Children's Environmental Health Experience and Interest among Pediatric Care Providers in Vietnam

Background. In rapidly developing regions of the world such as Southeast Asia, marked industrialization with insufficient regulation places children at increased risk for significant environmental exposures. Health care providers have a key role in identifying, treating and preventing environmentally-related illnesses. Objectives. The authors undertook a survey of pediatric health care providers in Vietnam in order to gain preliminary insight into environmental hazard knowledge, and attitudes and beliefs regarding the relative importance of environmental factors in child health that could guide future initiatives towards building up capacity for children's environmental health in the region. Methods. A formal written and self-administered survey instrument was adapted from the World Health Organization's Children's Environmental Health Survey and translated into Vietnamese. The survey was administered via convenience sampling after formal introduction to children's environmental health (CEH) was made through lectures or meetings with pediatric care providers affiliated with the major children's hospitals and pediatric departments in Vietnam. Results. One hundred forty-one pediatric care providers completed the survey. Most indicated environmental factors are considered to be very important in child health (84%); 98% felt the magnitude of the problem is increasing; and air pollution is seen as the top environmental health issue facing the country. The most commonly identified problems in their clinical experience included: food poisoning due to microbiological agents (85%); pesticide poisoning (77%); tobacco smoke exposure (75%); and inadequate sanitation (60%). Although most (80%) endorsed asking about children's environmental conditions in clinical practice, a little more than a third (39%) were confident taking an environmental exposure history. For most key topics, less than half had received specific training. A majority (63%) of survey respondents were very interested in more environmental health training. Conclusions. Pediatric health care providers in Vietnam believe that environmental hazards in child health is an important topic that is routinely encountered in their care of patients, but training, experience and self-efficacy in these topics are limited. Introduction Clinical, toxicological, and epidemiological evidence of the influential role of environmental factors on health and development of children has accumulated greatly in the United States and Europe. In rapidly developing nations, economic pressures and ineffective regulatory systems place children at increased risk for significant environmental exposures. These risks have been raised for children in Southeast Asia and the Western Pacific (a World Health Organization-designated region including island states such as Samoa, Papua New Guinea, and Tonga) which are among the most rapidly industrializing areas …


Introduction
Clinical, toxicological, and epidemiological evidence of the influential role of environmental factors on health and development of children has accumulated greatly in the United States and Europe.In rapidly developing nations, economic pressures and ineffective regulatory systems place children at increased risk for significant environmental exposures.These risks have been raised for children in Southeast Asia and the Western Pacific (a World Health Organizationdesignated region including island states such as Samoa, Papua New Guinea, and Tonga) which are among the most rapidly industrializing areas of the world, and where half of the world's children live. 1 Children in these settings face the "triple burden of disease": a high-level of communicable disease (traditional morbidities such as diarrheal disease); the increasingly severe burden of non-communicable disease (so-called new morbidities such as asthma); and the emerging risks of new diseases and stressors related to the changing social and physical environment (e.g., obesity). 2n these settings, local research, public health surveillance, and the capacity for understanding and reducing the burden of pediatric environmental illness is largely undeveloped.

Research
Health care providers (HCP) have unique and critical roles in that they identify, treat, and prevent environmentally related health problems as well as advocate for healthy environmental conditions for children.However, the lack of adequate preparation in standard medical curricula and the need for specialized training is a clear theme emerging from two decades of the children's environmental health movement in the United States and within international health agencies such as the World Health Organization (WHO). 3The North American Pediatric Environmental Health Specialty Unit (PEHSU) network of centers has arisen as a model approach toward the building of needed capacity. 4 In these academically based regional centers, on-going training of HCPs, the public health sector, and the public is developed and delivered in multiple and audience-specific formats.In addition, the units provide management expertise for children with suspected or known exposure to environmental hazards as well as diagnosis, management and treatment of pediatric illnesses related to environmental issues.

Results
Approximately 230 medical staff attended the training sessions.Surveys were collected from 141 attendees.The 61% response rate reflects nonresponse of eligible attendees as well as the number of ineligible attendees (not pediatricians, not involved in pediatric care).The survey took approximately 15 minutes to complete.Questions that arose during respondent selfadministration were answered on the spot by the study team, which included a native speaker.The response rate varied for individual survey questions and the investigators have no knowledge of why some respondents didn't answer certain questions.
Table 1 summarizes the demographic and pediatric practice characteristics of the 141 survey respondents.The number of responses varied for specific questions and the proportion of specific (non-missing) responses is described.There were more female respondents (63%) than male.Most served low-to middle-income patients (combined 90%) and worked primarily in hospital settings (85%).Almost all identified the area where they practiced as urban (91%) and within the public sector (92%).
The reported training experience for key children's environmental health topics are portrayed in Figure 1.The response rate was high (94-97%) for the individual questions in this section. Among

Research
The respondents were also asked to provide open-ended responses listing the three most important CEH problems in Vietnam (Figure 2) and their local community.Eighty-four percent of the survey takers provided their top national topic, with 82% and 71% providing their second and third national topics, respectively.The most popular responses for the top national environmental health problems were air pollution (25%), water contamination (19%), food safety (14%) and tobacco smoke (14%).Few noted waste disposal (2%), asthma and respiratory health (1%), sanitation (1%), and school exposures (1%).Top priorities for their local regions were comparable (data not shown).
Several of the questions related to environmental health experience, attitudes, or behavior in everyday practice.Many (80%) endorsed asking about the environments where a child lives, plays, and goes to school during clinical history taking.A smaller majority (64%) reported it is very important to include environmental exposure questions in the clinical history, with 36% indicating it is somewhat important and none reporting it is not important.Seventyfour percent of those who responded reported parents sometimes pose pediatric environmental health questions.When asked for their opinion on how much control pediatricians have over environmental health hazards, 51% indicated minimal control, 41% identified some control and only 8% reported much control.
In response to self-efficacy questions about taking an environmental history, less than half (39%) were confident, half (51%) somewhat confident, and 9% were not confident.More than a third (40%) were confident, more (47%) were somewhat confident and 13% were not confident discussing the In order to calculate percentages for each category, we summed all the respondent rankings (from each of the 141 survey respondents) in all categories, regardless whether they were first, second, or third in importance, to generate our base (n=335).For the numerator, we used the frequency of all first, second and third responses within each category.The chart total does not equal 100% due to rounding.thefigure.Providers were also asked about care of their pediatric patients who work.Forty-six percent of those who responded had experience with a workrelated pediatric injury and 32% had experience with a work-related toxic exposure (Figure 3).Two-thirds (67%) of the providers reported inquiring about toxic work exposures during the clinical history.When providers identify youth exposed to dangerous working conditions, nearly all (90%) considered it their responsibility to take action.Many would act by informing parents (68%) and some would also contact the employer (19%), the government (10%), an NGO (2%) and/or other venue of support (1%).Their confidence that the dangerous situation would be addressed was low, with 60% not confident, 30% somewhat confident and 10% confident.

Discussion
We surveyed 141 pediatric HCPs in Vietnam to inform future efforts toward development of pediatric environmental health expertise and capacity in the region.We found pediatric HCPs endorse environmental hazards in child health as an important topic that is routinely encountered in their care of patients, but training, experience, and perceived self-efficacy on these topics are limited.
Similar surveys of pediatric providers in developing countries are not in the published literature for comparison.However, surveys conducted among pediatric care providers in the United States and Canada in the last decade demonstrate similar themes.These studies find that pediatric HCPs in these developed-nation settings also recognize the importance of environmental factors in child health and commonly receive questions from patients and families on these issues. 6-10However, as in our survey in Vietnam, providers in the United States and Canada report training and resources for these topics is limited yet desired. 7,8,11Similar to our findings, self-efficacy is generally low but varies by topic.10][11] These other surveys did not include data on provider perspectives regarding working youth.In Vietnam, we found working youth health hazards are commonly encountered

Figure 3 -Pediatric Care Provider Self-Reported Experience With Patients Affected by Environmental Exposures
The total number of survey respondents was 141, but not all respondents answered every question.The number of respondents for each question is reported in the chart.

Conclusion
Based on WHO estimates, 25% of the global burden of disease is due to preventable environmental exposures with the greatest burden to children in low-income and developing countries.

Table 1 -Demographic and Professional Characteristics of Pediatric Health Care Providers Surveyed in Vietnam (n=141*)
the 15 topics, respondents most frequently endorsed having received: specific training for waste disposal and sanitation (53%); environmental asthma triggers (52%); food safety (52%); environmental tobacco smoke (52%); and pesticide poisoning (36%).The topics for which respondents were least likely to *Not all questions were answered by all survey respondents.Beaudet et al.Research Pediatric Environmental Health Experience in VietnamFigure 1 -Pediatric Care Provider Self-Reported Training Experience by Topic AreaThe total number of survey respondents was 141, but not all respondents answered every question.The number of respondents for each question is reported in the figure.

Table 2 -Respondents Training Interests (Open-ended, Top 3 priorities a , n=300) Air Pollution Asthma and Respiratory Health Water Contamination Food Safety Non-Specific b Other c Tobacco Smoke
on child health, pesticide poisoning, heavy metal poisoning, lead poisoning, prenatal toxic exposures, genetic diseases, pyodermatitis, skin diseases, arsenic contamination, dioxin/Agent Orange exposure, infectious diseases, television, child and safety toys. ).

2,4,28,29
33. Do you gather information about the environment where the child lives, plays and studies (e.g.school)?☐ Yes ☐ No 34.Do you gather information about any toxic exposures a youth might have from doing work within or outside of the home?☐ Yes ☐ No Pediatric Environmental Health Experience in Vietnam Beaudet et al.