AUMS) who generously participated in this study. The authors would like to acknowledge Mrs. Dr. Nahid Sharahei, for organizing and coordination of educational sessions and evaluation exams.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDr. Mansour Ghiyath-eddin, Dr. Mehrnoush Abtahi, Air Pollution and Its Effects, Comprehensive Book of Public Health, Chapter 4, Section 5 - Tehran 2019\u003c/li\u003e\n\u003cli\u003eNational document on the prevention and control of non-communicable diseases and related risk factors in the Islamic Republic of Iran for the period 1394 to 1404. National Committee for the Prevention and Control of Non-Communicable Diseases\u003c/li\u003e\n\u003cli\u003eAir pollution and the no communicable disease prevention agenda: opportunities for public health and environmental science. Environ. Res. Lett. 16 (2021) 065002.\u003c/li\u003e\n\u003cli\u003eNCD Alliance, Forum of International Respiratory Societies (FIRS), Our right to health, our right to clean air: Improving air quality to address NCDs. PUBLISHED,21st May 2019. Available at: https://ncdalliance.org/resources/airpollution-policybrief \u003c/li\u003e\n\u003cli\u003eAir Pollution and Health: A Review of Global Studies and Research on the Effects of Air Pollution on Health. Tehran, Tehran Municipality Cultural and Artistic Organization, Shahr Publishing Institute, First Edition 2016.\u003c/li\u003e\n\u003cli\u003eZhou M, He G, Fan M, Wang Z, Liu Y, Ma J, et al. Smog episodes\u0026rsquo; fine particulate pollution and mortality in china. Environ Res. 2015;136(2015 Jan):396-404.\u003c/li\u003e\n\u003cli\u003eChan S, Bloom DE, (2019), The macroeconomic burden of NCD associated with air pollution in China. Plos ONE 14(4): e0215663.\u003c/li\u003e\n\u003cli\u003eFurong Zhua,1, Rui Dinga,1, Ruoqian Leia, Han Chenga, Jie Liua, Chaowei Shena, et al. The short-term effects of air pollution on respiratory diseases and lung cancer mortality in Hefei: A time-series analysis. Respiratory Medicine 146 (2019) 57\u0026ndash;65.\u003c/li\u003e\n\u003cli\u003eErrol M. Thomson. Air Pollution, Stress, and Allostatic Load: Linking Systemic and Central Nervous System Impacts. Journal of Alzheimer\u0026rsquo;s Disease 69 (2019) 597\u0026ndash;614.\u003c/li\u003e\n\u003cli\u003eRiegelman RK, Garr DR. Evidence-based public health education as preparation for medical school. Acad Med. 2008;8(4):321\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eEnglander R, Frank JR, Carraccio C, Sherbino J, Ross S, Snell L, ICBME Collaborators. Toward a shared language for conpetency-based medical education. Med Teach. 2017;39(6):582\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eSkochelak SE, Hawkins RE, Lawson LE, Starr SR, Borkan J, Gonzalo JD. Health Systems Science, 1st Edition. Elsevier Health Sciences; 2016. https://bo google.co.il/books?id=q8-fDQAAQBAJ.\u003c/li\u003e\n\u003cli\u003eBen-Shlomo Y. Public health education for medical students: reflections over the last two decades. J Public Health (Bangkok). 2009;32(1):132\u0026ndash;3.\u003c/li\u003e\n\u003cli\u003eKimberly S.GehleMD, MPHJewel L.CrawfordMDMichael T. HatcherDrPH. Integrating Environmental Health into Medical Education. American Journal of Preventive Medicine. Volume 41, Issue 4, Supplement 3, October 2011, Pages S296-S301.\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":"Training, Environmental and industrial pollutants, Screening, Medical student, Clerkship, Internship, Evaluation","lastPublishedDoi":"10.21203/rs.3.rs-8344207/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8344207/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Routine monitoring, identification, early diagnosis and screening of diseases caused by environmental and industrial pollutants by all physicians who will practice in large and polluted cities or areas affected, must be integrated into the theoretical and practical curriculum. Thus, the present study was designed and executed to operationalize and assess the feasibility of this important issue.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The current study employed a single-group pretest-posttest design, and was conducted at Arak Medical school, Iran. Over a period of six months, this study was implemented on 131 community medical clerks and 60 community medical interns during their respective one-month rotations.\u003cstrong\u003e \u003c/strong\u003eThe study was implemented in four phases:\u003c/p\u003e\n\u003cp\u003ePhase 1, the production of educational content, contains identifying various environmental and industrial pollutants, how these substances cause disease, and the recognition and screening methods for various pollution-related diseases.\u003c/p\u003e\n\u003cp\u003ePhase 2, the production of measurement and evaluation tools. Questionnaires derived from the produced educational contents were designed and constructed in three domains: Knowledge, Attitude, and Practice.\u003c/p\u003e\n\u003cp\u003ePhase 3, Educational interventions for the medical clerks and interns were measured using pretests and posttests administered through questionnaires specific to each group. Following the pretests, at the end of the one-month intervention period, a posttest was administered.\u003c/p\u003e\n\u003cp\u003ePhase 4, the analysis of data was statistically analyzed in two stages, the pretest and the posttest, using the SPSS software version 26.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The mean posttest scores of medical clerks compared to their pretest demonstrates a significant increase (P \u0026lt; 0.0001). The comparison of the percentages of correct responses given by medical clerks between the pretest and posttest shows a statistical significance increase (P \u0026lt; 0.0001).\u003c/p\u003e\n\u003cp\u003eThe mean posttest scores of medical interns compared to their pretest demonstrates a significant increase (P \u0026lt; 0.0001). The comparison of the percentage of correct responses given by medical interns between the pretest and posttest is statistically significant (P \u0026lt; 0.0001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The necessity of possessing knowledge, skills, and familiarity with the topics related to environmental and industrial pollutants, is felt for future physicians. It is suggested that these topics be included in the medical students' curriculum in a structured and goal-oriented manner.\u003c/p\u003e","manuscriptTitle":"The Effect of Screening Training for Diseases Caused by Environmental and Industrial Pollutants on the Evaluation Scores of Medical Clerkship and Internship","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-16 09:55:25","doi":"10.21203/rs.3.rs-8344207/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":"f30338ee-8eae-4a95-9827-39d8ed091b93","owner":[],"postedDate":"February 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T19:54:11+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-16 09:55:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8344207","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8344207","identity":"rs-8344207","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}