Abstract
Introduction
The rising impact of climate change on global health warrants the integration of climate change education when training health professionals. Climate change education is rarely addressed in health professions curricula and graduates are often not adequately prepared for climate change issues. Effective climate change education among health professionals creates an opportunity to develop resilient health systems that can be leveraged to combat climate change-related health challenges.
Aim
This integrative review aims to address the question: How can climate change education be integrated in health professions curricula as a tool for environmental sustainability?
Methods
This integrative review was conducted using the Whittemore and Knafl five-step process. Several databases were searched to identify relevant literature published between January 2014 and August 2024. Forty-one articles met the inclusion criteria.
Results
Thematic analysis generated five domains, each with a specific theme generated inductively after engaging with the individual themes from each included article. These themes are: curriculum development, regulatory bodies, faculty development, resources and models. Furthermore, climate change is recognized as critical in health profession education globally, however, its integration varies between countries based on contextual differences.
Conclusion
Most high-income countries have made significant progress toward integrating climate change education in health professions education. However, low- and middle-income countries lag behind as most LMICs believe that this is a problem only faced by high-income countries. A radical, multipronged approach is essential to equip future health professionals with the knowledge to tackle climate extremes. Continuous education and collaboration among leaders and health professionals provide untapped opportunities for implementing context-specific models to achieve environmental sustainability.
Keywords
Background
Climate change is a major global threat to human health and the health system. Climate change is projected to cause around 250,000 additional deaths annually between 2030 and 2050 due to malnutrition diarrhea, malaria, and heat-related stress (World Health Organization [WHO], 2021). Environmental sustainability means managing natural resources to fulfill current needs without compromising the ability of future generations to meet theirs (Mensah, 2019; Morelli, 2013). The focus is to create a balance between reducing carbon emissions, renewable energy and equitable resource access (Sen et al., 2024). The core of climate change education is to develop knowledge and skills in health professions, which will in turn play critical roles in improving environmental sustainability. The link between climate change and its related health problems provides validation for the dire need to include health professionals in climate change solutions (Dickman, 2022). Health professionals need to be at the forefront of mitigating these effects (Diallo et al., 2023; Romanello et al., 2022). Health professions education provides a unique and untapped opportunity that can be leveraged in climate change mitigation (Maibach et al., 2019). This can be achieved by utilizing health professionals to educate the public, policymakers and colleagues on the effects of climate change (Howard et al., 2023). Additionally, they can assist individuals and communities in mitigating the adverse effects of climate change within the healthcare systems (International Council of Nurses [ICN], 2018). To achieve these multiple roles, health professionals need to be well prepared.
Integrating climate change education into health professions education is not an easy task. Globally, climate change is rarely addressed in health professions curricula and graduates are often not adequately prepared to deal with its consequences (Eilam, 2022). Several studies done in recent years show that key issues that impede the integration of climate change education in health professions education curricula include, a lack of adequate training on climate change among health professions educators, a lack of emphasis from curriculum regulators, and a lack of support from educational institutions due to already crowded training schedules among other factors (Barna et al., 2012; McDermott-Levy et al., 2019). Irrespective of these challenges several high-income countries have started integrating climate change education into the health professions curriculum. Mathers et al. (2023) compared American and European universities regarding the incorporation of climate change courses in their pharmacy curriculum. They identified different approaches used in this integration with some universities offering a 10-week course, while others presented lectures. Some universities opted for collaborations in developing relevant programs. While these measures are a good starting point, the mere introduction of a course in climate change and sustainability is not adequate. The ability to apply these principles, methods, and approaches should be ingrained in all graduates and specific evaluation criteria should be developed to measure the impact. Therefore, a critical analysis of teaching approaches should be adopted to foster learner awareness, involvement, and sustained impact. Moreover, learners should be allowed to develop projects and carry out activities to mitigate climate change.
Low- and middle-income countries are highly affected by the adverse effects of climate change. Higher education institutions (HEI) provide a fundamental pillar to raise awareness on the climate change agenda (Reimers, 2021). Dzvimbo et al. (2022) identified the multifaceted role of HEIs in climate change, actualizing sustainable development goals and measures to mitigate environmental disasters and possible social and economic losses. The critical role that HEIs plays in promoting environmental sustainability has been identified as a complementary strategy for mitigating carbon emissions and promoting environmental sustainability in eastern and southern African countries (Shobande & Asongu, 2022). Climate change issues surrounding eastern and southern African countries affect the food supply chain and consequently the food security of the entire continent (Beltran-Peña & D’Odorico, 2022; Shobande & Asongu, 2022). Despite East African governments having recently embedded climate change in school curricula, health professionals were not part of these initiatives due to constraints regarding timeliness and were not therefore able to participate (Apollo & Mbah, 2021; Darling-Hammond et al., 2020). Apollo and Mbah (2021) and Darling-Hammond et al. (2020) identified that health professionals lack coherent approaches to leverage climate change education as a tool in their adaptation and mitigation strategies. Therefore, effective climate change education among health professionals creates an opportunity to develop resilient health systems that can be leveraged to combat climate change-related health challenges. This paper aims to address the question of how climate change education can be integrated in health professions curricula as a tool for environmental sustainability?
Methods
An integrative review was appropriate for this paper as it provides a current, comprehensive synthesis of the literature to provide a holistic overview and understanding of the topic under study. This integrative review was conducted using the Whittemore and Knafl (2005) five-step process which includes problem identification, a literature search, selection, and data extraction, and data analysis. Databases including Google Scholar, PubMed, and MEDLINE were searched using keywords.
Study Design
The study is an integrative review, and forms the first part of a three-phased study. Further parts of the study will include a modified Delphi and a feasibility study. An integrative review was conducted using Whittemore and Knafl, five-step process (2005) These steps are: problem identification, a literature search, the selection of data, data extraction, and data analysis and the presentation of results. These steps contribute to the rigor of this study (Toronto & Remington, 2020; Whittemore & Knafl, 2005). The steps are further outlined below.
Problem Identification
The following research question guided the integrative review: How can climate change education be integrated in health professions curricula as a tool for environmental sustainability in Low- and middle-income countries (LMICs)?
Search Strategy and Selection of Articles
The integrative review was guided by the steps suggested by Whittemore and Knafl (2005) and the research problem. Keywords were linked through Boolean operators and modifiers to generate a search string. The keywords were, “climate,” “education,” and “health professions.” A librarian refined the search string. The final search string in this review was:
((Climat* AND change*) OR environment*) AND (education* OR curricul*) AND (sustainab* OR renew*) AND (“health* profession*” or “health care profession*”) AND (universit* OR “higher education” OR tertiary) AND (“low income countr*” or “middle income countr*” or “low and middle-income countr*” or “Developing countr*”).
This search was conducted on Google Scholar and the following EBSCO host databases: MEDLINE, CINAHL with full text, Academic Search Ultimate, APA PsycInfo, ERIC, E-journals, CAB Abstracts, Africa-wide information, Education Source.
In the second stage, a two-step selection process involving two researchers was guided by a set of inclusion criteria. Selected articles had to focus on climate change education for environmental sustainability among health professionals. A date limit was set for articles published between January 2014 and August 2024 (Table 1).
Inclusion and Exclusion Criteria.
Before the screening commenced, 444 records were excluded through automatic and physical deduplication. Of the remaining 156 records, 108 were eliminated for various reasons, including inappropriate contexts and different subjects. Finally, 48 records were selected for screening, and the librarian assisted in providing access to these articles. For these seven were eliminated as they did not meet the inclusion criteria. Forty-one articles met the inclusion criteria and were included in the review (Figure 1).
Data Extraction
The data extraction process was based on the 41 articles included in the review (see Supplementary Material). A Google Form was used to extract the data. The headings used in the extraction form were: author, title of the study, year, country, purpose of the study, population group, study design, results or outcomes, data collection methods, data analysis methods, recommendations and limitations were identified. The data extraction was carried out by both authors.
Data Analysis
The integrative review was underpinned by the contemporary framework for integrative reviews, which was applied throughout the process of data analysis (Whittemore & Knafl, 2005). Data were independently analyzed and interpreted by two researchers, and updated continuously. After analysis, the authors determined the ability of the data to answer the research question. Areas of difference necessitated mutual agreement to merge themes. Finally, consensus, verification and confirmation of the themes and sub-themes were performed by the authors (Table 2).
Data Analysis Table.
Results
Study Selection
The results are data based extracted from the 41 selected articles. The majority of the articles were from the USA, Canada, Spain, Finland, Saudi Arabia, and South Africa. The majority of the studies focused on the nursing profession and had a qualitative approach.
Study Characteristics
Five themes, each with a specific sub-themes, were generated inductively after engaging with the individual themes from each included article. These themes are: curriculum development, regulatory bodies, faculty development, resources, and models (Table 3).
Themes in Climate Change Education.
Discussion
There is a dire need for the integration of climate change in the education among health professionals in both high-income and low-income countries (Maxwell & Blashki, 2016). The following discussion explores the five themes derived from the articles analyzed in the review.
Curriculum
The sub-themes generated from this domain include self-study modules, online modules, content development, teaching materials, community involvement, and practical experience. It is not realistically possible to have a standard curriculum for climate change due to contextual differences between countries (Maxwell & Blashki, 2016). Studies on health professions education (HPE) do, however, indicate an emphasis on integrating climate change education into the curriculum in order to improve health outcomes. This integration is being achieved through various strategies such as case studies, webinars elective courses, and virtual tele-mentoring sessions on climate change in HPE (Cadet, 2022; Hatfield et al., 2022; Katzman et al., 2023; Simmonds et al., 2022; Wasco, 2019). This is a good starting point that can provide an untapped flexible learning opportunities that can be leveraged in teaching climate change to health professionals. Lemery et al. (2020) explored the different learning approaches used by United States (US) universities in incorporating climate change at undergraduate, graduate, and postgraduate levels. They found out that the following strategies were used by universities in HPE on climate change to include the provision of longitudinal curricula over the course of the degree course on climate change, use of two-week short courses on climate change, simulated case-based scenarios, use of peer-reviewed slide decks, elective courses and field trips, use of guest lectures by experts, Masters’ programs, and graduate fellowships on climate change (Columbia University, School of Public Health, 2020; Fleischer, 2014; Howard & Huston, 2019; University of California San Francisco, 2020). While these measures can be regarded as a good starting point, the mere introduction of a course in climate change and sustainability is not adequate. The ability to apply these principles, methods, and approaches should be ingrained in all health professions graduates at different levels. Specific evaluation criteria should also be developed to measure the impact. The future of environmental sustainability will be hedged on the acquired knowledge and skills, and the impetus to action.
The development of relevant and up-to-date content is imperative for effective climate change education. Different models can be used in developing valid content on climate change. The Analyze, Design, Develop, Implement, and Evaluate (ADDIE) model should form the gold standard in curriculum content development and instructional design in climate change education (Keating et al., 2022). Additionally, Lemery et al. (2020) argue that the four dimensions framework (big picture context, learning objectives, teaching methods and assessment, and local administrative and institutional contexts) suggested by Lee et al. (2013) and Maxwell and Blashki (2016), could also be utilized as a model to guide in conceptualizing and designing a curriculum on climate change for health professionals. This will ensure that the content in the HPE curriculum prepares graduates for the complexities of climate change in the workplace.
From this review, it seems that different approaches can be used to achieve climate change education in health professionals. These include the use of infographics, recent publications on climate change and multimedia interviews (Hackett et al., 2020; Wasco, 2019). In addition, it is important to involve subject experts with domestic and global experience on climate change issues in the development of curriculum content through communities of practice (Keating et al., 2022). Designing instructional materials is just the first step in the journey, and there is a dire need to develop a system of assessing mastery regarding this topic, to achieve competency in climate change issues.
The increasing recognition of the role of HPE in tackling climate change issues signifies a change in perspective, aligning with the principles of public health and community participation. Community involvement and practical experiences provide health professions students with real-world experience of the impacts of climate change. From the review, several studies suggest the dire need for health professionals to become involved in community-based projects and practical experiences. This will facilitate comprehension of the real-life implications of climate change among health professionals (Irlam et al., 2023; McDermott-Levy et al., 2018). A study by Tiitta et al. (2024) suggested that HPE students can participate in practical activities such as gardening to understand and relate the different concepts in climate change. Furthermore, health professionals can form “green teams” at the workplace to promote sustainable and environmentally friendly services at work and in community settings (Gaudreau et al., 2024). Moreover, universities can also incorporate mock disaster drills in school or community settings to help students integrate the different concepts of climate change (McDermott-Levy et al., 2018).
Similarly, a study by Bell (2010) suggests that medical students can use journals for reflective practices during their placements in rural and remote sites. They can use these to record the health effects of climate change. Community involvement creates a good opportunity for the health professionals to work with the communities they serve, thereby paving the way for more sustainable health interventions, because HPs are at the forefront of community initiatives.
Involvement of Regulatory Bodies
Training programs, the accreditation of programs and continuous professional education were the main themes identified under this domain. Context-specific approaches to incorporate climate change education in health professions syllabi to guide adoption by institutions of higher learning are pivotal in shaping how climate change education is rolled out for maximum benefit, especially in LMICs. In response to the changing educational and professional demands, regulatory bodies are vital in determining the curricula used in HPE and integrating various aspects of climate change to adequately prepare HPE students for future challenges. A study by Butterfield et al. (2021) showed that there is a widening gap between regulatory bodies for nursing education and nursing practice on climate change issues. The Healthy University Approach provides a great starting point in this regard. This approach, however, demands more attention and consistent visibility (Álvarez-Nieto et al., 2022; Dooris et al., 2021; Stephens & Leslie, 2023). In LMICs, regulatory bodies need to be at the forefront to advocate for the inclusion of climate change education in HPE. Moreover, multinational collaborations and capacity-building initiatives can assist in developing regulatory frameworks that advocate for climate change issues in practical and impactful ways (Bell et al., 2019; Kotcher et al., 2021). Furthermore, regulatory bodies’ proactive efforts on climate change will help equip the next generation of health professionals with the competencies to deal with climate change issues in the 21st century.
Continuous professional development is critical to ensure that health professionals have up-to-date knowledge on the issues of climate change (Kotcher et al., 2021). In the review, several studies highlighted the role of HPE regulatory bodies in offering continuous professional development opportunities on the issues of climate change for healthcare professionals to remain knowledgeable on climate change interventions and impacts (Bell et al., 2019; Iira et al., 2020; Kotcher et al., 2021; Valois et al., 2016).
A study by Bell et al. (2019) showed that health professionals who participated in CPD on climate change issues had greater confidence in dealing with the impacts of climate change in their practice. This points out that CPD is not only necessary for maintaining current knowledge, but also provides an untapped opportunity for improving HP's response to climate change issues. Climate change presents a critical health challenge at the intersection of climate and health. It should be addressed by adequately trained health professionals. According to the World Economic Forum Report (2020), extreme weather and climate action are likely global risks. Equipping health professionals with relevant education and tools to advocate, act and engage on climate change for environmental sustainability should be a priority. The call to integrate climate change into health professions education is judicious to mitigate the harmful effects of climate change. Health professionals need to be adequately prepared to face the challenges brought by climate change (McKinnon et al., 2022; Portela Dos Santos et al., 2023). Health professions educators are at the center of developing these health professions to be climate resilient. They have a mandate to adequately prepare the health professions in aspects of climate change (Boekels et al., 2023).
Faculty Development
Faculty responsible for health professions education are inadequately prepared to teach climate change to health professionals (Madden et al., 2020; Tun et al., 2020). Health professionals have a critical role in mitigating the accelerating influence of climate change. Furthermore, a shift to learning new knowledge related to climate change, and teaching this content in their course material is expected and will greatly impact the quality of health professions education (Dalapati et al., 2023; Field et al., 2023). The centrality of health faculty shaping the future of health professional and their preparedness to mitigate these anticipated extremes will influence environmental sustainability tremendously.
Health professions faculty require effective transformational leadership offering overarching support for policy and advocacy for climate change education. Leadership in health professions education requires newer perspectives juxtaposed by widely unfamiliar and unprecedented challenges at the intersection of climate change and education (Bernhardt et al., 2023; Tiitta et al., 2024). Climate change should be addressed through advancing public and political engagement and publications in scientific journals (Kumpu, 2022). Transformative leadership is required in HPE to drive change and inspire a commitment to develop health professionals (Trott et al., 2023). The central themes emerging from this review include that HPE leadership should further develop frameworks, models, and educational initiatives based on the likelihood of future global pandemics and the convergence with health consequences of climate change (Thibault, 2020) . In addition, partnerships should be established with community and health systems leaders to address the intricacies of the intersection of climate change and health toward economic sustainability.
The goal of incorporating the use of innovative teaching approaches is to develop health professionals’ knowledge and attitudes in critical thinking toward climate change and environmental sustainability. Various teaching approaches have been suggested in this regard, such as team-based learning, online learning, simulations, case studies, and scenario-based approaches (Cadet, 2022; Tiitta et al., 2024). Innovative teaching methods that cross different subjects and include hands-on activities like gardening, role modelling, and using resources wisely are essential for promoting environmental sustainability (Cadet, 2022; Siemon et al., 2024). Such multidimensional teaching approaches provide a paradigm shift in the way that students relate to climate change by providing novel experiences and improving the retention and application of content (Haleem et al., 2022). This strategic approach will foster critical thinking, problem-solving and adaptive skills for future health professionals (Hatfield et al., 2022). The ability of the educator and learner to co-create context-specific learning activities has the potential to improve climate change education within different geographical regions driven by environmental priorities (Hügel & Davies, 2024; Siemon et al., 2024).
According, to Al-Ansi et al. (2023), through the use of modern teaching approaches such as augmented reality (AR) and virtual reality (VR), immersive digital experiences, interactiveness and engagement will revolutionize climate change education. AR augments the actual world with digital data, while VR creates an entirely fabricated experience to provide an immersive environment with interactive or non-interactive options that can be used to teach climate change and the importance of environmental sustainability (Zhao et al., 2023). The innate ability of AR and VR to provide customized learning experiences through which the information is tailored to learners’ requirements and skills increases learner engagement and motivation. The involvement of ambassadors, champions, or “green teams” can be used to promote and implement greener practices among health professionals (Gaudreau et al., 2024). Ambassador programs, champions, or “green teams” aim to raise awareness of climate change while encouraging learners to implement environmental sustainability. Participation in the ambassador program is associated with greater sustainability empowerment (Solly et al., 2022). The Climate Ambassador program is a six-chapter, four-hour course comprehensive intervention with numerous modules to scale up health professionals to advocacy and leadership (Speiser & Hill, 2022).
Resources
Resources play a fundamental part in training program leaders seeking to integrate evidence-based climate change education into curricula. To a large extent, resources to determine the success of these programs (Philipsborn et al., 2021). Health professionals are trailblazers in developing innovations that can address environmental and climate change issues. Financial support therefore, is critical to ensure timely results (Gaudreau et al., 2024). Furthermore, financial support is required to equip health professionals to develop knowledge and skills to support environmental sustainability (Gaudreau et al., 2024). In addition, financial incentives are needed to rally support within health professions for action. Such actions could include forming “green teams,” workplace grants for research, renewable energy, environmental sustainability drives, and engaging the community for action to reinforce knowledge and improve skills (Gaudreau et al., 2024). Limited resources in terms of continuous professional education, patient education materials, policy statements, action alerts and the sustainability of the health professions environments are impediments to addressing environmental sustainability (Kotcher et al., 2021). Consensus is required to support LMICs with the requisite resources (expertise, financial, and non-financial resources) to support climate change education among health professions (Shaw et al., 2021). Health professionals are at the core of health systems and resources will determine the ability of robust health systems to support climate action by mitigating the effects of climate change through environmentally sustainable efforts.
Models
The call to action for a response by health professions practice, research, advocacy and education to mitigate the harmful health effects of global climate change can be achieved through frameworks and models for action. Through this literature review, overarching frameworks and models that can offer support for the implementation of climate change education in health professions were identified (Brennan & Madden, 2023; Leffers et al., 2017). The Healthy Universities approach is one such model that adopts an ecological model of health with a multifaceted interplay of environmental, behavioral, and organizational factors (Álvarez-Nieto et al., 2022; Leffers et al., 2017). The One Health approach, with a collaborative impetus between policymakers, educators, and citizens to identify and mitigate challenges related to climate change can be used to advocate for the addition of health professions in collaboration for climate change action (Gaudreau et al., 2024). Similarly, the Ecological Planetary Health model can be used for integrating climate change education into health professions education curricula as well as continuous professional education (Gaudreau et al., 2024; McDermott-Levy et al., 2019). Furthermore, the Ecological Planetary Health Model goes further to highlight the critical connections and overarching effect that health professions have on behavior and action to mitigate climate change and improve health outcomes (Leffers et al., 2017; Neal-Boylan et al., 2019; Pathak & McKinney, 2021).
A similar framework inclined to assist health professions in integrating climate change education is the “WE ACT PLEASE” framework that describes five contents of domains of pollution from health care sources: Waste, Energy/water, Agriculture/food, Chemicals, and Transportation (WE ACT). It identifies six key professional elements to mitigate these, namely Professional, Obligation, Leadership, Education, Accountability, Science and Engagement (PLEASE) (Gaudreau et al., 2024; Schenk, 2019). The framework has been widely used for environmental stewardship in nursing practice, and the approach can also be adopted in the context of HPE.
Strengths and Limitations
The review was able to develop themes to guide the development of climate change education for HPE. The review provides a call to action for all stakeholders involved to improve climate change education for environmental sustainability. The paper has also made a significant contribution to the research on climate change, particularly in LMICs. The possible limitations of this review may inherently have been brought about by the search string and inclusion criteria, which may have excluded relevant studies. Studies in other areas, for instance non-English speaking countries, were excluded, which might have brought in much-needed guidance.
Implications of the Results on Practice
Health professionals need training to understand the health risks associated with climate change and how to manage climate-related health issues. Climate change education should be incorporated into the curricula of HPE. The evidence points to a total overhaul of HPE curricula compelling regulatory bodies to not only incorporate climate change education but also further develop frameworks to ensure innovative teaching approaches for environmental sustainability. Government policies are also critical to ensure the embedding of climate change education into the core curricula of health professions education. Future research should focus on the effectiveness of incorporating climate change education into HPE.
Conclusion
Climate change and its detrimental effects are regarded by most LMICs as a problem facing HICs. This perceived lack of urgency and laxness is myopic and ill-considered, as these countries bear the brunt of climate change. Floods, changing weather patterns, prolonged droughts, and extreme weather conditions have been witnessed in Africa. The majority of the studies in this review are from high-income countries, indicating a paucity on this topic from LMICs.
Shifting climate patterns indicate a clear move away from established climatic conditions. A radical, multipronged approach to equip future health professionals with the requisite knowledge to tackle climate extremes is critical. Furthermore, designing continuous professional development programs for health professionals who are not currently enrolled in a university program would be essential in rallying health professionals around climate change for environmental sustainability. Health professionals are at the center of this conundrum and have challenging roles in taking care of the individuals, families, and communities they serve. Models and frameworks should guide implementation and provide a roadmap to actualizing environmental sustainability. Successful outcomes will require concerted efforts to ensure that measurable outcomes are actualized. Furthermore, leaders, resources, regulatory bodies, and health professionals must collaborate and develop context-specific approaches to improve health care responses to climate change.
The review contributes by identifying themes for climate change education for environmental sustainability among HPEs. These themes are curriculum, the role of, regulatory bodies, faculty development, resources, and models. Through this review, we provide a strategic focus for implementing climate change education among HPEs in LMICs and beyond.
PRISMA 2020 Flow Diagram for New Systematic Reviews which Included Searches of Databases and Registers Only.
Supplemental Material
sj-docx-1-son-10.1177_23779608251351117 - Supplemental material for Climate Change Education for Environmental Sustainability among Health Professionals: An Integrative Review
Supplemental material, sj-docx-1-son-10.1177_23779608251351117 for Climate Change Education for Environmental Sustainability among Health Professionals: An Integrative Review by Moses M Mulu, BSN, MSN, PhD and Mirriam M Kivuva, BSN, MSN in SAGE Open Nursing
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
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