Drawing a line from CO2 emissions to health - Evaluation of medical students’ knowledge and attitudes towards climate change and health following a novel serious game: a mixed-methods study

doi:10.21203/rs.3.rs-3872968/v1

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Research Article

Drawing a line from CO₂emissions to health - Evaluation of medical students’ knowledge and attitudes towards climate change and health following a novel serious game: a mixed-methods study

https://doi.org/10.21203/rs.3.rs-3872968/v1

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Background

Education is urgently needed to equip medical students with knowledge, values and skills to promote planetary health. However, the current literature offers little insight into evidence-based approaches and best practices. In response to this pressing need, a novel serious game was introduced into the medical curriculum at Erasmus Medical Center in 2023. The aim of this study was to evaluate the knowledge and attitudes of medical students after they had played a serious game that addresses climate change and health.

Methods

In accordance with a mixed-methods design, quantitative data were collected using pre- and post-intervention surveys. Differences were assessed using the Wilcoxon signed rank test. Focus group discussions were held after the game to explore the underlying mechanisms that led to the changes in knowledge and attitudes as identified in the survey. The transcripts were then thematically analysed.

Results

145 students played the game, of which 59 (40.7%) students completed the pre- and post-intervention surveys. After the game, self-reported knowledge and the proportion of students who recognized the importance of climate change education, to inform patients and society about the health impacts of climate change, significantly increased. Moreover, survey results indicated a significant increase in climate worry subsequent to the game. Eleven students participated in the focus group discussions. Thematic analysis highlighted participants’ reflections on the roles and responsibilities in climate change and health, along with their recognition of climate and health co-benefits as tools for action. Another significant aspect was the importance participants placed on learning alongside peers with diverse attitudes. Additionally, participants appreciated the tangible overview of climate change and health provided by the serious game.

Conclusions

Our novel serious game positively influenced medical students’ knowledge and attitudes towards climate change and health. The accompanying climate worry needs attention through the empowerment of students’ agency to foster change.

planetary health

serious game

climate change

medical education

health

The effects of climate change on human health are regarded as ‘the biggest public health threat of the century’. (1) Rising temperatures present a substantial risk to human health, food security, water supply and livelihoods. Heat-related mortality, cardiovascular disease and altered distribution patterns of infectious diseases merely scratch the surface of the myriad health impacts of climate change. (1) The healthcare sector, with its objective of safeguarding and promoting health, is a significant emitter of greenhouse gases, accounting for approximately 4.6% of global net emissions. (2) Health systems require immediate transformation and resilience-building against the consequences of climate change and other planetary crises, such as air pollution and biodiversity loss. The current and future health workforce plays a crucial role in this endeavour.

Climate change is a critical component of an emerging discipline called planetary health. Planetary health is defined as the intersectionality between the health of the environment and the health of human individuals, while acknowledging the anthropogenic nature of environmental disruption. (3) The Association for Medical Education in Europe (AMEE) asked for the integration of planetary health education into medical curricula. According to their call, the primary objective of education on this topic is to build students’ knowledge and attitudes towards safeguarding the health of both humans and the planet. (4) Climate change is defined as one of the nine planetary boundaries that together describe the environmental limits within which humanity can operate safely to avoid irreversible changes to the planet’s ecosystems. (5) Although crossing the planetary boundary of climate change has far-reaching consequences for human health, only 15% of medical schools globally included elements of climate change and health in their curriculum. (6) A 2021 Dutch Association of Medical Students survey revealed that, out of 3489 respondents, 83% expressed a desire to learn more about the intersection between climate change, health and sustainability in healthcare in their curriculum. (7)

Despite the clear urgency of climate change and health education in medical curricula, the current literature bulges with calls for action and educational frameworks; however, these frameworks offer little insight into evidence-based approaches and best practices. (8–10) To answer this call for change, the Erasmus University Medical Center (Erasmus MC) in Rotterdam, the Netherlands implemented a collaborative serious game that teaches the interlinkages between climate change and human health. Serious games are designed for purposes beyond entertainment, often with educational objectives, and have been recognized as a potentially meaningful tool for enhancing medical education. (11, 12) In this case, engaging and game-like elements facilitate learning about climate change and health, and stimulate students to reflect on their role in advocating for climate-resilient health systems. In accordance with Kolb’s Experiential Learning Theory, playing the game is assumed to provide a concrete and immersive experience, that stimulates a positive attitude and sense of responsibility towards the topic. (13)

In 2023, the serious game was embedded in a public health course for third-year bachelor medical students at Erasmus MC for the first time. The primary objective of this study was to evaluate students’ knowledge and attitudes towards climate change and health following the serious game. The secondary objective was to identify opportunities and strategies for improving the game.

Study Design

A mixed-methods study design was adopted to evaluate students’ knowledge and attitudes towards climate change and health following a serious game. Quantitative data were collected using pre- and post-intervention questionnaires. Qualitative data were gathered from focus group sessions held with a subsample of participants after the game.

Setting and Participants

The study was conducted at Erasmus MC in Rotterdam, The Netherlands. Medical education at Erasmus MC consists of a three-year bachelor’s phase followed by a three-year Master’s phase. The study was carried out during a four-week introductory course on public health for third-year bachelor students in February 2023. The students had not received prior formal education on planetary health or climate change and health. A 45-minute plenary introductory lecture on planetary health was included in the course (JM, AN, FC), and 17 small-group sessions were planned, in which 20–24 students could participate in a serious game. Attendance at the lecture and small-group session was voluntary, but the content was included in the mandatory course examination. Students were eligible for participation in the study if they were third-year medical students at ErasmusMC.

Serious Game

An infographic presenting an overview of the serious game, including the venue setup and aims and learning objectives is presented in Fig. 1, and a detailed explanation is provided in Additional file 1. A brief description is included below.

Figure 1. Overview of the serious game.

The two-hour sessions were divided into three parts: An introduction - in which the teachers (2–3) introduced themselves, the theme, outline and learning objectives; Part 1 of the game – in which the interlinkages between climate change and health were discussed in smaller subgroups (3–6 students) during four rounds. The teacher explained the planetary boundaries concept and the focus of the game on the planetary boundary of climate change in relation to health during the first round; Part 2 of the game – a group discussion and reflection on personal and professional responsibilities (either with the entire group or in the same smaller subgroups).

The sessions were facilitated by a pool of 13 teachers (final-year medical students, public health researchers) with knowledge of the topic. They attended a three-hour teacher training session beforehand and were provided a teacher manual. During the training, they played the game and received practical tips and instructions for facilitation.

Quantitative Data Collection and Analysis

All third-year Bachelor students who attended the small-group session (n = 145; 35.8% of the entire cohort) were invited to participate in this study. The students were asked to scan a QR-code that directed them towards an online version of the participant information leaflet and an informed consent form in LimeSurvey. (14) Participation in the study was not required to attend the session. After informed consent was provided voluntarily, the students were asked to complete the pre-intervention questionnaire (see Additional file 2) in LimeSurvey. At the end of the small-group session, the students were asked again to complete the post-intervention questionnaire (see Additional file 2) in LimeSurvey.

The pre-intervention questionnaire was divided into three parts: (1) demographic information, (2) knowledge about climate change and health and (3) attitudes towards climate change and health and its importance for medical students/doctors. The post-intervention questionnaire was the same, except for the substitution of demographic information with evaluation questions. In addition, respondents were asked whether they attended the introductory lecture and were willing to participate in a focus group discussion for further evaluation of the serious game.

The questions were designed by the research team, in line with the core objectives relevant to planetary health education in the medical curriculum at Erasmus MC, and informed by similar studies. (15–17) The knowledge part consisted of three self-reported knowledge questions and two exam questions to objectively evaluate respondent knowledge. The majority of the attitude and evaluation questions and the self-reported knowledge questions used 5-point Likert scales (strongly agree-strongly disagree). The attitude part included two existing European Social Survey questions on climate change worry and belief, which were equally measured on a 5-point Likert scale. (18)

Statistical analysis

Survey questions with 5–point Likert scales were converted into numerical values and clustered into three categories: Strongly agree/agree (1–2), neutral (3), and disagree/strongly disagree (4–5). The examination questions comprised four statements, two of which were true, and were categorized as follows: 0 or 1 statement, 2 statements and 3 or 4 statements correctly indicated as true or false.

Descriptive statistics were used to characterize the sample, and are summarised by the number of cases (n) and percentages (%) for categorical variables and mean and standard deviation (SD) for continuous variables. Differences between pre- and post-intervention responses regarding knowledge and attitudes were assessed using the Wilcoxon signed rank test. Bonferroni correction for multiple testing was applied to determine the level of significance (0.05 (original p-value)/12 (number of tests performed) = p < 0.004). Analyses were performed using IBM SPSS Statistics for Windows, version 28. (19)

Qualitative Data Collection and Analysis

Sampling and number of focus groups were based on the availability and willingness of students to participate. Two focus group discussions of 90 minutes each were conducted, one month post-intervention, in a meeting room at Erasmus MC. The sessions were facilitated by MS and AI, and supervised by VE. The facilitators alternated between moderators and note-takers. They met some of the focus group participants before in their role as teachers. MS and AI maintained a neutral stance while encouraging participants to express diverse opinions.

The first focus group consisted of six students (three females); five students attended the second focus group (four females). Participants received an information leaflet and opportunity to ask questions. The sessions were audio recorded, after verbal consent was obtained.

A set of unbiased, open-ended questions and probes was developed by the entire research team (see Additional file 3). While the quantitative study focused on the effect of the serious game on students’ knowledge and attitudes towards climate change and health, the primary objective of the qualitative study was to explore the underlying mechanisms that led to the observed outcomes. To support this objective, the attitudes of the focus group participants towards climate change in general and in relationship with human health were explored prior to asking the main questions about their experiences with the serious game. In addition, the perceived strengths and opportunities for improvement of the serious game were discussed.

Qualitative analysis

The audio recordings of the focus group discussions were transcribed verbatim (MS, AI) and de-identified. The six-stage thematic analysis framework by Braun & Clarke was adopted, which includes familiarization with the data, inductive generation of initial codes, searching for themes, reviewing themes, defining and naming themes, and writing the final report. (20) Using NVivo12 software, the initial coding of transcripts was performed independently by MS and AI and their analyses were compared. (21) Finally, the codes were grouped into themes. Themes were reviewed by three authors (MS, AI, VE) in relation to the generated pool of codes and the entire dataset. Finally, definitions and names were generated for each theme. The themes are presented in the text with illustrative quotations.

Ethics

This study was deemed exempt from additional review according to the Dutch Medical Research with Human Subjects Law by the Erasmus MC Ethical Review Committee (ref. no. MEC-2023-0037).

Study Sample

In February 2023, 14 small-group sessions took place, and the game was played by a total of 145 students (35.8% of the entire cohort). The pre- and post-intervention questionnaires were fully completed by 76 students (52.4% of invited students). Students who completed only the pre- or only the post-intervention questionnaire (n = 17) were excluded from the analysis. The final sample for assessment of knowledge and attitudes therefore consisted of 59 students (40.7% of invited students; 14.6% of the entire cohort).

The mean age of the final sample was 21 years, and 78% of the respondents were female. Thirty-nine percent of the participants attended the introductory lecture prior to the serious game in person, and 40.7% of the participants attended the introductory lecture online.

The study findings are outlined below, commencing with knowledge, followed by attitudes and, finally, strategies for improvement. In each section, the quantitative results are presented first, followed by the themes generated from the qualitative findings. Additional file 4 presents all the quantitative results.

Knowledge

Quantitative Results

Figure 2 summarises the pre-and post-intervention results regarding knowledge about climate change and health. The proportion of students who agreed/strongly agreed with the self-reported knowledge statements significantly increased (p < 0.001). In terms of objective knowledge, a significantly greater score was observed in response to the question addressing climate change vulnerability and inequity (p < 0.001). In contrast, the question about (in)direct health effects of climate change was scored lower in the post-intervention questionnaire, but this finding did not remain significant after Bonferroni correction (p = 0.02).

Qualitative Results

Overview of complex interlinkages between climate change and health - Focus group participants expressed that participation in the serious game enhanced their understanding of the intricate relationship between climate change and human health, corroborating the increased self-reported knowledge in survey responses. This observation could not be substantiated through the inconclusive objective knowledge results.

Participants perceived active and collaborative engagement with placing the cards on the table and establishing connections between them as helpful for grasping ‘the bigger picture’, the complexity of the problem and its far-reaching consequences for health at both the individual and societal level. Elucidating and discussing the hierarchy and order of the cards displayed supported students’ comprehension of the impact of climate change. They described that playing the game in small groups forced them to actively participate and critically reflect on their own understandings through discussion with their peers.

[in response to the request to order the cards] ‘…that you were to organize the health consequences by yourself. And also neatly place them above and below each other. That provided an overview for me, so that you leave with a sort of mental structure. During the group discussion, you would reconsider, ‘Yes, this card fits here or much earlier’, and then you start to see more connections in your mind.’ [male]

The least responsible suffer the greatest consequences – In one of the focus groups, participants indicated that the serious game taught them the uneven distribution of the climate change burden across countries and populations. The role of inequality was highlighted as a previously unknown yet significant aspect of the problem: ‘It’s not just a kind of natural phenomenon, […] but it’s also truly an unequal thing […]. That it’s also a social issue, alongside being purely geological […].’ [male] Participants expressed a sense of moral responsibility as citizens of a high-income country to limit their carbon footprint.

Instrument to acquire an in-depth level of knowledge - According to the participants, the planetary health introductory lecture prior to the serious game offered a basic level of knowledge. This was perceived as necessary to be able to actively contribute during the small-group session. The different levels of knowledge among players in the game stimulated them to share knowledge with one another. The aforementioned factors, along with the presence of a teacher who could clarify uncertainties, helped participants to deepen their comprehension of the topic.

Attitude

Quantitative Results

Figure 3 summarises the pre-and post-intervention results regarding attitudes towards climate change and health. Students reported being more worried about climate change after playing the game (from 42.4–69.5%; p < 0.001). Similarly, a significantly greater proportion of students acknowledged the anthropogenic nature of climate change after the game (from 88.1–94.9%; p = 0.003). Regarding the importance of climate change for healthcare and their personal roles and responsibilities, a significant increase in the proportion of students who agreed/strongly agreed with the statements ‘education on this topic is important because as a future medical doctor, I play an important role in informing patients/society about the health impacts of climate change’ was noted (Patients: From 71.2–93.2%; p = 0.003/Society: From 62.7–83.1%; p = 0.003).

Qualitative Results

The climate dilemma: Personal contributions help to get a handle on reality, but seem anything but efficient - Participants shared a sense of being caught in a climate dilemma. On the one hand, they indicated that climate change plays a role in their daily lives to various extents. Making small adjustments as individuals, as long as they are considered reasonable and affordable, seemed to provide them with a feeling of control over the situation. However, they expressed scepticism regarding the efficacy of their own behavioural changes, as they deemed their personal efforts of insignificant contribution to the Paris Agreement. It was repeatedly emphasized that responsibility rests with politicians and governments.

‘I find it a bit difficult; on one hand, I think it should come from the bottom-up, that people themselves are willing to, and on the other hand […] if it’s imposed by policy, it makes such a bigger difference than if I were to do it alone.’ [male]

The serious game fuels climate worry - In line with the significant increase in climate worry measured in the surveys, the focus group participants equally expressed serious concerns regarding climate change and its impact. They articulated feelings of grief and hopelessness: (student, female) ‘When I think about it, it does make me a bit sad. It’s kind of a doomsday scenario that is being portrayed.’ The game made them realize that the consequences of climate change can no longer be fully prevented. To some extent, this resulted in acceptance of reality but also evoked a sense of despair. They expressed a lack of trust in current global actions, and said that reaching climate change mitigation targets seems impossible.

Tangible overview of playing cards on the table releases wow-effect - There was a strong consensus among participants that by seeing the numerous playing cards organized on the table, the realization dawned on them that climate change is a comprehensive societal problem. The overview of playing cards on the table was (student, female) ‘an eye-opener that so many things are involved’. This raised their awareness of the importance and urgency of climate change, as well as of the health effects that are already occurring today.

Learning with and from different opinions and attitudes- The participants primarily played the game with fellow students who had a similar positive attitude towards the topic. However, they mentioned that sharing different attitudes among students allows for new insights and encourages solid explanation and justification of one’s own perspective. It was also mentioned that students who deny the problem could hinder the learning process.

‘I think that it’s always valuable, especially when it comes to topics that have a societal theme, to talk to people about them. It’s important to hear perspectives that you may not agree with or that you haven’t considered […]. That way, you are challenged […] to reflect on your own opinions. Otherwise you can easily remain trapped in your own beliefs and echo chamber.’ [female]

Forced to reflect on their own role as a medical student and future MD - Participants felt that the game including the reflection made them aware that issues related to climate change will be part of their future profession. Discussion of the roles and responsibilities of medical students and doctors in the field of climate change and health has served as a starting point for internal reflection.

‘When I come to class as a medical student and start thinking about it, […] I believe that subconsciously, I will make a more active connection between [climate change and health]. […] For me, the small-group session has ensured that I am extra aware of the connection between the two, and also that as a future physician, it will be something I will encounter frequently and something I can actively engage with.’ [female]

Understanding the co-benefits of climate action for health provides tools for action - There was consensus that the co-benefits of climate action for health offer a strong argument for medical doctors to be involved in the fight against climate change. In addition to feelings of sadness and despair, participants were rather optimistic about the concept of co-benefits and the tools for action it provides. In addition, participants indicated that medical doctors can contribute to climate change mitigation both at the individual patient level and at the system level. Since an active societal and political role of medical doctors is becoming more common, it is easier to express their opinions. Interestingly, the survey responses did not show an increased sense of responsibility for reducing the environmental impact of healthcare following the serious game.

The focus group discussions revealed some ambivalence regarding whether doctors should take part in or refrain from climate activism. A neutral stance was mentioned by some to be important for maintaining a professional doctor-patient relationship. Not everyone agreed: ‘I don’t think that encouraging people to be more aware of climate [change] is a political or climate activist choice or attitude. I think that it’s a fact that climate change impacts individual health as well as public health. Just as smoking […] in which doctors can also hold a strong opinion that you should not smoke, I also believe that doctors should be able to say […] that consuming red meat is not good for your own health, nor for the environment […]. I think it is important that doctors serve as role models in this regard. You don’t want a pulmonologist who smokes, and I wouldn’t want a doctor who consumes a lot of meat either.’ [female]

Strategies for improvement

The serious game was evaluated via the post-intervention questionnaire. More than 90% of the respondents were positive (agree/strongly agree) about the content and methodology of the serious game. It was graded an average of 7.9 out of 10(SD 0.9).

Qualitative Results

The focus group participants were generally positive about the serious game. They mentioned a few aspects that could be improved.

Uniformity of teachers’ approach – Participants felt that uniformity of the teacher’s approach to facilitating the game and reflective discussion is important for ensuring equal learning outcomes across groups. For example, a slide deck to support the reflective discussion was used inconsistently.

Integration of climate change and health education across the curriculum - Participants expressed their desire to have learned about climate change and health earlier in the curriculum. As a result, they recommended the topic to be integrated across subjects in the curriculum, instead of presenting it as a stand-alone topic. They equally emphasized the significance of repetition for solidifying their knowledge.

Final exchange between groups to stimulate peer-learning- Since exchange between students with potentially different perspectives and attitudes is valued by participants, they suggested that the different smaller groups that played the game together could present their findings to each other at the end of the session. Participants believed this could be of added value, since other groups might have different opinions or gathered different insights (student, male): ‘Explaining is one of the best ways to learn.’

The primary objective of our study was to evaluate the knowledge and attitudes towards climate change and health of third-year bachelor medical students following a novel collaborative serious game. Our quantitative findings demonstrate a significant increase in self-reported knowledge. The tangible overview of complex interlinkages between climate change and health emerged as a crucial factor in developing students’ understanding.

The majority of students acknowledged the linkages between climate change and health, its importance for healthcare and their personal responsibility to reduce its environmental impact prior to playing the game. Nevertheless, a shift towards more positive attitudes was noted following the game. In particular, their attitudes towards their role as future medical doctors in educating patients and society about the health impacts of climate change improved.

Playing the game as a medical student forced them to reflect on their own role and responsibilities, and understanding the co-benefits of climate action for health provided them with tools for action. It is important to acknowledge, however, that the increased awareness appeared to be accompanied by a greater level of concern about climate change and its impacts on health. Overall, the findings underscore the positive impact of the serious game on augmenting knowledge and attitudes towards climate change and health among third-year bachelor medical students at Erasmus MC.

Strengths and limitations

Our study presents the first evaluation of a novel educational methodology in the field of climate change and health. Our employment of a mixed-methods design enabled us to not only assess the impacts of the serious game, but also explore the underlying mechanisms responsible for its effects.

Nonetheless, participation in the serious game was voluntary, and the survey was completed by a mere 40.7% of the participating students. Hence, selection and response bias might have been introduced in favour of those who already held relatively positive attitudes towards the subject. This assumption is in line with the predominantly positive attitude outlined in the pre-intervention survey responses. To illustrate, 89.8% of respondents recognized climate change as a major issue for healthcare prior to playing the game. The sample size was relatively small, and since the number of focus groups was limited by the willingness of students to participate, its insights might lack a representative variety of perspectives. Furthermore, the absence of a control group in our study design hinders the attribution of any observed effect solely to the serious game. Another limitation is the use of predominantly self-assessed outcomes via a non-validated, nor pilot-tested survey. Expanding the range of validated questionnaires used to evaluate climate change and health education, with the Sustainability Attitudes in Nursing Survey (SANS) as a notable example, is necessary for improving the quality of evidence. (22)

Interpretation

Previous studies have confirmed that various approaches applied to climate change and health education, such as lectures, group assignments, stakeholder involvement and workshops, have a positive impact on the knowledge and attitudes of students. (23–26) Our study expands the existing evidence by adding a novel educational methodology to the palate of options for integrating climate change and health education into the medical curriculum.

A notable impact of the serious game was that the tangible overview of playing cards on the table evoked a wow-effect with regard to the complexity and magnitude of the impact of climate change on health. Although a desired consequence, this realization seemed to be accompanied by increased climate worry. Climate-related worry or anxiety can paralyze individuals and lead to helplessness. More importantly, if individuals do not believe that they have the agency to act and bring about change, they may be overpowered by hopelessness, which may translate into inaction. (27) The focus group participants in this study expressed a similar sense of despair and distrust in the efficacy of their own behavioural changes. One of the core objectives of overarching planetary health education is to equip students with the necessary values, skills and capabilities to sustainably promote human health. (4) Education in this field should therefore support emotional resilience and provide students with tools for concrete action, so that they feel a sense of agency to foster change. (4, 28)

Despite the above, the serious game did lead to a positive sense of responsibility, which is largely attributable to the reflection component of the game. Using reflexive pedagogy in climate change and health education enables students to develop skills to reflect and address the complexities of the topic and advocate for change. (29) Likewise, the co-benefits of climate action for health were recognized as providing tools for action. The authors of a similar study among undergraduate medical students reported that they found the right balance between shock and hope according to their evaluation of sustainability in quality improvement education. Their participants appreciated the focus on action and the examples of concrete, achievable sustainability projects by their near peers. (30) To this end, we will instruct teachers to put a greater emphasis on the co-benefits as tools for action during the reflection, to combat the potential increase in climate worry.

Our serious game was collaborative, rather than competitive, and learning alongside peers with diverse opinions and attitudes was highlighted as influential in shaping students’ attitudes. In addition to collaborative engagement, serious games are considered effective at enhancing cognitive abilities and affective engagement and stimulating motivation to learn. They foster a holistic understanding of scientific concepts, such as climate change and health, and prolong the retention of knowledge. (11, 12) The measured effects of our serious game on students’ attitudes may be explained through Kolb’s experiential learning theory (Fig. 4). (13) According to this theory, changes in attitudes and behaviour are produced through experiential learning. This process unfolds in a circular manner, starting with concrete experiences of the topic during the game. These experiences prompt reflection, fostered by collaboration and game feedback, which in turn culminates in the comprehension of abstract ideas, specifically climate change and health. Ultimately, this iterative approach leads to active experimentation (test of the new concepts). It is assumed that the serious game provided students with a realistic and immersive (hence the previously mentioned ‘wow-effect’) overview of the interlinkages between climate change and health. This resulted in active engagement, assumed to generate both positive feelings of enjoyment and internalised responsibility but also negative feelings of, in this case, worry about the subject and its consequences.

Recommendations

The findings of this study offer valuable insights into the effectiveness of a serious game for climate change and health education. Given the breadth of the topic, the intersection of personal opinions, social norms, and ideas on professional responsibilities, numerous aspects come into play, making it challenging to fully decipher all dynamics in a single study. Furthermore, longer-term evaluation studies are required to assess retention of knowledge, changes in attitudes over time and, ultimately, behavioural changes in students’ subsequent professional careers following climate change and health education.

Our key recommendations for educators include enhancing the integration of climate change and health education into the medical curriculum starting from the first year, and while doing so, considering the serious game as an effective tool for delivering complex concepts and positively influencing students’ attitudes. At Erasmus MC, the serious game will be included as a mandatory component of the medical curriculum beginning in February 2024, and beginning in September 2024, the field of planetary health will be fully integrated into the new medical curriculum. To optimize learning outcomes, we aim to strike the right balance between shock and hope, by providing concrete tools for action and emotional support. Learning alongside peers with diverse opinions and attitudes was enriching, and active engagement proved pivotal for fostering internalised responsibility.

Future research should consider incorporating a control group, validated questionnaires, a follow-up measurement and diverse settings to improve the generalizability of the results. Additionally, evaluation of mandatory educational sessions helps to recruit a larger, representative sample. A validated methodology to evaluate objective knowledge is warranted.

In conclusion, our novel collaborative serious game addressed an important gap in the Erasmus MC medical curriculum and positively influenced the knowledge and attitudes of third-year bachelor medical students towards climate change and health. However, playing the game also raised worries related to the subject. Yet, the serious game empowers medical students to cultivate the necessary knowledge, attitudes and skills to promote health in times of a climate crisis through active engagement and interactive discussions with peers.

AMEE: Association for Medical Education in Europe; MC: Medical Center; MD: Medical Doctor; SANS: Sustainability Attitudes in Nursing Survey; SD: standard deviation.

Ethics approval and consent to participate

This study was deemed exempt from additional review according to the Dutch Medical Research with Human Subjects Law by the Erasmus MC Ethical Review Committee (ref. no. MEC-2023-0037). We obtained informed consent from all subjects prior to their participation and subjects could withdraw from the study at any time.

Consent to publish

Not applicable.

Availability of data and materials

The datasets used during the study are available upon reasonable request by contacting the corresponding author.

Competing interests

The authors declare that they have no competing interests.

Funding

None

Author’s contributions

MS proposed the study and all authors helped to design the study. JM, AN and FC designed and implemented the serious game. MS and AI designed the data collection instruments and collected the data, with support from all authors. MS analysed and interpreted the quantitative data with support from AI and SO. MS and AI analysed and interpreted the qualitative analysis with support from VE. MS wrote the first draft of the manuscript in close collaboration with AI. All authors supported the writing process and approved the final manuscript.

Acknowledgements

We express our gratitude to Aimée de Croon, Emma Goslin, Wilma Oosthoek, Egid van Bree, Jorieke van der Stelt, Laura Warmerdam and Annemarie Bergsma for the development of the serious game. We would like to thank Liza Topouria, Lene Mesman, Naomi Oost, Femke ten Berge, Janneke Kovoor and Eileen Kikkert for their support in questionnaire development, recruitment of participants and quantitative data collection.

Author’s information

The research team consisted of three senior academics involved in design, coordination and teaching of public health education in the medical curriculum (EvB, SO, VE), two early-career medical doctors and PhD-students involved in development of planetary health education in the medical curriculum (MS, AI) and three final-year master medicine students who were involved in the development and implementation of the serious game (JM, AN, FC). MS, AI, JM, AN and FC also participated as teachers in the educational intervention.

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No competing interests reported.

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Drawing a line from CO2 emissions to health - Evaluation of medical students’ knowledge and attitudes towards climate change and health following a novel serious game: a mixed-methods study

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Abstract

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Introduction

Methods

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Setting and Participants

Serious Game

Quantitative Data Collection and Analysis

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Qualitative Data Collection and Analysis

Qualitative analysis

Ethics

Results

Study Sample

Knowledge

Quantitative Results

Qualitative Results

Attitude

Quantitative Results

Qualitative Results

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Qualitative Results

Discussion

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Drawing a line from CO₂emissions to health - Evaluation of medical students’ knowledge and attitudes towards climate change and health following a novel serious game: a mixed-methods study