https://orcid.org/0000-0001-8941-5349
Figures
Abstract
Climate change, air pollution, and ecological degradation are defining public health and health equity challenges of our time. Efforts to integrate and evaluate climate change curriculum in medical education is still nascent. Herein, the authors presented findings of a longitudinal evaluation of such curriculum at Harvard Medical School (HMS). Authors designed and administered competency-based and course content-specific pre/post surveys to first-year HMS students to evaluate the impact of the climate change, environment, and health curriculum. Survey development used an adapted Delphi process to solicit feedback from experts at HMS, students, and the Office of Medical Education and included seven-point Likert scale questions (dichotomized and analyzed using Fisher’s exact test). Once data saturation was reached, we conducted a thematic analysis to identify key themes and selected illustrative quotes to support each theme. Surveys were administered to the first-year class of 134 HMS students from August 2023 to December 2024. Response rates varied from 21/132 (15.7%) to 119/134 (82.1%). Comparing pre-to post-course responses, competency-based surveys demonstrated statistically significant improvements in 19/20 items (95.0%) and course content-specific surveys showed statistically significant improvements in 20/29 items (69.0%). The vast majority of open-ended responses affirmed the curriculum’s value. This study demonstrated that the curriculum significantly improved medical students’ self-perceived competence in climate-related topics. While statistically significant improvements were observed, results are based on self-reported perceptions and may be subject to response bias due to response rate attrition during the study. No formal validation process was conducted during survey development. As climate and health equity education continues to expand rapidly, often with little standardization, these findings offer insight for other institutions seeking to build measurably impactful curricula, and ultimately prepare medical students to more effectively deliver patient care on a warming planet.
Citation: Baker N, Shirley H, Kline MC, Malits J, Mandalapu A, Mazumder DR, et al. (2025) Evaluating the impact of a longitudinal, integrated climate change, health, and environment curriculum in undergraduate medical training at Harvard Medical School. PLOS Clim 4(12): e0000727. https://doi.org/10.1371/journal.pclm.0000727
Editor: Zerina Lokmic-Tomkins, Monash University Faculty of Medicine Nursing and Health Sciences, AUSTRALIA
Received: June 3, 2025; Accepted: November 2, 2025; Published: December 1, 2025
Copyright: © 2025 Baker et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The data has been submitted as a Supporting Information.
Funding: This work was supported by the National Institute of General Medical Sciences (T32GM144273 to MK and DRM; T32GM007753 to DRM). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. GB was supported by the Office of Medical Education at Harvard Medical School.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Over 230 medical journals and the World Health Organization have declared climate change the defining public health challenge of the 21st century [1,2]. Anthropogenic climate change has placed unprecedented stress on ecological and human adaptation, increasing the risk of crossing irreversible tipping points [3,4]. Climate change is resulting in worsening heatwaves, extreme weather events, disruptions in reliable access to clean water and nutritious foods, geographic redistribution of infectious diseases, and mass human displacement [5]. The health consequences of these impacts span every specialty and health system, with staggering health impacts. In 2021, an estimated 8.1 million deaths globally were associated with exposure to air pollution, largely attributable to fossil fuel combustion [6] and nearly 500,000 deaths globally were associated with exposure to excess heat [7]. According to the National Oceanic and Atmospheric Administration, the years 2023 and 2024 were the two hottest years on record [8]. The burden of climate change will be felt most acutely by those least responsible in the U.S. and around the world. Indeed, lower-income communities, women, the elderly, children, historically marginalized racial and ethnic groups, and individuals with housing insecurity face significant climate related health inequities. They contribute the least to emissions (with the wealthiest one-percent producing as many emissions as the poorest two-thirds of humanity) and simultaneously face both high exposure and limited adaptive capacity to climate hazards [5,9,10].
Climate change not only impacts public health, but also clinical care, including history taking, diagnostic reasoning, patient counselling, and the resilience of the healthcare delivery system itself. For example, in September 2024, Hurricane Helene caused the flooding of an intravenous (IV) fluid manufacturing plant responsible for 60% of the US IV fluid supply. A survey of healthcare providers revealed that 86% experienced IV fluid shortages, with countless health systems forced to alter surgical scheduling and fluid usage protocols [11]. This example highlights a broader trend – climate change made 74% of extreme weather events more likely or more severe, and healthcare systems are struggling to adapt [12].
To effectively address these rapidly evolving health challenges and equip future physicians with the tools they will need, medical schools must integrate climate literacy into its curricula [13]. In recent years, the Association of American Medical Colleges (AAMC) has called for the integration of climate change and health into medical education [14]. Institutions are heeding its call: 55% of U.S. medical schools reported required climate health topics in 2022, up from 27% in 2020 [15]. Globally, institutions have also documented climate curricular innovation in undergraduate [16–21] and graduate medical education [22–25], as well as in interprofessional health disciplines, including public health and nursing [26–30]. In response to the Accreditation Council for Graduate Medical Education (ACGME)’s feedback, HMS has developed and implemented 7 longitudinal societal themes that enable students to learn about topics of importance through curricular integration across courses [31]. HMS previously described its development of an institutionally recognized, required, longitudinal, integrated Climate Change, Environment, and Health (CCEH) societal theme [19] and accompanying home developed competency framework (Table 1). In that initial descriptive paper by Kline et al, authors describe in depth the process of designing the societal theme and the HMS competency framework, and then mapping each curricular integration to the competencies. It is one of the first and most comprehensive competency-based climate change curricula documented to date [32]. Our curricular framework has 5 core competencies, each of which has associated secondary competencies.
While a few institutions have documented the implementation of climate change content in undergraduate medical curricula, including single-course modules and elective offerings [33], very few have rigorously evaluated the longitudinal impact of such curricula on defined, competency-based outcomes. Prior studies have primarily relied on descriptive accounts or one-time student satisfaction surveys, limiting insight into whether these interventions translate into sustained educational gains. This study addresses this gap by conducting a comprehensive evaluation of the HMS CCEH curriculum from August 2023-December 2024, the first cohort of full implementation into pre-clerkship courses. We assessed CCEH’s impact in two ways, by evaluating 1) how the societal theme broadly affected development in capacities enumerated in our competency framework and 2) how specific curricular integrations, including lectures, case-based learning sessions, small group discussions, and preparatory materials, affected student self-reported understanding and confidence regarding climate health topics specific to each course.
Methods
Ethics statement
Our study protocol was reviewed by the HMS Program in Medical Education’s Educational Research Committee and deemed exempt from IRB review.
Members of Students for Environmental Action in Medicine (a chapter of Medical Students for a Sustainable Future), the curriculum faculty director, and a member of the HMS Office of Medical Education designed the surveys implemented in this study (Tables A-K in S1 Text). We used an adapted Delphi process to solicit feedback from experts at Harvard Medical School, students, and the Office of Medical Education to iterate and finalize the survey design. A formal survey validation process was not conducted. Two categories of surveys were developed: 1) the “competency-based survey,” which assessed broad, longitudinal competency development over time, (Table A in S1 Text) and 2) the “course content-specific survey,” which assesses immediate learning of specific topics integrated into specific courses (Tables B-K in S1 Text). The competency-based surveys directly mirrored language in the actual competency framework.
We administered these surveys to first-year undergraduate medical students in the pre-clerkship portion of the curriculum, which is the initial classroom-based portion of standard medical education before students begin clinical work.(entering class of 2023, n = 134). The CCEH curriculum was designed to specifically integrate into each of the pre-clerkship HMS “Pathways curriculum.” Pathways is the primary pre-clerkship educational track at HMS. HMS medical students in the “Health, Science, and Technology (HST)” track (a joint program with Massachusetts Institute of Technology) and Harvard dental students enroll in partially overlapping coursework, but do not receive exposure to the full curriculum. As a result, they were not included to participate in this study. Of note, HMS redesigned its pre-clerkship curriculum in AY2023−24, [31] and we adapted our curriculum to maintain its longitudinal, integrated pedagogy in each new course (Table 2).
Data were collected from July 30, 2023 to December 27, 2024. Pre-competency surveys were administered in July 2023 (the beginning of the 2023–2024 academic year), with identical post-surveys delivered at the conclusion of the pre-clerkship curriculum in December 2024 (Table A in S1 Text). Course content-specific surveys were administered throughout the 17-month period, with pre-surveys delivered before the introduction of CCEH content in each course, and an identical post-survey delivered at the end of the course (Tables B-K in S1 Text). Formal data were not collected in two courses: 1) “Professional Development Week,” due to the elective nature of the CCEH session and 2) “Immunity in Defense and Disease” due to an administrative data collecting error.
Each survey used a seven-point Likert scale ranging from 1) “strongly disagree” to 7) “strongly agree.” Based on standard deviation estimates from a previous cross-sectional curricular survey [19], our power calculation determined a minimum sample size of 18–20 needed for significance (at alpha of.05 and power of 0.80).
To elicit qualitative feedback, competency-based surveys included the question “Is the climate, environment, and health curriculum valuable in medical school? If yes, why? If not, why?” (Table A in S1 Text) Each course specific post-survey asked “Do you have any comments, criticisms, or suggestions about how the climate change content was organized or presented in (course name).” (Tables B-K in S1 Text).
All surveys were administered via email, using the Qualtrics XM 2025 survey platform. Each survey obtained written informed consent by containing the following statement, “ By participating in this survey, you consent to having your de-identified responses, analyzed solely in the aggregate, used in publications on this curriculum.” We protected student confidentiality by not collecting identifying information. Each survey was cross-sectional; we chose to not link pre- and post-survey data to allow for greater flexibility in student cohort participation over our extended 17-month study period.
We analyzed pre- and post-survey data for all survey respondents and dichotomized the pre- and post- data into two categories: “Agree” (somewhat agree to strongly agree) and “Not agree” (somewhat disagree to strongly disagree, and neither disagree nor agree). The resulting contingency tables were analyzed using Fisher’s exact test (Tables 3, 4) to determine changes in the proportion of respondents agreeing with statements in each set of pre- and post- survey questions. We considered P values of < 0.05 to be statistically significant. To determine the effect size of the intervention, we calculated Cramer’s V on all Fisher’s exact test analyses. Interpretation of the Cramer’s V coefficient was determined by the degrees of freedom in the Fisher’s exact test analysis. We analyzed our data using two-by-two tables (agree and not agree x pre and post intervention), each with just one degree of freedom. In this circumstance, Cramer’s V statistics between 0 and 0.10 indicate a small effect, those between 0.10 and 0.30 a medium effect, and V statistics between 0.30 and 0.50 or greater, a large effect. We analyzed statistics for all quantitative items using IBM SPSS Statistics for Windows, (Version 28.0, Armonk, NY: IBM Corp). We used an adapted Braun and Clark’s six phase thematic analysis framework [34] to inductively analyze open ended comments when response rate was adequate for analysis. When data saturation was reached, we conducted a thematic analysis to identify key themes and selected illustrative quotes to support each theme. Authors NB and GB familiarized themselves with the responses, generated initial themes independently, met to discuss initial themes, and then redefined themes until both authors were in agreement. Illustrative quotes were selected by NB and GB which conveyed sentiments shared by more than 1 participant.
Results
All surveys achieved response rates sufficient to be adequately powered. Of 134 eligible students, 110 (82.1%) completed the competency-based pre-survey and 52 (38.8%) students completed the competency-based post-survey (Table 3). Response rates during the academic year for the course content-specific pre- and post-surveys ranged from 21 to 117 per survey administration (Table 4). A standardized survey delivery process was used for each course, and the heterogeneity in response rate did not have a clear cause for variability. Every curricular integration listed in Table 2 was fully evaluated with pre-post surveys and detailed in Table 4 with two exceptions. The curricular integration in the course “Professional Development Week” was not evaluated because it was elective. And there was a survey delivery error in “Immunity in Defense in Disease”, and thus data was not collected for that integration.
Competency-based survey results
In our curriculum-wide competency-based survey, all 5 primary core competencies and 19/20 (95.0%) survey items showed statistically significant pre-post gains (Table 3). After exposure to the curriculum, a higher proportion of students felt they could: define the pathophysiological mechanisms by which climate change, air pollution, and ecological degradation impact human health (pre-survey: 36/110, 32.7% v post-survey: 48/52, 92.3%; p < 0.001, effect size = 0.557); apply knowledge of climate impacts on human health to the clinical care of patients including prevention, diagnosis, and risk reduction counseling (pre-survey: 21/110, 19.1% v post-survey: 47/52, 92.16%; p < 0.001, effect size = 0.688); analyze the historical and structural causes of climate change, air pollution and ecological degradation and describe the ways in which it creates/exacerbates health inequality (pre-survey: 47/111, 42.3% v post-survey: 46/50, 92.0%; p < 0.001, effect size = 0.465); describe the ways in which the health care system contributes to climate change and how health care delivery is vulnerable to climate-related events (pre-survey: 45/111, 40.5% v 49/51, 96.1%; p < 0.001, effect size = 0.523); and be prepared to explore roles health professionals and institutions can play in climate solutions (pre-survey: 78/109, 71.6% v post-survey: 45/47, 95.74%; p = 0.005, effect size = 0.272).
Course content-specific survey results
Surveys of individual courses revealed statistically significant improvements in 20/29 (69.0%) items (Table 4). For instance, after CCEH curriculum exposure in “Introduction to the Profession”, a higher proportion of students agreed with the statement, “I understand the main pathways by which climate change affects human health” (pre-survey: 82/132, 62.1% v post-survey: 52/55, 94.5%; p < 0.001, effect size = 0.328). After CCEH curriculum exposure in the course “Essentials,” a higher proportion of students agreed with the statement, “I understand the historical context of environmental racism” (pre-survey: 4/53, 7.5% v post-survey: 27/31, 87.1%; p < .001, effect size = 0.795). After CCEH curriculum exposure in “Integrated Human Pathophysiology 3,” there was a higher proportion of students in agreement with the statement, “I feel confident consulting patients regarding medication use in anticipation of extreme heat events” (pre-survey: 5/31, 16.1% v post-survey: 16/26, 61.5%; p = 0.002, effect size = 0.469). After the “Bridges” CCEH integration, there was a higher proportion of students in agreement with the statement, “I understand how to sort waste in a hospital setting” (pre-survey: 9/36, 25.0% pre-survey v 31/32, 96.9% post-survey:; p < 0.001, effect size = 0.729).
Free-response comments
In the competency-based pre-survey, 77/81 (95.1%) of students reported that the CCEH theme was valuable and 13/15 (86.7%) also affirmed this in the post-survey. Representative student responses are presented in Table 5. Each quote is from a different participant. Data saturation was reached only in the competency-based pre-surveys, and thus was the only survey in which we conducted thematic analysis. Themes included health impacts, medical professionalism/solutions, social importance, adaptation, health equity, social determinant of health. The competency based post-survey had only 15 open field responses, and did not reach data saturation. For these responses, we have provided 5 illustrative quotes in Table 5. In all of the course content-specific post-surveys, there were a total of only five comments, two of which reported there was too much climate curriculum in medical education. A thematic analysis was not done because data saturation was not reached.
Discussion
The impacts of climate change on clinical medicine and healthcare delivery has brought increased attention to the role of medical education in preparing future physicians to care for patients on a warming planet. HMS is one of the first U.S. based medical schools to formally recognize and support a required climate change, environment and health curriculum [32]. Our previous descriptive paper presented a novel competency framework and emphasized the importance of mapping curricula onto this conceptual model [19]. It also highlighted the importance of a pedagogy based on an integrated, longitudinal approach.
Climate and health education internationally is being advanced via a combination of consensus statements, proposed competency frameworks, and collaborative implementation efforts. Germany has integrated planetary health learning objectives into its national competency-based catalogue of learning objectives for medical education, which includes national examinations [35]. Formation of collaboratives such as the European Network on Climate and Health education, aim to facilitate transnational collaboration across medical schools in developing curricular models [36]. In Australia and Aotearoa New Zealand, health impacts of climate change are being recognized in standards for accreditation [37]. Consensus statements such as those released by the Association for Medical Education in Europe [38] and proposed frameworks such as core concepts for health professionals developed by the Global Consortium on Climate and Health Education [27] are aids in initial implementation, though many of these aforementioned efforts are largely advisory at this stage. Our competency framework represents a published, peer-reviewed, and now longitudinally evaluated implementation, offering a health equity anchored approach that bridges high-level recommendation, and practical curriculum design.
In our 17-month longitudinal evaluation of this curriculum, we had two goals: 1) to determine if our CCEH curriculum supported the development in our defined competencies and 2) to determine how each curricular integration affected student understanding of that specific topic. Our results suggest that the CCEH curriculum had success towards achieving these goals. Competency-based survey data showed wide-ranging and statistically significant improvement in development across the 5 competency domains across nearly all surveyed items. For many items, the improvement was large, as measured by percentage point change and effect size. For instance, at the beginning of the CCEH curriculum, only 15.5% of students agreed with the statement “I feel confident obtaining a basic environmental and occupational history from a patient,” while 96.1% agreed after, a 80.6% percentage point increase with an effect size of 0.763. Likewise, in our course content-specific survey data, we found statistically significant improvements in the majority of items studied, with numerous items showing large improvements. For instance, prior to the course “Essentials”, only 3.8% of students agreed that they “understood healthcare providers’ responsibility to address the health impacts of climate change,” while 83.9% agreed with this statement after the course, resulting a 80.1% percentage point increase with an effect size of 0.820. All items that did not achieve statistically significant improvement did nonetheless show pre-post survey gains. Many of these items had a very high baseline score: for example, over 85% of students reported a high degree of understanding the human-driven causes of climate change and associated impacts on vector borne disease transmissibility in pre-survey data (Table 4). Additionally, high baseline interest in leading climate solutions showed non-significant change (p = 0.127). This likely reflects pre-existing motivation among medical students rather than a curricular limitation, underscoring the importance of designing curricula that channel existing interest into actionable competencies and skills. While students demonstrated both high baselines and significant gains in knowledge based climate health pathways and mechanisms, some items assessing clinical readiness, such as counseling patients about air pollution exposure, showed moderate gains that did not reach statistical significance. This pattern suggests that while didactic learning effectively builds foundational knowledge, developing confidence in clinical application may require more immersive pedagogical approaches, such as standardized patient encounters, simulation exercises, or supervised clinical practice opportunities.
Of note, across both competency-based and course content-specific assessments, students appear to have experienced substantial improvement in understanding of both climate change’s impact on health equity topics and clinical skills such as obtaining environmental histories and counseling patients about climate-related health risks. Each of these were priority areas for students and faculty who developed this curriculum.
Open-ended comments in the surveys show that students found learning about climate change in medical school important because they 1) wanted to learn about climate related health impacts, 2) believed it was their professional responsibility to understand how it impacted their patients, 3) found intersections between climate change and health equity 4) found intersections between climate change and other social determinants of health, 5) thought it was an issue of social importance, and 6) understood it would help them adapt medical knowledge and clinical skills to the changing health burdens of a warming planet.
Collectively, these data suggest that our pedagogical approach, including curricular structure, competency framework, and content, was effective in curriculum development. Our findings will help us continue to iterate and improve our curriculum at HMS and may be useful to other medical schools who seek to develop similar curriculum.
Our study has several limitations. First, we decided to make pre-post surveys voluntary and unlinked to ensure anonymity and reduce survey burden on students. However, this approach limits our ability to draw conclusions at the individual-student level, and may introduce selection bias and non independence. Second, our reliance on self-reported data presents inherent limitations of subjectivity in medical education research [39]. Furthermore, our study did not assess the impact of specific teaching methods or the depth of content delivered. Additionally, our pre-survey consistently had higher participation rates than our post-surveys. Though this pattern is common in educational research, it could have introduced participation or selection bias if the pool of students who completed the post-surveys were more likely to agree that the curriculum was beneficial. Additional potential sources of bias could include differential engagement across the student body, as well as social desirability bias, even though surveys were anonymized. Survey instruments were developed by faculty experts but without formal validation, which may affect reliability and validity of measurement. In terms of study generalizability, while implementation of such a curriculum framework at less well-resourced institutions may require some degree of adaptation, the growing availability of free online resources [40] and replicable frameworks such as those described herein, combined with student-driven models that leverage motivated learners with appropriate faculty oversight, may help address capacity constraints across institutional settings.
Next steps for climate change education in medical school
Our study addresses an important gap by conducting a longitudinal study on the impact of a competency-based CCEH curriculum. Further longitudinal evaluations of climate change curriculum in medical school is needed. Such scholarship will contribute to a body of knowledge that will enable medical educators to understand best practices in delivering such curriculum and help organizations like the AAMC work towards recommendations on standardized curricular and competency frameworks. Such standardization may help in creating a meaningful approach to integrate climate-informed medical education into schools across the country and establish medical professionalism in this domain. Ultimately, such an approach can improve the knowledge and skills future physicians need to more effectively care for patients in the midst of this public health crisis.
Additional evaluation approaches can also be utilized in future assessments. For instance, more objective methods such as assessing the impact of curriculum on climate related assessment-based questions and objective structured clinical examinations (OSCEs) may provide additional opportunities for both data collection and student instruction, for example, evaluating a simulated patient presenting with heat illness [41]. Furthermore, longitudinal follow-up of the impact of the CCEH curriculum on clinical practice would aid in evaluating any lasting effects of our preclinical curriculum interventions in relation to Miller’s pyramid, as well as measuring impact over student career trajectories [42]. Lastly, as clerkship and graduate medical education show increasing integration of climate change and health topics, [43–46] expansion of education into clinical training, where trainees learn to apply their didactic learning and develop clinical habits, represents a crucial next step in developing physicians prepared to meet climate-related healthcare diagnostic, therapeutic, and healthcare delivery challenges during their careers.
Conclusions
This exploratory evaluation of self reported data suggests that our novel climate change, environment and health curricular theme has improved students’ self perceived competence and knowledge in climate related health issues. More studies are needed to further explore the promise of climate change, environment, and health curricula in closing the relevance-preparedness gap in medical education.
Supporting information
S1 Text. Climate Health Curriculum Evaluation Tool.
Table A: Competency based survey tool. Table B: Course specific survey tool – Introduction to the Profession. Table C: Course specific survey tool – Foundations. Table D: Course specific survey tool – Practice of Medicine. Table E: Course specific survey tool – Integrated Human Pathophysiology 1. Table F: Course specific survey tool – Essentials 1. Table G: Course specific survey tool – Integrated Human Pathophysiology 2. Table H: Course specific survey tool – Integrated Human Pathophysiology 3. Table I: Course specific survey tool – Immunology and Defense in Disease. Table J: Course specific survey tool – Mind, Brain, and Behavior. Table K: Course specific survey tool – Bridges.
https://doi.org/10.1371/journal.pclm.0000727.s001
(DOCX)
Acknowledgments
The authors wish to thank the Office of Medical Education at Harvard Medical School for their continued support.
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