What is the Pediatric Environmental Health Toolkit ? Pediatric Environmental Health Toolkit •Guidelines for Primary Care Providers •Patient Handouts Christine Ziebold MD PhD MPH cziebold@ih.org Preventing Harm to Growing Brains 1-21-2006 prepared by Greater Boston Physicians for Social Responsibility San Francisco Bay Area Physicians for Social Responsibility 1 Environmental Health in Pediatric Practice 2 Pediatric EH Education in MN • Fewer than 20% report training in env. history taking. • Most believe in importance of environmental exposures to children’s health. (54% had seriously affected patient ) • Most lack confidence in env history taking, discussing environmental exposures. • only postgraduate or dual degree public health programs at medical or nursing school mandate any EH content • medical students receive 2-3 h EH instruction without a formal examination. • family medicine residents may receive 3h over the period of their training • no data for pediatric and med-peds program • Preferred resources: AAP newsletters and patient education materials. [C.Ziebold, Poster presentation U of M conference “Promoting Healthy Communities for Children” 2005] (The Environmental History in Pediatric Practice: A study of pediatricians’ 3 attitudes, beliefs, and practices, Kilpatrick et al., EHP 2002) 4 “Toolkit” materials GOAL: Enable health care providers (pediatric and family physicians and nurses) to routinely inform about how to prevent toxic exposures, ie at each well-child visit. 5 6 1 For Patients: For Providers: Educational Handouts “Rx for Prevention” prescription slips keyed to 7 developmental stages • Reference Card: Brief summaries of 11 major toxicants -- potential health effects, routes of exposure, and prevention strategies “Tips for Prevention” 6 different magnets • Anticipatory Guidance Pocket Card: Priority guidance keyed to specific developmental stages 7 8 Pediatric Toolkit History Pilot Sites 2002-2004: • pilot study version of the Pediatric Environmental Health Toolkit. • 34 Pediatric and Family Practice physicians and 80 physicians-in-training • Diverse demographic mix: cross-section of urban/suburban/rural, English/Spanish speaking, and different incomes February 2005: • 6-month pilot study in 17 pediatric and family practices in MA and CA • follow-up at one year • [longitudinal pre-test post-test design with no comparison group] 9 10 Pilot Study Participant Characteristics (n = 28) Evaluation • Clinic site 43% California 57% Massachusetts • Written baseline survey to all participants • In-person site visits and conference call training for all sites • Check-in phone calls for 1st 3 months • 6 month written follow-up survey • Follow-up phone calls with small group • Patient focus groups • Age 21% 35yrs or less 46% 36 - 45yrs 21% 46 – 55yrs 11% 56 or more 11 • 79% female • Specialty 43% Family Practice 57% Pediatrics 4% Other 12 2 Change in provider’s selfrated knowledge (p < .01) Study Participant Characteristics Percent answering "adequate" or "more than adequate" 78% reported “much more” or “somewhat more” enthusiasm compared to their peers at baseline survey 100% 82% 80% Q: In general, how would you rate your knowledge of environmental health topics? likely bias towards physicians with more enthusiasm for giving environmental health advice 60% 43% 40% 20% 0% before after 13 14 Change in provider self efficacy (p < .01) Q: How would you rate your confidence level for discussing environmental health issues with your patients? Self-report of frequency giving health advice Q: How often do you advise families about the following health issues, as appropriate for the age of the child? Percent answering "somewhat" or "very confident" 93% 100% 80% • Never (= 1) 68% 60% • Some of the time (= 2) 40% • Most of the time (= 3) 20% • All of the time (= 4) 0% before after (Asked across 22 specific EH issues) 15 16 Change in giving advice (p < .05) 22 items were combined into a scale to represent “overall advice”. Mean for frequency giving advice (1=never, 4=always) 2.0 mercury in fish 2.3 pesticide on fruits and vegetables be 1.7 2.0 aft 1.7 pesticide use on children 2.0 1.0 1.5 2.0 2.5 3.017 Change in giving advice across all items (p = .01) Scale endpoints were 22 – 88. Mean standard deviation = 8.9 Mean scores for overall advice 70 60 56 53 50 40 before after 18 3 Top 3 Reasons for Not Using the Toolkit Change in Giving Advice Percent reporting "major" or "moderate" barrier Most participants at Time 2 (89%) attributed the Toolkit materials as the “main reason” or “part of the reason they currently discuss environmental health topics with their patients Staff time down not allow for logistics 66% Forgetting to use the materials 70% 89% Insufficient time 20% 40% 60% 80% 100% 19 Residency Program Participation 20 UCSF Residency Pretest (68 responses) • 70% report training in environmental health inadequate • 53% said they are ‘not very confident’ in discussing environmental health topics with patients • 94% of resident responders ‘agreed’ or ‘strongly agreed’ that residents should receive environmental health training. • 80 physicians-in-training participated • Toolkit resources used in weekly continuity clinic (one clinic control) • Lectures and case-based teaching on environmental health tied to toolkit • Training for faculty 21 22 Next Steps Bottom line UCSF residents • Edit toolkit, based on pilot study feedback •Adapt materials for PDA, and develop protocols for incorporation into patient charts •Second tier of testing, coupled with training programs •Partnerships with government agencies and institutions for broader dissemination (discussions underway with EPA, ATSDR/CDC, AAP’s CoEH etc) •2/3 respond that toolkit made them more aware of environmental issues their patients faced • 83% (15/18) agree that toolkit participation “made them want to learn more”. • 40% said that toolkit use “is part of the reason that (I) currently discuss environmental topics with patients”. 23 24 4 Planning and Development Physician Group Minnesota Training California Lisa Asta MD – Chair, Department of Pediatrics, John Muir Medical Center Guenter Hofstadler MD MPH – Pediatrician, Contra Costa Regional Medical Center COMING September 2006 Brian Linde MD - Pediatric Hospitalist, John Muir Medical Center and Contra Costa Regional Medical Center Mark Miller MD MPH – Pediatrician and Director, UCSF Pediatric Environmental Health Specialty Unit Massachusetts Siobhan McNally, MD – Pediatrician, Berkshire Medical Center and SPROUT – Berkshire Initiative for Children’s Environmental Health. Minnesota David Wallinga MD MPA – Senior Scientist, Institute for Agriculture and Trade Policy 25 26 For more information contact GBPSR Michelle Gottlieb (617) 216-5658 Mbgottlieb@comcast.net IATP Kathleen Schuler (612) 870-3468 Kschuler@iatp.org 27 5