Perception and role of physicians in the midst of the air quality crisis in Nuevo León, México

Introduction

Modernization has ushered in significant advances for humanity, but it has also given rise to challenges. Since the Industrial Revolution, the generation of large quantities of air pollutants has become a prominent issue. This anthropogenic pollution is now accountable for the annual deaths of 9 million people (1). Undoubtedly, this presents a global public health concern, with variations based on national and local contexts.

Mexico stands as the third most air-polluted country in the Americas and the foremost in North America (2). Specifically, the state of Nuevo León, particularly the metropolitan area of Monterrey (MAM), has been the subject of study due to the city’s characteristics and rapid urban growth (3). Despite efforts such as legal standards (NOM-172-SEMARNAT-2019) and programs like the Comprehensive Environmental Monitoring System, the problem persists. In 2022, over 240 days of pollution exceeding the standard were recorded (4). These elevated pollution levels not only exacerbate climate change and environmental impacts but also have severe consequences on public health (1).

Common acute health manifestations associated with air pollution include eye, nose, and throat irritation, wheezing, cough, and chest tightness, while chronic conditions encompass asthma, pneumonia, and bronchitis, along with other cardiorespiratory diseases (1,5-9). Beyond respiratory issues, air pollution contributes to or worsens various diseases, including autism spectrum disorder, retinopathy, fetal growth restriction (especially of the nervous system), low birth weight, and certain neurodegenerative diseases like Alzheimer’s, Parkinson’s, and dementia (1,10-13). Recent studies have also highlighted air pollution’s role in triggering or worsening mental health disorders (14,15). Cumulatively, exposure to air pollution increases morbidity and mortality, ranking it among the leading contributors to the global burden of disease (1,16-22).

Empirical studies conducted in the MAM have assessed the impact, revealing that residents unconsciously experience visual and respiratory symptoms during outdoor activities (23). Systematically, an increase in morbidity and hospital admissions is observed on days with poor air quality, especially among patients aged 5 to 59 years (24). Likewise, there is a recorded increase in mortality on days with worse air quality measurements (24,25).

Amid this environmental crisis, it is crucial to explore the awareness and knowledge levels of healthcare professionals. The World Health Organization (WHO) is currently developing training programs for healthcare professionals on air pollution to enhance their understanding of risks and methods for mitigation (26). Additionally, reflecting on the role of medical authorities in supporting and addressing this issue is essential. In some European countries like Italy and the United Kingdom, doctors are already required to take a stance on this matter (27-29).

In the meantime, comprehending the role that healthcare providers play in their daily interactions with patients is essential, as is recognizing their responsibility in influencing public health regulations. The case of the MAM provides a unique opportunity to delve into the perceptions of healthcare professionals, particularly amid a crisis of poor air quality that is increasingly evident at the citizen level, thanks to the active involvement of organized civil society.

This study aims to unravel the perspectives of healthcare professionals concerning the prevalence of health problems in their patients. It seeks to explore the pivotal role they play in the identification, awareness, education, and prevention of these issues during their clinical interactions and within other spheres of practice. Understanding their insights becomes crucial in the broader context of addressing the complex interplay between air pollution and public health. We present this article in accordance with the STROBE reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-45/rc).

Methods

Based on a comprehensive literature review, we developed a mixed-methods survey to assess physicians’ perceptions (Appendix 1). The survey aimed to evaluate:

• Awareness of the impact of environmental pollution on health and their perception of its societal and patient impacts.
• Self-perceived knowledge and sources of information on the topic.
• Knowledge and use of mitigation practices and strategies.
• Perception of their patients’ and society’s awareness of the pollution problem.
• Perception of their own role (and the profession’s) in addressing the issue.

The instrument comprised 27 multiple-choice or Likert-scale items and included 5 open-ended questions. The digital and anonymous survey was distributed via email to physicians affiliated with a private institution and openly shared on social media to reach a broader population.

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study did not involve any clinical research and the questionnaires were anonymous, thus the requirement for Institutional Review Board approval is waived. We covered aspects regarding confidentiality and informed consents were obtained from the participants.

Statistical analysis

As statistical analysis, the multiple-choice questions were reported using quantitative methods with descriptive statistics and the open-ended questions using qualitative coding to detect prevalent themes in the responses.

The main inclusion criterion was that participants practiced in the state of Nuevo León and were either medical graduates or in training. A total of 86 individuals responded to the survey, with 6 excluded for not meeting the inclusion criteria. The final sample (n=80) included 34 medical specialists, 27 sub-specialist physicians, 16 medical trainees, 2 general practitioners, and 1 medical resident. The respondents comprised 35 men and 45 women, ranging in age from 18 to 70 years, with the majority falling into the 31 to 40 years age group (n=22). Within the specialist category, pediatrics had the highest representation (35%), followed by family medicine (17%). Similarly, the subspecialty with the highest response was neonatology (15%), accounting for 22% of the sample predominantly dealing with pediatric cases. Most professionals were engaged in private outpatient care (68%), with 37% involved in teaching and 21% having research duties. While gender, age, and level of education/specialty area were considered, no significant influence on responses was observed.

Results

When queried about their knowledge of air pollution, 67% (n=53) of healthcare professionals perceived themselves as moderately or very informed, with only one person admitting a lack of knowledge. Notably, 71% (n=57) claimed to have read articles out of personal interest, potentially introducing a sample bias as those more sensitive or interested in the topic might have been more inclined to participate.

A significant 90% (n=72) of respondents indicated that air pollution is affecting the health of patients to a moderate or high extent. Concerning the effects of air pollution on health, the majority associated it with upper respiratory tract effects (63%; n=50), followed by lower respiratory tract effects (22%; n=18) and ocular effects (22%; n=18). This aligns with reported observations, emphasizing acute conditions in the respiratory and ocular systems (1).

However, awareness of non-acute diseases resulting from exposure to harmful particles in the air is limited. Regarding cancer, only 10% (n=8) mentioned its connection to oncological pathologies, with specific mentions of lung and breast cancer. In the neurological sphere, less than 4% (n=3) associated air pollution with the development of pathologies, with only two respondents highlighting mental health deterioration.

Healthcare professionals identified people with chronic diseases as the most affected by harmful effects, followed by those over 65 years old. Specialists believed that children under 4 years old were the second most affected group.

The survey revealed perceived causes of air pollution, with factory/industrial emissions (87%; n=70) ranking highest, followed by lack of efficient public transportation (79%; n=63) and loss of natural areas/vegetation (71%; n=57). Notably, 30% (n=24) were unfamiliar with the “AIRE” monitoring platform, which is a system that reports the air quality of all the cities in the state of Nuevo Leon (4); and 40% (n=32) claimed a lack of knowledge about technical aspects of air pollutants and thresholds for contingencies, based on their perception without verification.

While 75% (n=60) considered the air pollution problem in Nuevo León very serious, only half of the sample provided recommendations to patients. Recommendations were brief, including attention to air quality monitoring, the use of face masks, eye protection, humidifying the environment, avoiding smoking, and maintaining good hydration. Three respondents mentioned exercise, either as a contraindication for outdoor activities or with the use of face masks.

Barriers to providing recommendations included a lack of knowledge on addressing the issue (64%; n=51), lack of time (40%; n=32), and the perception that patients are not interested (36%; n=30). Strikingly, 81% (n=65) believed society is poorly or not informed about the issue. Regarding responsibility, 95% (n=76) believed healthcare professionals should play a significant role, but governmental authorities were seen as the primary agents for mitigation, followed by large industries and the general public. Respondents believed their actions in personal (80%; n=64) and professional (81%; n=65) lives aligned with combating air pollution, although the reasons for this judgment were not detailed.

Discussion

There is a clear recognition among professionals of the air pollution problem and its link to their patients’ health. However, this understanding predominantly centers on respiratory and acute manifestations, with limited acknowledgment of broader health impacts, such as cardiovascular, oncological, and recent research findings on neurodegenerative, metabolic, mental, and fetal disease (1,10-15).

Surprisingly, the lack of distinction in knowledge based on education or specialization implies a general awareness of the issue as common knowledge rather than a specialized domain. Expanding the survey to a larger sample could elucidate whether knowledge levels are indeed associated with professional training or practice type. Professionals seem unaware that the most affected population group are those aged 5 to 59 years considering the patterns of exposure, however they do acknowledge vulnerability of small children and older adults in terms of risk of harm (24).

Despite these knowledge gaps, professionals perceive themselves as well-informed, suggesting that existing medical education and individual updates might be inadequate in addressing this public health issue. The knowledge deficiency is evident in the lack of recommendations to patients and the admission of not knowing how to do so. The need for continuing education about air pollution for physicians due to this same issue has been invoked for Lebanese doctors (30).

While the majority acknowledges the severity of the air pollution problem in Nuevo León and recognizes its impact on patient’s health, there is a gap between recognizing their role and effectively acting as agents in addressing the issue. This highlights a lack of clarity about healthcare professionals’ role in protecting society from the risks of air pollution. In contrast to European countries where doctors are increasingly called upon to address environmental issues, the results indicate a need for a connection that allows healthcare providers to assume this commitment. This requires not only knowledge but also a commitment to public well-being, emphasizing the profession’s responsibility and the role doctors should play in safeguarding society based on their expertise.

The perception of consistent action in personal and professional spheres among the majority of the sample underscores the need to investigate the notion of professional duty they identify. Doctors may tend to overestimate their performance, indicating areas of opportunity in their knowledge and the provision of education and recommendations to patients. This gap can be attributed to a standard of professional responsibility that extends to their role as advocates for public health (31).

Another key concept that can be explored is professional citizenship, involving the assumption of a citizen role from their expert perspective to address community issues (32). Professional citizens can connect personal and public dimensions, initiating public conversations, and catalyzing actions for societal benefit. The proposed spheres of action for doctors, integrating professional citizenship, consist of Academic, Research, Clinical, and Political spheres. The first two incorporate the scientific aspect, while the latter two encompass the duty of serving patients and society (see Figure 1).

Figure 1 Proposals for action for healthcare professionals.

The present study has certain limitations that warrant consideration. Firstly, the small sample (80 respondents) may limit the generalizability of our findings, which could be more exhaustive to elucidate possible impact factors (age, gender, specialty, etc.). The lack of participants that work on public sector also represents an important limitation. Furthermore, the possibility of self-selection bias cannot be discounted, as respondents may have been more likely to participate if they possessed a heightened awareness or interest in the air quality crisis. Consequently, our findings may not fully capture the perceptions of those physicians less acquainted with or invested in the subject matter. These limitations signal the need for caution in extrapolating the study’s outcomes to broader contexts.

Conclusions

In conclusion, there exists a pressing need for enhanced education and continuous updates regarding the health impacts of air pollution. Simultaneously, empirical research initiatives are crucial to comprehensively understand pollution effects and assess the efficacy of potential solutions. Medical schools, as influential institutions, bear a critical responsibility to integrate this knowledge into their curriculum, especially within the broader context of the escalating climate change crisis. Ensuring that healthcare professionals are equipped with updated information can significantly elevate awareness of the gravity of air pollution, fostering a sense of urgency to implement education and prevention strategies in their daily interactions with patients.

Moreover, the imperative for doctors to engage in reflection on their professional responsibility and embrace integrated citizenship within their field is paramount. This introspection is crucial for physicians to advocate beyond their clinical practice, extending their influence into academic and political spheres. The collaborative involvement of institutions such as professional associations and civil organizations becomes pivotal in facilitating discussions, updates, and a platform for collective action. Through these avenues, medical professionals can have a more significant impact and actively support political initiatives geared toward addressing air pollution challenges.

The advocacy undertaken by medical professionals to intervene in instances of government negligence regarding emissions regulation encapsulates the bioethical principle that underscores “first, do no harm”. This principle resonates with the broader societal commitment of healthcare professionals to safeguard public health, highlighting the need for proactive engagement in environmental issues for the greater well-being of the community.

Acknowledgments

Special thanks to Paola Reynoso, Adelaida Caicedo Fajardo, and Yarinka Hernandez for their invaluable review and insightful recommendations. Additionally, gratitude is extended to Maria Enriquez for her dedicated work and ongoing inspiration.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Mellissa Withers) for the series “Equity in Health: Findings from the APRU Global Health Conference 2023” published in Journal of Public Health and Emergency. The article has undergone external peer review.

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-45/rc

Data Sharing Statement: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-45/dss

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-45/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-45/coif). The series “Equity in Health: Findings from the APRU Global Health Conference 2023” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study did not involve any clinical research and the questionnaires were anonymous, thus the requirement for Institutional Review Board approval is waived. We covered aspects regarding confidentiality and informed consents were obtained from the participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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