Anthropogenic climate change contributes to a wide array of increased human physical and mental health risks that manifest differently across communities due to varying hazards and vulnerabilities (1, 2). While urbanization represents one of four global mega-trends tracked by the United Nations (3), much of the world’s population remains rural: 45% as of 2018 (4). In the United States, rural areas constitute 97% of land area and 19% of the population (5). These areas have distinct characteristics with implications for climate adaptation and health. Their economies are often closely tied to natural resources and agriculture with limited community capacity to adapt due to poverty and other social vulnerabilities (6, 7). In the United States, rural communities are also less likely to be concerned about climate than those in urban areas (8). Most of Montana’s population is rural (65%) (9). In 2019, estimates placed 50 of the state’s 56 counties as less likely on average to say global warming is happening than the national average (67%) (8, 10).
Environmental and public health professionals recognize that environmental conditions affect human health (11, 12) and have called for action on climate change (13). The Lancet Commission described tackling climate change as the greatest public health opportunity of the 21st century (14). Because health is something that most people care about (15), communicating about the health effects of climate change can potentially help governments connect with wide publics on the issue (16, 17). Moreover, health care professionals themselves, particularly nurses, are “trusted messengers”; indeed, nurses have been the most trusted profession for the past 17 years in the Gallup Polls (18).
In this study we surveyed Montana environmental and public health professionals regarding their perceptions of climate change, its effect on human health, and the need for their offices and others to take action. Further, we analyzed how these perceptions relate to various factors, including sociodemographic and professional characteristics. To our knowledge, the climate risk perceptions of environmental and public health professionals have never been compared, nor have the climate change risk perceptions of health professionals in a frontier region of the United States like Montana been studied. Due to the importance of these professions for successful rural climate adaptation in their roles as content experts and trusted messengers (19), this study thus contributes a novel dimension to a growing literature on the role of health professionals in addressing climate change.
Montana’s changing climate
Montanans are already experiencing impacts of climate change, such as fewer snow days and longer fire seasons (20). We conducted this study of health professionals in association with Montana’s 2021 climate and health report: Climate Change and Human Health in Montana: a Special Report of the Montana Climate Assessment, 2021 (19). Released in December 2020, the report details current and projected health-related impacts of climate change in Montana based on increased temperatures, changes in precipitation patterns, altered ranges for infectious disease vectors, increased wildfires, and increased stress on crops (which can affect food supply, nutritional content, and cost of foods).
Montana also serves as home to a number of vulnerable populations who may be particularly affected by climate change (21): rural residents, laborers in outdoor occupations, and indigenous communities. Montana is relatively sparsely populated with 6.8 people per square mile (22) compared to 92.9 persons per square mile nationally (23). Outdoor occupations such as farming, fishing, forestry, construction, and extraction represent 65 out of every 1,000 state jobs (24). Indigenous residents—who like other racial and ethnic groups may be more socially vulnerable with fewer resources to adapt—comprise 6.6 % of Montana’s population (22) versus 1.3 % nationally (25).
Climate change beliefs and risk perception
Climate change is frequently viewed by the lay public as abstract and distant in time and effect (26, 27). People construe climate change as most likely happening elsewhere, to other people, or in the future. These characteristics of public risk perception can help explain why people choose not to engage in activities that might reduce the threat. Studies of risk perception suggest that perceived threat susceptibility and severity are important determinants of people’s behavioral responses (28, 29). Hence it is notable that only 34% of Montanans in 2019 were likely to say that climate will harm them personally in the future, based on downscaled national survey estimates (10), compared to 42% nationally. (In 2020, Montana and U.S. percentages have increased, but the discrepancy remains; since this survey was conducted in 2019, 2019 data from Yale is used.)
Public opinion data demonstrates consistently lower climate concern in Montana than nationally, typically by between 5–10 percentage points. The 2019 Yale Climate Opinion Maps estimate that 60% of Montana residents say that global warming is happening (67% nationally), while 45% say it is mostly human-caused (53% nationally), and 54% of Montanans are worried about it (60% nationally)(10). Climate change perceptions have been well-documented as correlating with political affiliation, ideology, and worldviews (30). Indeed, Montana is ranked as a “highly conservative” state according to 2018 Gallup data (31).
Views of environmental and public health professionals on climate change
Public and environmental health professionals both play an important role in climate adaptation (32) but typically have different organizational roles, expertise, and responsibilities for climate-related issues. For example, the Montana Public Health Association represents nurses, nutritionists, researchers, health educators, physicians and other licensed health practitioners (personal communication), while the Montana Environmental Health Association’s members include largely sanitarians, food inspectors, and disaster management personnel (personal communication). But few studies have assessed the climate change risk perceptions of these officials. One of the earliest such studies was a national survey of health department directors conducted in 2007–2008 in collaboration with the National Association of County and City Health Officials (NACCHO) (33). The researchers found that while most of the officials said that their jurisdiction had already experienced climate change in the last 20 years (69%) and would experience climate change in the next 20 years (78%), including one or more serious public health effects (59%), few of them strongly agreed that climate change was an important priority for the department (12%). Another 39% agreed climate change was a departmental priority, but not strongly. Results of a follow-up study in 2011–2012 by Roser-Renouf, Maibach, and Li found public health departments’ prioritization of preparing for climate change impacts declined significantly between 2008 and 2012 (34). Moreover, departments reported lower levels of perceived departmental climate risk assessment expertise and ability to develop adaptation plans.
Subsequent studies in the last decade and a half of health professionals have further explored health professionals’ climate change beliefs and risk perceptions. Because researchers typically employ somewhat differently phrased survey questions and sampling strategies, comparisons are difficult, but surveys since 2008 demonstrate high rates of agreement among health professionals that climate change is happening with less certainty that it is mostly human caused (35–37).
Previous climate and health studies have surveyed environmental health as well as public health professionals, though no study to our knowledge has directly compared the two groups. In Syal and colleagues’ survey of environmental health directors in 2011 (40), only 46 % said that the health effects of climate change in their jurisdiction would be serious. In a series of three consecutive yearly surveys conducted with National Environmental Health Association members in 2016, 2017, 2018, respondents were most concerned (34%) about the effects of increased asthma, allergies, and cardiorespiratory disease from higher rates of air pollution under climate change (38). Only 49% said they would personally be harmed in the future, but 72% said that actions to mitigate climate change would positively benefit their health (38). In a 2012 Association of State and Territorial Health Officers (ASTHO) survey, 75% of environmental health directors said that their state or territory would experience one or more serious health harms in the future (39) .
Research on climate change public opinion demonstrates national surveys can obscure large regional differences (8). A 2012 study of New York State local health department officials (38) (public and environmental health) found lower levels of concern and expertise than the national NACCHO survey reported above (33). Less than a third (32%) reported local effects from climate change already occurring in their jurisdiction and just 39% said that climate change posed a threat to public health in the next 20 years. Only one quarter of the respondents perceived climate change as an important priority for their local health department. (40). In a 2009 study of local public health officers in California, Bedsworth (41) found much higher rates of concern and activity than in New York. A vast majority (94%) said that climate was a very or somewhat serious threat to public health; and majorities of the health departments reported programs in climate-related areas such as extreme heat, air pollution, and infectious disease. In a 2009 Oregon study, 88% of local health officers said that climate change will increasingly impact public health in the next 20 years and 38% of departments were making some changes related to climate action (42).
Among the climate and health survey studies, only two to our knowledge have analyzed survey findings to establish the relationship between sociodemographic and professional characteristics, or other variables, on health professionals’ climate change perspectives. About half the professionals in Polivka’s public health nurses’ study in 2010 (35) said that their nursing division has a responsibility to address health-related effects of climate change, but most also said that they were not prepared to do so. A majority identified 4 out of 12 health effects as increased due to climate change with only subgroup differences by political ideology. However, there were differences on other measures by education, age, and political ideology. Less educated respondents were more likely to say that climate change is uncontrollable by humans than those with more years of college; younger respondents were more likely to say that nursing could lessen the health effects of climate change than those who were older; and liberals were more likely to say that climate change was anthropogenic and would have negative impacts than conservatives.
A 2011 study (43) assessed the relationship between environmental health directors’ environmental attitudes, political views, gender, and risk perception on implementation of climate adaptation programs in the department. The authors found that environmental attitudes and political views contributed to the risk perception of the directors; gender did not. Forty-nine percent said they felt a responsibility for their department to address the health effects of climate change. Moreover, environmental health directors’ climate and health risk perceptions accounted for 27% of the variance in the number of climate change impacts being addressed.
Sociodemographic and other factors related to climate change beliefs have been better studied with the public. In a meta-analysis of the determinants of climate change beliefs using studies of members of the public from across 56 nations, sociodemographic factors—gender, age, income, education and race—were found to have little effect compared to political affiliation, values, trust in scientists and understanding of the climate science consensus, and experience of local weather change (30). Van der Linden found similar relationships—though lesser effects from local experiences—in a study of determinants of climate risk perceptions (44).
The climate change beliefs, perceptions, and injunctive norms of health professionals in a rural, conservative state are likely to be affected by its political culture. At the same time, these experts have scientific training, actively engage with colleagues in medical and other scientific communities, and have direct experiences of changes in their community’s health that could also potentially influence their levels of issue concern. In order to further explore the risk perceptions of public and environmental health professionals, we pose the following research questions:
RQ1: What are the climate change local observations, beliefs, risk perceptions, and injunctive norms of public and environmental health professionals in Montana, a rural and conservative state?
RQ2: (a) What is the relationship between the professional and sociodemographic characteristics of rural health professionals and their climate change belief and risk perceptions? (b) What is the relationship between the professional and sociodemographic characteristics and climate risk perception of rural health professionals on their injunctive norms for prioritization of climate change within their department?