Why use indicators to measure and monitor the inclusion of climate change and environmental sustainability in health professions’ education?

Abstract

Currently, health professionals are inadequately prepared to meet the challenges that climate change and environmental degradation pose to health systems. Health professions’ education (HPE) has an ethical responsibility to address this and must include the health effects of climate change and environmental sustainability across all curricula. As there is a narrow, closing window in which to take action to avoid the worst health outcomes from climate change, urgent, systematic, system-level change is required by the education sector. Measuring, monitoring, and reporting activity using indicators have been demonstrated to support change by providing a focus for action. A review of the literature on the use of indicators in medical education for climate change and health, however, yielded no publications. The framework of targets and indicators developed for implementation of the Sustainable Development Goals (SDGs) by 2030 and the UNESCO initiative of the Education for Sustainable Development provide a guide for the development of indicators for HPE. Engaging stakeholders and achieving consensus on an approach to indicator development is essential and, where they exist, accreditation standards may have a supporting role. Creating capacity for environmentally sustainable health care at scale and pace should be our collective goal as health professions’ educators.

Keywords:

• Evaluation
• multiprofessional
• indicators
• climate change
• health professions’ education
• sustainable development goals
• curriculum
• environmentally sustainable healthcare

Introduction

Anthropogenic climate change continues to accelerate, with profound negative consequences for human health (United Nations Environment 2019). The World Health Organization (WHO) regularly confirms that climate change is the greatest threat to human health and the defining public health issue of the 21st century (WHO 2019a). Climate change also threatens the integrity of health systems, challenging their capacity to provide health care particularly to vulnerable populations. Building climate-resilient health systems are recognised internationally as an essential response to this threat (WHO 2015). Health systems are, however, also part of the problem. Health care is carbon-intensive and is a significant contributor to national carbon emissions. The sector also produces large amounts of waste. Health care needs to reorientate to reduce its carbon footprint through developing models of care that are carbon neutral and less wasteful. To mobilise the health sector to achieve these outcomes requires an informed and skilled health workforce. But, as the WHO (2019b) describes, the current health workforce has a limited understanding of climate change and health. This restricts their capacity to respond and impedes the implementation of national climate change and health strategies. Future health professionals must be prepared for these roles and this requires health professions’ education (HPE) to integrate the health effects of climate change and environmentally sustainable health care into curricula (Madden et al. 2018; Maric and Nicholls 2019; Neal-Boylan et al. 2019). Student groups have also advocated for this change (IFMSA 2020). There has, however, been a limited response by the education sector globally to systematically build the capacity of the health workforce to meet this need (Madden and de Witt 2017). This continuing lack of action to prepare graduates for future practice is now holding back the capacity of the health sector to adapt and mitigate (WHO 2019b). This article explores how indicators that monitor the response by HPE can support change.

Practice points

• HPE must prepare graduates for the health effects of climate change and to practice environmentally sustainable health care.

• The SDGs comprise a global framework of collective goals that identify educational indicators.

• Indicators can provide a focus to mobilise HPE to collaborate to achieve this.

• Consistency in the expression and method used to report an indicator aids effectiveness.

International agreements

International governments recognise the essential role of education to meet national commitments to the Paris Agreement and restrict global warming to below 2 °C. This understanding is enshrined in a series of United Nations (UN) agreements. Article 12 of the Paris Agreement commits countries to cooperate in measures to enhance climate change education (UN 2015a). The Sustainable Development Goals (SDGs) commit nations to take urgent action on climate change including through improving education (UN 2015b). The UNESCO (2017) Declaration of Ethical Principles in relation to Climate Change includes Article 11 on the responsibility of the education sector to develop the necessary knowledge and skills.

Country level response

Some countries, such as the United Kingdom (UK), have enacted legislation creating legally binding targets to support the system-level change necessary to reach national emission reduction targets. The Climate Change Act 2008 requires the UK government to achieve net zero emissions by 2050; this covers all departments including education. System level change is complex and sector-specific guidance has been produced to facilitate this (The Quality Assurance Agency for Higher Education [QAA] 2014; Sustainable Development Unit 2018). Measuring and monitoring progress and regular reporting using indicators have allowed the UK National Health Service to achieve remarkable success, reducing carbon emissions and moving to more sustainable forms of health care over the past 10 years. This information has been used to engage the health sector to drive further change, demonstrating the contribution of a well-chosen, system-level indicator, in this case carbon emissions, to create an aligned discussion (Pencheon and Wight 2020).

Use of indicators to inform change in HPE

Quantitative indicators are measures that can be updated to track change over time. By measuring and monitoring what we do in HPE, we know whether strategies and interventions to expand climate change and environment sustainability in curricula are effective.

The essential qualities of an indicator supporting sustained reporting are established; it must be specific, accurate, observable, measurable, credible, readily understood, and actionable (Frumkin et al. 2015). Developing an indicator requires clarity on its purpose, use, and users. Identifying stakeholders and involving them in development helps to meet their needs, allowing potential barriers to implementation to be described (Navi et al. 2017).

The education sector, including HPE, uses indicators to measure the quality of education at all levels of delivery, such as course, program, faculty, university, and country levels (Garcia-Aracil and Palomares-Montero 2010; Nolte et al. 2011). Common, well-known indicators of performance are the number of enrolments and completions. These indicators can be used to inform change. For instance, in Australia, there is strong commitment to expand the number of Aboriginal and Torres Strait Islander people enrolling in and completing tertiary education. Monitoring has informed strategies to meet this commitment.

Current use of indicators in medical education for climate change and health

For this perspective, a literature search was completed to inform a systematic review to assess published indicators for measuring the progress of a medical curriculum towards integrating climate change. Inclusion criteria were primary peer-reviewed studies reporting indicators for climate change in a medical curriculum. For the search strategy, Medline and PubMed were searched. No papers meeting these inclusion criteria were identified.

The experience of The Lancet Countdown reflects the challenge of developing robust indicators. Indictor 5.3 ‘Inclusion of health and climate change within medical and public health curricula’ is intended for annual international reporting (Watts et al. 2017). Developing a method to measure this has, however, proved challenging – (personal email from Dr. Nick Watts, Executive Director: Lancet Countdown). The MJA-Lancet Countdown reports The Lancet Countdown indicators using Australian data. From 2021, it intends to report a simplified version of Indicator 5.3, for medical curricula alone. A method for measuring this is being explored by a collaboration of medical programs.

In the absence of indicators with established measurement processes, it is important to determine what we should measure and, how we successfully engage others in the process. The indicator framework developed for the implementation of the SDGs provides a guide.

Sustainable development goals (SDG) indicator framework

To support urgent action, the SDGs incorporate global targets and an indicator framework to achieve the 2030 agenda (UN 2020). Table 1 below describes the three SDGs, 4 (Quality Education), 12 (Responsible Production and Consumption), and 13 (Climate Action), that include education targets and the indicator for reporting these. To enable consistency in reporting, these three SDGs use the same indicator. These targets and indicator build on work over the past 20 years on education for sustainable development and how this is measured to report progress at national levels (Tilbury and Janousek 2006). This indicator provides an approach for HPE for reporting at all potential levels, international, national, institutional, and program.

Table 1. Targets and indicators for the implementation of Sustainable Development Goal 4 Quality Education, Goal 12 Responsible Production and Consumption, and Goal 13 Climate Action, ratified by the UN General Assembly in July 2017.

Goal 4. Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all
Target 4.7 By 2030, ensure that all learners acquire the knowledge and skills needed to promote sustainable development, including, among others, through education for sustainable development and sustainable lifestyles, human rights, gender equality, promotion of a culture of peace and non-violence, global citizenship and appreciation of cultural diversity and of culture’s contribution to sustainable development	Indicator 4.7.1 Extent to which (i) global citizenship education and (ii) education for sustainable development are mainstreamed in: (a) national education policies (b) curricula (c) teacher education (d) student assessment
Goal 12. Ensure sustainable consumption and production patterns
Target 12.8 By 2030, ensure that people everywhere have the relevant information and awareness for sustainable development and lifestyles in harmony with nature	Indicator 12.8.1 As for Indicators 4.7.1 and 13.3.1
Goal 13. Take urgent action to combat climate change and its impacts
Target 13.3 Improve education, awareness-raising and human and institutional capacity on climate change mitigation, adaptation, impact reduction, and early warning	Indicator 13.3.1 As for Indicators 4.7.1 and 12.8.1

Aligning indicators across SDGs avoids measuring and reporting becoming complex. If processes are too complex, people and organisations cannot effectively engage. This challenge was recently highlighted in the business literature describing reporting sustainability measures in companies. ‘A lack of standardisation in the criteria, terminology and methodology’ used to collect data is cited as the reason for the difficulty in comparing the sustainability performance of companies (Siew 2017). A proliferation of measurement tools has left companies unsure which to use and, as reporting is voluntary, practices vary. Inconsistencies undermine the capacity of a sector to provide transparent reporting on its progress which in turn affects credibility. Pencheon and Wight (2020) highlight the value of using the same national and international indicators for reporting in an area of practice.

While measuring is necessary, it is insufficient alone. Engaging people is also essential and results can provide a tool for communication to promote discussion. By reflecting the adequacy of its response back to the sector, an indicator can create an informed appetite for change (Navi et al. 2017). Comprehensive stakeholder engagement in the original development of indicators and agreed ways of collecting and communicating the data are ways to achieve engagement. Otherwise, change remains a voluntary, fragmented, and fragile activity that is easily disrupted, in particular by a lack of resources or change of personnel.

Potential contribution of accreditation processes

Within HPE, it is arguably easier to achieve the consensus required within the health professions that are regulated. Accreditation can assist where an accreditation requirement exists. An example of this is strengthening interprofessional learning (IPL) in Australia (Australian Health Ministers’ Advisory Council, 2017). The introduction of IPL as an accreditation requirement for medical programs and in other health professions has created a sustained focus on developing curricula with the expressed goal to influence interprofessional practice within the health sector.

The UK General Medical Council has responded to the scale of the threat to human health that climate change presents by introducing a graduate outcome statement that requires newly qualified doctors to be able to ‘apply the principles, methods and knowledge of ….sustainable healthcare to medical practice (GMC, 2018). This statement includes several parts emphasising the environment as a determinant of health including, for example (h) ‘that they must be able to evaluate the role of ecological, environmental…….hazards in ill-health and discuss ways to mitigate their effects.’ All UK undergraduate medical programs are required to demonstrate that their curricula and assessments allow graduates to meet this outcome by the summer of 2020. While a very effective vehicle for mobilising change systematically at a system level, there are, however, weaknesses in incorporating accreditation requirements into indicators. Information collected during accreditation processes is not readily sharable to allow comparison between programs and institutions within a country (Nolte et al. 2011). Accreditation requirements for health professions also vary significantly between countries, limiting their contribution to international comparisons.

Conclusion

HPE is unified globally by the commitments made by governments to take action through the education and health sectors to respond to climate change and create sustainable ways of practice. Currently, health professionals are inadequately prepared to meet the challenges that climate change poses for health systems. HPE has an ethical responsibility to address this. The goal of HPE and its leaders should be to urgently mobilise to enable the health sector to achieve excellence in environmentally sustainable health care. The development of HPE indicators can provide a focus for action. The education targets and shared indicator for the SDGs provide an approach to reporting that could be adapted for this purpose.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Notes on contributors

Diana Lynne Madden

Diana Lynne Madden, BSc(Med)Hons 1, MBBS, MPH, MSc, FFPH(UK), FAFPHM, FPHAA, is the inaugural Professor of Population and Planetary Health, co-Associate Dean Learning and Teaching at the School of Medicine Sydney, University of Notre Dame Australia, Sydney, Australia, and a past President of the Australasian Faculty of Public Health Medicine.

Michelle McLean

Michelle McLean, PhD, MEd, is a Professor of Medical Education at Bond University, Gold Coast, Australia. She is currently integrating planetary health into the Bond Medical Program.

Meagan Brennan

Meagan Brennan, BMed, FRACGP, FRACGP, FASBP, PhD, is a clinician researcher and medical educator with expertise in breast cancer and public health. She is an Associate Professor, School of Medicine Sydney, University of Notre Dame Australia, Sydney, Australia, and a breast physician at Westmead Hospital, Sydney, Australia.

Aishah Moore

Aishah Moore, BMed, FRACGP, is a General Practitioner in Sydney, Australia. She is currently a Foundation Years Tutor and Medical Education Development Officer in the School of Medicine Sydney, University of Notre Dame Australia, Sydney, Australia.