challenges

Article
Understanding the Knowledge, Attitudes, and Practices of
Healthcare Professionals toward Climate Change and Health
in Minnesota
Madison Kircher 1,2, * , Brenna M. Doheny 3 , Kristin Raab 2 , Emily Onello 3 , Stephanie Gingerich 4
and Teddie Potter 4

1 Council of State and Territorial Epidemiologists (CSTE), Atlanta, GA 30341, USA

2 Environmental Health Division, Minnesota Department of Health, St. Paul, MN 55164, USA
3 Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School,
Duluth Campus, Duluth, MN 55812, USA
4 School of Nursing, University of Minnesota, Minneapolis, MN 55455, USA
* Correspondence: maddy.kircher@gmail.com; Tel.: +1-507-250-5462

Abstract: Climate change is an urgent public health issue that is impacting health locally and across
the world. Healthcare professionals are on the front lines for public health, caring for people affected
by climate change; yet few studies have assessed their knowledge and experiences of local climate
change effects. The purpose of this study was to improve our understanding of the health impacts
of climate change in Minnesota from the perspective of healthcare professionals. An electronic
survey was administered by the Minnesota Department of Health (MDH) to a convenience sample
of Board-certified nurses and physicians in Minnesota. Seventy-five percent of respondents agreed
that climate change is happening, and 60% agreed that it is currently impacting the health of their
patients. However, only 21% felt well prepared to discuss climate change, and only 4% discussed
Citation: Kircher, M.; Doheny, B.M.;
climate change with all or most of their patients. Similarly, results from open-ended questions
Raab, K.; Onello, E.; Gingerich, S.;
highlighted the importance of climate change and acknowledged the challenges of discussing this
Potter, T. Understanding the
topic. While most respondents recognized the health impacts of climate change, they also reported
Knowledge, Attitudes, and Practices
feeling uncomfortable discussing climate change with patients. Thus, there is an opportunity to
of Healthcare Professionals toward
Climate Change and Health in
develop targeted resources to support healthcare professionals in addressing climate change.
Minnesota. Challenges 2022, 13, 57.
https://doi.org/10.3390/ Keywords: climate change; public health; healthcare professionals; planetary health
challe13020057

Academic Editor: Susan Prescott

Received: 15 September 2022 1. Introduction

Accepted: 14 October 2022 Human health is inextricably linked to the health of the biosphere, yet human caused
Published: 1 November 2022 disruptions of the Earth’s natural systems persist and must be urgently addressed. While
Publisher’s Note: MDPI stays neutral other planetary health threats have impacts on human health, climate change is perhaps
with regard to jurisdictional claims in the most visible planetary health crisis for healthcare professionals. From the perspective of
published maps and institutional affil- international and national health organizations, the connection between climate change and
iations. human health could not be clearer. “Climate change is the single biggest health threat facing
humanity”, “a health emergency”, and a “code red for humanity” [1–3]. Evidence points to
a multitude of climate related impacts, including heat-related illnesses, respiratory illnesses,
zoonotic and vector-borne diseases, water and food-borne diseases, impaired mental health
Copyright: © 2022 by the authors. and well-being, and injury and death related to severe weather event [1]. Between 2030
Licensee MDPI, Basel, Switzerland. and 2050, it is estimated that climate change will cause an additional 250,000 deaths and
This article is an open access article
the migration of 216 million people across six regions [1,4]. Addressing climate change can
distributed under the terms and
have the co-benefit of improving human health, and the health of all life on the planet.
conditions of the Creative Commons
Every region faces unique climate challenges and Minnesota is no exception. Between
Attribution (CC BY) license (https://
1895 and 2020, Minnesota’s average temperature warmed 3.0 degrees F, with winter warm-
creativecommons.org/licenses/by/
ing driving the overall trend [5]. Average daily minimum or low temperatures rose at more
4.0/).

Challenges 2022, 13, 57. https://doi.org/10.3390/challe13020057 https://www.mdpi.com/journal/challenges

Challenges 2022, 13, 57 2 of 17

than twice the rate of average daily maximum temperatures [5]. Annual precipitation also
increased by an average of 3.4 inches during the same period [5]. Much of this gain has
been delivered by heavier rainfall, including 3-inch precipitation events that have increased
by 65% and these trends are projected to continue [5,6]. According to the Intergovernmental
Panel on Climate Change (IPCC) Sixth Assessment Report (2021), Minnesota is projected
to face severe climate variability in the future. The IPCC report (2021) finds a high degree
of certainty that Central North America will experience larger increases in temperature
from the norm than much of the world, particularly in the winter months [7]. There will
also be increased annual precipitation with particular risk of extreme precipitation and
flooding [7]. Minnesotans will likely experience hotter temperatures, with extended heat
waves, increased periods of drought, and more wildfires [7]. The growing season will also
continue to expand, extending the pollen season [7].
All of these climate changes impact the health and wellbeing of Minnesotans. Causal
pathways include injuries and deaths from heat waves and floods; vector-borne diseases
from changing tick and mosquito populations; illnesses from contaminated drinking water
from flooding; respiratory and cardiovascular illnesses from increases in wildfires, ozone,
fine particulate matter, pollen, and mold; and mental health impacts from experiencing an
extreme weather event or from a loss of sense of place. Climate change can also impact
livelihoods, such as farming, commercial fishing, and recreational businesses. Extreme
weather events can cause loss of property, land, and pets, and disrupt people’s sense of
safety. People at particular risk for eco-anxiety and disruptions of well-being due to climate
change include youth and communities of color [8,9].
Healthcare professionals need to understand the health impacts of climate change
and must be ready to practice in a climate-changed world. Previous studies have explored
physicians’ attitudes toward climate change and health through surveys conducted at
the national level. Results from these studies have shown that physicians believe climate
change is affecting the health of their patients, but they feel unprepared to address these
issues with their patients [10–13]. One limitation of these studies is that they have focused
on the perspectives of physicians in specialties with direct connections to the health impacts
from climate change without assessing the attitudes of physicians in different specialties or
comparing their perspectives with other healthcare professionals, such as nurses.
The perspective of nurses is important because they are the largest portion of the
healthcare workforce in the United States [14]. Nurses are also trusted healthcare profes-
sionals who assess, treat, and educate patients about health risks. A survey of 489 nurses
indicated moderate levels of awareness, yet high levels of concern about the health impacts
of climate change [15]. The survey also revealed that primary barriers are lack of knowledge
about what to do and feeling overwhelmed by the magnitude of the problem [15].
Public attitudes about climate change have shifted over time. According to a study
from the Yale Program on Climate Communication in 2020, 72% of Americans think global
warming is happening compared to 57% in 2010 [16]. Additionally, the study found that
71% of Minnesotans think global warming is happening [17]. These data may indicate that
patients across the country, as well as in Minnesota, have increased receptivity to learning
about the health impacts of climate change.
To gain a better understanding of the health impacts of climate change in Minnesota,
the Minnesota Department of Health (MDH) conducted a statewide survey of licensed
physicians and nurses on their knowledge, attitudes, and practices toward climate change
and health. The study expanded on previous research by surveying physicians and nurses
in the same study to compare healthcare professionals’ perspectives toward climate change
and health. The study also explored the barriers healthcare professionals are facing in
addressing climate change with their patients. The information can be used by educational
institutions, state agencies, licensing boards, and other organizations to educate healthcare
professionals and develop patient-centered educational materials and resources, aiding
healthcare professionals in addressing climate-related health outcomes.
Challenges 2022, 13, 57 3 of 17

2. Materials and Methods

A multidisciplinary research team, including nurses, research scientists, and a physi-
cian advised the study and developed the cross-sectional survey for data collection. The
team selected and modified several questions from previously conducted surveys of health-
care professionals on climate change and health and developed and evaluated new ques-
tions to meet the study objectives [10–13,18]. Each question was formatted as single- or
multiple-response or open-ended depending on the nature of the question. The survey
was developed and administered using Verint survey software. A sample of nurses and
physicians in Minnesota piloted the survey tool. The MDH institutional review board
(IRB) evaluated the study’s protocol and deemed it minimal risk, exempting it from further
IRB review.

2.1. Respondents
In 2021, MDH administered the 21-item electronic survey to a convenience sample
of nurses and physicians in Minnesota. The Minnesota Board of Nursing disseminated
the survey to 131,496 nurses in Minnesota, including registered nurses (RN), advanced
practice registered nurses (APRN), and licensed practical nurses (LPN). Additionally,
five healthcare professional organizations in Minnesota, including two nursing and three
physician organizations, disseminated the survey in newsletters or separate emails to
their mailing lists. In total, the survey was sent to approximately 152,785 nurses and
12,344 physicians, but not all were Board certified and actively practicing in Minnesota.
Participants received an email containing an explanation of the research project and a link
to the online survey. A follow-up email was sent approximately one week after the initial
email was sent. Completed surveys were returned anonymously.

2.2. Survey Tool

Two screening questions assessed whether respondents were licensed and currently
practicing in Minnesota. If respondents were not licensed and actively practicing, they were
directed out of the survey. Seven survey questions addressed participant demographics,
including type of license, practice, or type of work, setting, and area where their patients
reside. Additional demographic questions assessed the number of years practicing, age,
and gender. Two closed-ended questions assessed belief in climate change and the health
impacts of climate change. Respondents who disagreed or strongly disagreed that climate
change was impacting the health of their patients, clients, or community members skipped
to the last section of the survey. In the next section, questions assessed the role of climate
change in causing or exacerbating specific health conditions; respondent’s level of concern,
comfort, and preparation in discussing climate change and health with patients; whether
healthcare professionals are positioned and should have an active role in addressing climate
change with patients or clients; proportion of patients with which they discuss climate
change; and barriers to addressing climate change. Two additional open-ended questions
in this section assessed conversations respondents have had about climate change with
patients or clients and what else they are currently doing to address climate change. All
respondents saw the final four questions of the survey, which included two closed-ended
questions that assessed resources needed and how respondents received the survey and
two open-ended questions about current sources of information about climate change and
other thoughts about climate change and health. Participants could omit answers to any of
the questions. Data collection occurred from 20 April to 17 May 2021.

2.3. Data Analysis

Respondents who indicated they were not licensed or currently practicing in Min-
nesota were removed from analysis. Additionally, only surveys that met a predefined
minimum completion of 80% of the questions were retained for data analysis. The percent
of completed questions was calculated based on the total number of questions each respon-
Challenges 2022, 13, 57 4 of 17

dent was shown to account for the survey’s skip pattern. The survey and skip pattern can
be viewed in Appendix A.
Descriptive statistics were used for initial analysis of all responses. Chi-squared testing
compared age groups to belief in climate change. Statistical significance was defined as
p < 0.05. Normally distributed data are presented as mean ± SD.
Responses to open-ended questions were qualitatively analyzed independently of the
quantitative survey responses. A thematic coding framework was empirically developed
for each question, and all responses were independently coded by two members of the
research team. Responses that were unrelated to the question or incomprehensible were
removed from analysis. Results were quantitated by counting the frequency of each theme,
and percentages were calculated as the frequency of a given category or subcategory out of
the total number of valid responses.

3. Results
3.1. Demographics
MDH received 6572 survey responses. A total of 4453 completed surveys were in-
cluded in the analysis. Out of the 4453 responses, 87% of respondents identified as female
and 10% of respondents identified as male. The mean age was 50.5 ± 12.9 years. The
majority of the respondents were nurses (97%), including RN (78%), LPN (14%), and APRN
(8%), while less than 1% of respondents were physicians. Respondents had practiced for
a mean of 22.6 years ± 13.8 years. The majority of respondents reported practicing in
hospitals (39%) or in clinic/ambulatory settings (27%). Almost half (48%) of respondents
indicated that the majority of their patients reside in suburban areas, 44% selected rural
areas, 43% urban areas, and only 5% selected tribal areas (Table 1).

Table 1. Respondent demographics and relation to belief in climate change.

Respondents Who Agree or

Number of Respondents
Demographic Factor Strongly Agree That Climate
n (%)
Change Is Happening n (%)
Gender
Female 3863 (87) 2950 (76)
Male 434 (10) 289 (67)
Prefer not to answer 93 (2) 32 (34)
Other 10 (0) 3 (30)
No response 53 (1)
Total 4453 (100)
Age (y) 1
18–29 267 (6) 233 (87)
30–44 1177 (26) 917 (78)
45–59 1581 (36) 1084 (69)
60+ 1328 (30) 1014 (76)
No response 100 (2)
Total 4453 (100)
Years practicing (y)
0–4 426 (10) 350 (82)
5 to 9 535 (12) 432 (81)
10 to 14 550 (12) 408 (74)
15 to 19 446 (10) 304 (68)
20+ 2463 (55) 1791 (73)
No response 33 (1)
Total 4453 (100)
Challenges 2022, 13, 57 5 of 17

Table 1. Cont.

Respondents Who Agree or

Number of Respondents
Demographic Factor Strongly Agree That Climate
n (%)
Change Is Happening n (%)
License 2
MD 36 (1) 31 (86)
DO 7 (0) 2 (29)
RN 3474 (78) 2606 (75)
APRN 364 (8) 281 (77)
LPN 607 (14) 416 (69)
Other 39 (1) 31 (79)
No response 27 (1)
Practice or type of work 2
Primary care 952 (21) 700 (74)
Critical care 642 (14) 465 (72)
Surgical care 546 (12) 392 (72)
Other specialty care 1362 (31) 1040 (76)
Scientific research 56 (1) 37 (66)
Other 1285 (29) 974 (76)
No response 24 (1)
Setting 2
Clinic or ambulatory 1185 (27) 882 (74)
Hospital 1721 (39) 1264 (73)
Professional office 164 (4) 111 (68)
Academic 154 (3) 118 (77)
LTC 757 (17) 575 (76)
Other 701 (16) 544 (78)
No response 112 (3)
Patient residence 2
Tribal 241 (5) 177 (73)
Urban 1929 (43) 1499 (78)
Suburban 2130 (48) 1609 (76)
Rural 1951 (44) 1392 (71)
Other 150 (3) 106 (71)
No response 50 (1)
1 Chi-squared (χ2 ), p-value: 45.0, <0.05, compared belief in climate change to age group. 2 Respondents were able
to choose more than one option to answer the question.

3.2. Attitudes toward Climate Change and Health

Of the total respondents included in the analysis, 75% (n = 3303) strongly agreed or
agreed that climate change is happening, and 60% (n = 2696) strongly agreed or agreed
that “Climate change directly or indirectly impacts the health of my patients, clients, or
community members”. More females (76%) agreed that climate change is happening than
males (67%). There was an association between belief in climate change and age, with
individuals aged 18–29 (n = 267) more likely to strongly agree or agree that climate change
is happening (χ2 = 45.0, p < 0.05) than the other age groups. Eighty-seven percent of
individuals between the ages of 18–29 believed in climate change compared to 78% of ages
30–44, 69% of ages 45–59, and 76% of ages 60 and over (Table 1).
Among those who strongly agreed, agreed, or neither agreed nor disagreed that climate
change impacts health (n = 3468, 78%), more than two-thirds considered climate change to
always, often, or sometimes play a role in causing or exacerbating respiratory problems
(74%) and mental health issues (66%). Lower percentages of respondents indicated that
climate change caused or exacerbated extreme heat illness (55%), vector borne diseases
(47%), and physical trauma related to extreme weather (41%) (Figure 1). More than three-
quarters of the respondents reported feeling concerned about the health impacts of climate
 Challenges 2022, 13, 57 6 of 17

22, 13, x FOR PEER REVIEW 6 of 17

change on patients/clients (76%). In addition, the majority of respondents (59%) strongly
Challenges 2022, 13, x FOR PEER REVIEW 6 of 17
agreed or agreed that “Healthcare professionals are positioned to help patients/clients
understand the health impacts from climate change”.

Figure 1. Perceived impact of climate change on patient or client health conditions (n = 3443).
Figure
Figure1.1.Perceived
Perceivedimpact
impact of
of climate changeon
climate change onpatient
patientororclient
clienthealth
health conditions
conditions (n3443).
(n = = 3443).
Despite this, only 20% strongly agreed or agreed that they feel well prepared to
Despite
Despitethis,
this, only
only 20%
20% strongly agreed
agreed or or agreed
agreedthat
thatthey
theyfeel
feelwell
well prepared
prepared to to
discuss the health impacts of climate change with patients or clients. Similarly, only 21%
discussthe
discuss thehealth
healthimpacts
impacts of of climate change
changewith withpatients
patientsororclients.
clients.Similarly, only
Similarly, only21%21%
felt comfortablefeltcounseling
comfortable patients/clients about climate
counseling patients/clients change
about climateand health (Figure 2).
felt comfortable counseling climatechange
changeand andhealth
health(Figure
(Figure2).2).
Even fewer, 4%, reported
Even thatreported
fewer, 4%,
4%, they discuss the impacts of climate changechange
on health with with all
Even fewer, reportedthatthatthey
theydiscuss
discuss thethe
impacts
impactsof climate
of climate changeon health
on health with
all or most of all
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oror patients,
most
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13%
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13% thisdiscuss
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thissome
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ofpatients, and
their patients,
and 83% withand a83%
few or
with none
a few of
ortheir
none patients.
of their patients.
83% with a few or none of their patients.

Figure 2. Respondent self-reported level of concern, preparation, comfort, role in addressing climate
Figure 2. Respondent
change,self-reported
Figure and whetherlevel
2. Respondent they of concern,
feel preparation,
positioned
self-reported level ofto
comfort,
help patients
concern,
role in(n
or clients
preparation,
addressing
= role
comfort, 3448). climate
in addressing climate
change, and whether they feel positioned to help patients or clients (n = 3448).
change, and whether they feel positioned to help patients or clients (n = 3448).
3.3. Barriers to Discussing Climate Change and Desired Resources
3.3. Barriers to Discussing Climate Change and Desired Resources
Figures 3 and 4 presents summary statistics for barriers to discussing climate change
Figures 3with
and patients
4 presents
andsummary
resourcesstatistics
needed tofor barriers
address to discussing
climate climate
change. The threechange
most commonly
with patients reported
and resources needed
barriers to address
were lack climateregarding
of knowledge change. Thehowthree most commonly
to approach this issue with my
reported barriers wereorlack
patients of knowledge
clients regarding
(57%), lack of howand
time (40%), to perceived
approach lack
this issue withinterest
of patient my (29%).
Challenges 2022, 13, 57 7 of 17

3.3. Barriers to Discussing Climate Change and Desired Resources

Figures 3 and 4 presents summary statistics for barriers to discussing climate change
with patients and resources needed to address climate change. The three most commonly
Challenges 2022, 13, x FOR PEER REVIEW
reported barriers were lack of knowledge regarding how to approach this issue with 7 of 17
Challenges 2022, 13, x FOR PEER REVIEW 7 ofmy17
patients or clients (57%), lack of time (40%), and perceived lack of patient interest (29%).
Respondents most often selected the following resources as being helpful in discussing
climate
patient change with
or client
client patients:materials
education continuing education
(46%), courses
and case
case (57%),
studies or research articles
clinical care
care (46%),
examples
patient or education materials (46%), and studies or clinical examples
patient
(38%). or client education materials (46%), and case studies or clinical care examples (38%).
(38%).

Figure 3.Barriers
Barriers todiscussing
discussing climatechange
change withpatients
patients orclients
clients (n==3381).
3381).
Figure 3. Barriers to
Figure 3. to discussing climate
climate change with
with patients or
or clients(n
(n = 3381).

Figure 4. Resources requested by respondents (n = 4196).

Figure 4.
Figure 4. Resources
Resources requested
requested by
by respondents
respondents(n
(n== 4196).
4196).

A total
A total of
of 510
510 respondents
respondents provided
provided a valid
valid response
response to
to the
the open-ended
open-ended question,
question,
A total of 510 respondents provided aa valid response to the open-ended question,
“Please describe
“Pleasedescribe sources
describesources
sourcesofofof information
information on the health impacts from climate change that
“Please information ononthethe health
health impacts
impacts fromfrom climate
climate change
change that
that you
you already
you already rely
rely on or
on or that
that you would
you recommend recommend
would recommend to other healthcare
to other healthcare professionals.”
professionals.”
already rely on or that you would to other healthcare professionals.” Scientific
Scientific
research research
Scientificorresearch or journal
or journal
journal articles articles
(109articles (109 responses)
(109 were
responses) responses) were mentioned
were the
mentioned mentioned the most often,
the followed
most often, most often,
by
followed
followed
news by news
by news
articles articles
or thearticles
media oror the media
theand
(98), media (98), and
(98), or
internet and internet or
internet(61)
websites websites
or websites
(Table S1).(61) (Table S1).
(61) (Table S1).

3.4. Climate
3.4. Climate Change
Change Conversations
Conversations
A total
A total of
of 929
929 participants
participants provided
provided responses
responses to
to the
the prompt
prompt “Please
“Please provide
provide one
one or
or
more examples of conversations you have had with patients related to climate change
more examples of conversations you have had with patients related to climate change and and
health”. (Table
health”. (Table S2).
S2). The
The most
most frequent
frequent theme
theme of
of these
these conversations
conversations was
was impacts
impacts of
of climate
climate
change on respiratory health (355), particularly increased severity and frequency of
Challenges 2022, 13, 57 8 of 17

3.4. Climate Change Conversations

A total of 929 participants provided responses to the prompt “Please provide one
or more examples of conversations you have had with patients related to climate change
and health”. (Table S2). The most frequent theme of these conversations was impacts of
climate change on respiratory health (355), particularly increased severity and frequency of
allergies (154), and exacerbation of asthma (122) and COPD (48). A number of respondents
also discussed air quality/air pollution (112) (Table S2). The second most cited theme was
related to health impacts from temperature changes (276), including hotter summers and
extreme heat-related impacts (133), sun and UV exposure (53), and winter weather and
extreme cold (51). These conversations primarily aimed to increase patient awareness of
health harms and provide recommendations. Other themes mentioned were mental health
impacts (84) and impacts on underlying chronic conditions (non-respiratory) (46).

3.5. Actions or Other Thoughts Related to Climate Change and Health

A total of 439 participants provided responses to the question “What else, if anything,
are you doing to address climate change with patients or clients?” Educating patients about
climate change and health impacts was the theme most often shared (111). Respondents
also discussed ways patients can protect themselves from the health impacts of climate
change (86). The next most common response was engaging in and/or recommending
individual actions for climate change mitigation (62). A total of 137 respondents indicated
that they were not doing anything to address climate change with patients or clients.
Reasons for this inaction included a lack of knowledge on the subject (18), prioritizing other
health issues (16), viewing the issue as not relevant to their patients or practice (19), or
political polarization around climate change (15) (Table S3).
A total of 856 participants responded to the open-ended question “What other thoughts
do you have regarding the health impacts from climate change?” This question was pre-
sented to all survey participants regardless of their answers to the initial questions assessing
belief in climate change and its health impacts. The responses were first categorized based
on the respondents’ perception of climate change impacting health. A total of 373 responses
expressed agreement that climate change is impacting health, whereas 383 indicated dis-
agreement with this premise, and 100 indicated uncertainty or neutrality (Table S4).
Themes among the responses indicating agreement included that climate change is
having real health impacts (163), there is a need for more resources and education (74), and
challenges to discussing and addressing climate change (72), including the politicization of
climate change (36) and lack of time (12). Among responses that were categorized as neutral,
21 expressed skepticism or uncertainty and a need for more evidence of health impacts of
climate change and 21 indicated that other health problems were more important to address.
Of the respondents disagreeing that climate change impacts health, the most frequent theme
was that the issue is political (118), dismissing climate change as a political tactic rather
than an actual threat. Other themes included that climate change is not occurring (74), that
it is occurring but due to natural reasons rather than being anthropogenic (82), and that
other health issues are more important (71).

4. Discussion
MDH conducted a survey of healthcare professionals in Minnesota to assess their
observations of the clinical manifestation of climate change, examine their knowledge,
attitudes, and practices toward climate change and health, and explore the barriers they are
facing in addressing climate change with patients. The findings from this study identified
that respondents recognize that climate change is happening, are concerned about the health
impacts on patients, and believe they have a role in addressing climate change. However,
we also found that they do not feel comfortable nor prepared to discuss climate change
with their patients, and there are many barriers and resources needed to support healthcare
professionals in addressing climate change with patients. Healthcare professionals play
an important role in educating patients about a variety of health risks. Therefore, we
Challenges 2022, 13, 57 9 of 17

must address their concerns and utilize this opportunity to advance our response to
climate change.

4.1. Healthcare Professionals Understand the Climate Change Is Happening

Quotes from respondents:
“This is something we all need to recognize as happening here and now”
“I think climate change related health problems are only going to increase as problems get
worse (more fires, less vegetation, increased tick population, poorer air quality)”
Our findings reinforce earlier study findings that healthcare professionals believe
climate change is happening and are concerned about climate change and its adverse effects
on human health. The majority of respondents agreed that climate change is happening
(75%), similar to but slightly lower than specialty physician studies, which found that
81–98% of respondents believed in climate change [10–13]. A study of nurses, based on a
different framework, also found moderate levels of awareness about the health impacts
from climate change (2.97 mean score out of 0–4) [15].
Sixty percent of respondents agreed or strongly agreed that climate change was cur-
rently impacting the health of their patients or clients, demonstrating that healthcare
professionals in Minnesota are recognizing current impacts from a changing climate. Find-
ings from specialty physician surveys found that 64% of family physicians, 69% of thoracic
physicians, and 74% of allergists reported that climate change was currently impacting
the health of their patients [11–13]. The youngest age grouping, ages 18–29 years, had
the highest percentage of respondents reporting that they believe in climate change (87%).
These findings are similar to a recent Yale study, which found that younger adults were
more likely than older adults to view global warming as personally important and report
feeling concerned about climate change [16]. However, this age group also had the lowest
number of respondents, making up only six percent (6%) of the total survey participants.

4.2. Healthcare Professionals Are Concerned about the Health Impacts on Their Patients
Quotes from respondents:
“I spoke with my patient about why his COPD and seasonal allergies seem to be worse
over the last few years. I explained to him that our warming climate meant a prolonged
pollen season and that this was affecting his health.”
“I experience climate grief often. I think it is the fundamental and primary problem we
face right now, and our society has to change in fundamental ways to address it. We are
connected to the earth, and affronts to the earth are affronts to ourselves and our health.”
Excluding respondents who disagreed that climate change is impacting health, more
than three-fourths of respondents (76%) reported feeling concerned about the health im-
pacts of climate change on their patients. A similar percentage of respondents (74%)
reported always, often, or sometimes associating climate change with respiratory condi-
tions among their patients, suggesting that they are concerned because they are seeing
the health impacts of climate change on their patients firsthand. Two-thirds of respon-
dents also reported always, often, or sometimes associating climate change with mental
health conditions (66%) among their patients, further suggesting that climate change is
already having health impacts in Minnesota. In a study of family physicians from 2019,
respondents also reported most often seeing respiratory disease and mental health issues in
practice [13]. Studies by George Mason University found similar results, with the majority
of respondents indicating they were observing the impacts of climate change on the health
of their patients, most commonly as increases in respiratory conditions due to air pollution
or allergies [10–12]. These earlier studies did not include mental health conditions as
an option.
Challenges 2022, 13, 57 10 of 17

4.3. Healthcare Professionals Have a Role in Helping Patients Understand the Health Impacts from
Climate Change
Quotes from respondents:
“I may not talk about climate change directly, but I educate patients on how to prevent
disease and injury related to climate change such as heat exhaustion, Lyme disease, fire
safety, etc.”
“It IS happening and we should confront it and assist as much as we can with patients
NOW, because it is only going to worsen!”
As previously noted, a study of family physicians found a high level of belief in
climate change (98%); however, less than one-third (31%) of the physicians in this study
expressed that they should have an active role in addressing climate change with their
patients [13]. Our study of a predominantly nursing cohort found that more than half
(58%) of respondents believed that healthcare professionals should have an active role
in addressing climate change with patients, suggesting that there is growing recognition
among healthcare professionals to integrate climate change into the delivery of healthcare.
This increase may reflect an attitude difference between nurses and physicians, or it
may represent a shift in the perceptions of healthcare professionals about their responsibili-
ties. Our study occurred amid robust public and professional discourse regarding climate
change and its impact on health. Many major medical journals published clear and urgent
calls to action by healthcare professionals and others [19–23]. In addition, professional
organizations in Minnesota, including the Minnesota Organization of Registered Nurses
(MNORN) and Health Professionals for a Healthy Climate (HPHC), sponsored training
opportunities to educate healthcare professionals about climate and health. Local profes-
sional medical societies, such as the Minnesota Academy of Family Physicians, adopted
formal resolutions about climate change and health, and fourteen healthcare professional
organizations signed on to and presented a Declaration on Climate Change and Health to
the Minnesota State Legislature in 2021 [24,25].

4.4. Healthcare Professionals Do Not Feel Prepared to Address Climate Change with Patients
Quotes from respondents:
“I don’t know enough about climate change and how affects health to discuss”
“This is a very important issue that I do not know enough about and is NOT talked about
enough in a healthcare setting.”
Despite the large portion of respondents recognizing the importance of climate change,
many indicated that they were not well equipped to address climate change with patients or
clients. Only 1 in 5 respondents reported feeling well prepared (20%) or comfortable (21%)
counseling patients about climate change and health, while almost half of respondents
disagreed or strongly disagreed with these statements. Similarly, only 4% of respondents
reported that they discussed climate change with all or most of their patients, indicating
that feeling unprepared or uncomfortable may be preventing healthcare professionals from
engaging in conversations about climate change with patients.
More than one-third of those who responded to the question asking what else they
are doing to address climate change indicated they were not doing anything, further
demonstrating the gap between awareness and action. Those who did report addressing
climate change with patients most often mentioned educating patients about climate change
and health (25%) and discussing ways patients can protect themselves from the health
impacts of climate change (20%).

4.5. Barriers to Addressing Climate Change

Quotes from respondents:
“I wish I was better prepared, with more knowledge. I have not thought about these
climate change questions in a survey like this before today.”
Challenges 2022, 13, 57 11 of 17

“I did not know this was something we should be discussing with patients and I think
many professionals would need information regarding climate change and the impact it
can have on healthcare.”
Closed and open-ended questions provide insight into the barriers preventing health-
care professionals from addressing climate change with patients. The most common barrier
from the closed-ended question was a lack of knowledge regarding how to approach this
issue with patients or clients (57%), which may be contributing to feeling unprepared or
uncomfortable in addressing climate change with patients.
The second most common barrier reported was lack of time, which has also been
identified in earlier studies [13]. On average, the length of an office visit with a primary
care physician lasts about 15 min [26]. While it has been estimated that nurses may spend
twice as much time with patients, they still only spend about one-third of their shift with
patients [27]. Similarly, many respondents noted that patients often have urgent health
conditions, including COVID-19, that they must prioritize given time constraints.
Another common barrier referenced by both respondents who agreed and disagreed
that climate change was impacting health was the political positioning of climate change.
In response to the open-ended question asking about other thoughts related to climate
change and health, those who believed that climate change is impacting health referred to
the politicization as a barrier, while those who disagreed that climate change is impacting
health dismissed climate change as a political tactic rather than an actual threat. The topic of
climate change remains a polarizing political issue across the nation. Political affiliation was
found to correlate with belief in climate change in a recent study from Yale University [16].
In this study, respondents reporting a more conservative political affiliation were less likely
to believe that climate change is happening [16].

4.6. Applications to Practice

Quotes from respondents:
“CEU courses should be offered for free from organizations locally and globally to help
healthcare professionals”
“I hope that in the near future hospitals will address the lack of information available to
medical staff to educate the public”
While our study identified many barriers to addressing climate change within the
healthcare system, respondents also highlighted resources that would be helpful and
can be used to inform next steps. Respondents most often indicated that continuing
education courses (57%) and research articles (46%) are needed. Providing these resources
would directly address the lack of knowledge that was reported as a barrier by healthcare
professionals in this study. Another important next step involves working with academic
institutions to ensure that all healthcare professional schools have climate change and
health content in their curriculum. This goal may be facilitated by developing partnerships
with State Boards of Medicine and Nursing to discuss the urgent need for climate-ready
professionals. Patient or client education materials were another commonly requested
resource, potentially identifying a solution for healthcare professionals with limited time to
get important information about climate change to patients.
Most respondents in our study reported believing that climate change is important
and impacting health, but we also identified a proportion of respondents who appeared to
be undecided about climate change and the impacts on health. Almost 1 in 5 respondents
(18%) neither agreed nor disagreed that they were concerned about the health impacts of
climate change on patients, suggesting that there may be an undecided or naïve group
toward whom educational efforts may be targeted. We also identified a subset of healthcare
professionals who care for patients with climate-related conditions, but never or rarely
consider climate change as playing a role in causing or exacerbating the health conditions.
This finding further demonstrates opportunities for education of healthcare professionals.
Challenges 2022, 13, 57 12 of 17

To enhance education and provide better healthcare services, future studies are needed
to determine unique impacts that climate change has on vulnerable populations in Min-
nesota including youth; rural; elderly; and Black, Indigenous, People of Color (BIPOC).
As the world heats we will need more data about demographic shifts in Minnesota re-
lated to relocation and immigration due to extreme weather events and/or inhospitable
environments both inside and outside Minnesota. We also need evaluative studies to
understand and promote best practices both in climate change mitigation and adaptation
for health protection.

4.7. Limitations
Our study originally aimed to compare physicians and nurses on their perspectives
toward climate change and health; however, relatively few physicians responded to the
survey. The disproportionately low rate of physician responses limited the ability to
compare and contrast their knowledge, attitudes, and practice with nurses and limited
the ability to generalize the findings to physicians across Minnesota. Additionally, our
study used a convenience sample, which may also impact the representativeness and
generalizability of our findings to healthcare professionals in Minnesota. While recent data
from MDH suggests that nursing professionals (RNs, APRNs, LPNs) outnumber physicians
(MD/DOs) with a ratio of 6:1, physicians in our survey constituted less than 1% of the total
response [28]. The greater response by nurses may have been due to a stronger outreach to
nurses. The Minnesota Board of Nursing disseminated the survey to Board certified nurses,
while the Minnesota Board of Medical Practice did not distribute the survey to physicians.
An additional limitation of our study is the possibility of response bias resulting from the
wording of the survey questions. While our advisory committee attempted to reduce bias
in the development of the survey questions, it is possible that the wording of the questions
influenced how respondents answered the questions.

5. Conclusions
While the majority of healthcare professionals who responded to the survey be-
lieved climate change is important and impacting health, we found that only about
1 in 5 respondents reported feeling well prepared to discuss climate change with patients
(20%) or comfortable counseling patients about climate change and health (21%). Our
study identified significant challenges facing healthcare professionals in addressing climate
change with patients with respondents most often reporting lack of knowledge (57%), lack
of time (40%), and perceived interest among patients (29%) as barriers to these conversa-
tions. Even though this study focused on climate change, we believe these barriers also
impact discussions about other planetary health threats. Healthcare professionals are a
vital source of information for patients; thus, these barriers need to be addressed through
education and resource development to make progress in addressing climate change locally
and across the world. Additional research is needed to investigate whether conversations
by a healthcare professionals can influence a patients’ knowledge and behavior related to
climate change and how healthcare organizations can better develop skills in their employ-
ees for having climate-related conversations. Our findings also highlight an educational
imperative to develop ‘bedside’ ready training for nurses and other healthcare professionals
on integrating climate and planetary health conversations into patient care. Climate change
and other disruptions of the Earth’s natural systems drive cascading impacts not only
to human health but to planetary health as well. Given the dire state of our planet and
the urgent climate crisis, we call all healthcare professionals and allies to lead the way in
developing a new norm—threats to planetary health are real and healthcare professionals
can provide a trusted voice in helping people adapt to and mitigate climate change and
other planetary health crises. With adequate education, restoring planetary health can be a
core strategy at every clinic visit, in every treatment plan, and every community and public
health initiative.
Challenges 2022, 13, 57 13 of 17

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/challe13020057/s1, Table S1: Analysis of open-ended question,
“Please describe sources of information on health impacts from climate change that you already rely
on or that you would recommend to other healthcare providers” (n = 510); Table S2: Analysis of
open-ended question, “Please provide one or more examples of conversations you have had with
patients related to climate change and health.” (n = 929); Table S3. Analysis of open-ended question,
“What else, if anything, are you doing to address climate change with patients or clients? (n = 439);
Table S4. Analysis of open-ended question, “What other thoughts do you have regarding the health
impacts from climate change?” (n = 856).
Author Contributions: Conceptualization, M.K., K.R., B.M.D., E.O., S.G. and T.P.; methodology, M.K.,
K.R., B.M.D., E.O., S.G. and T.P.; software, M.K. and B.M.D.; validation, M.K., K.R., B.M.D. and E.O.;
formal analysis, M.K.; investigation, M.K., K.R. and B.M.D.; resources, M.K.; data curation, M.K. and
B.M.D.; writing—original draft preparation, M.K., K.R., B.M.D., E.O., S.G. and T.P.; writing—review
and editing, M.K., K.R., B.M.D., E.O., S.G. and T.P.; visualization, M.K. and K.R.; supervision, K.R.;
project administration, M.K.; funding acquisition, M.K. All authors have read and agreed to the
published version of the manuscript.
Funding: This work was supported in part by an appointment to the Applied Epidemiology Fel-
lowship Program administered by the Council of State and Territorial Epidemiologists (CSTE) and
funded by the Centers for Disease Control and Prevention (CDC) Cooperative Agreement Number
1NU38OT000297-03-00. The findings and conclusions are solely those of the authors and do not
necessarily reflect the views of the Centers for Disease Control and Prevention.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or
in the decision to publish the results.

Appendix A
Minnesota Survey of Healthcare Professionals on Climate Change and Health.
1. Are you a nurse or physician that is currently licensed to practice or has been licensed to practice in the past
12 months in Minnesota?
# Yes, I am a nurse that is licensed to practice or has been licensed to practice in the past 12 months in Minnesota
# Yes, I am a physician that is licensed to practice or has been licensed to practice in the past 12 months in
Minnesota
# No
2. Are you actively practicing in your licensed field or have you practiced in the past 12 months? (Practicing in
this context may involve seeing patients, clients, or community members and can include in-person or virtual
appointments.)
# Yes
# No
Demographic Information

3. What best describes your current health provider license? (Check all that apply)
# MD
# DO
# RN
# APRN
# LPN
# Other ____________________
4. Which of the following best describes your practice or type of work? (Check all that apply)
# Primary care (family medicine, internal medicine, pediatrics)
# Critical or emergency care
Challenges 2022, 13, 57 14 of 17

# Surgical care
# Other specialty care ____________________
# Scientific research
# Other ____________________
5. Which of the following best describes the primary setting for your practice? (Check all that apply)
# Clinic or ambulatory care
# Hospital
# Professional office
# Academic (teaching or research)
# Long-term care facility or home health care
# Other ____________________
6. Which of the following describes the areas in which the majority of your patients or clients reside? (Check all
that apply)
# Tribal
# Urban
# Suburban
# Rural
# Other ____________________
7. How many years have you been practicing? Years ________________________________________
8. What is your age? Age ________________________________________
9. What is your gender?
# Female
# Male
# Other
# Prefer not to answer

Information about Climate Change and Health

The following items focus on your knowledge, attitudes, and practices related to climate change and health and
your experiences in your practice with patients, clients, or community members.
10. To what extent do you agree or disagree with the following statement: Climate change is happening.
# Strongly agree
# Agree
# Neither agree nor disagree
# Disagree
# Strongly Disagree
11. To what extent do you agree or disagree with the following statement: Climate change directly or indirectly impacts
the health of my patients, clients, or community members.
# Strongly agree
# Agree
# Neither agree nor disagree
# Disagree
# Strongly Disagree
Below is a list of some health conditions that may be linked to climate change.
12. When you see patients or clients with the following categories of conditions, how often do you consider that climate
change is playing a role in causing or exacerbating the conditions?
Challenges 2022, 13, 57 15 of 17

I Don’t See
I Don’t Patients/Clients
Never Rarely Sometimes Often Always
Know with These
Conditions
Respiratory problems (asthma, allergies,
# # # # # # #
COPD, etc.)
Vectorborne diseases (Lyme disease, West Nile
# # # # # # #
virus, Rocky Mountain Spotted fever, etc.)
Extreme heat illnesses (dehydration, heat
# # # # # # #
stroke, heat exhaustion, etc.)
Physical trauma related to extreme weather
# # # # # # #
(severe storms, fires, floods, etc.)
Mental health issues (depression, stress,
anxiety, high-risk coping behavior, # # # # # # #
post-traumatic stress disorder, etc.)

13. Please indicate the extent to which you agree or disagree with the following statements.

Strongly Neither Agree Strongly

Agree Disagree
Agree Nor Disagree Disagree
As a healthcare professional, I am concerned about the
# # # # #
health impacts of climate change on patients/clients.
Healthcare professionals are positioned to help
patients/clients understand the health impacts from # # # # #
climate change.
I feel well prepared to discuss the health impacts of
# # # # #
climate change with patients/clients.
I feel comfortable counseling patients/clients about
# # # # #
climate change and health.
Healthcare professionals should have an active role in
discussing climate change and health with their # # # # #
patients/clients.

14. With what proportion of your patients or clients do you discuss the impact of climate change on their health?
# All
# Most
# Some
# A few
# None
15. Please provide one or more examples of conversations you have had with patients related to climate change
and health.
______________________________________________________________
16. Which of the following barriers prevent you from discussing climate change-related health issues with patients or
clients? (Check all that apply)
# Lack of time
# Lack of knowledge regarding how to approach this issue with my patients or clients
# My patients or clients would not be interested
# My patients or clients would not be knowledgeable enough about climate impacts to discuss this issue
# Discussing this issue with my patients or clients will not make much difference in their overall health
# Climate change is not occurring
# Not applicable—I don’t face barriers discussing climate change-related health issues with patients or clients.
# Other ____________________
17. What else, if anything, are you doing to address climate change with patients or clients?
______________________________________________________________
Challenges 2022, 13, 57 16 of 17

Information about Climate Change for Healthcare Professionals

18. Which of the following resources related to climate change and health, if any, would be helpful for you? (Check all
that apply)
# Research articles demonstrating the link between climate change and clinical outcomes
# Treatment or assessment options
# Continuing education course on climate change and health
# Patient or client education materials
# Case studies or clinical care examples demonstrating best practices for discussing climate change and health
with patients or clients
# Other ____________________
# I don’t need any resources
19. Please describe sources of information on health impacts from climate change that you already rely on or that you
would recommend to other health care providers.
______________________________________________________________
20. Optional: What other thoughts do you have regarding the health impacts from climate change?
______________________________________________________________
21. How did you hear about the survey?
# Licensing board
# Professional organization
# Other ____________________
Thank you so much for your time and sharing your feedback. Your input will be used to develop resources for
Minnesota healthcare professionals on climate change and health.
Here are some immediate resources for more information on this topic:
Minnesota Department of Health: Climate & Health (opens in a new window)
Centers for Disease Control and Prevention: CDC’s Climate and Health Program (opens in a new window)
American College of Physicians: Climate Change Toolkit (opens in a new window)
Alliance of Nurses for Healthy Environments: Climate Change (opens in a new window)
Health Professionals for a Healthy Climate: Climate change is a health emergency (opens in a new window)
Lancet Countdown: Tracking the connection between public health and climate change (opens in a new window)

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