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1 Childrens Health Articles The Environmental History in Pediatric Practice: A Study of Pediatricians Attitudes, Beliefs, and Practices Nikki Kilpatrick,1 Howard Frumkin,2,3 Jane Trowbridge,1 Cam Escoffery,1 Robert Geller,3,4,5 Leslie Rubin,3,4,6,* Gerald Teague,3,4 and Janice Nodvin3,6,* 1Department of Behavioral Sciences and Health Education, and 2Department of Environmental and Occupational Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; 3Pediatric Environmental Health Specialty Unit, and 4Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia, USA; 5Georgia Poison Center, Atlanta, Georgia, USA; 6Marcus Institute, Atlanta, Georgia, USA behaviors, including self-efficacy and out- We conducted a mail survey of practicing pediatricians in Georgia to assess their knowledge, atti- come expectancy. Self-efficacy is a persons tudes, and behaviors regarding recording patients environmental histories. Of 477 eligible pedia- level of confidence about performing a par- tricians, 266 (55.8%) responded. Fewer than one in five reported having received training in ticular behavior, including confidence in environmental history-taking. Pediatricians reported that they strongly believe in the importance overcoming barriers to performing that of environmental exposures in childrens health, and 53.5% of respondents reported experience behavior. Outcome expectancy refers to the with a patient who was seriously affected by an environmental exposure. Pediatricians agreed belief that a particular (desired) outcome will moderately strongly that environmental history-taking is useful in identifying potentially haz- follow as a consequence of a behavior. For ardous exposures and in helping prevent these exposures. Respondents reported low self-efficacy example, a pediatrician who is confident regarding environmental history-taking, discussing environmental exposures with parents, and about environmental history-taking (high finding diagnosis and treatment resources related to environmental exposures. The probability of self-efficacy) and who expects useful informa- self-reported history-taking varied with the specific exposure, with environmental tobacco smoke tion to flow from this portion of the history and pets most frequently queried and asbestos, mercury, formaldehyde, and radon rarely queried. (high outcome expectancy) is more likely to The pediatricians preferred information resources include the American Academy of Pediatrics, take a history than is a physician without newsletters, and patient education materials. Pediatricians are highly interested in pediatric envi- these attributes. Assessing these constructs ronmental health but report low self-efficacy in taking and following up on environmental histo- within a population provides the opportunity ries. There is considerable opportunity for training in environmental history-taking and for to identify strategies for behavior change as increasing the frequency with which such histories are taken. Key words: childrens environmental well as methods for accomplishing these health, clinical history, environmental history, environmental medicine, medical history. Environ changes (32,33). Health Perspect 110:823827 (2002). [Online 8 July 2002] In the present study we assessed the atti- http://ehpnet1.niehs.nih.gov/docs/2002/110p823-827kilpatrick/abstract.html tudes, beliefs, and practices of Georgia pedia- tricians regarding childrens environmental health, focusing particularly on the environ- Children confront a wide range of potential medical schools (810) and a more recent mental history. We also sought additional hazards in the environment and are especially study focusing exclusively on environmental information regarding the pediatricians susceptible to toxic effects because of their medicine (11) found a fairly stable pattern: training and informational sources. We inter- developing organ systems, immature biologic about one in four schools offer no instruction preted the results with reference to the con- defenses, and increased exposure due to small at all in this area, and of schools that do, the ceptual constructs of outcome expectancy size, diet, behaviors, and other factors (1). mean number of hours of instruction over 4 and self-efficacy. Public concern for these exposures is high (2), years is < 10. Over two-thirds of medical and patients frequently ask their physicians school deans reported that the emphasis on Methods about the health effects of environmental environmental medicine in their schools cur- Our target population consisted of pediatri- exposures (3). In recent years the intersection ricula is minimal (12). A similar pattern cians practicing in Georgia. We obtained the of pediatrics and environmental health, or prevails in residency training (1317). mailing roster from the Georgia Chapter of childrens environmental health, has The clinical history is an essential part of attracted considerable attention (4). This field data collection and doctorpatient commu- Address correspondence to H. Frumkin, Department has been defined as the diagnosis, treatment, nication (1822). The environmental history of Environmental and Occupational Health, Rollins School of Public Health of Emory University, 1518 and prevention of illness due to perinatal and (questions eliciting the parents concerns and Clifton Road, Atlanta, GA 30322 USA. Telephone: pediatric exposures to environmental haz- probing potential environmental hazards to (404) 727-3697. Fax: (404) 727-8744. E-mail: ards, together with the creation of healthy which a child is exposed) is readily included [email protected] environments for children (5). in the routine medical history (2325). *Current address: May South, Atlanta, GA, USA. Clinical practice plays an important role However, medical professionals seldom elicit We thank the many busy pediatricians who took in advancing and protecting childrens envi- an environmental history from their patients the time to participate in this study. This research was partially funded by the ronmental health. Health care providers such (26,27). Pediatricians who do ask about Southeast Pediatric Environmental Health Specialty as pediatricians can help limit childrens environmental exposures usually limit their Unit at Emory University, a project funded by the exposures to environmental hazards by edu- inquiry to lead and environmental tobacco U.S. Environmental Protection Agency and the cating parents, identifying hazardous expo- smoke (28). Agency for Toxic Substances and Disease Registry, sures, diagnosing and treating children, and Whether providers perform preventive through the Association of Occupational and advocating for prevention (6). However, practices such as history-taking, vaccination, Environmental Clinics. A preliminary version of these results was presented at the annual meeting of physicians have little training in environmen- and lead screening is significantly affected by the American Public Health Association in Boston, tal health (7). A series of studies by Levy their knowledge, attitudes, and beliefs Massachusetts, in November 2000. assessing the extent of teaching in occupa- (29,30). More generally, Bandura (31) has Received 30 August 2001; accepted 3 February tional and environmental medicine in U.S. identified several factors that help predict 2002. Environmental Health Perspectives VOLUME 110 | NUMBER 8 | August 2002 823

2 Childrens Health Kilpatrick et al. the American Academy of Pediatrics. The We mailed the questionnaire with a [from Georgia Composite State Board of roster consisted of 1,416 potential respon- cover letter and a stamped, addressed return Medical Examiners records, which are pub- dents, of whom we eliminated 41 because envelope in February 2000. We sent a sec- licly accessible on the Internet (34)]. Date of their practices were outside Georgia or ond mailing, with a reminder letter and a licensure is a rough proxy of age. Of the 156 because they were not pediatricians. Of the second copy of the questionnaire to all non- surveys sent to rural physicians, 8 were remaining 1,375, we randomly selected 500 respondents. During data entry, we identi- returned as undeliverable, and 91 of the to receive a mail survey. fied missing values and excluded them from remaining 148 were returned, a response rate The questionnaire consisted of 21 items the data analysis; we checked data by run- of 61.5%. Of the 344 surveys sent to urban divided into four separate domains. The first ning frequencies on each variable to check physicians, 15 were returned as undeliver- domain ascertained information about the for outliers and data entry errors, and we able, and 175 of the remaining 329 were pediatricians demographics, the practice set- randomly sampled and checked 10% of the returned, a response rate of 53.2%. Among ting, and the patient population. The second questionnaires for accuracy. We ran descrip- the respondents, the mean number of years domain queried attitudes, beliefs, and self- tive statistics using SPSS, version 10.0.5 of licensure ( SD) in Georgia was 14.9 efficacy on childrens environmental health, (SPSS Inc., Chicago, IL). 13.9, and among nonrespondents, the mean with an emphasis on environmental history- The study was approved by Emory number of years of licensure ( SD) in taking. The third domain inquired about the Universitys Human Investigations Georgia was 13.5 12.4. Therefore, respon- pediatricians current behaviors, with ques- Committee. dents were slightly more likely to be rural tions on how often particular questions are than were nonrespondents, and the two asked during patient visits and on the cir- Results groups did not differ regarding years of cumstances in which they are asked (i.e., Of the 500 questionnaires mailed, 266 were medical licensure in Georgia. routinely, based on suspicion of a possible completed and 23 were returned as undeliv- Demographics. Table 1 shows the demo- environmental exposure, based on a parents erable. The overall response rate was there- graphic characteristics and practice profiles concern about a possible environmental fore 266 of a possible 477 respondents, or of the respondents. The mean age ( SD) exposure). The final domain, on informa- 55.8%. We excluded 38 of the 266 returned was 45.7 12.1 years, and the mean number tion, asked about the pediatricians preferred questionnaires from analysis because the of years in practice was 14.8 11.4. The sources of information and about what respondents reported that they were not cur- respondents were about equally divided sources or methods they would find most rently in pediatric practice. Therefore, the between men and women, the majority was helpful in learning more about childrens final sample analyzed consisted of 228 prac- white, and the majority practiced in urban environmental health. Before the survey, we ticing pediatricians. locations, mostly in private, primary care pilot tested the questionnaire on five pedia- We compared respondents and nonre- practices. However, various specialties were tricians and made modifications to improve spondents in two ways: urbanrural residence also represented, including pediatric cardiol- clarity and convenience. (from the addresses) and date of licensure ogy, rheumatology, and immunology; Table 1. Description of respondents and their Table 2. Pediatricians background in environmental medicine. practices. Question Response No. Percent Characteristic No. Percent Any specific training in environmental history-taking? Yes 34 14.9 Age (mean SD) 45.7 12.1 No 188 82.5 Years in practice (mean SD) 14.8 11.4 Past experience with a patient affected by an environmental exposure? Yes 122 53.5 Sex No 103 45.2 Male 125 54.8 Do you own a copy of the Handbook of Pediatric Environmental Health? Yes 50 21.9 Female 103 45.2 No 172 75.4 Race African American 17 7.5 Asian 31 13.6 Table 3. Pediatricians self-reported attitudes, beliefs, and self-efficacy regarding environmental health. White 165 72.4 Hispanic 10 4.4 Mean SD Native American 1 0.4 Other or not specified 3 1.3 Attitude statementsa Location Conducting an environmental health history on all my patients would Urban 149 65.4 Help parents prevent exposures to environmental threats (n = 223) 3.97 0.70 Rural 79 34.6 Identify the exposures causing specific symptoms (n = 222) 3.91 0.69 Type of practice Add more work on my staff (n = 223) 3.53 0.97 Primary care 184 80.7 Take up too much time (n = 223) 3.11 0.93 Specialty 34 14.9 Create a potential reimbursement problem (n = 220) 3.06 1.12 Urgent care/emergency 10 4.4 Belief statements (n = 227) Practice setting The role of environmental health impacts on children is 4.30 0.78 Private without HMO 154 67.5 of little importance (1) of great importance (5) Public 40 17.5 Assessing environmental exposures through history-taking in pediatric practice is 4.00 0.86 Teaching 14 6.1 of little importance (1) of great importance (5) Other 7 3.9 The magnitude of childrens environmental related-illnesses is 3.85 0.82 Private with HMO 9 3.9 decreasing (1) increasing (5) Research 1 0.4 The amount of control pediatricians have over environmental health hazards is Patients on Medicaid or public assistance minimal (1) maximal (5) 2.78 0.87 024% 52 22.8 Self-efficacy statementsb (n = 221) 2549% 65 28.5 Taking a patient history that includes questions on environmental exposures 2.80 0.72 5074% 60 26.3 Discussing with parents or guardians the impact of environmental issues on health 2.81 0.74 75100% 45 19.7 Finding treatment and diagnosis resources related to environmental exposures 2.51 0.77 aResponse choices ranged from 1, strongly disagree, to 5, strongly agree. bResponse choices ranged from 1, not confident, HMO, health maintenance organization. to 4, very confident. 824 VOLUME 110 | NUMBER 8 | August 2002 Environmental Health Perspectives

3 Childrens Health Environmental history in pediatric practice neonatology; allergy and asthma; and hema- taking an environmental history would create environment-related illness is increasing tology/oncology. About one-half of the more work for office staff (mean, 3.53). (mean, 3.85). However, the responses sug- respondents reported that 50% of their However, other statements of logistic barri- gested little belief that pediatricians have con- patients were enrolled in Medicaid. ersthat taking an environmental history trol over environmental health hazards, with Training and past experience. As shown would take too much time or would create the mean score (2.78) falling below the mid- in Table 2, fewer than one in five respon- reimbursement problemselicited little or no point of the continuum. We also found no dents reported having had any training in agreement (means, 3.11 and 3.06, respec- gender or urbanrural differences in the self- environmental history-taking. Just over one- tively, with 3.00 representing the midpoint reported beliefs. However, white pediatricians half of the respondents reported a past expe- between disagreement and agreement). One gave slightly lower scores and Asian-American rience with a patient who had been seriously pediatrician wrote an additional response to pediatricians gave slightly higher scores to the affected by an environmental exposure, such the final question: We do not get paid for importance of the role of environmental as a case of lead poisoning. Approximately counseling. We found no gender, rural health impacts on children and the impor- one in five respondents had a copy of the urban, or practice type differences in the tance of assessing environmental exposures American Academy of Pediatrics Handbook answers to these attitude questions (data not through history-taking. Moreover, urgent care of Pediatric Environmental Health (25), which shown). However, Asian-American pediatri- providers gave slightly lower scores to these was published approximately 6 months cians tended to have a stronger belief and items than did primary care providers or spe- before the survey. Several reported in hand- white pediatricians a weaker belief, com- cialists (data not shown). written notes that they were planning to pared with African-American and Hispanic As shown in Table 3, we asked respon- order the handbook, and one requested pediatricians, that environmental history- dents to respond to four self-efficacy state- ordering information. taking would help parents prevent exposures ments, also using a four-point Likert scale. The pediatricians answers to these ques- to environmental threats. For all three self-efficacy statementson his- tions did not differ by sex, race, ruralurban As shown in Table 3, we asked respon- tory-taking, on discussing environmental location, or practice type (data not shown). dents to respond to four belief questions. exposures with parents, and on finding diag- Attitudes, beliefs, and self-efficacy. Table 3 Respondents also scored these questions on a nosis and treatment resources related to envi- shows data on the pediatricians attitudes, Likert scale from 1 to 5, with the lower scores ronmental exposuresthe mean responses beliefs, and self-efficacy regarding environ- representing less belief in the importance of fell between somewhat confident and con- mental history-taking. Respondents scored environmental health issues. The responses fident. We found no gender, racial, or rural the attitude statements using a Likert scale of generally indicated that the pediatricians urban differences in the answers to these 15, from strongly disagree to strongly attach considerable importance to environ- items, but urgent care providers reported agree. As shown in Table 3, pediatricians mental exposures. The role of environmen- lower self-efficacy in taking a patient history agreed relatively strongly that environmental tal health impacts on children yielded a that includes questions on environmental history-taking would help parents protect mean score of 4.30, and assessing environ- exposures than did primary care providers or their children from hazardous environmental mental exposures through history-taking in specialists (data not shown). exposures (mean, 3.97) and would help iden- pediatric practice yielded a mean score of We asked respondents if they would like tify exposures causing specific symptoms 4.00. Pediatricians showed a tendency to to learn more about childrens environmental (mean, 3.91). There was less agreement that believe that the magnitude of childrens hazards. A large majority89%answered 100 affirmatively. One pediatrician indicated a desire to get involved in childrens environ- Routine interview mental health efforts in Georgia: I am very Clinical interested in helping any way I can. suspicion Practices. Figure 1 shows data on the 80 Parental pediatricians self-reported interview prac- concern tices. We presented pediatricians with a list of environmental exposures and asked them which of the exposures they routinely 60 include in their histories, which of the expo- Percent sures they had asked about during the previ- ous month based on clinical suspicion, and which of the exposures they had asked about in the previous month in response to 40 parental concerns. High numbers of respon- dents reported routinely asking about ciga- rette smoking around the child (88.2%), pets in the home (73.7%), source of drink- 20 ing water (65.4%), lead (59.6%), and hous- ing (54.4%). We saw a similar pattern regarding clinical suspicion, although for three exposures (molds, home heating 0 source, and indoor air) clinical suspicion had triggered more questions than had routine occupation monoxide Smokers Pets Water Lead Housing Sun Television Molds Heat Indoor air Outoor air Hobbies Carbon Parental history-taking. We also saw a similar pattern (albeit with lower proportions) for exposures Figure 1. Percentage of pediatricians reporting asking about individual exposures and the triggers for discussed as a result of parental concern, asking about them. although parents were relatively less likely to Environmental Health Perspectives VOLUME 110 | NUMBER 8 | August 2002 825

4 Childrens Health Kilpatrick et al. initiate discussion about drinking water, in childrens environmental health, a high report using professional organization sites as lead, housing, sunlight, and television expo- level of belief in the impact of environmental commercial medical information portals. sures, and relatively more likely to ask about exposures on their patients health, and a Our response rate of 55.8% was reason- molds and indoor and outdoor air pollution. high level of interest in learning more about able for a mail survey. However, it was well Fewer than 5% of respondents reported ask- the field. Moreover, they perceived few logis- below 100%, which may have introduced ing about asbestos, mercury, nitrates, tic barriers, such as time, effort, or cost, to some selection bias. By available measures formaldehyde, and radon in response to any incorporating the environmental history into ruralurban status and years of licensure in of the three triggers (data not shown). their clinical visits. Georgiathe repondents and nonrespon- Male and female pediatricians were On the other hand, pediatricians dents were roughly similar. However, respon- equally likely to report routinely taking a reported very little prior training in taking dents may still have been more interested in basic environmental history (housing, environmental histories and low self-efficacy pediatric environmental health and more parental occupation, and environmental regarding taking these histories, discussing eager to engage the subject (including learn- tobacco smoke). However, this routine his- environmental exposures with parents, and ing more about it) than nonrespondents. tory-taking varied by race/ethnicity (72.1% locating diagnosis and treatment resources Our results may therefore overstate the level of whites, 82.4% of blacks, 51.6% of related to environmental exposures. Low of interest among pediatricians. Similarly, Asians, and 80% of Hispanics; p = 0.05). outcome expectancythe belief that it is because our results are based on self-report Pediatricians in urgent care and emergency difficult to follow up on interview responses and because respondents may be motivated practices (90%) and in specialty practices by providing appropriate information, diag- to give the right answer, the level of interest (79.4%) were more likely to routinely take a nosis, and treatmentaggravates the impact may be overstated. Nevertheless, we believe basic environmental history than were those of low self-efficacy. These findings would our results indicate a considerable reservoir of in primary care practices (66.3%), although adversely affect the likelihood that pediatri- interest in pediatric environmental health, this difference did not reach statistical sig- cians elicit environmental histories from considerable opportunity for educating pedi- nificance (p = 0.11). Urban pediatricians their patients. atricians about this field, and considerable were more likely than their rural counter- This was a study of attitudes and behav- opportunity for increasing environmental parts to take such a history (73.8% and iors, and not of knowledge. A separate set of history-taking. 60.8%, respectively; p = 0.04). questions relates to what pediatricians know Sources of information. We asked the about pediatric environmental health issues: REFERENCES AND NOTES pediatricians about their sources of informa- how to recognize, treat, and prevent lead tion on environmental exposures. Their toxicity; how to diagnose and treat pesticide 1. National Research Council. Pesticides in the Diets of Infants and Children. Washington, DC:National Academy responses are shown in Table 4. The most toxicity; how to evaluate indoor environ- Press, 1993. common source of information identified ments for health hazards; and so on. 2. Pew Charitable Trusts. Public Opinion Research on Public was the American Academy of Pediatrics Pediatricians knowledge can be assessed Health, Environmental Health and the Countrys Public Health Capacity to Adequately Address Environmental (89.0%). Other important sources included through study of relevant questions on board Health Problems. Philadelphia:Pew Charitable Trusts, professional literature (67.5%), government examinations and through surveys similar to 1999. agencies (58.8%), mass media (27.2%), and the one reported here. 3. Szneke P, Nielsen C, Tolentino N. Connecticut physi- cians knowledge and needs assessment of environmen- colleagues opinions (27.6%). When asked Our data point to clear opportunities to tally related health hazards: a survey. Conn Med about sources they would find most helpful address these problems. In addition to their 58:131135 (1994). in obtaining further information, the high level of belief that environmental expo- 4. U.S. EPA. Environmental Health Threats to Children. EPA 175-F-96-001. Washington,DC:U.S. Environmental responses were similar, as shown in Table 5: sures are important, respondents were able Protection Agency, 1996. Available: http://www.epa.gov/ guidelines from the American Academy of to identify strongly preferred sources of epadocs/child.htm [cited 26 May 2002]. Pediatrics (69.3%), newsletters (58.8%), information. Chief among them is the 5. Childrens Environmental Health Network/Public Health Institute. 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