The environment in pediatric practice: a study of New York pediatricians' attitudes, beliefs, and practices towards children's environmental health

Environmental Exposures and Pediatric Cardiology: A Scientific Statement From the American Heart Association

Environmental toxicants and pollutants are causes of adverse health consequences, including well-established associations between environmental exposures and cardiovascular diseases. Environmental degradation is widely prevalent and has a long latency period between exposure and health outcome, potentially placing a large number of individuals at risk of these health consequences. Emerging evidence suggests that environmental exposures in early life may be key risk factors for cardiovascular conditions across the life span. Children are a particularly sensitive population for the detrimental effects of environmental toxicants and pollutants given the long-term cumulative effects of early-life exposures on health outcomes, including congenital heart disease, acquired cardiac diseases, and accumulation of cardiovascular disease risk factors. This scientific statement highlights representative examples for each of these cardiovascular disease subtypes and their determinants, focusing specifically on the associations between climate change and congenital heart disease, airborne particulate matter and Kawasaki disease, blood lead levels and blood pressure, and endocrine-disrupting chemicals with cardiometabolic risk factors. Because children are particularly dependent on their caregivers to address their health concerns, this scientific statement highlights the need for clinicians, research scientists, and policymakers to focus more on the linkages of environmental exposures with cardiovascular conditions in children and adolescents.

Endocrine-disrupting chemicals: Mainstream recognition of health effects and implications for the practicing internist

Rapidly advancing evidence documents that a broad array of synthetic chemicals found ubiquitously in the environment contribute to disease and disability across the lifespan. Although the early literature focused on early life exposures, endocrine-disrupting chemicals (EDCs) are now understood to contribute substantially to chronic disease in adulthood, especially metabolic, cardiovascular, and reproductive consequences as well as endocrine cancers. The contribution to mortality is substantial, with over 90,000 deaths annually and at least $39 billion/year in lost economic productivity in the United States (US) due to exposure to certain phthalates that are used as plasticizers in food packaging. Importantly, exposures are disproportionately high in low-income and minoritized populations, driving disparities in these conditions. Though non-Hispanic Blacks and Mexican Americans comprise 12.6% and 13.5% of the US population, they bear 16.5% and 14.6% of the disease burden due to EDCs, respectively. Many of these exposures can be modified through safe and simple behavioral changes supported by proactive government action to both limit known hazardous exposures and to proactively screen new industrial chemicals prior to their use. Routine healthcare maintenance should include guidance to reduce EDC exposures, and a recent report by the Institute of Medicine suggests that testing be conducted, particularly in populations heavily exposed to perfluoroalkyl substances-chemicals used in nonstick coatings as well as oil- and water-resistant clothing.

Environmental health knowledge of healthcare professionals: Instrument development and validation using the Rasch model

INTRODUCTION

environmental risk factors constitute a major public health issue, calling for preventive actions and interventions at multiple levels. An important step in this direction is increasing the environmental health (EH) knowledge of the healthcare professionals. In this context, tools designed to measure such knowledge are of imperative importance. The aim of the present study was to develop an EH knowledge tool for healthcare professionals.

METHODS

a group of experts defined the knowledge areas of the EH tool and their corresponding items. An online pilot and a validation study were performed. Internal consistency reliability was measured with the Kuder-Richardson 20 (KR-20) estimate, the construct validity and uni-dimensionality of the tool were assessed with the Rasch model. Known-groups validity was analysed with the two-sample t-test.

RESULTS

a total of n = 151 and n = 444 healthcare professionals and end-year medical and nursing students, participated in the pilot and the validation study, respectively. The resulting 33-item EH knowledge questionnaire for healthcare professionals (EHKQ-HP) obtained a KR-20 = 0.82. The scale is uni-dimensional. Its construct validity was verified, and its items cover a wide range of difficulties. Separation statistics were adequate and known-groups behaved as hypothesized.

CONCLUSIONS

the EHKQ-HP is a valuable resource for measuring the EH knowledge of the healthcare professionals. As such it will be useful in detecting EH knowledge gaps, and helping public health agents in making informed decisions when developing interventions for increasing this very knowledge. This would consequently help in improving the health of the general population.

Development and Validation of the Prevention of Toxic Chemicals in the Environment for Children Tool: A Questionnaire for Examining the Community's Knowledge of and Preferences Toward Toxic Chemicals and Children's Brain Development

Early-life exposures to toxic chemicals can adversely impact brain development. Understanding people's knowledge of the impact of toxic chemicals on brain development is critical to reduce widespread exposure to chemicals. Yet it is unknown what people know about risks of toxic chemicals and how to reduce exposures. We developed and validated the questionnaire, PRevention of Toxic chemicals in the Environment for Children Tool (PRoTECT), to examine people's knowledge and attitudes about the influence of toxic chemicals on child development. We used best practices for developing and validating scales. First, we drafted items to assess knowledge of the impact of toxic chemicals on brain development, levels of concern regarding exposures, and preferences for prevention of neurodevelopmental disorders. Second, we received feedback on item clarity from five focus groups consisting of 46 community participants. In addition, 17 experts completed a content validity scale for each item and provided qualitative feedback. We administered the revised 18-item questionnaire to 190 participants of child-bearing age for scale development, and using exploratory factor analysis, we found evidence for a four-factor model of PRoTECT, RMSR = 0.05, of which 16 of the 18 items had adequate content validity with loadings >0.40 on a derived factor. We discuss future directions and applications of PRoTECT.

Evaluating Effectiveness of Online Learning Modules in Pediatric Environmental Health Education

OBJECTIVE

Content and training about pediatric environmental health are lacking in healthcare professionals' education. In an initiative to improve pediatric environmental health education, the Pediatric Environmental Health Specialty Unit (PEHSU) program offers free, interactive, web-based ("eLearning") modules on environmental health topics. The aim of this study is to determine the effectiveness of PEHSU eLearning modules in increasing knowledge about pediatric and reproductive environmental health.

METHODS

This is a retrospective analysis of 994 users who had completed at least one of the 12 PEHSU eLearning modules and its associated pre-test and post-test scores between March 2016 and November 2018. Users who completed modules between March 2016 and April 2018 received a 6-month follow-up survey to assess the impact of the knowledge gained on their clinical practice.

RESULTS

A wide range of clinical professionals and nonclinical professionals utilized and completed the PEHSU eLearning modules. For all users, post-test scores were significantly higher than pre-test scores, with an increase of 30.55% ± 22.37 (paired t-test, p < 0.0001), after completion of eLearning modules.

CONCLUSION

PEHSU eLearning modules are effective at increasing environmental health knowledge of clinical and nonclinical professionals. Further studies are needed to determine long-term knowledge retention and clinical impact.

Home visits for pediatric asthma - A strategy for comprehensive asthma management through prevention and reduction of environmental asthma triggers in the home

Families often struggle to manage their child's asthma. Clinicians caring for children with asthma struggle too as they are tasked with balancing the limited time available in clinic and the need to provide comprehensive care. As a direct consequence, critical gaps in asthma care remain with respect to asthma education and the identification and reduction of environmental asthma triggers in the home. A home visit model that augments clinic-based care is a viable way to fill gaps in understanding, address incomplete adherence patterns, improve disease control by shifting the focus of asthma management to reduction of environmental asthma triggers, and bring cost savings to the health care system.

Doc, can you test me for "toxic metals"? Challenges of testing for toxicants in patients with environmental concerns

Laboratory testing is an important tool to assist clinicians in evaluation of patients with potential environmentally-related illness, however, it can be challenging to select or interpret the appropriate toxicological tests. Recent advances in analytical techniques and expanded consumer access to environmental laboratories led to a rise in laboratory testing for various environmental toxicants, including metals. However, most environmental tests have scant clinical evidence and are not validated for clinical use. While the tests themselves may not present direct harm to the patients, the results of inappropriately selected tests may lead to significant patient stress and unnecessary follow-up or treatment. Given the lack of environmental health content in medical training, pediatricians may feel ill-equipped to address most environmental issues they encounter in practice, including the interpretation of environmental toxicant lab results. This article provides an overview of how to approach a child and family with environmental health concerns about "toxic metals", select appropriate metal tests if indicated, and enlist the assistance of the Pediatric Environmental Health Specialty Units (PEHSU) for further management guidance.

Maternal role strain and depressive symptoms among female sex workers in Mexico: the moderating role of sex work venue

Stressors that arise in parenting are likely to have an adverse impact on the psychological well-being of female sex workers (FSWs), particularly in low- to middle-income countries (LMIC). This study examined the association between maternal role strain and depressive symptoms among 426 FSW mothers with dependent-age children (aged < 18 years) in Tijuana and Cd. Juarez, Mexico (2016-2017). Four dimensions of maternal role strain (e.g., child emotional and behavioral problems) were examined in relation to maternal depressive symptoms. We also investigated whether the relationship between maternal role strain and depressive symptoms was modified by venue of sex work. Compared to indoor/establishment-based FSWs, street-based FSWs reported significantly more child-related financial strain. In multiple regression analysis, having more depressive symptoms was associated with identifying as a street-based FSW, greater use of drugs, lower emotional support, more child-related financial strain and more emotional and behavioral problems in children. A significant interaction was identified such that the association between maternal role strain and depressive symptoms was stronger for indoor/establishment-based compared to street-based FSWs. These findings suggest the need to address parenting strain and type of sex work venue in the development of counseling programs to improve the mental health of FSWs in LMIC.

Building Capacity in Pediatric Environmental Health: The Academic Pediatric Association's Professional Development Program

BACKGROUND

Environmental exposures contribute to multiple diseases in children; yet, few pediatricians have training in pediatric environmental health (PEH), and few academic health centers have PEH expertise. To build national capacity in PEH, the Academic Pediatric Association (APA) launched a professional development program that since 2002 has encouraged the establishment of post-residency/post-doctoral training programs, supported a special interest group, and convened an annual mentored retreat for PEH trainees.

OBJECTIVE

Describe the APA's professional development program in PEH and assess its impact by tracking careers of former trainees.

METHODS

Careers were tracked through interviews with trainees and program directors supplemented by searches of institutional websites. Publication listings were obtained through PubMed. Publication impact was assessed using bibliometric and altmetric measures. Grant histories were accessed through the National Institutes of Health RePORTER project. Information on advocacy work was obtained through interviews with program directors.

RESULTS

Fifty-five trainees (36 physicians and 19 health scientists) completed PEH training and attended the APA retreat between 2002 and 2017. Forty-one (75%) are pursuing academic careers, 11 are associate or full professors, 11 are practicing general pediatrics or a pediatric subspecialty, 2 are Centers for Disease Control and Prevention epidemiologists, and 1 is a data scientist. Forty-two former trainees (76%) listed "environment" or "environmental" in their job titles or on their websites. Former trainees have published 632 scientific papers. These papers have been cited 3094times, have a relative citation ratio of 2.97, and have been read or viewed 1,274,388times. Twenty-one former trainees have been awarded 43 National Institutes of Health grants. Trainees have developed education and advocacy skills by teaching medical students and residents, presenting grand rounds, preparing policy papers, presenting legislative testimony, and making presentations to public audiences.

CONCLUSIONS

The APA's professional development program has contributed to the expansion of national capacity in PEH. Former trainees are populating the field, generating new knowledge, and moving into leadership positions.

Building New York State Centers of Excellence in Children's Environmental Health: A Replicable Model in a Time of Uncertainty

Public health programs may be seriously affected in periods of federal retrenchment. During these times, state-based strategies provide an alternate pathway for advancing public health.A 12-year campaign to secure state support for a network of Centers of Excellence in Children's Environmental Health (CEH) promoting health of children across New York State is described. It was driven by rising rates of asthma, birth defects, developmental disorders, and other noncommunicable diseases in children; growing evidence associating hazardous environmental exposures with these conditions; and recognition that federal resources in CEH are insufficient.Critical campaign elements were (1) formation of a statewide coalition of academic health centers, health care providers, public health officials, community advocates, and other stakeholders; (2) bipartisan collaborations with legislative champions and government leaders; (3) assessment of the burden of developmental disorders and noncommunicable diseases associated with environmental exposures among children; (4) maps documenting the presence of environmental hazards in every county statewide; (5) iterative charting of a changing political landscape; and (6) persistence. The 2017 award of a 5-year, $10 million contract to establish Centers of Excellence in CEH demonstrates the value of this statewide strategy.

A needs assessment on addressing environmental health issues within reproductive health service provision: Considerations for continuing education and support

BACKGROUND

This needs assessment was initially undertaken to explore the beliefs and knowledge of nurses and physicians about the impact of environmental toxicants on maternal and infant health, as well as to describe current practice and needs related to addressing environmental health issues (EHI).

METHODS

One hundred and thirty-five nurses (n = 99) and physicians (n = 36) working in Saskatchewan completed an online survey. Survey questions were designed to determine how physicians and nurses think about and incorporate environmental health issues into their practice and means of increasing their capacity to do so.

RESULTS

Although participants considered it important to address EHIs with patients, in actual practice they do so with only moderate frequency. Participants reported low levels of knowledge about EHIs' impact on health, and low levels of confidence discussing them with patients. Participants requested additional information on EHIs, especially in the form of online resources.

CONCLUSION

The results suggests that while nurses and physicians consider EHIs important to address with patients, more education, support, and resources would increase their capacity to do so effectively. Based on the findings, considerations and recommendations for continuing education in this area have been provided.

Rochester's Healthy Home: A community-based innovation to promote environmental health action

Environmental hazards in the home can contribute significantly to disease. These hazards disproportionately affect low income, urban, and minority children. Childhood lead poisoning and asthma are prime examples of health concerns to which poor housing conditions may contribute significantly. A community-academic partnership in Rochester, New York created a model Healthy Home, an interactive museum in a typical city home, to help residents, property owners, contractors, and community groups reduce environmental hazards. The Healthy Home project educates visitors about home environmental health hazards, demonstrates low-cost methods for reducing home hazards, and helps visitors develop individualized strategies for action. In its first year of operation, over 700 people visited the Healthy Home. Evaluation surveys indicate that the Healthy Home experience motivated visitors to take action to reduce environmental hazards in their homes. Follow-up phone interviews indicate that most visitors took some action to reduce home environmental hazards. The Healthy Home has established a diverse Advisory Council to share its messages more broadly, invite input into future directions, and recruit visitors. This paper presents experiences from the Healthy Home's first year, highlighting the partnership principles that guided its development and lessons learned from the process.

Childhood Leukemia and Primary Prevention

Leukemia is the most common pediatric cancer, affecting 3800 children per year in the United States. Its annual incidence has increased over the last decades, especially among Latinos. Although most children diagnosed with leukemia are now cured, many suffer long-term complications, and primary prevention efforts are urgently needed. The early onset of leukemia-usually before 5 years of age-and the presence at birth of "pre-leukemic" genetic signatures indicate that pre- and postnatal events are critical to the development of the disease. In contrast to most pediatric cancers, there is a growing body of literature-in the United States and internationally-that has implicated several environmental, infectious, and dietary risk factors in the etiology of childhood leukemia, mainly for acute lymphoblastic leukemia, the most common subtype. For example, exposures to pesticides, tobacco smoke, solvents, and traffic emissions have consistently demonstrated positive associations with the risk of developing childhood leukemia. In contrast, intake of vitamins and folate supplementation during the preconception period or pregnancy, breastfeeding, and exposure to routine childhood infections have been shown to reduce the risk of childhood leukemia. Some children may be especially vulnerable to these risk factors, as demonstrated by a disproportionate burden of childhood leukemia in the Latino population of California. The evidence supporting the associations between childhood leukemia and its risk factors-including pooled analyses from around the world and systematic reviews-is strong; however, the dissemination of this knowledge to clinicians has been limited. To protect children's health, it is prudent to initiate programs designed to alter exposure to well-established leukemia risk factors rather than to suspend judgment until no uncertainty remains. Primary prevention programs for childhood leukemia would also result in the significant co-benefits of reductions in other adverse health outcomes that are common in children, such as detriments to neurocognitive development.

A Multimedia E-Book-A Story of Health: Filling a Gap in Environmental Health Literacy for Health Professionals

Narrative approaches and storytelling are emerging as powerful health promotion tools that can spark interest, increase understanding of determinants of health, and translate complex science. A Story of Health, a multimedia e-book with continuing education credits was designed to harness the power of storytelling to increase environmental health literacy. Health professionals are a key audience. They recognize that patients may be suffering from preventable illnesses of environmental origin but often feel ill-equipped to educate individuals and families about risks associated with common exposures. A Story of Health seeks to fill this gap and help readers develop the competencies they need in order to help patients make informed choices, reduce health risks, improve quality of life, and protect the environment. Americans rate nurses and medical doctors as having the highest honesty and ethical standards of all professions. These medical professionals can play a key role in changing patterns of patient behavior and influencing public policies. The e-book provides an easily accessible method of developing environmental health competency. The multimedia format with graphical interpretations allows for quick reviews of topics or for more in-depth analysis via links to additional resources. The CE evaluations have been overwhelmingly positive.

Pediatric Environmental Health Specialty Units: An Analysis of Operations

BACKGROUND

In 1998 the Agency for Toxic Substances and Disease Registry (ATSDR) secured the first federal funding to develop an innovative network of public health-oriented entities: Pediatric Environmental Health Specialty Units (PEHSUs). PEHSU goals were to provide pediatric and environmental health education to health care providers and health profession students, to offer consultation to health care professionals, parents, and others regarding environmental health exposures, and to provide referrals to specialized medical resources when necessary. This report analyzes the productivity of US PEHSUs from 1999 to 2014.

METHODS

This was a retrospective analysis of federally mandated quarterly reports filed by each PEHSU. These reports document specific goal-related deliverables outlined under cooperative agreements awarded to the Association of Occupational and Environmental Clinics (AOEC) with funding from the Environmental Protection Agency (EPA) and ATSDR. Costs were obtained from grant budget information available from the administrator of the grants, AOEC.

RESULTS

Total EPA/ATSDR funding for PEHSUs paid to AOEC during 1999-2014 was $23,847,452. The average cost to the EPA/ATSDR of running each PEHSU in 2014 was $169,256. Through over 8000 consultations and educational activities, PEHSUs reached 702,506 people: 298,936 health professionals, 61,947 health professional trainees, 323,817 members of the public, and 17,806 public health officials and others.

CONCLUSIONS

PEHSUs have grown into an established, productive network of clinical and educational centers whose expertise and activities have benefited both the public and health care professionals alike. The federal contributions to the cost of operating these centers have been more than offset by the benefits PEHSUs have conferred on the communities they serve.

A Scoping Review of Maternal and Child Health Clinicians Attitudes, Beliefs, Practice, Training and Perceived Self-Competence in Environmental Health

Clinicians regularly assess, diagnose and manage illnesses which are directly or indirectly linked to environmental exposures. Yet, various studies have identified gaps in environmental assessment in routine clinical practice. This review assessed clinicians' environmental health practices, attitudes and beliefs, and competencies and training. Relevant articles were sought using a systematic search strategy using five databases, grey literature and a hand search. Search strategies and protocols were developed using tailored mesh terms and keywords. 43 out of 11,291 articles were eligible for inclusion. Clinicians' attitudes and beliefs towards environmental health and routine clinical practice were generally positive, with most clinicians believing that environmental hazards affect human health. However, with the exception of tobacco smoke exposure, environmental health assessment was infrequently part of routine clinical practice. Clinicians' self-competence in environmental assessment was reported to be inadequate. Major challenges were the time required to complete an assessment, inadequate training and concerns about negative patients' responses. Clinicians have strong positive attitudes and beliefs about the importance of environmental health assessments. However, more concerted and robust strategies will be needed to support clinicians in assuming their assessment and counselling roles related to a wider range of environmental hazards.

Are healthcare providers asking about environmental exposures? A community-based mixed methods study

People living near environmental hazards may develop symptoms and health conditions that require specialized monitoring and treatment by healthcare providers. One emerging environmental hazard is coal ash. Coal ash is comprised of small particles containing heavy metals, polycyclic aromatic hydrocarbons, and radioactive elements. The overall purpose of this study was to explore whether healthcare providers ask patients if they live near an environmental hazard like coal ash storage sites and to assess what health conditions prompt a provider inquiry. Focus groups were conducted in 2012 and a cross-sectional survey was administered in 2013. Overall, 61% of survey respondents reported that their healthcare providers never asked if they lived near an environmental hazard. One focus group member stated “No, they don't ask that. They just always blame stuff on you….” Respondents with asthma and other lung conditions were significantly more likely to be asked by a healthcare provider if they lived near an environmental hazard. Due to the unique exposures from environmental hazards and the low prevalence of patients being asked about environmental hazards, we recommend that healthcare providers take environmental health histories in order to understand patients' exposures, to monitor symptoms of exposure, and to assist with education about reducing exposure.

Counseling patients on preventing prenatal environmental exposures--a mixed-methods study of obstetricians

OBJECTIVE

Describe the attitudes, beliefs, and practices of U.S. obstetricians on the topic of prenatal environmental exposures.

STUDY DESIGN

A national online survey of American Congress of Obstetricians and Gynecologists (ACOG) fellows and 3 focus groups of obstetricians.

RESULTS

We received 2,514 eligible survey responses, for a response rate of 14%. The majority (78%) of obstetricians agreed that they can reduce patient exposures to environmental health hazards by counseling patients; but 50% reported that they rarely take an environmental health history; less than 20% reported routinely asking about environmental exposures commonly found in pregnant women in the U.S.; and only 1 in 15 reported any training on the topic. Barriers to counseling included: a lack of knowledge of and uncertainty about the evidence; concerns that patients lack the capacity to reduce harmful exposures; and fear of causing anxiety among patients.

CONCLUSION

U.S. obstetricians in our study recognized the potential impact of the environment on reproductive health, and the role that physicians could play in prevention, but reported numerous barriers to counseling patients. Medical education and training, evidence-based guidelines, and tools for communicating risks to patients are needed to support the clinical role in preventing environmental exposures that threaten patient health.

The Environment and Children's Health Care in Northwest China

Background

Industrialization in the northwest provinces of the People’s Republic of China is accelerating rapid increases in early life environmental exposures, yet no publications have assessed health care provider capacity to manage common hazards.

Methods

To assess provider attitudes and beliefs regarding the environment in children’s health, determine self-efficacy in managing concerns, and identify common approaches to managing patients with significant exposures or environmentally-mediated conditions, a two-page survey was administered to pediatricians, child care specialists, and nurses in five provinces (Gansu, Shaanxi, Xinjiang, Qinghai, and Ningxia). Descriptive and multivariable analyses assessed predictors of strong self-efficacy, beliefs or attitudes.

Results

960 surveys were completed with <5% refusal; 695 (72.3%) were valid for statistical analyses. The role of environment in health was rated highly (mean 4.35 on a 1-5 scale). Self-efficacy reported with managing lead, pesticide, air pollution, mercury, mold and polychlorinated biphenyl exposures were generally modest (2.22-2.52 mean). 95.4% reported patients affected with 11.9% reporting seeing >20 affected patients. Only 12.0% reported specific training in environmental history taking, and 12.0% reported owning a text on children’s environmental health. Geographic disparities were most prominent in multivariable analyses, with stronger beliefs in environmental causation yet lower self-efficacy in managing exposures in the northwestern-most province.

Conclusions

Health care providers in Northwest China have strong beliefs regarding the role of environment in children’s health, and frequently identify affected children. Few are trained in environmental history taking or rate self-efficacy highly in managing common hazards. Enhancing provider capacity has promise for improving children’s health in the region.

Environmental risks and children's health: what can PRAMS tell us?

Environmental exposures during pregnancy have a lasting impact on children's health. We combined environmental and maternal risk factor survey data to inform efforts to protect children's health. We made recommendations for future use of such data. A modified version of the Pregnancy Risk Assessment Monitoring System (PRAMS) mail survey was conducted based on weighted sampling design with low-income and non-low income women in Monroe County, NY (1,022 respondents). A series of environmental questions were included in the questionnaire. Data were analyzed using Chi square tests and Poisson loglinear regression model to identify patterns in environmental health risk and sociodemographic characteristics. We identified women who rented their homes, had lower incomes, and lived in inner city zip codes as "high environmental health risk" (HEHR). HEHR respondents were more likely to report that a health care provider talked with them about lead and on average reported more behaviors to protect their children from lead poisoning. Combining environmental and perinatal risk factor data could yield important recommendations for medical practice, health education, and policy development. However, at present PRAMS gathers only limited and inconsistent environmental data. We found that existing PRAMS environmental questions are insufficient. Further work is needed to develop updated and more comprehensive environmental health survey questions and implement them consistently across the country.

Improving pediatrician knowledge about environmental triggers of asthma

BACKGROUND

Control of environmental triggers (ETs) greatly improves asthma outcomes in children. Disseminating these findings to general pediatricians has not been well established.

METHODS

After delivering a structured and standardized presentation on ET identification and control to pediatricians, we surveyed them about knowledge and practices of ET assessment and management. We analyzed matched responses for pre/post and 3- to 6-month follow-up using McNemar's χ(2) test.

RESULTS

Matched data were available for 367 participants, and 3- to 6-month follow-up data were available for 83. There was a significant posttraining increase in intention to ask about ETs and recommend ET management. After 3 to 6 months, all responses remained significantly higher than baseline, except "likely to refer to an asthma specialist."

CONCLUSION

Pediatricians reported a significant improvement in knowledge about ETs of asthma and a willingness to incorporate exposure history questions and remediation recommendations in their routine practice.

Effect of an environmental health educational programme for paediatricians in an Egyptian University Hospital: before and after study

OBJECTIVES

To study the effect of an educational intervention on paediatricians' knowledge, attitudes and practices regarding children's environmental health and to identify the sources of information and common environmental history taking constrains.

DESIGN

Before and after study.

SETTING

Zagazig University Paediatric Hospital.

PARTICIPANTS

Practising paediatricians from all specialty units.

MAIN OUTCOME MEASURES

The outcome of a specifically designed educational programme about paediatric environmental health was assessed using structured pre- and post-test questionnaires.

RESULTS

Nearly half the participants were aware about most of the paediatric environmental health-related topics. Textbooks/guidelines (85.7%) and the Internet (64.3%) were the main sources of information. The participants demonstrated relatively strong positive attitudes towards the importance of children's environmental health. However, less than half of them (44.6%) reported environmental history taking as a routine practice; where lack of time (94.6%), wide range of hazardous exposures (91.1%) and lack of expertise and training (91.1%) were the main constrains. Significant improvement in participants' knowledge, attitudes and practices was revealed after the educational programme.

CONCLUSIONS

There is a demand for continuous medical education about environmental health in paediatric practice, particularly environmental and occupational history taking.

Assessment of indoor air pollution in homes with infants

Infants spend most of their indoor time at home; however, residential air quality is poorly understood. We investigated the air quality of infants’ homes in the New England area of the U.S. Participants (N = 53) were parents of infants (0–6 months) who completed telephone surveys to identify potential pollutant sources in their residence. Carbon monoxide (CO), carbon dioxide (CO₂), particulate matter with aerodynamic diameter ≤0.5 µm (PM_0.5), and total volatile organic compounds (TVOCs) were measured in 10 homes over 4–7 days, and levels were compared with health-based guidelines. Pollutant levels varied substantially across homes and within homes with overall levels for some homes up to 20 times higher than for other homes. Average levels were 0.85 ppm, 663.2 ppm, 18.7 µg/m³, and 1626 µg/m³ for CO, CO₂, PM_0.5, and TVOCs, respectively. CO₂, TVOCs, and PM_0.5 levels exceeded health-based indoor air quality guidelines. Survey results suggest that nursery renovations and related potential pollutant sources may be associated with differences in urbanicity, income, and presence of older children with respiratory ailments, which could potentially confound health studies. While there are no standards for indoor residential air quality, our findings suggest that additional research is needed to assess indoor pollution exposure for infants, which may be a vulnerable population.

Integrating environmental health into medical education

Although environmental factors contribute to more than 25% of all global disease, and toxic agents ranked fifth in underlying causes of U.S. deaths in 2000, environmental medicine education is largely omitted in the continuum of U.S. medical education. The paucity of specialists trained in environmental medicine (i.e., occupational medicine and other preventive medicine specialties and subspecialties), coupled with the lack of adequate general medical education on how to prevent, diagnose, refer, or treat patients exposed to hazardous substances in the environment, contributes to lost opportunities for primary prevention or early intervention to mitigate or minimize environmentally related disease burden. Survey findings of graduating medical students over the past few years have identified environmental health as a medical school topic area that can be improved. This article reflects a panel presentation on the challenge of including environmental health in general medical education. It was given at the 2010 "Patients and Populations: Public Health in Medical Education" conference cosponsored by the CDC and the American Association of Medical Colleges. A variety of educational strategies, models, and educational resources are presented that illustrate how recommended competency-based environmental health content can be integrated into medical education to better prepare medical students and physicians without specialized expertise in environmental medicine to provide or facilitate environmental preventive or curative patient care.

Teaching home environmental health to resident physicians

Healthy Homes programs seek to integrate the evaluation and management of a multitude of health and safety risks in households. The education of physicians in the identification, evaluation, and management of these home health and safety issues continues to be deficient. Healthy Homes programs represent a unique opportunity to educate physicians in the home environment and stimulate ongoing, specific patient-physician discussions and more general learning about home environmental health. The Case Healthy Homes and Patients Program addresses these deficiencies in physician training while providing direct services to high-risk households. Pediatric and family practice resident physicians participate in healthy home inspections and interventions for their primary care patients and follow up on identified risks during health maintenance and acute illness visits.

Clinical services in environmental pediatrics

Pediatric healthcare providers are confronted with environmental health problems frequently: the child with asthma exacerbated by the odor of paint in school or mouse antigen at home, the family who wants to know the risks and benefits of using different types of sunblock, or the community that asks the provider for advice on the potential health impacts of building the new elementary school next to the on-ramp to the interstate highway. Pediatric providers have not been well trained to deal with these questions in medical or nursing schools, residency training, or continuing-education settings. This article provides guidance on history taking, the physical examination, laboratory evaluations of patients and the environment, and making an assessment about and managing environmental health problems. Pediatric Environmental Health Specialty Units are discussed as a source of consultation and referral. The identification and utilization of evidence-based resources are stressed and clinicians are cautioned about non-evidence-based assessments such as clinical ecology and hair analysis and non-evidence-based management strategies such as chelation for autism.

Translating knowledge about environmental health to practitioners: are we doing enough?

BACKGROUND

Practitioners see a large number of children affected by environmental exposures each year. A national network of pediatric environmental health specialty units has been established to strengthen prevention capacity, yet the effectiveness of that translational resource has not been assessed.

METHODS

We supplemented a qualitative systematic review of previous assessments of healthcare provider capacity with a self-administered survey sent to the membership of the Michigan chapter of the American Academy of Pediatrics. We mailed surveys twice between October 2007 and January 2008 and obtained a 39.4% response rate.

RESULTS

Our systematic review identified 8 relevant studies, all of which relied on self-report questionnaires and surveys. Recognizing this methodological weakness, we found that national and state samples consistently identified significant gaps in self-efficacy and knowledge about environmental hazards across a broad range of child care providers. In the Michigan survey, respondents voiced high self-efficacy in dealing with lead and second-hand smoke, but confidence in managing pesticide, mercury, mold, polychlorinated biphenyl, and air pollution exposures was much lower (P < 0.0001). Pediatricians routinely referred affected patients to lead/toxicology clinics and allergist/immunologists but not to the regional pediatric environmental health specialty unit.

CONCLUSIONS

Gaps persist in practitioner knowledge about environmental health nationwide and across disciplines. Despite methodological weaknesses, educational opportunities and other efforts should be studied to determine best practices for enhancing the evaluation of environmental health concerns in children.

Who's in charge of children's environmental health at school?

Children spend many hours each week in and around school buildings. Their short- and long-term health outcomes and ability to learn are affected by numerous environmental factors related to the school buildings, the school grounds, the school transportation system, and the use of various products and materials in and around the school. Many school buildings are old, and they-and even newer buildings-can contain multiple environmental health hazards. While some districts self-report they have environmental health policies in place, no independent verification of these policies or their quality exists. Teachers and other staff, but not children who are more vulnerable to hazards than adults, are afforded some protections from hazards by Occupational Safety and Health Administration (OSHA) regulations, by their employment contracts, or through adult occupational health services. Major environmental problems include: indoor air quality, lighting, pests and pesticides, heavy metals and chemical management issues, renovation of occupied buildings, noise, and cleaning processes and products. No agency at the federal or state levels is charged with ensuring children's health and safety in and around school buildings. No systematic means exists for collecting data about exposures which occur in the school setting. Recommendations are made for dealing with issues of data collection, federal actions, state and local actions, and for building the capacity of the Environmental Protection Agency and the Centers for Disease Control and Prevention-designated and funded Pediatric Environmental Health Specialty Units (PEHSU) in responding to and evaluating risks to children's environmental health in schools.

Children's Environmental Health Faculty Champions Initiative: a successful model for integrating environmental health into pediatric health care

BACKGROUND

Pediatric medical and nursing education lack the environmental health content needed to properly prepare health care professionals to prevent, recognize, manage, and treat environmental exposure-related diseases. The need for improvements in health care professionals' environmental health knowledge has been expressed by leading institutions. However, few studies have evaluated the effectiveness of programs that incorporate pediatric environmental health (PEH) into curricula and practice.

OBJECTIVE

We evaluated the effectiveness of the National Environmental Education Foundation's (NEEF) Children's Environmental Health Faculty Champions Initiative, which is designed to build environmental health capacity among pediatric health care professionals.

METHODS

Twenty-eight pediatric health care professionals participated in a train-the-trainer workshop, in which they were educated to train other health care professionals in PEH and integrate identified PEH competencies into medical and nursing practice and curricula. We evaluated the program using a workshop evaluation tool, action plan, pre- and posttests, baseline and progress assessments, and telephone interviews.

RESULTS

During the 12 months following the workshop, the faculty champions' average pretest score of 52% was significantly elevated (p < 0.0001) to 65.5% on the first posttest and to 71.5% on the second posttest, showing an increase and retention of environmental health knowledge. Faculty champions trained 1,559 health care professionals in PEH, exceeding the goal of 280 health care professionals trained. Ninety percent of faculty champions reported that PEH had been integrated into the curricula at their institution.

CONCLUSION

The initiative was highly effective in achieving its goal of building environmental health capacity among health care professionals. The faculty champions model is a successful method and can be replicated in other arenas.

The National Children's Study: a 21-year prospective study of 100,000 American children

Prospective, multiyear epidemiologic studies have proven to be highly effective in discovering preventable risk factors for chronic disease. Investigations such as the Framingham Heart Study have produced blueprints for disease prevention and saved millions of lives and billions of dollars. To discover preventable environmental risk factors for disease in children, the US Congress directed the National Institute of Child Health and Human Development, through the Children's Health Act of 2000, to conduct the National Children's Study. The National Children's Study is hypothesis-driven and will seek information on environmental risks and individual susceptibility factors for asthma, birth defects, dyslexia, attention-deficit/hyperactivity disorder, autism, schizophrenia, and obesity, as well as for adverse birth outcomes. It will be conducted in a nationally representative, prospective cohort of 100,000 US-born children. Children will be followed from conception to 21 years of age. Environmental exposures (chemical, physical, biological, and psychosocial) will be assessed repeatedly during pregnancy and throughout childhood in children's homes, schools, and communities. Chemical assays will be performed by the Centers for Disease Control and Prevention, and banks of biological and environmental samples will be established for future analyses. Genetic material will be collected on each mother and child and banked to permit study of gene-environment interactions. Recruitment is scheduled to begin in 2007 at 7 Vanguard Sites and will extend to 105 sites across the United States. The National Children's Study will generate multiple satellite studies that explore methodologic issues, etiologic questions, and potential interventions. It will provide training for the next generation of researchers and practitioners in environmental pediatrics and will link to planned and ongoing prospective birth cohort studies in other nations. Data from the National Children's Study will guide development of a comprehensive blueprint for disease prevention in children.