Clinical and Health Affairs
The Role of the Environment in Pediatric Practice in Minnesota
Attitudes, Beliefs, and Practices
By Leonardo Trasande, M.D., M.P.P., Christine Ziebold, M.D., Ph.D., M.P.H., Jeffrey S. Schiff, M.D., M.B.A., David Wallinga, M.D., M.P.A., Patricia McGovern, Ph.D., M.P.H., R.N., and Charles N. Oberg, M.D., M.P.H.
Abstract
Pediatricians can help limit children’s exposures to environmental hazards, but few studies have assessed their comfort with discussing and dealing with environmental health issues. We surveyed the membership of the Minnesota Chapter of the American Academy of Pediatrics to assess pediatricians’ attitudes and beliefs about the effect the environment can have on children’s health, and to assess their practices in regard to screening for, diagnosing, and treating illnesses related to environmental exposures. Results showed that Minnesota pediatricians agree that children are suffering from preventable illnesses of environmental origin but feel ill-equipped to educate parents about many common exposures and their consequences. Responses also indicated significant demand for education on the subject and for a referral center that can evaluate patients who may be suffering from environmental exposures.
Pediatricians and other health care providers can prevent children from suffering health consequences associated with exposure to environmental hazards by educating parents about what may be dangerous. This is easier said than done, however, because most physicians receive little training in environmental health and, thus, feel ill-equipped to discuss environmental exposures and manage diseases of environmental origin.1,2 A study of Georgia pediatricians found that 53.5% reported seeing patients who were seriously affected by environmental exposures but only 1 in 5 had received specific training in environmental pediatrics.3 Additional studies by researchers in New York and Wisconsin found that pediatricians expressed confidence in their ability to screen patients for and educate parents about the consequences of lead exposure but felt much less able to deal with pesticide, mercury, and mold exposure.4,5
Minnesota pediatricians have at their disposal many resources to help them help patients who are suffering from environmental exposures. Those resources include lead clinics, poison control centers, and the Pediatric Environmental Health Specialty Unit (PEHSU) for the Great Lakes Region, located at the University of Illinois at Chicago. Funded by the Centers for Disease Control and Prevention and the Environmental Protection Agency, the Chicago PEHSU, which serves Minnesota, Michigan, Illinois, Indiana, Wisconsin, and Ohio, is 1 of 11 in the United States.6 The PEHSUs provide education about children’s environmental health as well as consultation services for health professionals, public health professionals, and others. Survey data from Wisconsin suggest that pediatricians do not routinely refer to the Chicago PEHSU despite significant unmet demand for additional clinical resources.6 This suggests either a need to increase awareness of the PEHSUs or that the PEHSUs may not provide sufficient support to meet the needs of child health professionals across the nation.
We surveyed the membership of the Minnesota Chapter of the American Academy of Pediatrics (AAP) to assess whether pediatricians perceive a lack of self-efficacy (the judgment that one is capable) for screening patients for common environmental exposures, diagnosing and treating patients with diseases of environmental origin, and finding resources about the effects of environmental exposures on children’s health.
Methodology
We developed a 4-page survey that was modeled after a previous survey by Kilpatrick et al.3 The questionnaire consisted of 26 items, divided into 3 sections. The first section ascertained beliefs, attitudes, and feelings about physicians’ self-efficacy regarding the environment and its effect on children’s health. This section also inquired about pediatricians’ current behaviors, asking how often they ask particular questions during patient visits and the circumstances under which they ask those questions. The second section of the survey asked pediatricians to identify their preferred sources of information as well as others they might find helpful if they wanted to learn more about children’s environmental health. The survey ended by asking respondents for demographic and practice information. Before administering the survey, we pilot-tested the questionnaire on 2 pediatricians and made modifications to improve clarity and convenience. The Institutional Review Board of the Mount Sinai School of Medicine reviewed and approved this study. Waiver of signed consent was granted.
We mailed the questionnaire to all 822 members of the Minnesota chapter in December 2004. Six weeks later, we sent a second copy to those pediatricians who had not responded.
Of the 822 questionnaires mailed to Minnesota pediatricians, 197 were completed and 5 were returned as undeliverable. The overall response rate was 197 of a possible 817 respondents, or 24.4%. After excluding 20 of the 197 returned questionnaires because the respondents reported that they were not currently in pediatric practice, the final sample analyzed consisted of 177 practicing pediatricians.
We asked participants to rate their agreement with a series of belief statements on a Likert scale of 1 to 5, with 1 indicating that they “strongly disagree” and 5 that they “strongly agree.” The statements focused on whether the physicians thought history-taking helped identify exposures that caused specific symptoms, whether asking about a patient’s potential exposures would take up too much time during the visit, and the significance of environmental exposures on children’s health. In addition, pediatricians were asked to assess their ability to help families control children’s exposure to environmental health hazards and to rate whether they believed the magnitude of children’s environment-related illness is increasing.
In addition, we asked participants to rate statements about their confidence in their ability to take an environmental history, discuss exposures with parents, and find resources to evaluate exposures to lead, mold, pesticides, and mercury.
They were also asked whether they routinely inquired about certain categories of environmental exposures (eg, lead, pesticides, mold) during well-child visits, whether they knew about or made referrals to the regional PEHSU, and how many referrals they might make to a clinic specializing in the evaluation and treatment of children’s environmental health concerns, if such a clinic existed in the state.
In addition, pediatricians were asked whether they had a copy of either the AAP’s Handbook of Pediatric Environmental Health, which was published in 1999, or the newer Pediatric Environmental Health, which was published in 2003. They were also asked to select from a list their preferred sources of information about children’s environmental health and to suggest new ones they felt may be helpful. During data entry, we identified missing values and excluded them from the data analysis. We also checked data by running frequencies on each variable to check for outliers and data entry errors, and we randomly sampled and checked 10% of the questionnaires for accuracy. Statistical analyses were conducted using SAS 9.1.3 (Research Triangle Institute, Cary, NC).
Results
Of the 177 pediatricians in the sample, approximately half worked in a public community clinic and half in a private primary care practice. Although most practiced primary care, various specialties including neonatology, adolescent medicine, pediatric cardiology, gastroenterology, and allergy were represented. The mean age of respondents was 34.3 years, and the mean number of years in practice was 10.7. An equal number of men and women were represented in the sample. Nearly 10% of the respondents reported that 50% or more of their patients were enrolled a publicly funded insurance program.
♦ Beliefs and Attitudes
Respondents indicated that they strongly believe the environment plays an important role in the health of children (mean response 4.36, on a 1 to 5 scale) and that it is important to assess their patients’ exposure to potentially harmful substances in the environment during clinic visits (mean 3.88) (Table 1). The pediatricians also tended to believe that the magnitude of children’s environment-related illnesses is increasing (mean 3.63) and that they have little control over their patients’ exposure to health hazards in the environment (mean 2.77).
Respondents seemed to value the environmental health history as a way to identify exposures that cause specific symptoms (mean 3.93). They also thought it helps parents protect their children from hazardous environmental exposures by making them aware of the potential harm certain exposures can cause (mean 3.81).
♦ Self-Efficacy
When asked about self-efficacy, respondents voiced high levels of confidence in their ability to incorporate questions about lead exposure when taking a child’s medical history (mean 4.11), discussing the consequences of lead exposures with parents (mean 4.03), and finding resources to help them diagnose and treat illnesses related to lead exposure (mean 3.89). However, the pediatricians were much less confident in their ability to do the same for pesticide, mercury, and mold exposures, as the mean responses were much lower than those for lead exposure. For incorporating questions about pesticide, mercury, and mold exposure during history-taking the means ranged from 2.45 to 3.07; for discussing the health consequences of these environmental exposures with parents, from 2.61 to 3.11; and for finding resources to diagnose and treat illnesses related to such exposures, from 2.41 to 2.79.
♦ Clinical Practices
Almost all (93.4%) of the respondents reported a past experience with a patient who had been affected by an environmental exposure such as lead poisoning (Table 2). When presented with a list of environmental exposures and asked which of them they routinely address during well-child visits, 78 (44.1%) of the 177 respondents said they do all of the following: routinely ask about cigarette smoking around the child (90.4%), sun exposure (81.9%), lead exposure (73.5%), housing age/type (67.2%), firearms in the home (66.7%), pets in the home (63.3%), parental/teen occupation (57.6%), water quality (53.1%), and window guards and other devices designed to prevent injury in the home (45.8%). They asked less often about potential exposure to carbon monoxide (28.8%), dust mites (23.2%), mold (22.0%), and air pollution (13.6%). For purposes of comparison, 91.5% of respondents routinely asked about diet and nutrition, while 89.8% asked about immunizations, and 89.2% about development. Fewer than 10% of respondents reported routinely asking about pesticides, mercury, polychlorinated biphenyls, asbestos, radiation exposure, nitrates, radon, arsenic, volatile organic compounds, and phthalates.
♦ Awareness and Education
Only 1 in 8 respondents had received any training in environmental history-taking (12.4%) (Table 2). Interest in learning more about environmental exposures and their effect on children’s health was very high (88.1%). The pediatricians’ most common source of information about environmental exposures was the professional literature (91.5%). Other important sources included lectures/grand rounds (71.1%), websites of professional organizations such as the AAP (63.3%), local health departments (58.8%), and government agency websites (55.4%). When asked which sources they would find most helpful for obtaining more information, the responses were similar: guidelines from the AAP (70.6%), presentations by specialists (47.4%), continuing medical education classes (44.1%), patient education materials (42.3%), newsletters (35.6%), and professional literature (35.0%). Less than half of respondents (48.6%) had a copy of either the AAP’s Handbook of Pediatric Environmental Health or Pediatric Environmental Health.
Relatively few pediatricians (2.3%) knew about the Chicago PEHSU, and none of the respondents had referred patients to it. Despite the relatively low referral rate to the PEHSU, demand for clinical referral resources was extremely high: 87.7% of respondents said they would refer patients to a clinic “where pediatricians could refer patients for clinical evaluation and treatment of their environmental health concerns.” The 177 respondents indicated they would make at least 844 referrals to such a clinic if one were available. If this sample is representative of Minnesota pediatricians, it suggests that they would make 3,967 referrals annually to a Minnesota clinic for children’s environmental health concerns.
Discussion
Minnesota pediatricians who took our survey indicated a great deal of interest in children’s environmental health, a belief that environmental exposures affect their patients’ health, and a high level of interest in learning more about how environmental exposures can affect health. They did not mention lack of time or cost as being barriers to addressing this issue by incorporating the environmental history into clinical visits. They also perceived environmental health concerns to be significant and common in their practices. Pediatricians reported having had very little training in taking environmental histories, not being confident in their ability to discuss children’s environmental exposures with parents, and not being aware of resources that can help diagnose and treat patients with illnesses related to environmental exposures. The one exception where pediatricians said they did feel confident is in dealing with lead poisoning.
Our data point to clear opportunities to address these problems. Respondents indicated the AAP is a highly credible information source. Medical literature and government agencies were also listed as preferred sources of information, considerably more so than Internet-based sources. The federally sponsored PEHSU was the least-used resource for pediatricians. Further work is needed to delineate the reason why; however, lack of familiarity appears to be a major contributor, and proximity to Minnesota may be another. A PEHSU located more than 1 to 2 hours away may not be useful to a pediatrician who evaluates a child who has had an environmental exposure that could be hazardous or who has an illness that may be caused by something in the environment. For that reason, pediatricians may find a nearby clinic where they can refer patients for a complete, in-person evaluation more valuable, just as they might refer patients to a nearby pediatric cardiologist or endocrinologist rather than one at a faraway, highly specialized institution. This is most strongly suggested by the heavy referral volume that a local clinic specializing in pediatric environmental health would achieve. These findings are consistent with previous data collected in New York and Wisconsin, and raise a question about the extent to which pediatric residency curricula address environmental exposures and the management of any related clinical problems. Additional research is needed to evaluate what is being taught and what curriculum needs, if any, exist to best prepare pediatricians to deal with the growing concerns about the influence of environmental determinants on children’s health and development.
Our response rate of 24.4% may have introduced some selection bias, but this is not uncommon for a physician mail survey.7 Respondents may have been more interested in pediatric environmental health and, thus, more eager to take part in the study than nonrespondents. Our results may therefore overstate the level of concern about environmental health problems among children, and of pediatricians’ interest in learning about environmental health. Similarly, because our results are based on self-reports and because respondents may be motivated to give the “right” answer, the level of interest may be overstated. Nevertheless, we believe our results indicate a considerable reservoir of interest in pediatric environmental health and considerable opportunity for educating pediatricians about these concerns. Specifically, they point to the need for a local clinical resource specializing in pediatric environmental health.
Conclusion
Environmental exposures are increasingly seen as preventable causes of childhood morbidity. Physicians and other health care providers can screen for exposure to hazards in the environment and educate parents about the consequences of such exposures and how to prevent them. Our findings clearly suggest that a multifaceted approach is needed to prevent and treat illnesses that may be caused by environmental exposures. This would include a focused educational campaign aimed at physicians and other health care providers about children’s environmental health and the availability of resources that can help them if they encounter a patient who may be suffering the effects of such an exposure. Additional clinical resources for children’s environmental health in the state could also also help in diagnosing and treating patients with illnesses that may be caused by exposure to toxins in the environment. MM
Leonardo Trasande is in the department of community and preventive medicine and the department of pediatrics at Mount Sinai School of Medicine in New York City, Christine Ziebold is in the department of pediatrics at the University of Iowa in Iowa City, Jeffrey Schiff is with the Minnesota Department of Health and the Minnesota Chapter of the American Academy of Pediatrics, David Wallinga is with the Institute for Agriculture and Trade Policy in Minneapolis, Patricia McGovern is with the Division of Environmental Health Sciences in the University of Minnesota School of Public Health, and Charles Oberg is with the Division of Epidemiology and Community Health in the School of Public Health and the department of pediatrics in the School of Medicine at the University of Minnesota.
This study was supported by the Beldon Fund. We thank the many pediatricians who took the time to respond to this survey.
References
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