ADVANCEMENT OF THE SCIENCE
TABLE 3
Effect of Knowledge and Attitude on Information-Sharing Behaviors
Predictor
B
SE
p -Value
95% Confidence Interval
F
Partial η ²
Occupation Knowledge
0.056 0.064 0.624
0.021 0.052 0.042
.008 .220
[0.015, 0.096] [-0.038, 0.166] [0.542, 0.705]
7.180 1.508
0.015 0.003 0.318
Attitude
<.001
225.693
Note. R 2 = .357 and adjusted R 2 = .353.
( p = .220), and attitude was the strongest ( B = 0.624) and most significant ( p < .001) predictor of information-sharing behaviors (Table 3). Additionally, the adjusted mean, ranging from 0 (not at all likely to engage) to 1 (very likely to engage) for information- sharing behaviors among nurse practitioners/ registered nurses (0.617) was higher than that among physicians/physician assistants (0.562), with a mean difference of ±0.056. Qualitative Supplemental Table S1 presents selected quotes from participants regarding their cur- rent knowledge and the adverse health effects they believe are associated with nitrate con- tamination in drinking water. Themes that emerged from our analysis were uncertainty or a lack of knowledge, cancer, pregnancy and pediatric complications, other diseases and long-term effects, vague symptoms, and acute effects. Overall, the responses ranged from statements of a lack of concern or lack of knowledge to a desire for further education. Discussion In our study, the HCPs reported low knowl- edge of the health risks associated with nitrate contamination in drinking water. This lack of knowledge is likely due to minimal formal training or education on environ- mental nitrate exposures and the associ- ated adverse health outcomes. Consistent with this theory, our survey results showed that a limited number of HCPs had received any formal training or education about this important health topic. This lack of environ- mental health education and subsequent lack of HCP knowledge have resulted in low over- all self-confidence levels reported by HCPs when discussing nitrate contamination and associated health risks with patients.
Previous research has found that environ- mental health education for HCPs is largely lacking in the U.S. continuing education cur- riculum (Gehle et al., 2011; Roberts & Reigart, 2001; Tinney et al., 2015). Similar gaps in environmental health education have been identified in medical student training, with medical students rarely asking about paren- tal occupations for pediatric patients, which could increase the risk of other environmental exposures (Roberts & Reigart, 2001). Occupations in agriculture could present further environmental health risks for fami- lies who live in rural areas, who therefore might be at increased risk for developing can- cer (Carozza et al., 2008; Ward et al., 2018). Education in environmental health provides HCPs with the ability to recognize and pre- vent exposure-related illnesses, counsel patients on risks (e.g., water quality issues), and advocate for preventive interventions shown to reduce disease burden. Despite an overall lack of knowledge, education, and confidence, physicians/phy- sician assistants and nurse practitioners/ registered nurses appear highly open to improving their understanding of nitrates in drinking water. Studies show that physi- cian attitudes strongly influence whether or not they act on evidence: When physicians view an issue as low priority or irrelevant, they are less likely to counsel patients or adopt recommended practices (Cabana et al., 1999). Because attitude was the stron- gest predictor of information‑sharing in our study, interventions that specifically target HCP beliefs and perceived relevance could increase the likelihood that HCPs discuss nitrate risks with at‑risk patients, or poten- tially alter their approach. We believe that the findings about openness to behavior change and the likelihood of HCPs
to share educational materials with patients about nitrate contamination are the most important takeaways from our study, which suggests an opportunity for future education and training. Recent studies have assessed medical student preparedness to discuss envi- ronmental health with future patients and found a similar openness to engage in these conversations when provided with sufficient education and training (Garg & Mulloy, 2018; Kligler et al., 2021). These assessments among medical students are consistent with our find- ings, which showed that HCPs want to inform their patients about environmental exposure risks such as nitrate contamination, but that HCPs report lacking the environmental health education and knowledge to provide appropri- ate resources or counseling. Our study has several limitations. First, participants were a heterogeneous sample of HCP specialties, resulting in substantial variability in responses. Future studies could select specific specialties or stratify results by HCP specialty (e.g., pediatrics, general medicine). Second, no survey instrument existed prior to this research. Although the instrument developed here demonstrated good face, content, and construct valid- ity, no comparative survey was available to assess validity or reliability further. Third, although the sample size was sufficient for statistical analysis, the low response rate (1.8%) limits generalizability. The findings of our study have large impli- cations for multiple health sectors. In the U.S. to our knowledge, no studies have explored HCP perspectives related to knowledge, atti- tudes, and awareness about nitrate in drink- ing water sources. Further research should expand on our survey results by evaluating HCP perspectives in other agriculturally dominant areas across the U.S.
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Volume 89 • Number 3
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