Family medicine residents' knowledge of, attitudes toward, and clinical practices related to environmental health: Multi-program survey

OBJECTIVE

To assess family medicine residents' knowledge of, attitudes toward, and clinical practices related to environmental health (EH).

DESIGN

Two-part study with questionnaire construction using a modified Delphi method, and a Web-based questionnaire administered to family medicine residents between November 2015 and January 2016.

SETTING

All Canadian family medicine programs (for questionnaire construction) and 4 Ontario family medicine training programs (for questionnaire administration).

PARTICIPANTS

First- to third-year family medicine residents (for questionnaire administration).

MAIN OUTCOME MEASURES

Responses to 93 survey items that measured family medicine residents' knowledge of, attitudes toward, and clinical practices related to EH.

RESULTS

For the final administered questionnaire, 203 of 887 (22.9%) family medicine residents responded. Although 92.0% of respondents somewhat or strongly believed that taking an environmental exposure history was important, only 18.1% of them had specific training in taking environmental exposure history, and 48.4% believed that taking an exposure history takes up too much time in office practice. While 82.9% of residents correctly identified recreational water use as a cause of gastroenteritis, only 60.2% correctly identified radon as a cause of lung cancer and 37.6% knew that elevated ground-level ozone is associated with asthma. Only 10.8% believed their supervisors had a good understanding of environmental exposures. Residents who believed their supervisors understood environmental exposures were more likely to take exposure histories for patients with uncontrolled asthma (P < .05), and those who discussed EH exposure with supervisors frequently, or thought environmental exposure histories were very important, were more likely to provide patients with EH education materials (P < .01).

CONCLUSION

Although family medicine residents are aware of the importance of assessing patients' environmental exposures, they lack training and mentorship in EH. As a health determinant of critical importance, EH should be a high priority for inclusion in postgraduate family medicine education.

Cancer health effects of pesticides: systematic review

OBJECTIVE

To review literature documenting associations between pesticide use and cancer.

DATA SOURCES

We searched MEDLINE, PreMedline, CancerLit, and LILACS to find studies published between 1992 and 2003 on non-Hodgkin lymphoma, leukemia, and 8 solid-tumour cancers: brain, breast, kidney, lung, ovarian, pancreatic, prostate, and stomach cancer.

STUDY SELECTION

Each title and abstract was assessed for relevance; disagreements among reviewers were resolved by consensus. Studies were assessed by a team of 2 trained reviewers and rated based on methodologic quality according to a 5-page assessment tool and a global assessment scale. Studies rated below a global score of 4 out of 7 were excluded.

SYNTHESIS

Most studies on non-Hodgkin lymphoma and leukemia showed positive associations with pesticide exposure. Some showed dose-response relationships, and a few were able to identify specific pesticides. Children's and pregnant women's exposure to pesticides was positively associated with the cancers studied in some studies, as was parents' exposure to pesticides at work. Many studies showed positive associations between pesticide exposure and solid tumours. The most consistent associations were found for brain and prostate cancer. An association was also found between kidney cancer in children and their parents' exposure to pesticides at work. These associations were most consistent for high and prolonged exposures. Specific weaknesses and inherent limitations in epidemiologic studies were noted, particularly around ascertaining whether and how much exposure had taken place.

CONCLUSION

Our findings support attempts to reduce exposure to pesticides. Reductions are likely best achieved through decreasing pesticide use for cosmetic (non-commercial) purposes (where children might be exposed) and on the job.

Non-cancer health effects of pesticides: systematic review and implications for family doctors

OBJECTIVE

To investigate whether there are associations between exposure to pesticides and 4 chronic non-cancer health effects: dermatologic, neurologic, reproductive, and genotoxic effects.

DATA SOURCES

We searched PreMedline, MEDLINE, and LILACS using the key word pesticide combined with the term for the specific health effect being searched. Reviewers scanned the references of all articles for additional relevant studies.

STUDY SELECTION

Studies since 1992 were assessed using structured inclusion and quality-of-methods criteria. Studies scoring <4 on a 7-point global methodologic quality scale were excluded. In total, 124 studies were included. These studies had a mean quality score of 4.88 out of 7.

SYNTHESIS

Strong evidence of association with pesticide exposure was found for all neurologic outcomes, genotoxicity, and 4 of 6 reproductive effects: birth defects, fetal death, altered growth, and other outcomes. Exposure to pesticides generally doubled the level of genetic damage as measured by chromosome aberrations in lymphocytes. Only a few high-quality studies focused on the dermatologic effects of pesticides. In some of these studies, rates of dermatitis were higher among those who had had high exposure to pesticides on the job.

CONCLUSION

Evidence from research on humans consistently points to positive associations between pesticide exposure and 3 of the 4 non-cancer health outcomes studied. Physicians have a dual role in educating individual patients about the risks of exposure and in reducing exposure in the community by advocating for restrictions on use of pesticides.