meaning of environmental factors in education

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Environmental factors in school classrooms: How they influence visual task demand on children

Kalpa negiloni.

1 SankaraNethralaya, Unit of Medical Research Foundation, Chennai, India

2 Shanmugha Arts, Science, Technology & Research Academy (SASTRA) University, Thanjavur, India

3 Elite School of Optometry, Chennai, India

Krishna Kumar Ramani

Rachapalle reddi sudhir, associated data.

All relevant data are within the manuscript and its Supporting Information files.

The key visual factors in a classroom environment include the legibility, angle subtended at the eye, illumination, contrast, and colour of the visual task. The study evaluated the visual environmental factors in the school classrooms.

Materials and methods

The distance Visual Acuity (VA) demand was evaluated based on the size of visual task i.e. the smallest size of chalkboard writing and its viewing distance. The environmental factors which can have an effect on the visibility in classrooms such as illuminance on the chalkboard and at student’s desk, chalkboard contrast, light sources and the student’s perception of their classroom visual environment were measured. To quantify the distance VA demand and to compare with a standard high contrast VA chart measure, a validation of the measurements was performed by chalkboard simulation experiment. The “acuity reserve” to be included to the measured distance VA demand was evaluated.

We included twenty-nine classrooms of eight schools. The median distance VA threshold demand was 0.28 logMAR(0.25,0.45). The median illuminance on front desk position and chalkboard contrast was 130 lux(92,208) and 40(36,50) respectively with 62% classrooms having low illumination (<150lux). The acuity reserve evaluated to be included to the distance VA demand was 0.13logMAR and 0.29 logMAR in classrooms with optimal and low chalkboard illumination respectively which was based on the results of the simulation experiment. The median distance VA demand including the acuity reserve was 0.09 logMAR(-0.03,0.23) [Snellen Equivalent: 20/25(20/19,20/34)].

The study findings highlight the increased visual task demand in school classrooms and the need for appropriate seating arrangements in classrooms based on the visual acuity of children. The study emphasises regular audit of the classroom environment along with the school eye screening.

Introduction

The critical external factors namely illumination, acoustics, thermal quality, colour and age of school building are typical conditions in determining the quality of a classroom. The poor quality of these characteristics in a classroom can be an environmental stressor increasing strain and subsequently can reduce the academic performance of students [ 1 , 2 ]. Light of different wavelengths can influence various functions such as vision, circadian rhythms, mood, cognition and most importantly the classroom learning and performance [ 3 , 4 ]. Poor lighting reduces visibility and can cause visual discomfortleading to disinterest and lack of concentration. There is a need to understand the classroom visual environment in schools. While the trend of smartboard use is emerging in Indian classrooms, it is far from replacing the conventional chalkboard system (black/ green). Maintenance of good contrast levels on the chalkboard is a prerequisite for better visibility. The Bureau of Indian Standards (BIS) recommends glare index of 16 and lighting level of 150–300 lux on the chalkboard and student desk in a classroom. The evidence of the existing lighting levels in a classroom meeting this stipulation is limited [ 5 , 6 ].

Children spend one-third timein a day at school performing tasks that rely on varying visual demands. Reading and writing from chalkboard is an important visual task in a classroom. The demand imposed on the visual system for better visibility of the visual task is the visual acuity demand and demand for the better performance of the task is the visual task demand. The distance and near visual acuity demand in South Indianschool classrooms and the classroom parameters were evaluated and compared to the recommendations provided by the Indian Standards. An increased distance visual task demand of 20/30 was reported which was based on the writing on the chalkboard and its viewing distance [ 7 ]. However, factors such as the illuminance levels, letter legibility, stroke-width and chalkboard contrast can have an effect on the visual acuity measure. This necessitates the estimation and the inclusion of an acuity reserve to advice on distance-visual performance in a school classroom. This study aimed to evaluate the classroom visual environment factors such as the distance visual acuity demandbased on the chalkboard writing and including the acuity reserve, illuminance levels on the chalkboard and at student’s desk, chalkboard contrast and the student’s perception of their classroom visual environment. These visual environmental factors were compared to the visual capability of an individual in the classroom, to estimate the proportion of children under visual stressin their respective classrooms.

This is a cross-sectional study conducted in schools located atChennai, South India during August 2014 to February 2015. The classroom visual environmental factorssuch as distance visual acuity demand, chalkboard and desk illumination, light sources, chalkboard contrast and student’s perception of these visual factors were evaluated. We included all the schoolswhich were a part of our regular eye screening programme in schools. This study was approved by the Institutional Review Board and Ethics Committee. We obtained written informed consent from the school authorities and study participants prior to the study.

Visual acuity demand

One class representing each grade in every school was selected randomly and 29 such classrooms (grade four to 12) of eight schools were included in the study. The distance Visual Acuity (VA) demand was evaluated based on the chalkboard viewing distance and the vertical height of lower case letters of the teacher’s handwriting (in English language only) on the chalkboard applying the same formula and calculation as in previous studies [ 7 , 8 ]. The visual angle subtended at the eye by the visual task was measured based on the viewing distance and visual task size to calculate the snellen and logMAR equivalent distance VA demand. A minimum of 30 letters (centre and side positions) on the chalkboard was measured using a millimetre scale in each of the measured classrooms due to the variability in handwriting (consistency) on the chalkboard. During measurement, care was taken to avoid parallax error. Capital letters and small case letter writing on the chalkboard were excluded and all the measurements were taken by a single observer. The student’s desk was categorised as front, middle and last desk positions (1 to 9) as shown in Fig 1 . The viewing distance from the centre of the chalkboard to all these positions was measured thrice and its average was taken. The distance visual acuity threshold demand was evaluated based on the smallest letter size and longest viewing distance in a classroom.

Chalkboard simulation experiment

To compare the obtained distance VA demand with a high contrast standard visual acuity chart (Early Treatment Diabetic Retinopathy Study, ETDRS logMAR chart) measure, a validation experiment was designed to identify the “acuity reserve” or “conversion factor” under optimal (150–300 lux) and low (<150 lux) [ 5 , 6 ] illumination chalkboard simulation, to advice on the distance visual performance.

The inclusion criteria were subjects with binocular visual acuity better than 20/200 and the presence of low to moderate myopia. Thirty optometry students and optometrists were included with a mean age of 23.7±3.2 years (19, 32). All the subjects had bilateral myopia with mean spherical equivalent power of -1.71±0.68 D (-0.75D, -3.50D) in the eye with low myopia and better unaided visual acuity. The unaided monocular and binocular VA of the subjects was evaluated using an ETDRS logMAR VA chart (Precision Vision, La Salle, Illinois) and recorded. The mean unaided visual acuity in the eye with better visual acuity was 0.72±0.19 logMAR (0.40, 1.00).

Experimental set up

A black chalkboard was used for classroom simulation experiment. Lowercase of English alphabets without any ascenders and descenders were selected to fit a 5x5 grid. The height and width of the letter were maintained with a fixed dimension of 3.4cm based on the previous study i.e. the average size of teacher’s writing [ 7 ]. A total of three sets with six lower case letters in each were designed. All the subjects were positioned at a farther distance i.e. the distance where the subject cannot recognise any letters written on the chalkboard. The distance between the chalkboard and subjects was initially set at 12 m. The subjects were asked to move slowly and gradually closer towards the chalkboard, maintaining the chalkboard at their eye level, till a point when they could recognise the letters on the chalkboard. The criterion was set as recognising at least four out of six letters. The distance from the chalkboard to the point of recognition of letters was measured and marked as D1. This was repeated thrice with different sets of letters to avoid memorising the letters and the average of the distance was taken. To represent a classroom environment, tube light which was the common artificial light source in schools was used. The uniformity value for illuminance on the chalkboard was calculated as the minimum illuminance value divided by the average illuminance value [ 9 ]. The average illuminance level on the chalkboard measured using a Luxmeter was 200 lux (uniformity index: 0.80) for optimal simulation and 90 lux (uniformity index: 0.84) for low illumination simulation.

Based on the viewing distance for a fixed letter height, the chalkboard simulation visual acuity was calculated. Based on the vision level or ETDRS visual acuity of the subject, the actual visual acuity required to view the fixed letter height was evaluated. The difference in visual acuity measure between the actual visual acuity value and chalkboard simulation under optimal and low illumination were calculated. This difference was considered as the “acuity reserve” or “conversion factor” to be included to the measured distance visual acuity demand for the chalkboard under low and optimal chalkboard illumination.

Illumination and contrast on the chalkboard

The illumination levels on the chalkboard and student’s desk were measured twice during a day (between 8:30–9:30 AM, and between 03:30–04:30 PM) using a calibrated luxmeter (LX 101, Lutron Electronic Enterprise Co., Ltd, Taiwan). All the measurements were taken on a bright sunny day (30° to 34°C). The uniformity value for illuminance on the chalkboard and student’s desk was calculated as the minimum illuminance value divided by the average illuminance value [ 9 ]. The total number and positioning of the doors, windows and artificial light source (including working condition) was documented for each classroom. A calibrated photometer (PR-655 Spectrascan Spectroradiometer, Photo Research Inc., Chatsworth, CA) was used to measure the luminance levels (quantified in Cd/m 2 ) of the letter on the chalkboard and its background. The measurements were repeated twice, during the morning (first lecture hour, AM) and afternoon (cleaning the chalkboard and minimum of three-time chalkboard use, PM). The contrast levels were represented as Weber contrast (Luminance (L) contrast = L background - L target / L background ). The student’s desk was categorised as front, middle and last desk positions (1 to 9) as shown in Fig 1 . The illuminance levels and the visual acuity demand at these desk positions were evaluated.

Student’s perception of classroom environment

The survey of student’s perception of chalkboard visibility, lighting levels on their desk, the presence of glare and contrast levels on the chalkboard was evaluated by administering a four-item structured (closed-ended) questionnaire ( S1 Text ). The survey questions included visibility on the chalkboard, lighting levels, glare and, chalkboard contrast. Students were queried regarding the presence or absence of glare on board and the position of glare (centre or side position) on the chalkboard if present. The illumination levels (lighting) on the desk perceived by students was categorised as poor, normal or excess lighting. The contrast of letters on the chalkboard were categorised as good or poor contrast. Questions were asked in English and alsoexplained in the local vernacular language (Tamil) if questions were not clear. Details regarding the seating positions of these students in their respective classroom were documented.

Evaluation of visual stress in classrooms

The distance visual acuity demand when children are seated at different desk positions in their respective classrooms was evaluated. The acuity reserve was included to the measured VA demand based on low or optimal illuminance measures on the chalkboard in the respective classrooms.

The average class size of 29 classrooms included in the study was 36±10 children (20, 58). A total of 1038 children (51% girls) were present in the measured 29 classrooms. Based on the report of vision screening performed in these schools, the distance visual acuity was measured using a Pocket vision screener (PVS) with a cut off visual acuity level of 0.20 logMAR or 20/30. The vision screening report noted only one child of 1038 children having best corrected visual acuity of 20/200 in both the eyes. All the other children had best corrected visual acuity of better than 20/30. Based on the vision levels of children, the proportion of children under visual stress in their respective classrooms was evaluated. “Visual stress” was defined as “visual requirement in excess of what the child has”. The risk of visual stress in classrooms was measured by calculating the proportion of classrooms with visual acuity demand worse than 20/30. We analysed the risk of visual stress at different desk position in classroom with the 20/30 cut off visual acuity.

Statistical analysis

All the data was entered in Excel (Microsoft office 2013) and the statistical analysis was performed using IBM Statistical Package for Social Sciences (SPSS) version 20. Descriptive analysis of the classroom environment variables was performed and the values were presented as median (interquartile range 25 th and 75 th percentile). Non-parametric tests were performed and p-value less than 0.05 was considered as statistically significant.

Visual acuity demand and chalkboard simulation experiment

The median distance visual acuity threshold demand based on the smallest size of the chalkboard writing and longest viewing distance was 0.28 logMAR (0.25, 0.45) in twenty nine classrooms of eight schools ( S1 Table ). Based on the chalkboard simulation experiment, the median visual acuity under optimal and low illumination chalkboard simulation was approximately one and a half logMAR lines (Median: 0.13 logMAR) and three logMAR lines (median: 0.29 logMAR) less than the actual ETDRS acuity and the difference was statistically significant (optimal; p = 0.008 and low; p<0.001). After including the acuity reserve, the median visual acuity threshold demand was 0.09 logMAR (-0.03, 0.23). The median VA demand at front desk position was 0.50 logMAR (0.35, 0.62).

The illuminance level and the uniformity index on the chalkboard are presented in Table 1 . The median illuminance level on the chalkboard and student’s desk positions (1 to 9) categorised based on low (<150 lux), optimal (150–300 lux) and excess (>300 lux) levels are presented in Table 2 and Fig 1 . In each of the observed classrooms, on an average twofluorescent lamps (range, 1–6 tube lights), twowindows (range, 1–4) and onedoor (range, 1–2) were theavailable light sources. Five classrooms had no artificial light source and were dependent on three to four windows and one door for lighting. Seven classrooms with 3–4 tube lights and 1–2 lights were found in non-working/ unrepaired condition. The mean illuminance level on the front desk position in the five classrooms without artificial light source was 204±150 lux (range, 47–435). The mean illuminance level of students sitting beside window was 313±276 lux (range, 45–1252), directly below tube light was 243±177 (57–816), and in other positions it was 152±165 lux (22–1210).

IQR—Interquartile range. Descriptive information on the range is provided to present the maximum and the minimum limit of the variables

IQR- Interquartile range. Descriptive information on the range is provided to present the maximum and the minimum limit of the variables

The contrast of letters on the chalkboard during first and last lecture hour (cleaning the chalkboard and minimum use of the chalkboard, 3–5 times) was assessed in 10 classrooms of four schools. The mean luminance levels on the surface of the board (L background ) measured during the start of the day (first lecture hour) was 1.30 ± 0.59 Cd/m 2 (0.39, 3.52) and during the last lecture period was 1.46 ± 0.56 Cd/m 2 (0.61, 3.98). The mean Weber contrast during the first lecture was 43 ± 13 (20, 71) and 39 ±11 (21, 59) during last lecture hour and was statistically insignificant (p = 0.440). There was statistically no significant difference in the Weber contrast between 10 measured classrooms between the first (p = 0.994) and the last measurement (p = 0.928). In a newly painted blackboard, the mean Weber contrast was 71 ± 4 (66, 77).

A total of 343 children (grades four to ten from 12 classrooms) responded to the survey questions. Twenty-eight (8%) children reported that the letters on the chalkboard were not visible in their respective classrooms from their seating (desk) position. Among them, four children were noted to have uncorrected refractive error. Regarding illumination level, 13% (45 out of 343) children perceived their desk illumination to be poor, 83% (285 out of 343) as normal lighting and 4% (13 out of 343) children reported excess lighting. Based on the categorisation of actual illuminance on student’s desk, 54% (185 out of 343) desk positions had illuminance level less than 150 lux, 42% (143 out of 343) had illuminance between 150–500 lux and 4% (15 out of 343) had illuminance more than 500 lux. The actual illuminance level was compared to student’s perception of lighting levels on their desk position as shown in Fig 2 . The presence of glare on the chalkboard was reported by 26% (90 out of 343) children, with 72% (n = 65) reporting glare on the sides of the chalkboard. A total of 208 children responded to symptom survey related to contrast. Among them, 28% of students perceived chalkboard to have poor contrast levels in their classrooms (Actual mean contrast: 41±11) and 72% perceived the boards in their respective classrooms to have good contrast levels (Actual mean contrast: 46±11).

Visual stress in classrooms

The visual acuity demand and proportion of classrooms with increased demand(> 20/30), when children are seated at different desk positions are presented in Fig 1 . Optimal illuminance level (150–300 lux) on the chalkboard was noted in 31% classrooms (n = 9) and the remaining 69% classrooms (n = 20) had low illumination level (<150 lux). Overall, nine classrooms had VA demand greater than 20/30 causing visual stress in children. The proportion of children and classrooms under the risk of visual stress when seated at different desk positions (front, middle and last) is presented in Fig 3 . A logistic regression was performed to ascertain the effect of student desk position (front, middle and last row) on having visual stress. We found that the children seated in middle row had an Odds of 4.34 (95% CI 3.592, 5.254, p<0.05) times risk of visual stress when compared to children seated in front row. Similarly, when seated in last row they had an Odds of 9.12 (95% CI 7.467, 11.129, p<0.05).

Proportion of children under visual stress in different desk positions is based on comparing the visual acuity level of children and their respective classroom visual demand.

Proportion of classrooms under visual stressin different desk positions is based on comparing the classroom visual acuity demand and cut off acuity demand level of 20/30.

This study highlights the existing levels of the school classroom visual environmental factors. The study recommends an acuity reserve of one and a half lines (0.13 logMAR) and three logMAR lines (0.29 logMAR) to be included to the distance visual acuity demand evaluated for chalkboard writing under optimal (150–300 lux) and low (<150 lux) illumination respectively to compare with a standard visual acuity chart measure.

An increased average distance visual acuity demand of 20/25 was noted in classrooms which were based on the smallest chalkboard writing and longest viewing distance in the classroom. The average visual acuity demand was 20/63 for children seated in the front desk of the classrooms. The findings highlight the presence of increased visual task demand in viewing the chalkboard in school with optimal and low chalkboard illuminance levels.

Good lighting is an essential component in designing a school building. The Government of India recommends standard lighting design for Educational Buildings, especially schools, as the premises are used for awide range of activities embracing a complex array of different visual tasks. The study results highlight that illuminanceof less than the standard recommendation of 150 lux was noted on student’s desk in more than 38% classrooms. The illuminance levels werelower in the middle desk positions in the classroom as compared to other desk positions. This could be due to the positioning of light sources (artificial and natural light). Children with poor vision, slow learners, or other difficulties are usually placed in the front desk position in a classroom. The illuminance front desk position on 62% of the classrooms in the study had lower illuminance levels, which was consistent with previous research. A study conducted in schools of Dharward, India reports that the classroom interior standards, including the illumination, were found to be lower than the BIS recommendation [ 10 ]. The levels of uniformity in illuminance level of chalkboard and desk in most of the classrooms were below the recommended value of 0.8 [ 9 , 11 ]. Variation in daily weather conditions can affect the measured illuminance levels. The current study limited itself only to lighting measurement performed on a single day. However, the data collection was performed on a bright sunny day and measurements were taken twice in a day. The classroom interiors need to be redesigned to provide uniform illuminance levels on chalkboard and students desk. The ancient to 20 th century school classrooms have always been designed with rings or rows of seats to focus the attention of many towards one. The difference has been open classroom lit with natural sunlight as opposed to closed rooms with an additional artificial light source. Good lighting has a positive effect ona student’s learning and performance in a classroom. Classrooms are now dependent on artificial light sources in addition to the natural light sources. With technological improvement, light source designed for school vision has been found to increase reading speed by 35%, decrease in frequency of errors by 45% and the decrease in hyperactive behaviour by 76% and saving energy up to 57% [ 12 ]. One of the major public health problems globally studied is the myopia which has genetic and environmental risk factor. The prevalence of myopia in children has significantly increased in Asian countries, including in India [ 13 ]. The important environmental risk factors being studied are increased near work, less outdoor, visual environment and ergonomics, and urbanisation [ 13 ]. Hua et al found that higher ambient light level is a protective factor for non-myopic students on myopia onset and retarded axial growth in myopic and non-myopic students [ 9 ]. Norton and Siegwart based on their detailed review of literature proposed a model supporting optimal illuminance levels as a protective factor for normal refractive development and lower light levels for causing myopia progression possibly due to the elevation of retinal dopamine activity [ 14 ]. Zhou et al designed a bright classroom with an aim of resembling the light conditions to outdoors and to prevent myopia progression [ 15 ]. Children and teachers rated better reading comfort at different intensities in bright classrooms compared to the traditional classrooms.

In school classrooms, the contrast of letters on conventional board system (black/green chalkboard) is an important factor for better visibility. The contrast reduction due to ocular disorders and reduced contrast of the task material, both have an effect on visibility and learning. Decreased contrast can reduce visual span, reading speed and saccade size in reading. BIS recommends the chalkboard to be painted matt black or green with reflection factor maintained between 15–30% to ensure easy readability from any point in a classroom [ 5 , 6 ]. The current study reported no difference in the contrast levels with cleaning and using the chalkboard several times during a day. The contrast measure may be affected by various factors such as the illuminance on the surface of the board, reflectance property based on the thickness of the chalk material and the period of board use. The current study used a calibrated and reliable photometer for the best possible contrast measure. In one of the classrooms, a newly painted blackboard had the contrast range of 66 to 77, highlighting the influence and need to maintain recommended luminance on the board for better visibility.

An interesting finding in the current study was that students sitting in desk position with low illuminance levels (less than 150 lux) perceived and reported lighting levels were normal (60%)or excess (9%) at their desk. This could be due to the adaptation of the visual system under different illumination through a coordinated action of the mechanical, photochemical and neural process in the visual system. This cannot be generalised considering the response bias and understanding of normal illuminance level by children. Presence of glare on the side portions of the chalkboard reported may be due to the reflections from the doors and windows which are generally positioned in the corners of a classroom. Further study on the effect of a range of light levels on the visual system would aid providing a better visual classroom environment for children without visual stress and discomfort.

An increased visual acuity demand in viewing the chalkboard is reported by including the acuity reserve based on the chalkboard illumination. The study also highlights that the visual acuity demand did not match the vision levels of children, causing visual stress. We report 23% of children in front desk and 73% seated in last desk position did not meet the visual demand in their respective classroom. Even children with normal visual acuity or better than 20/30 acuity were at risk of visual stress in their classrooms when seated at last desk position. Children with visual impairment or low vision when seated in front desk were at risk of visual stress with an average visual demand of 20/48 acuity. This suggests the need for visual environmental modifications in school classrooms. Children with mild to moderate visual impairment can be advised on the size of chalkboard writing and seating position in a classroom to continue mainstream schooling. A recent study on children with “mild visual impairment” and range of “20/400 to 20/200” visual acuity, suggest a maximum of 4.3m and 85cm to 1.7m as the viewing distance from the chalkboard to view the chalkboard writing with a minimum size of 3cms and 4cms respectively [ 16 ].

An increased visual acuity demand was noted in school classrooms with varying lighting and contrast demand. Majority of classrooms had measures below the standard recommendations. Children with normal visual acuity in few of the measured classrooms did not meet the visual acuity demand in their respective classrooms. Further assessment of the effect of classroom visual factors in children with visual anomalies may provide additional important information. The inclusion of acuity reserve based on the type of classroom illumination can aid a clinician to understand the chalkboard visual acuity demand and recommend classroom modifications for varying levels of visual acuity of children. The children with visual impairment can be advised on the classroom environmental modifications and can continue in mainstream schools. This study also highlights the need for regular audit of environmental variables of the school classrooms along with school eye screening.

Supporting information

Acknowledgments.

We would like to thank all the school authorities and the subjects who have participated in this study. Our special thanks to Mr. Shankar Malhari for improvising the technical writing of the manuscript.

Funding Statement

The author(s) received no specific funding for this work.

Data Availability

UNESCO declares environmental education must be a core curriculum component by 2025

Over 80 ministers and vice ministers and 2,800 education and environment stakeholders committed to taking concrete steps to transform learning for the survival of our planet by adopting the Berlin Declaration on Education for Sustainable Development (ESD) at the end of a three-day virtual World Conference held from 17 to 19 May.

The Conference, followed online by over 10,000 viewers, was organized by UNESCO in cooperation with the Federal Ministry of Education and Research of Germany and the German Commission for UNESCO as advisory partner.

UNESCO has called for Education for Sustainable Development to be a core component of all education systems at all levels by 2025.  

UNESCO’s launch of a new publication , which analyzed educational plans and curricula frameworks in close to 50 countries informed the discussions. UNESCO found that more than half make no reference to climate change, while only 19% speak about biodiversity.

The Berlin Declaration on Education for Sustainable Development outlines a range of policies to transform learning encompassing teaching, learning, professional training and civic engagement. It also highlights the need to implement Education for Sustainable Development with focus on cognitive skills, social and emotional learning, collaboration skills, problem solving, resilience-building.

“We need training for sustainable development not to be a privilege but accessible to all people. The success of the Education for Sustainable Development programme for 2030 will bring us closer to all the SDGs,” said German Chancellor Angela Merkel in her welcoming address, describing Germany’s broad network of partners working on sustainability at all levels of education and training.

Throughout the Conference, countries shared plans to integrate Education for Sustainable Development. Ms Anja Karliczek, Germany’s federal minister of education and research, shared the commitments of 18 countries of the European Union to implement the Education for Sustainable Development for 2030 framework, underscoring it as a driver for the achievement of all the SDGs.

Laurent Fabius, who presided COP21 where the Paris Agreement was sealed, stated the “fight against climate change begins at school.”  He recalled commitments in the Paris Agreement to education, and called for increased efforts to improve teacher training on ESD and increase financing. “2021 is the year in which we will overcome the pandemic and embark on a sustainable development model for the future that must include ESD. If we miss this occasion, we will lose decades. This is a race against the clock.”

The voices of young people were given a platform throughout the Conference, as those leading the call for change so that they can #LearnForOurPlanet.

The adoption of the Berlin Declaration will create momentum for the implementation of ESD for 2030 Roadmap – the framework for this decade of Education for Sustainable Development. Every UNESCO Member State will be asked to create a network of actors who together can implement the ambitious vision for education.

From Berlin, 2021 will provide key opportunities for governments to apply this commitment, including the United Nations Biodiversity Conference (COP 15) and the United Nations Climate Change Conference (COP26) in Glasgow.

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Event International Conference of the Memory of the World Programme, incorporating the 4th Global Policy Forum 28 October 2024 - 29 October 2024

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However, inflammation caused by processed and sugary foods leads to decreased blood flow and slowed body functions, reducing concentration and memory.

Students should be encouraged to drink half their body weight in ounces of water per day in addition to eating lean proteins, fibre, and fresh fruits and vegetables.

True enough, what we eat makes us what we are.

It doesn't matter to the brain whether or not the laughter is genuine. In both cases, four "happy" chemicals—serotonin, oxytocin, dopamine, and endorphins—will be released from the brain.

Blood flow, attention, engagement, memory, T-cell production, and immune function are all boosted by these chemicals.

Stress, anxiety, blood pressure, and muscle tension can all benefit from these chemicals.

Make your students laugh by sharing humorous anecdotes and jokes throughout the day, and remember to laugh, laugh, and laugh some more yourself.

Millions of students around the world struggle with academics. Dr. Study provides a variety of online learning and tutoring programs to assist your child to get ahead.

Creating Environments To Support Young Children’s Development

It is widely accepted that early childhood is a formative period for shaping a child's development and future happiness.

Many adult societal outcomes (such as physical and mental health, criminality, and educational attainment) have been shown to have their origins in early childhood experiences.

This is why it is so important to put resources into this period of a child's life.

In addition, the local government has a major impact on the process of creating kid-friendly public spaces.

• This article provides the most convincing evidence to date on how children's physical environments affect their growth and development.

This has the potential to assist municipal governments in meeting their obligation to shape the form of their cities.

What Physical Environmental Factors Affect Early Childhood Development?

Evidence on the effects of early childhood environments on development ranges from high-quality meta-analyses and systematic reviews to low-quality single-study and case-study evidence.

• Some of the physical environmental factors that affect a child's growth and development in the first few years of life have been suggested by the current best available evidence.

According to global standards, this article focuses on infants, toddlers, and children up to the age of eight.

The Built Environment

An extensive review of Australian evidence suggests that environmental toxins (such as fine particles from traffic) negatively impact children's neurological development. The effects of even mild exposure to environmental toxins on infant and child brain development are profound.

When children don't have to worry as much about being hit by a car, they are free to explore their surroundings at will.

As a result, young children benefit from more chances to engage in play, spontaneously interact with others, and use physical activity as a means of transportation.

For the same reasons, it's thought that having access to child-friendly public spaces (like health and social services, kindergartens, and schools) close to the child's home is good for their development in the early years.

• However, more study is needed to determine how the built environment influences children's growth and development.

Nature And Open Public Spaces

Early childhood development, particularly in terms of physical and mental health, has been found to benefit from exposure to green spaces in several systematic reviews. Nature and public open spaces (like playgrounds, school grounds, club/pay facilities) can also aid in the growth and development of young children, so increasing their availability is important.

Outdoor settings and public parks are ideal places to engage in risky and creative forms of play, as well as to meet new people and get some exercise.

More privileged children often have backyards with benefits that are comparable to what less privileged backyards offer, so this may be of even greater significance for children from lower socioeconomic backgrounds.

Climate And The Physical Environment

Extreme heat and warmer temperatures have been linked to negative effects on children's growth and development.

And because they rely on their carers for basic necessities like moving to a warmer/cooler area, donning a coat, and consuming liquids, young children are especially vulnerable to weather extremes.

• In light of the growing negative effects that climate change is having on people's health, new research suggests that the impact of climate change and weather extremes on children's development should not be overlooked.

Given that future climate change impacts are projected to be even more severe, it's crucial to keep this in mind.

It has been shown, for example, that pedestrians can benefit from the shade provided by street tree canopies and that parks and other natural areas provide a cooler space during warmer weather.

It has also been shown that street trees can reduce temperatures for pedestrians.

What Can Municipalities Do To Support Early Childhood Development?

In their capacity as custodians of the public's trust, local governments have the power to shape the built environment and set standards for how it is used by families with young children.

The most recent and relevant studies suggest that there are a variety of adjustments that municipal governments can make to better facilitate early childhood development.

• Foster children's natural curiosity and curiosity about the world around them. This could be achieved by increasing the accessibility and availability of green, open spaces and by creating safe, walkable neighbourhoods with reduced exposure to vehicular traffic.
• Prevent young children's exposure to harmful substances in the environment. This could include providing optimal temperature control in indoor environments frequently frequented by young children and reducing high traffic exposure near child-relevant destinations (child care centres, libraries, swimming pools).
• Families and kids should be included in neighbourhood planning. This isn't always simple, but there are guides(link is external) that can help you figure it out.

When designing environments to foster children's early learning and development, local governments may need to collaborate with other child-focused groups in the area.

Preschool And The Transition To School 

In all five of the developmental domains measured by the AEDC, preschool attendance was associated with reduced vulnerability.

Children who participate in preschool programmes may benefit from the stimulating and structured learning opportunities that help them develop academically, socially, and emotionally.

On the other hand, children who were cared for in daycare but not in a preschool programme, as well as those who were cared for informally by non-parents or who were cared for solely by their parents, showed higher rates of developmental vulnerability.

In addition, children living in the poorest areas were less likely to enrol in preschool than their counterparts.

Both privileged and underprivileged children benefited from preschool, but those from underprivileged backgrounds were more likely to be vulnerable than their peers who did not participate in preschool.

Children living in low-income areas who did not attend preschool were at greatest risk. Attending preschool has been shown to improve a child's chances of reaching their full potential and making a smooth transition into elementary school.

• Consequently, it is possible that early developmental vulnerabilities and inequities are exacerbated by the lower rates of preschool attendance among children from low-income families.

To learn more about how early childhood education and care affects children as they get ready for school, check out the research snapshot.

You want the best for your children and that includes giving them a strong foundation in maths , english and early childhood learning .

With Dr Study, you can be sure that your child is getting the best possible early childhood education that is tailored to each their needs.

Frequently Asked Questions

What are the 5 environmental factors, what are the four factors that influence learning.

There are a number of the factors that influence an individuals learning like  movement, repetition, feedback, stress, and emotions .

What Are the Factors That Influence Learning?

• Intellectual factor: The term refers to the individual mental level. ...
• Learning factors: ...
• Physical factors: ...
• Mental factors: ...
• Emotional and social factors: ...
• Teacher's Personality: ...
• Environmental factor:

What Are the Environmental Factors That Influence Students’ Behaviour?

These factors are related to the external system, namely the school, peer pressure, the family, the community and the media. They are the social systems in which other people influence students in their daily life.

How Does the Social Environment Affect Learning?

The social environment influences learning by creating a language environment and an experience environment that stimulates the mind to grow and systematically rewards a child for learning. We see now more clearly than before that there are critical periods for mental development in the pre-school years.

The conditions in which we grow can either foster or hinder our capacity for learning. Students' academic success can be hindered by adverse environmental factors such as poverty and violence, but they can benefit from the guidance of knowledgeable educators and loving family members.

This article's purpose is to offer advice on how to ensure your children have the best possible conditions at home and at school for their intellectual development. Air and noise pollution, as well as the intensity and duration of daylight, are just a few environmental factors that have been shown to have an impact on students' ability to learn.

Due to its potential to significantly impact learning, context plays an essential role in the educational process.

Researchers have found that pre-schoolers who are exposed to particular types of music show significant improvement in spatial reasoning skills compared to their non-listening peers.

Adults, in particular, benefit from working with others as opposed to working alone on projects.

Genetics are less of a factor than previously thought in determining academic achievement, according to recent studies.

It's crucial to zero in on the most significant aspects of a school's setting, such as the quality of relationships, the level of stress, and the nature of the expectations placed upon students.

Establishing trusting connections with students, using visuals, project-based learning, discussion, and pre-during-post comprehension strategies, and providing rubrics, assignment samples, and opportunities for continuous feedback have all been shown to reduce disruptive conduct and anxiety in the classroom.

It's crucial to provide students with ample time for self-reflection and additional attempts at high-stakes tests and assignments on which they may have underperformed.

If you want your brain to grow and develop at its full potential, you should get between 9 and 13 hours of sleep each night and engage in at least two hours of vigorous physical activity each day.

While fueling your body with the nutrients it needs to perform at its best is essential, the inflammation caused by processed and sugary foods can impair your ability to focus and remember things.

All students, in addition to eating lean proteins, fibre, and fresh fruits and vegetables, should consume half their body weight in ounces of water daily.

The local government can have a significant impact on the development and future happiness of children by making public spaces more child-friendly.

Meta-analyses and systematic reviews provide the highest quality evidence on the effects of early environments on development, while single studies and case studies provide the lowest.

This article presents the most compelling evidence to date on the ways in which children's physical environments affect their growth and development, and it may help local governments fulfil their responsibility to shape the form of their cities.

Exposure to green spaces, such as playgrounds, school grounds, and club/pay facilities, has been found to be beneficial for early childhood development, particularly in terms of physical and mental health.

Parks and other outdoor spaces should be made more accessible because they are great places for people of all ages to socialise, get some exercise, and engage in risky and imaginative play.

It is essential to bear in mind the evidence linking climate change and weather extremes to detrimental effects on children's growth and development.

This data suggests that bilingual children enter regular schools with a slight developmental head start.

Children from low-income families were more likely to be vulnerable than their more affluent peers who did not attend preschool, despite the fact that preschool participation was associated with reduced vulnerability across all five developmental domains measured by the AEDC.

A child's developmental vulnerabilities and inequities may be exacerbated by the lower rates of preschool attendance among children from low-income families, despite the fact that research shows that preschool attendance increases a child's chances of reaching their full potential and making a smooth transition into elementary school.

Reviewing the research synopsis, one can gain a better understanding of the effects of ECEC on young children.

The purpose of this research was to investigate the impact of socioeconomic disadvantage on the relationship between AHDN and academic trajectories, as well as the academic trajectories of elementary school students with known and suspected health and developmental conditions.

Content Summary

• This post is meant to give you some pointers on how to foster your kids' healthy mental growth by designing their home and school environments in particular ways.
• This article will discuss some of these influences and offer advice on how students can adopt a greener way of life to improve their health while they are still in school.
• Instil in your children the importance of healthy sleep habits, such as avoiding caffeine and sugar after noon, dimming the lights and turning off electronics a few hours before bedtime.
• The effects of even mild exposure to environmental toxins on infant and child brain development are profound.
• Important aspects of early childhood development, such as creativity, play, and a sense of ownership, can be fostered by involving children and families in urban planning.
• The purpose of this study was to describe the academic trajectories of elementary school students with known and suspected health and developmental conditions, as well as to examine the effect of socioeconomic disadvantage on the connection between AHDN and academic trajectories.
• Children with AHDN were not doomed to fail in school; in fact, a few of them were on the most successful learning paths.
• Children who are having difficulty making progress in school are more likely to benefit from early intervention if their trajectories are any indication.
• A larger portion of available resources should be earmarked for AHDN children who are also from low-income families.

Olga has a PhD in Management from Monash University. Her research focused on how personal differences and social networking impact creativity in the tech industry. She has extensive teaching experience at universities and private tutoring centers, praised for her engaging methods and clear insights. Olga also writes for top academic journals and creates innovative programs that enhance skills and consulting methods. She believes in the power of education to inspire ongoing growth in both studies and careers.

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What is Environmental Education? 

Environmental education is a learning process that increases people's knowledge and awareness about the environment and associated challenges, develops the necessary skills and expertise to address the challenges, and fosters attitudes, motivations, and commitments to make informed decisions and take responsible action.

Why Does Environmental Education Matter?

Did you grow up catching fireflies, playing in the creek, or building forts in your backyard?   Most children in today’s world won’t , which means that when they grow up, they may not have a vested interest in protecting our natural resources and natural spaces.  Environmental educators across North Carolina are working to change that. 

Environmental education is critical for a sustainable future. It provides time in, and a connection to, the outdoors which research has shown to improve academic p erformance and physical, mental, and emotional health - making it just as important for our participants as it is for the planet.  More than ever, children and adults need to know how ecological systems work and why they matter. The health of the environment is inseparable from humans’ well-being and economic prosperity . People require knowledge, tools and sensitivity to successfully address and solve environmental problems in their daily lives. 

Environmental education...has the power to transform lives and society. It informs and inspires. It influences attitudes. It motivates action. Environmental education is a key tool in expanding the constituency for the environmental movement and creating healthier and more civically-engaged communities. -North American Association for Environmental Education

Environmental education works.

Over the last few decades, thousands of studies have been completed to analyze the effectiveness of EE.  “The studies clearly showed that students taking part in environmental education programming gained knowledge about the environment. But the studies also showed that learning about the environment is just the tip of the iceberg.” (NAAEE)    

This research has demonstrated that environmental education:

Has widespread public support

Improves standardized test sc ores and academic performance

Promotes 21st century skills such as critical thinking, oral communication, analytical skills, problem solving, and higher-order thinking

Supports STEM topics and is interdisciplinary

Bolsters civic engagement and empowerment

Sparks stewardship behavior and environmental actions

Encourages students’ personal growth including teamwork, confidence, autonomy, and leadership

Increases motivation and interest in learning

Is an “equalizer” allowing educators to cater to multiple student interests, skills, abilities, and special needs,Helps improve teacher skills and classroom engagement

Is a cost-effective investment, promoting multiple environmental and societal benefits, and

Strengthens communities by connecting schools to local organizations and agencies.

To learn more about the original research, you can check out eeWorks and the Children’s and Nature Network’s Research Library.

Environmental Education Promotes

Environmental literacy.

“Environmental education is a resource that transcends the classroom—both in character and scope. In the classroom and beyond, the desired outcome of environmental education is environmental literacy.  What is Environmental Literacy? In North Carolina, environmental literacy is defined as the ability to make informed decisions about issues affecting shared natural resources while balancing cultural perspectives, the economy, public health and the environment. 

An environmentally literate citizen: 

Understands how natural systems and human social systems work and relate to one another,

Combines this understanding with personal attitudes and experiences to analyze various facets of environmental issues,

Develops the skills necessary to make responsible decisions based on scientific, economic, aesthetic, political, cultural and ethical considerations; and 

Practices personal and civic responsibility for decisions affecting our shared natural resources.

Environmental literacy is dependent upon formal education opportunities as well as nonformal education about the environment that takes place in settings such as parks, zoos, nature centers, community centers, youth camps, etc. It is the combination of these formal and nonformal experiences that leads to an environmentally literate citizenry.  North Carolina requires an environmentally literate citizenry who make informed decisions about complex environmental issues affecting the economy, public health and safety, and shared natural resources, such as the water, air and land on which life depends.” - North Carolina’s Environmental Literacy Plan

Ways to Get Involved in Environmental Education

Learn more about the organizations and research supporting environmental education. Increase our efforts to support North Carolina’s classroom teachers, naturalists, park rangers, nonformal educators, government employees, students and volunteers by contributing to EENC . Spread the word. Encourage your kids’ teachers to get involved.  Volunteer at your local environmental education center. Become an environmental educator. Join our community .

Want a printable copy of this information to share?  We have two PDF versions available:

With citations

With clickable links

The 6 Environmental Factors that Affect the Learning Process

Learning itself is the process of acquiring new knowledge, understanding, skills, attitude, behavior, and preferences. It is both an emotional and intellectual process.

A person starts learning immediately after birth, and their behavior changes throughout their life, through direct or indirect experiences.

The continuous process of learning is often affected by the environment in which it takes place. One’s individual situation and the environment contain several factors that affect the learning capacity of a person.

Learning in a healthy environment helps you acquire a deeper understanding and sound knowledge of the subject matter.

So, it is essential to be aware of such environmental factors that hamper the learning process of an individual, and learn to avoid negative stimulants to increase one’s performance.

Learning has been made effortless and accessible through distance learning that became the new normal during the global pandemic.

Students can now take their school and university classes from home and access all the information available on their fingertips.

Students willing to learn about the environment and its effect on the learning process can find free essays about environment.

There are numerous environment essay examples written by students on the internet, which can be an excellent source for better understanding the environmental stimulants.

Online learning has also facilitated professors to provide an adequate education for students in the most straightforward ways.

Along with the emergence of online learning, the pandemic has also drastically shifted the education system and learning process.

Although it has numerous benefits, it has caused a disbalance in the education system. Students with gadgets and broadband have access to study resources, and those without devices are struggling to get a proper education.

Environmental Factors that Affect the Learning Process

Some other home environmental factors that affect the learning process directly or indirectly are:

1) Family size

The children may be in a nuclear or joint family. In a nuclear family, the learner may find silence with a peaceful learning environment but may not get anyone to assist in their lessons.

However, it may be a bit noisy and messy in a joint family, but the children can find other individuals, who can help and support their studies and learn better. So, both family size has its pros and cons, affecting the learning process of children accordingly.

2) Family culture, traditions

All families have their own culture and follow their customs differently.

The culture implanted in the children during their growth shapes their perception and cognitive capacity.

Hence, the learning process is affected by family culture , traditions, religion, and other similar factors.

3) Socio-economic status

The socio-economic status of a family influences the children’s academic inclusiveness and performance during their learning.

The social class also affects the parents’ educational expectations towards their children and their educational participation. The higher the status, the higher are the chances of educational opportunities being presented to the students and vice versa.

4) Occupation/profession

The parents and other guardians in a family can teach many divergent things to a child since infancy. As such, the job of parents also affects their personality and thinking.

Parents learn many things related to their occupation and teach their children the same.

Parents are the caregiver of their offspring and play a crucial role in shaping the children’s personality, cognition, and behavior. They affect the learning process of children directly.

Children inherit parents’ traits and develop other attributes from their parents’ activities during their growth phase.

Parents are the first teachers for their babies. In such ways, the learning is affected by parents, behavior, character, cognition level, attitude, and personality.

6) Other factors

Apart from the factors above, some other factors can adversely affect children’s learning. Factors like the luminosity of light , the intensity of noise, and greenery around the home influence children’s focus while learning.

For example, students find it difficult to read and focus on a dim light and high bright light, so the light needs to be at optimum luminosity.

The surroundings can highly influence young brains, and everything present in the learning environment has the potential to positively or negatively affect the learner’s competence, confidence , and understanding.

Misalignment between the resources and needs of learners cannot facilitate the process. Instead, it demotivates the person.

The surrounding environment and family should support the learner, as it is essential for a more in-depth focus and insight into the particular subject matter.

Being aware of the home environment factors that affect learning, parents, and guardians should provide a conducive learning environment to the learner for best learning practice.

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The Importance of Environmental Education for a Sustainable Future

Environmental education is vital to winning the fight against climate change. Without it, the leaders of tomorrow will be ill-equipped to overcome the environmental challenges the world will face. Parents and teachers can help students understand their role as environmental stewards by encouraging student outdoor learning programs and supporting young folks who engage in student activism. To celebrate World Teachers’ Day 2023, which every year falls on October 5, we take a look at the importance of environmental education and how to address climate change in classrooms.

Education can make a difference in the fight against climate change. Recent surveys show that people with more education were more likely to view climate change as a threat and that, today, most people see climate change as a major threat to our planet.  

However, promoting environmental education in schools can be tricky. Climate change is seen as a bipartisan “political” issue in some countries, and many educational bodies push against climate education entirely. 

More must be done to ensure that young people have access to environmental education. Robust climate education will give the decision-makers of tomorrow the skills they need to advocate for nature, protect vulnerable environments, and mitigate the effects of global warming. 

The Importance of Environmental Education

Education is often overlooked in the fight against climate change. While policy changes and global commitments are necessary to prevent global warming from further worsening, improved education is the first step toward achieving our goals. 

Environmental education can help alleviate climate anxiety , too. This is broadly defined as a “chronic fear of environmental doom” and may be exacerbated by a lack of understanding. Educational resources that clearly explain the mechanisms behind global warming equip students with the knowledge they need to do something about climate change. This can help them feel empowered and foster a greater appreciation for the planet’s resources. 

Environmental education can also promote critical thinking, communication, and problem-solving skills. This is particularly important today, as students need to be able to evaluate the long-term impact of social, economic, and ecological policies. Combating climate change effectively requires a global effort and activism often relies heavily on a thorough understanding of the issue and the ability to persuade others that something must be done. 

Improvements in public education may also promote a sense of stewardship and aid conservation efforts. In particular, environmental education programming can make a real difference to researchers who are advocating for policy changes. 

For example, recent public programmes like the BBC’s Planet Earth II and Wild Isles appear to have significantly impacted researchers at the University of Exeter in the United Kingdom. Reflecting on the public program, Professor Callum Roberts states that the “UK must now deliver genuine protection for wildlife,” and should focus on building resilience against climate change. 

Connecting Students with High-Quality, Reliable Resources

Environmental education can empower the decision-makers of tomorrow and improve the public understanding of climate change. However, connecting students with the resources they need to understand global warming can be difficult – particularly if students live in a nation like the US, where climate change is seen as a partisan “political” issue. 

Climate-aware parents can introduce their children to climate change with outdoor play in natural environments. Natural playgrounds, like those built from sustainable materials and found objects, are the perfect place to discuss environmental protection and the importance of stewardship over the Earth’s resources. 

Living a sustainable lifestyle at home can be an important part of children’s environmental education. Parents can help their kids understand the importance of sustainability by reducing their home’s carbon footprint together, by implementing and practicing environmentally friendly habits in the home. Simple sustainable activities — such as upcycling furniture and composting leftover food scraps as well as teaching children how to recycle – help reduce our own emissions and promote a sense of responsibility for the environment. 

You might also like: How to Live a More Sustainable Life in 2023

Student Activism

A sense of stewardship is vital for the long-term preservation of the Earth’s natural resources. However, students who care about climate change should be empowered to engage in activism, too. Youth activism has a meaningful impact on policy and shows politicians that climate change is a hot-button issue for future voters. 

Successful activism begins by educating students about the issues. Teachers can strengthen their students’ understanding of climate change and ecological protection by hosting student projects that encourage outdoor learning . By building eco-systems on school grounds or signing up for community clean-ups, students will learn to take pride in the world around them and become well-equipped to share their knowledge with others.

Most high schools and universities have a climate advocacy group that young people can join to amplify their voices and make a difference. Students can further their climate advocacy by joining groups that have partnered with the Climate Action Network (CAN). The CAN helps 1900+ organisations get the support and funding they need to prevent environmental degradation and fight climate change. 

Climate-conscious students can also partner with non-governmental organisations (NGOs) like: 

• African Conservation Foundation
• Born Free USA
• Break Free From Plastic

These NGOs tackle the biggest environmental issues today and can put students in a position to maximise their impact and gain important professional development skills. 

You might also like: How Youth Climate Action Is Shaping a More Sustainable Future

Professional Development

Preventing climate change requires more than goodwill and public understanding. The decision-makers of tomorrow need to be equipped with interdisciplinary skills to tackle the challenges that climate change presents. However, many teachers are ill-equipped to teach environmental education in their classrooms. 

More must be done to empower climate-conscious teachers. Professors should feel comfortable discussing the facts of climate change in their classrooms. They should be able to identify the transferable skills that their class can give to climate-conscious students. Fortunately, teachers today can find plenty of free resources from sites like: 

• Our own environmental news website dedicated to our younger audience, Kids.Earth.Org
• NASA’s Vital Signs of the Planet
• WWF’s Science that Affects Our World
• British Council’s Climate Resources for School Teachers

These resources are entirely free and can be weaved into any class. A climate-inspired project will help students connect with the importance of environmental education and give them the skills they need to take on skeptics in the future. 

Conclusion  

Environmental education is key to understanding and preventing climate change. A robust climate education can empower students and help them engage with advocacy and activism groups. Even minor education experiences, like participating in a community clean-up, can help students understand the importance of stewardship and build the interdisciplinary skills they need to advocate for environmental protection. 

In case you didn’t know, we have a Kids’ website aimed at explaining a wide range of environmental topics to younger generations. Visit Kids.Earth.Org to learn more about climate change

About the Author

Charlie Fletcher

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Education We Need for the World We Want

Environmental education has the power to transform lives and society. It informs, inspires, and influences attitudes. It motivates action. EE is a key tool in expanding the environmental movement and creating healthier and more civically-engaged communities.

About EE and Why It Matters

What Is Environmental Education?

Environmental education (EE) is a process that helps individuals, communities, and organizations learn more about the environment, and develop skills and understanding about how to address global challenges. It has the power to transform lives and society. It informs and inspires. It influences attitudes. It motivates action. 

Why Do We Need Environmental Education?

The environment sustains all life on earth. It provides us with nourishment and inspiration. Our economy thrives on a healthy environment. A growing body of research tells us that time spent in nature provides physical and psychological benefits. Our personal and cultural identities are often tied to the environment around us. At the same time, it’s impossible not to be deeply concerned about the unprecedented environmental, social, and economic challenges we face as a global society—from climate change and loss of species and habitats, to declines in civic engagement, decreasing access to nature, a growing gap between the haves and have nots, and other threats to our health, security, and future survival.

Demonstrating the Power of Environmental Education

Environmental education is a process that helps individuals, communities, and organizations learn more about the environment, develop skills to investigate their environment and to make intelligent, informed decisions about how they can help take care of it. 

The Tbilisi Definition of Environmental Education: 1977

EE is a learning process that increases people’s knowledge and awareness about the environment and its associated challenges, develops the necessary skills and expertise to address the challenges, and fosters attitudes, motivations, and commitments to make informed decisions and take responsible action.  Learn about the history of EE through the History of EE eeLEARN module , exploring some of the milestones and people who have influenced the field.

EE is built on the principles of sustainability, focusing on how people and nature can exist in productive harmony. As the Brundtland Report stated (Our Common Future, 1987), “to create a more sustainable society, we need to determine how to meet the needs of the present without compromising our ability to meet the needs of the future.” The work in this field focuses on building ecological integrity, and environmental health, and creating a fair and just society with shared prosperity.

Key Underpinnings of the Field

The field of EE is characterized by key underpinnings, including a focus on learners of all ages—from early childhood to seniors. It focuses on the importance of experiential, interdisciplinary education, and helping all learners develop problem-solving and decision-making skills, understand how to be a civically engaged citizen, and how to create a more diverse, inclusive, and equitable society. EE also advances key societal issues—from the Next Generation Science Standards to STEM to climate change education.

• Focus on systems thinking
• Lifelong learning: cradle to grave
• Equity & Inclusion
• Focus on sound science
• Built on a sustainability platform
• Interdisciplinary
• Sense of place
• Reflects best practice in education (learner-centered, experiential, and project-based learning)
• Informed decision making

Environmental Education Professionals

Environmental education is a broad umbrella that is focused on creating a more sustainable future using the power of education. In addition to being a process for learning, it is a profession that is focused on using best practice in education to help create societal change to address the social and environmental issues facing society. Environmental educators work in all segments of society. They work with students, teachers, administrators, and school boards to green schools—focusing on curriculum, professional development, schoolyards, and school buildings, and more. They work with businesses to educate managers, employees, and vendors about environmental, health, and economic issues. They are facilitators of citizen science programs to help people understand the scientific process and use the data to help protect species, habitat, communities, and ecological processes. They are professors in universities who train the next generation of teachers, environmental professionals, business leaders, and others. They work with journalists to tell the story about the value of environmental education and with decision makers to advocate for environmental education. They work hand-in-hand with conservation professionals to help engage people and communities in finding solutions to conservation issues—from loss of biodiversity to climate change. And they work with health professionals who educate doctors, nurses, and other health professionals about the critical link between health and environment and how to increase time in nature to address health issues. They are naturalists helping to connect more people to nature and build stewardship values that last a lifetime. 

More about environmental education: EE Briefing for Grantmakers Across the Spectrum Guidelines for Excellence Framework for Assessing Environmental Literacy

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Environmental education is a process that allows individuals to explore environmental issues, engage in problem solving, and take action to improve the environment. As a result, individuals develop a deeper understanding of environmental issues and have the skills to make informed and responsible decisions.

The components of environmental education are:

• Awareness and sensitivity to the environment and environmental challenges
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• Attitudes of concern for the environment and motivation to improve or maintain environmental quality
• Skills to identify and help resolve environmental challenges
• Participation in activities that lead to the resolution of environmental challenges

Environmental education does not advocate a particular viewpoint or course of action. Rather, environmental education teaches individuals how to weigh various sides of an issue through critical thinking and it enhances their own problem-solving and decision-making skills.

The National Environmental Education Act of 1990  requires EPA to provide national leadership to increase environmental literacy. EPA established the Office of Environmental Education to implement this program.

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Why do some students learn faster than others | Explained

L earning is a fundamental aspect of human cognition, driving personal and professional development. However, not all individuals learn at the same pace. Some seem to grasp concepts quickly, while others require more time and effort.

This discrepancy raises the intriguing question: Why do some people learn faster than others? Exploring this phenomenon unveils a complex interplay of biological, psychological, and environmental factors, each contributing to individual differences in learning speed.

Biological Factors:

One crucial aspect influencing learning speed is the structure and function of the brain. Neuroscientific research has revealed that variations in brain anatomy and neurotransmitter systems play a significant role. For instance, studies suggest that individuals with higher levels of dopamine, a neurotransmitter associated with motivation and reward, tend to learn faster as they exhibit enhanced attention and engagement with learning tasks. Additionally, differences in neural connectivity, particularly in regions responsible for memory and information processing, contribute to variability in learning efficiency.

Genetic factors also play a role in determining learning abilities. Twin studies have shown that genetic influences can account for a substantial portion of the variability in cognitive abilities, including learning speed. Variations in genes related to synaptic plasticity, the process by which neurones adapt and strengthen connections in response to learning, contribute to individual differences in learning aptitude.

Psychological Factors:

Individual differences in cognitive abilities, such as working memory capacity, processing speed, and attentional control, significantly influence learning speed. For example, individuals with higher working memory capacity can hold and manipulate more information simultaneously, allowing them to learn complex concepts more efficiently. Similarly, faster processing speed enables individuals to encode and retrieve information rapidly, facilitating quicker learning.

Motivation and mindset also play crucial roles in learning speed. Research in educational psychology suggests that individuals with a growth mindset, who believe that intelligence and abilities can be developed through effort and persistence, tend to learn faster than those with a fixed mindset. Furthermore, intrinsic motivation, stemming from personal interest and enjoyment of the learning task, enhances engagement and accelerates learning progress.

Environmental Factors:

Environmental factors, including educational opportunities, teaching methods, and socioeconomic status, profoundly impact learning outcomes. Access to quality education, enriched learning environments, and supportive educational resources can enhance learning speed by providing individuals with the necessary tools and opportunities for intellectual growth.

Effective teaching strategies, such as personalised instruction, active learning techniques, and scaffolding, can also promote faster learning by catering to individual learning styles and needs. Furthermore, social influences, such as peer interactions and collaborative learning experiences, contribute to accelerated learning through knowledge sharing, discussion, and collective problem-solving.

The quest to understand why some people learn faster than others unveils a multifaceted interplay of biological, psychological, and environmental factors. While genetic predispositions and brain characteristics set the stage for individual differences in learning speed, psychological factors such as cognitive abilities, motivation, and mindset modulate learning outcomes.

Moreover, environmental influences shape learning trajectories by providing resources, opportunities, and social contexts that either facilitate or hinder learning progress. By comprehensively understanding these factors, educators and policymakers can implement evidence-based practices to optimise learning experiences and support diverse learners in reaching their full potential.

• Open access
• Published: 13 May 2024

Exploring perceptions of pre-clerkship students about workplace learning in the clinical learning environment at Gulf Medical University, UAE

• Nooreen Adnan   ORCID: orcid.org/0000-0002-7984-7284 1 ,
• Farah Azhar   ORCID: orcid.org/0000-0002-6958-3406 2 &
• Syeda Rubaba Azim   ORCID: orcid.org/0000-0002-3536-7684 1  

BMC Medical Education volume  24 , Article number:  528 ( 2024 ) Cite this article

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Medical students view clinical workplace placements as an inspiring and motivating learning environment where active student participation is pivotal to development of students’ identity. The progress from pre-clerkship to clerkship education harbors many challenges which consist of experiential learning, adjusting to the clinical environment, and understanding roles & responsibilities. Workplace learning is underpinned by various adult learning theories including social theories,constructivism, supported participation and legitimate peripheral participation. Workplace learning course was recently initiated for pre-clerkship students at a medical university in UAE, which will enable their smooth entry into the clerkship phase of the curriculum.

The research aims to explore students’ perceptions of various domains of their clinical learning environment (CLE), highlight the challenges they face, and extract valuable feedback to improve their environment.

This study was conducted qualitatively by using focus groups method in order to explore students’ perceptions of the clinical learning environment. Two focus group discussions were conducted ( n  = 8 +/-10) to determine the common challenges of workplace learning and its potential solutions. Data were analyzed using thematic analysis. The approach used to carry out this study was phenomenology, as it helps to understand the learning and behavior of these students who are undergoing this pre-clerkship training in order to transition smoothly to the clerkship phase.

The focus groups helped to deeply explore the perceptions of students about their clinical learning environment. It helped to reveal the challenges encountered by the students including the significance of proper orientation of staff and students, language barrier, availability of learning opportunities, and supervision quality. The focus groups provided worthwhile suggestions to improve the learning opportunities in the clinical learning environment which include orientation of the staff and students what to expect, improved supervision, mentoring and providing learning opportunities to encourage participation.

This study attempted to identify the pre-clerkship students’ perception of their clinical learning environment and the challenges they face over there. Possible suggestions by the students included a formal orientation for the staff and students to be carried out at the beginning. Efforts should be made by clerkship directors to provide students with learning opportunities by increasing patient exposure, encouraging participation, and providing high-quality supervision.

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Introduction

Clerkship is a progression of students principally from a non-clinical environment to a clinical one towards the later years of the undergraduate medicine curriculum [ 1 ]. To enable students to have a smooth entry into the clerkship phase and help lessen the anxiety related with the transition, many medical schools have integrated workplace learning into the pre-clerkship curriculum. Hence a workplace learning course was introduced for the pre-clerkship students at Gulf medical University as well [ 2 , 3 ]. Typically, the undergraduate medicine curriculum at the Gulf Medical University consists of five years with a one-year internship. The pre-clerkship phase consists of second and third year MBBS where the students will undergo clinical postings daily for four hours during their typical week at the hospital, where they are rotated in all of the major departments. After the pre-clerkship phase, the students’ progress to the clerkship phase (fourth and final year). This shift from pre-clerkship to clerkship phase raises many challenges which include employing basic clinical skills, experiential learning, adapting to the clinical environment and understanding roles and responsibilities [ 4 ]. Workplace learning course was recently introduced for the pre-clerkship students which can facilitate their smooth entry into clerkship phase of the curriculum and reduce the anxiety associated with the transition [ 2 ]. Workplace learning is a combination of individual, organizational and social processes that can together create an optimal learning environment. It is understood as applying knowledge at the workplace, already learned in the classroom known as knowledge contextualization [ 5 ].

In order for workplace learning to be practiced effectively, it is pertinent to understand its basis and relate it to the adult learning theories. Learning in a clinical workplace environment can be supported by some of the adult learning theories in literature. Though the adult learning theories suggest that self-direction is an optimal way for medical students to learn in clinical postings but in addition to self-direction, appropriate guidance from expert practitioners would greatly help the learners to accomplish what they cannot accomplish on their own, particularly those who haven’t attended clinical postings earlier [ 5 ]. Here the concept of ‘supported participation’ as proposed by Billet’s pedagogy of workplace learning is important [ 6 ]. This means participation of learners is supported by the environment in which learning occurs. The influence of the environment and the presence of experienced people at the workplace greatly modify learning at workplace and can be described as learning within the construct of social constructivism. This is where the social theories of learning can be applied [ 7 ]. The socio-cultural theorists view participatory experiences as learning by constructivism and describe different ways in which learners develop professional knowledge, skills, and more importantly, workplace identities [ 8 ]. Vygotsky aimed to match the developmental stage of the learner with the paradigm of zone of proximal development [ 9 , 10 ]. This means how a learner can benefit with the support of an experienced individual at the workplace. As peripheral participants in these professional communities, students may find the amount they have to learn overwhelming, and they may struggle with their identity as a community member being in that transition stage where they are exposed first time to a clinical setting [ 11 ]. Vygotsky’s theory explains that learning is accomplished by novice learners while working with the support of experienced healthcare professionals. Additionally, Lave & Wenger hold the opinion that participation in social practice will ultimately result in learning [ 12 , 13 ]. They have explained workplace learning through legitimate peripheral participation [ 7 ]. Legitimate peripheral participation can be explained as: a new learner enters the clinical workplace (community),which in this case is the second and third year pre-clerkship students, and is gradually involved in increasingly complex activities i.e., from observation to more participation and hence the novice learner becomes a part of that community, sharing many of the workplace activities. The students are mostly observing the workplace activities in the pre-clerkship phase and gradually they move towards complex activities as they progress to the clerkship phase. Wenger also proposed that social theories support the sense of belonging and workplace activities help to form the professional identity of the learner, even at the initial stage [ 14 ]. Furthermore, in order to improve workplace learning in clinical settings, faculty development programs for clinical educators can be arranged focusing on social learning theories, so that the faculty is well oriented and support these learners in this transition phase [ 15 ].

As workplace placements are a new addition to the curriculum, this study intends to explore students’ experience of their clinical learning environment and obtain valuable feedback to further improve their training and learning [ 16 ]. This study was conducted to see how this experience has been for the students being part of the workplace environment and how it will be useful for them in transitioning to the clerkship phase. This study was conducted using focus group interviews which consists of the collection, analysis, and integration of the findings qualitatively to obtain a deeper understanding of the clinical learning from the students’ perspective. This will support local course management and clinical educators in gaining better understanding of the processes and make changes to improve the learning process for students in the clinical learning environment. As this is a recently introduced course it will help to view its strengths and its potential challenges with relevant suggestions to further improve it. This will enlighten stakeholders all over the world who wish to start this training or are already in the process. The goal is to improve effective patient care through these future practitioners.

The research objective is to explore pre-clerkship students’ experiences of learning in the clinical environment in the UAE. It aims to explore students’ experience of various domains of their clinical learning workplace, regarding workplace environment and learning opportunities and extract valuable feedback to further improve their CLE. This study was conducted with the pre-clerkship students before they progress to the clerkship phase of their study. Workplace learning was introduced in their curriculum so that they get an early exposure to the workplace environment which will help them to glide into a smooth transition into their formal clerkship phase.

The study setting is Gulf Medical University, UAE which is affiliated to a private teaching hospital and outpatient clinic. The pre-clerkship phase consists of second and third year MBBS where the students will undergo clinical postings daily for four hours during their typical week at the hospital and are rotated in all the major departments, namely medicine, surgery, gynecology, and pediatrics. The students are posted in outpatient clinics across the city where they interact with patients. Workplace learning was recently introduced for second and third year MBBS students which provide opportunities for students to apply and perform the skills like history taking and physical examination learnt in the simulated setting at their university, on real patients under supervision and observe the clinicians interact with the patients in the clinics. All students undergo structured certificate courses in Basic Surgical Skills, Basic Orthopedic Skills and Universal Standard Precautions at the Skills Development Center as part of this course. They are also trained in the American Heart Association accredited Basic Life Support (BLS) Provider course. This course prepares the students to integrate into the hospital settings and perform professionally during the clerkships in years 4 and 5 and during internship.

The main outcomes for the current curriculum of these pre-clerkship students for workplace learning are:

Demonstrate knowledge of the common clinical conditions encountered in the outpatient setting.

Apply the basic science knowledge in the organ-system courses to clinical contexts.

Communicate effectively with patients, family, peers and mentors in the clinical setting.

Perform clinical skills like history taking, general examination and focused systemic examination.

Appreciate the importance of maintaining patient medical records.

Observe management of common clinical conditions encountered in the outpatient setting.

Reflect upon the experiences during clinical observations and / or learning for self-improvement.

Workplace learning was introduced for the students at our university to facilitate their entry into the clerkship phase. It is important that a thorough benchmark evaluation is done for the clinical learning environment to measure the quality of training from various aspects, and further steps can be planned to make workplace learning a better experience for the learners. Therefore, this study aimed to learn about this phenomenon in depth by using qualitative methods (focus groups). These methods help to study complex phenomena in their natural context. Since this study has a descriptive design and aims to explore the perspective of students about the clinical learning environment that they experience; the theory of phenomenology was applied here. Phenomenology involves data collection from individuals who have lived through the experience of the phenomenon being studied [ 17 ]. This aligned with our goals to understand and construct meaning from the lived experiences of students [ 18 ].This approach deepened our understanding of the complex phenomena involved in learning, behaviours and communication which occupy centre stage in this critical transition between preclinical to clinical phase [ 19 ]. Our goal was to understand the meaning participants attribute to their experiences of preclinical training and this led enhanced understanding and suggestions to improve the status quo. A focus group method was utilized as it provides a robust and interactive discussion between participants that can trigger exploration of contrasting opinions and reflection on common practices. It was considered to conduct group interviews because they are a quick and feasible way to collect data from many people concurrently. Focus groups use group interaction as an important aspect and therefore were considered to be the appropriate data collection method for this research [ 20 , 21 ].

The study was conducted on the students of the pre-clerkship phase (second and third year MBBS). The purposive sampling technique was used so that students from each clinical posting site can be selected to give an overview of the clinical learning environment. Each focus group had eight to ten students [ 22 , 23 ]. The groups were large enough to allow for varying perspectives and small enough so that everyone could actively participate [ 24 , 25 ].

Data collection

The students were informed about the study via email by the department secretary. A mutually convenient time was agreed with the students to collect data so that their learning activities were not affected. The purposive sampling technique was used so that students from each clinical posting site can be selected to give an overview of the clinical learning environment. Thus, it would be representative of the target population [ 22 ]. 3–4 students were identified from each clinical group to be included in the focus group discussions. Some students regretted it and finally the first group comprised of ten students and the second group comprised of eight students. The participants were provided with an information sheet which they read and signed on the consent form [ 25 ].

The focus group discussions were moderated by me, the author and my co-author was also present with me in these interviews to help me facilitate the discussion. The second co-author was present to observe the discussion. The discussions were tape-recorded & transcribed. Preceding the interview, key trigger questions were devised to facilitate the discussion. I was responsible for putting up the trigger questions and facilitating the discussion, while my co-author helped me record the session, took notes and supported me in summarizing the discussion towards the end of the session, along with debriefing. Each group discussion took between sixty to ninety minutes, depending upon the degree of the discussion [ 25 , 26 ]. It was ensured that all members had an equal chance of expressing themselves to ensure data reliability. A non-judgmental attitude, having little moderator control was adopted so that the participants could have an honest and interactive dialogue [ 14 ]. The findings of the focus group discussion were summarized at the end and the participants were asked to review them. This is known as member checking and helps to strengthen the findings of the discussion [ 22 ]. Debriefing was done immediately after the interview with my co-authors, which helped to analyze the data smoothly [ 27 ].

The number of focus groups reached adequacy when no new information was collected from the participants, after interviewing two student groups. This is called data saturation as any more information obtained would be redundant [ 26 ].

Data analysis

Krueger’s framework analysis was selected as it guides in a stepwise fashion to analyze qualitative data efficiently for focus group [ 25 ].

Ritchie & Spencer has defined ‘Framework analysis’ as an analytical process involving separate, interconnected steps (Fig.  1 ). These are familiarization, identifying themes, indexing, charting, mapping, and interpretation [ 26 ]. The strength of framework analysis is that it permits themes to develop from research questions and the participants’ responses [ 22 ].

Data analysis started during the discussion by combining the narratives with the observation notes, together with my co-authors. We went over the notes, listened to the recordings and ensured that all points were transcribed without missing any points. Familiarization was done by listening to the audio recording, reading the transcripts while referring to the summary of the discussion made post-interview. This helped us to get an overview of the major themes. The codes were identified by highlighting words and phrases of the narrative and categories were made. Indexing and charting, which is called data management collectively was done next and included organizing data, by comparison, highlighting, and placing them under the newly formed themes. This led us to the final steps where the mapping and interpretation which was analytical to establish links in the collected data. Krueger’s criteria to interpret data were followed which guided to look at frequency; specificity; emotions; extensiveness (intensity of comments and big ideas) and the big picture in the data [ 24 ]. The coding of the participants is shown in Table  1.

Table  2 illustrates the various themes and categories within those themes that emerged as a result of data analysis. These themes are discussed systematically, supported by actual quotes from the participants. The themes were derived based on factors which influence the clinical learning environment as put forward by Dornan et al., 2007 (Fig.  2 ) [ 5 ]. These factors are aligning well with the themes generated during the focus group interviews. These broad factors are the human factors, curricular factors and organizational factors and are briefly discussed as follows:

Factors influencing the clinical learning environment

Supervision (human factors).

High-quality supervision is an important dimension of workplace instruction, in addition to getting access to patients and promoting independence. High-quality supervision helps students learn independently by interacting with the patients [ 28 ]. Sympathetic feedback from the supervisor has a positive influence on the students’ learning and enhanced academic performance [ 15 ]. The results that were generated from the focus groups also highlighted the fact that effective supervision tends to have a positive impact on the students and improves the clinical learning environment making it more conducive to learning. This holds especially true for these pre-clerkship students who have been exposed to this new environment and will lead to their motivation and active participation and interaction with the patients. Effective supervisors need to be good role models, be clinically competent and knowledgeable.Some important features of good quality supervision include good interpersonal communication skills, teaching skills, and the ability to offer constructive feedback, which the students have also emphasized upon in the interviews [ 29 ].

Preparedness of students’ entry (curricular factors)

A clinically oriented introductory period can ease students’ entry into clinical practice, improve their ability to take part in clinical activities, and diminish the anxiety associated with the progress to clerkships [ 3 ]. Organizational efforts to improve clerkship transitions include clarifying roles, encouraging socialization and using faculty to offer support to the students in order to dissipate students’ anxieties. The importance of belongingness has been stressed in undergraduate health professions education because it has great influence on the well-being and performance of students [ 30 ]. The students in the focus groups have expressed their thoughts that a proper orientation to the students and staff about their postings will help create a sense of inclusion into the clinical workplace and promote their participation further. Belongingness has been understood as being connected or accepted by others through the interaction between learners and people around them in a certain environment [ 31 ]. Therefore, it is important to understand the perception of belongingness by the students as it points towards their workplace engagement [ 32 ].

Participation & interaction (organizational factors)

Workplaces embody socially constituted learning spaces where participatory practices are key pedagogical strategies [ 6 ]. The students learn through active participation and interaction with the workplace community in the clinical setting [ 33 ]. The motivation of clinical staff towards the educational support of learners, the welcoming attitude of interpersonal relationships in the clinical workplace, the availability of suitable resources are various ways of nurturing student participation [ 34 , 35 ].This has been further indicated by the students during the focus group sessions that encouragement of participation and interaction with the workspace staff further encourages students to make meaningful contributions and the postings worth attending.

Theme one: preparedness of student entry (human & curricular factors)

The first theme about how the workplace is prepared to receive the students consists of the orientation of the doctors and staff and the workplace environment which should be conducive to learning.

Orientation of the doctors and staff

Students reported that the staff and doctors were expecting the students when they reached there, however the majority of the students in both the focus groups stated that,

“Doctors were unaware about the year we belong to, had no idea about our learning objectives, and which skills to focus on; some doctors were not expecting us.” (1TY5) . “…nurses and other staff are not oriented; they didn’t expect us and they don’t help us so we feel left out and become uncomfortable.” (2SY6) . “Support staff & nurses…. had a welcoming attitude but they were initially not aware about students coming there and their purpose of visit.” ( 1TY6 ).

Workplace environment

Students regarded the workplace environment as friendly and highly interactive, where the doctors and staff were easily approachable.

“Got a good chance to be exposed to this learning environment. Doctors teach us at every opportunity and the environment is good and friendly. They tell us about cases, very interactive.” (1TY3). “Doctors and staff were helpful…everything about this clinic gave me a wonderful opportunity to learn.” (2SY2) .

Theme two: learning opportunities (organizational factors)

The second theme which was identified during the interviews was the learning opportunities which included factors like engagement of students in workplace activities, patient influx, rotation schedules and availability of physical space in the workplace.

Engagement in workplace activities

The students said that most doctors would allow them to interact with the patient. Students were exposed to real-life situations, and this supported their development of gaining confidence in their approach toward patients.

“Doctors make sure that whenever there is an interesting case, they will teach us and tell us about the next visit for follow-up.” (2SY3) . “We learned the importance of patient documentation and electronic logs. Common diseases like diabetes, hypertension is there so it gives us a chance to become thorough with those diseases.” (2SY8) . “Nurses could help or assist in the initial assessment of the patient so that students feel part of the team.” (1TY8) .

Physical space

Students reported in the focus groups that the clinics are small and there is hardly space for 2–3 students to sit or even stand sometimes. The students said that due to lack of space they keep standing for almost four hours, which is uncomfortable and they start losing interest.

“There were no chairs; we were standing for a long time about four hours.” (1TY1) .

“There is no proper place for us to sit and discuss our findings and case with doctors.” (2SY8)

Patient influx

The patient influx for most of the morning postings was very low. Students who were posted in the evening had more patient influx than in the morning. The students also pointed out that the general practitioners don’t have a variety of cases,

“Some clinics had a good influx of cases and have doctors who are willing to teach…some clinics will have very few doctors, so it’s not a fair share for all students as they are rotating in the same site for two years.” (1TY6) . “The general practitioners don’t have time to discuss with us as they have many cases; there is no variety and cases are repeated a lot.” (2SY6) . “Limited cases at few places…the patient flow is very low and repetitive cases are present. Sometimes there are no patients. “(1TY3) .

Language barrier

This is a common challenge reported by many students. The doctors and nurses don’t have time to translate or summarize the case for students as all of them are not Arabic speaking students. The students are not able to follow what is happening and find this very frustrating.

“Some of the doctors would summarize /translate their conversation with the patient for us, as quite often patients and doctors speak a language different than English. Some will not do so, due to lack of time .” (1TY4). “If the doctor and patient speak the same language, students cannot understand what’s going on;… it gets worse if the nurse is also speaking in the same language.” (2SY7)

Rotation schedules

There should be proper schedules to which doctor the student should be reporting to at each clinic.

“There were no proper schedules for where we need to go, we could choose our own doctor. There were no assigned doctors for us.” (1TY4) . “Especially in evenings, there are a lot of patients, in the mornings patients are few, and most of the posting time we are free.” (1TY6) .

Theme three: quality of supervision (human factors)

The students expressed their views that the supervisors are good and approachable. General feedback is given; however, there is no structured feedback session and only provided upon prompting.

“Doctors are quite busy in their schedules so no time for proper feedback. If we don’t ask about it, we don’t get it.” (1TY10) . “No structured or written feedback.” (2SY8)

Possible solutions to the identified challenges

Discussed below are possible solutions to the challenges commonly experienced by students which emerged from the focus group discussions.

Theme one: preparedness of student entry

Proper orientation of the staff.

There can be proper orientation programs for the doctors and healthcare staff regarding the students’ postings and their learning outcomes. The learning objectives for students could be aligned with those of the university so that the learning is contextualized.

“We need doctors to guide us what to do in clinics and how to make our postings more productive. For that they need to be properly oriented and trained.” (2SY1) . “…………. the doctors should be well oriented, they should have more workshops or training in order to be well-prepared to receive the students.” (1TY4) . “Doctors should be well aware of our training level and learning objectives.” (1TY1) .

Theme two: learning opportunities

Language barrier:.

Doctors or nurses could summarize the case for the students so that they are in the loop during doctor-patient interaction.

“They should also do a quick translation after the patient has left so that we have the opportunity to learn something.” (2SY7)

Patient influx and rotation schedules

The students suggested that instead of morning, evening rotations could be scheduled as more patients are there in the evening.

“Hospital postings would be a good idea in addition to clinics; maybe we will get more opportunities. Other universities have postings in hospitals.” (2SY5) . “We should get chances to switch from one clinic or other or we should be rotated periodically to get fair chance to see all kinds of patients and interacting and benefitting with so many clinicians.” (2SY6) . “Evening timings are preferred because of more patients. Till 12 noon there are no patients.” (2SY7)

Physical Space

There should be separate discussion rooms available for students where they can discuss the cases with their peers and doctors.

“Each clinic should have separate discussion rooms.” (2SY3) . “Proper discussion rooms should be there in each clinic as many students are not allowed in the doctor?s room because of infection control.” (1TY3) . “Evening timings are preferred because of more patients. Till 12 noon there are no patients.” (2SY7)

Theme three: supervision

There should be proper and structured feedback sessions scheduled in which the student and supervisor can discuss the progress of the student.

“Feedback should be formally given and scheduled so that we learn about our gaps.” (2SY4) . “There is hardly any feedback so, we decided to set our own goals and direction, helped us to become self-directed learners.” (1TY2)

The focus groups explored thoroughly the students’ perceptions regarding their learning opportunities, level of participation and supervision. The key findings which were revealed during the focus groups highlight the importance of the preparedness of the students’ entry into the workplace which included the orientation of the staff about the expected outcomes of the students. The findings of this study also emphasize on the fact that efforts can be made to improve the quality of supervision and increase the number of learning opportunities for the students, to shape the clinical learning environment more educationally conducive for them [ 2 ].

The students will also benefit if a proper instructional design strategy can be incorporated in this part of the curriculum i.e. pre-clerkship postings. This can be done through one of the common instructional design models, known as ADDIE. It stands for Analysis, Design, Development, Instruction and Evaluation [ 36 ] This can be utilized as follows:

Addie Model

Analysis: As discussed in the introduction, the need for introducing pre-clerkship training before the actual clerkship for undergraduate medical students was important in order to alleviate the anxiety and stress associated with this major transition of students’ lives.

Design: The clinical postings were designed in such a way that the students would be spending four hours at their respective posting in a typical week. They will be rotated in all major departments.

Development: The students will be spending their time at the postings by being attached to their supervisors who will be assigning them tasks for each day. The students will be interacting with the patients, the staff and the doctors and all these organizational factors will help them feel a part of the workplace community and create a favorable learning environment.

Implementation: For effective implementation, the staff and the doctors will need to be oriented to the students postings and their objectives. Their positive and welcoming attitude will encourage students to participate in the workplace activities. The administrator needs to make sure that students are attending their postings regularly and following the given timings.

Evaluate: This can be evaluated at the end of the academic year using the Kirkpatrick model. The effectiveness can be evaluated during the implementation stage where the students’ reaction and learning can be seen and then summative at the end of the academic year to look at their behavior and the outcome of this pre-clerkship course [ 37 ].

These findings of the focus group interviews are discussed below thematically in detail along with the potential solutions to the challenges faced by the participants to improve the CLE (Fig.  2 ).

Preparedness of student entry (human & curricular factors)

The students reported that their clinical learning environment was student-friendly and the doctors and staff were easily approachable. The students described that though they had a welcoming attitude, most of the doctors and staff were not aware of the students’ postings and students’ training level and learning objectives. This highlights the significance of a clinically oriented introductory period which would facilitate students’ entry into the clinical environment and motivate them to participate in workplace activities [ 1 , 3 ]. Atherley et al. advocates that it is necessary to have formal orientations and staff training so that they would be better equipped to receive the new learners [ 38 ]. Students also expressed their feeling of lack of being part of the team. A sense of belongingness to the workplace and identity formation of students as individual learners can be created by facilitating the interpersonal relationships at the workplace, having supervisors with a welcoming attitude, healthcare staff being supportive and having a good mentorship for which their seniors can play a definitive role [ 35 , 39 ].

Potential solutions

Students suggested that a formal orientation should be arranged by the clerkship directors for the doctors and healthcare staff so that they are aware of the students’ training purposes and learning outcomes [ 2 ]. Workshops can be conducted for the doctors and nursing staff, where a welcome introduction to the department is given, students’ roles and responsibilities and supervisor expectations are clarified [ 38 ]. In this way, socialization will also be promoted and students’ apprehension due to transition will be considerably reduced.

Learning opportunities (organizational factors)

During focus group discussions, many students reported that most often doctors allow them to interact with the patient and involve them in follow-up and documentation. They also revealed the nursing staff as cooperative that supported students’ learning by involving them in various patient care tasks. At other sites, students experienced less encouragement to participate and could not get adequate support from the staff. Participation relies heavily on the interactions between the staff and learners as it strongly influences undergraduate medical students’ success [ 40 ]. Participation can be improved by the motivation of clinical staff towards the students’ educational needs, providing adequate resources, and creating opportunities to support their learning [ 34 , 35 ]. The link between favorable learning climates and participation in the workplace has been strongly supported by studies of undergraduate medical students in workplaces [ 41 ].

Students suggested a discussion room to be available for students where they could discuss the cases with their peers and doctors. Many studies have emphasized the importance of the physical condition of the clinics and the availability of space as important constituents of favorable clinical learning environment [ 35 , 40 , 42 ].

It was pointed out by most students that the patient influx is more in the evening than in the morning. Students also pointed out that they should be posted in hospitals in addition to the clinics, to have a wider exposure of patients. This aspect of the clinical learning environment is well-established in literature that access to appropriate patients is an important dimension of workplace instructional quality [ 28 , 41 ].

Another point raised by the students is that the majority of the students faced problems due to the language barrier. In the UAE, the local language is Arabic so many patients speak the same language. Although the official language for communication is English, but in this multicultural country where most of the patients are from the Middle East, they mostly communicate in Arabic. If the doctor, nurse, or the patients are communicating in the same language, unknown to the students, it becomes difficult for the students to understand the conversation.

The learning opportunities can be increased for the students by providing access to more patients, encouragement to participate, strengthening interaction with the workplace team, provision of physical space, and overcoming the language barrier for certain interactions [ 6 , 38 ]. The nurses could involve them in the initial assessment of the patient, which helps to develop an identity and the students participate as a team member in imparting patient care [ 41 ].

Regarding the language barrier, Sreekanth claims that the Google language tool (GLT) can improve the communication between patient and doctor [ 43 ]. Another way is to make student group combinations in such a way that they can help each other in understanding the language in clinical placements, which can be viewed as formal peer-to-peer learning. This denotes that formal student support systems play a significant role in dealing with many of the challenges that students face in their learning environment [ 44 ]. It can be done by providing mentorship to students involving the faculty and seniors [ 45 ]. This would help to alleviate the students’ stress, promote socialization, and further optimize the learning environment [ 38 ].

Quality of supervision (human factors)

Students reported that there are very few structured feedback sessions which help the students to improve their learning. It made the students feel doubtful about themselves if they were able to achieve their outcomes or not [ 46 ]. This highlights the significance of proper orientation of the doctors and its strong correlation with the quality of supervision and feedback. Immediate and constructive feedback should be provided before, during, and after the rotation to build a supportive learning environment. Literature has almost always emphasized that quality of supervision has a significant impact on medical students’ learning in the clinical workplace [ 29 , 42 ].

The students reported that supervision be improved by providing regularly scheduled structured sessions and provide constructive feedback to the students to improve their learning. The supervisors should also be well aware of the local training bodies’ requirements and guide students accordingly [ 30 ].

Recommendations for practice

The findings of this study could be utilized by curriculum leaders and stakeholders in UAE and the region beyond because it has unfolded many important factors and suggestions about the CLE. Based on the results of this study, the learning environment for students at the clinical workplace can be optimized in the following ways (Fig.  3 ).

Formal orientation programs

Students suggested that a formal orientation should be arranged by the clerkship directors for the doctors and healthcare staff so that they are aware of the students’ training purposes and learning outcomes [ 47 ]. This would also help to create multiple learning opportunities for the new learners as they gradually become an integral part of the clinical workplace [ 38 ]. A way to ensure this is that workshops and training can be conducted for the doctors and nursing staff, a welcome introduction to the department, where students’ roles and responsibilities and supervisor’s expectations are clarified. In this way, socialization will also be promoted and students’apprehension due to transition will be considerably reduced.

Increased Learning Opportunities

The postings should include hospitals and students should be rotated at all sites equally. Evening postings are more appropriate due to the larger patient influx at that time; as patients provide the most important learning prospects for the students [ 38 ]. The importance of discussion rooms and physical space is also stressed by the students. Participation and learning processes are mutually dependent and learning through involvement in daily practices shapes the learning process and desired outcomes [ 6 ]. Therefore, encouraging students to participate in different aspects of patient care can make them feel part of the team.

Student support systems

Another important recommendation to encourage socialization is by providing formal student support [ 38 ]. This can be done by developing strategies for providing mentorship to students and forming student support systems involving the faculty and seniors [ 45 ]. This role can be appointed to the existing training residents who can schedule meetings with the students at regular intervals. This would help to alleviate the students’ stress, promote socialization, and further optimize the learning environment.

High-Quality supervision

The students also stressed the importance of high-quality supervision as it shapes the learning process of the students and helps to identify their gaps. To implement it, supervision should include structured and constructive feedback to the students to improve their learning and there should be a self-reflective practice from both supervisors and students [ 38 ].

Implications of the study

This study holds a reasonable prospect that the populations in which the research is carried out stand to benefit from the results of the research, and the future students. Other stakeholders may be included such as the clerkship directors and clinical educators. They are also interacting with these students and can give an insight into the common problems encountered by the students and their probable solutions [ 11 ]. These students’ perceptions may vary over a period of time once they proceed to the clerkship phase. Data from the same students may be collected in the clerkship stage so they are better able to identify the challenges of this course. This would make the current course better, while at the same time laying strong foundations for the clerkship phase training.

The perception of students was generally satisfactory towards their workplace environment. The students felt welcomed, were encouraged to participate in workplace tasks and found the interaction with their supervisors and healthcare staff appropriate. However certain factors like improved learning opportunities, proper physical space, low patient influx at some sites and difficulty communicating with patients in their language were explored in depth during focus group discussions. These discussions brought into light the potential measures that could be taken to further strengthen the learning environment for the learners. The findings of this study could be utilized by curriculum leaders and stakeholders in this context and beyond the region because it has unfolded many important factors and suggestions about the CLE. This study will become one of the types of evidence in order to implement this training course for medical undergraduates and also get ideas to improve certain aspects where this course is already implemented.

Thematic Analysis (Krueger and Casey, 2009)

Factors affecting the clinical learning environment

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on request. It includes the transcript of the focus group discussions.

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Acknowledgements

We express our gratitude to Prof. Manda Venkatramana (Vice Chancellor Academics and Dean College of Medicine, Gulf Medical University) and Dr. Pankaj Lamba (Clinical Assistant Professor Ophthalmology and MD/MBBS Phase III Director, Gulf Medical University).

Self-funded at all stages of design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

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Nooreen Adnan: NA did a thorough literature search, designed the concept of the study and conducted it. She also analyzed and interpreted the focus groups data regarding students’ clinical experiences. Farah Azhar: FA helped in data interpretation and drafting and proofreading the manuscript. Syeda Rubaba Azim: SRA helped in data analysis and interpretation. All authors read and approved the final manuscript.

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Ethical approval was taken from Ethical committee of Gulf Medical University Ajman UAE where this study was conducted. Since this article is part of my Master’s thesis work, an ethical approval was also obtained from my university (University of Dundee). Both ethical approval letters are attached. All methods were performed in accordance with the relevant guidelines and regulations of Good Clinical Practice (GCP), followed by the university. Written and informed consent was obtained from all participants who took part in the focus group discussion.

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Adnan, N., Azhar, F. & Azim, S.R. Exploring perceptions of pre-clerkship students about workplace learning in the clinical learning environment at Gulf Medical University, UAE. BMC Med Educ 24 , 528 (2024). https://doi.org/10.1186/s12909-024-05312-6

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A Systematic Review Using Feminist Perspectives on the Factors Affecting Girls’ Participation in STEM Subjects

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• Msafiri Mgambi Msambwa   ORCID: orcid.org/0000-0003-2223-090X 1 ,
• Kangwa Daniel 1 ,
• Cai Lianyu 1 &
• Fute Antony 2  

Although women are increasing in science, technology, engineering, and mathematics (STEM), men still dominate these fields at the highest levels. This systematic review examined 165 studies published between 2013 and 2023 on the factors affecting girls’ participation in STEM subjects. The feminist’s intersectionality and the social cognitive theories were used to identify and thematically categorize the factors as personal, environmental, and behavioral. Furthermore, the intersectionality theory explains how to mitigate them by advocating for systems that promote non-discrimination between men and women without igniting their differences or similarities or excluding men by only furthering women’s agendas. Findings indicate that only 17 studies attributed girls’ low participation in STEM subjects to personal factors (interest, poor self-concept, and negative attitudes), 100 studies to environmental factors (lack of collaboration, stereotypes, and role modelling), and 48 studies to behavioral factors (low motivation, low self-efficacy, and lack of career plans). Among the actions and strategies proposed to mitigate the negative effects of these factors include personal (hands-on STEM exposure, improve self-confidence and self-efficacy), environmental (role modelling, enabling STEM learning environment, and suitable STEM equipment), and behavioral (interest, motivation, and guidance). The results provide policymakers, educators, and practitioners with valuable insights on creating an enabling STEM learning environment that supports more girls in STEM subjects, further contributes to the global efforts to achieve the Sustainable Development Goals especially on quality education and gender equality, and recommends further research on how education systems can create supportive STEM learning environments using the feminist’s perspectives.

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Msafiri Mgambi Msambwa, Kangwa Daniel & Cai Lianyu

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Msambwa, M.M., Daniel, K., Lianyu, C. et al. A Systematic Review Using Feminist Perspectives on the Factors Affecting Girls’ Participation in STEM Subjects. Sci & Educ (2024). https://doi.org/10.1007/s11191-024-00524-0

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• Guidelines for Examining Unusual Patterns of Cancer and Environmental Concerns
• Resources and Tools

Phased Approach to Respond to Community Inquiries: Phase 3

• Conduct a feasibility assessment to determine whether an epidemiologic study would provide meaningful answers.
• Establish a community advisory committee (CAC) to create a link back to the community for valuable information.
• Consider different aspects to include in the study design and protocol development.

Phase 3: Considerations for epidemiologic studies

Feasibility assessment.

The feasibility of designing and conducting an epidemiologic study is dependent upon a variety of factors. For that reason, a feasibility assessment should be conducted to determine whether it is practical to conduct a study that would provide meaningful answers. The feasibility assessment should address multiple issues, including, but not limited to, data availability, adequate sample size to detect meaningful differences or associations, staff capacity, and other resources. In addition, to support studies and investigations it may be important for STLT health departments to consider all sources of funding and resources that may be available to them, including funding at the federal and state or local level, as well as nontraditional sources of funding.

When it has been determined that an epidemiologic study is feasible, do the following:

• Schedule meetings to discuss the initial findings and proposed approach for further assessment with the initial inquirer and other community members.
• Provide a detailed description of the next steps for evaluation. These next steps should be based on summary findings from the analysis of the 10 criteria in Phase 2 .
• Develop a summary that includes a rationale for continuing the investigation. For example, the assessment identified a potential spatial cluster or environmental factors that warrant further exploration.

Establish a community advisory committee

A community advisory committee (CAC) can contribute valuable sources of information and liaise with other community members. A CAC can provide specific details on the community, including help with cultural sensitivities or knowledge of current and/or historical environmental concerns in the area. A CAC can serve as a communication link back to the community at large.

Open communication will be needed to set goals, establish timelines, and discuss other issues (e.g., possible study limitations) so that expectations are clear. As previously mentioned, it may be important to also discuss issues related to resource requirements and other barriers that may impact conducting an epidemiologic study. Every community is different; however, agencies may be able to work with some existing organizations (e.g., neighborhood or religious organizations) to establish a CAC.

CAC and other community members can provide important insight and assist investigations:

• Help promote participation in studies and conduct outreach
• Identify specific tasks for community members that would contribute to the success of the investigation
• Identify additional data sources within the community (e.g., local lists that may be maintained which would identify previous residents)
• Identify population mobility patterns and housing development considerations

Consider the following for study design and protocol development

The following sections highlight the most important considerations for study design and protocol development. Consider developing a peer review committee with external partners to assess study design issues. Committee members should have a breadth of related skill sets in epidemiology, cancer, biostatistics, toxicology, and environmental health. The final draft of the protocol should be shared with the CAC in advance of initiating the study.

Case definition

Generate a formal case definition ahead of further analyses. Include the type of cancer, the population, the geographic area of concern, and the time period of interest. Review the study area and revise (if necessary) before starting additional analyses. For example, early assessments may have indicated that a particular contaminant was of concern and that more populations were found to be at potential risk for exposure to this contaminant. Thus, the study area would be expanded to include the other populations who were at potential risk for the exposure of concern.

A hypothesis regarding cancer cases or potential environmental contaminants was likely already generated during the assessment phase. However, hypotheses can evolve during an investigation, particularly if a potential exposure source has not been identified 1 . Re-review and update hypotheses regarding the cancer cases and contaminant(s) of interest (i.e., based on observations within the assessment phase to formulate analyses a priori). The hypothesis helps to guide the collection of data, the analysis plan, and interpretation of results.

Study population

Define the population of interest for the study. Ask the following questions to help define the study population as well as the time period of interest:

• How are the boundaries defined for the geographic area of interest?
• What are the characteristics of the population? Are there specific characteristics that are noted for the people with cancer (i.e., age group, race/ethnicity)?
• What is the latency period for the particular cancers of interest? What years of residence would need to be included to reflect the latency/development period assumed for the cancers of concern?
• How long have the residents lived in the area? What is the mobility and migration of former residents?
• Is there a potential for in utero exposures for the cancer(s) of concern based on where the mother lived during pregnancy?

Latency and change of residence add to the complexity of these investigations. Because residential history data are generally not available, collecting such data is critical as part of any epidemiologic study. Given the long latency period associated with cancers in adults, behaviors and exposures that might have contributed to the development of cancer in a person typically occur years to decades before the diagnosis. For example, malignant mesothelioma, a tumor of the lining of the lung, is associated with asbestos exposure, and the latency period between first exposure to asbestos and death from mesothelioma is often 30 years or longer 2 .

Latency in an epidemiologic investigation influences the exposure period relevant to the investigation. For example, if a person with cancer did not live in the suspected area of cancer concern during the relevant exposure period, then that person's cancer would not likely be related to an exposure in the area of concern. Conversely, the latency period might limit the ability to detect unusual patterns of cancer or identify cancers related to an environmental exposure that occurred in the past. In a mobile population, patterns resulting from an environmental contamination occurring years or even decades earlier might go undetected because exposed residents may have moved away from the community before the cancer developed. Thus, as persons move in and out of different communities, their cumulative exposure profile will change.

Because childhood cancers generally have shorter latency periods than cancers in adults, changes of residence might be less of an issue in the investigation of unusual patterns of childhood cancers. However, childhood cancer investigations may have the same limitations as adult counterparts. For example, in one California study of 380 children with a diagnosis of leukemia, approximately 65% of the study participants changed residence between birth and diagnosis 3 , indicating that even among cancers with short latency periods, migration might be an important factor. Account for latency when designing any additional analyses or studies.

Additional environmental data

If additional environmental data are needed, partner with state or local environmental regulatory agencies. ATSDR, including the regional offices, can also provide technical assistance, such as review of environmental sampling plans. Outline the types of sampling needed and resources available or necessary to conduct such sampling. Also, consider the following:

• Potential sources and routes of exposure (e.g., through air inhalation, water ingestion, in utero )
• Contaminant transport (e.g., if exposure occurs via ambient air, meteorological factors such as wind direction and speed are important)
• Other contributing sources of exposure
• Boundaries of potential spread/movement (important to understand the potential at-risk population)
• Any prior or ongoing remediation or reduction activities related to the environmental concern of interest
• Role of participating agencies in data collection and identification of resources to support the collection of environmental data.

Existing health data for case finding

Primarily, cases of cancer among the study population are identified from a state’s cancer registry, using the case definition. Consider multiple existing data sources for use to help identify cases. Forming partnerships with health information exchange or network entities may help with identifying other existing data sources. For additional support and guidance, CDC/ATSDR can provide technical assistance.

Contributing risk factors

An environmental factor may have been identified as a potential risk factor for the cancer of interest; however, cancers may be caused by several different risk factors or through multiple causal mechanisms 4 . Review additional risk factors for the type(s) of cancer under investigation, such as social determinants of health, behavioral risks, occupational exposures, and in some cases genetic factors.

Types of epidemiologic studies to consider

Methods used in environmental epidemiology are observational, not experimental. This makes the process of identifying a causative agent more difficult because researchers may not have access to information about other exposures or other variables that can create bias in the analysis 1 5 6 . However, additional studies can potentially help make inferences about cancer cases and potential associations. Consider the following types of descriptive or analytical studies:

• Case-series study : A case-series study is a descriptive analysis of persons with a similar cancer diagnosis. This study can be particularly helpful when there are small numbers of cases and it is not feasible to pursue other studies (e.g., statistical challenges associated with a small number of individuals diagnosed with the disease). Case-series studies are often designed to collect more information about each person to identify any commonalities. For these studies, identify as many relevant cases as possible to avoid selection bias. Depending on the findings, a further analytical study may be possible or warranted (see case-control or cohort below).
• Ecological study : An ecological study compares aggregated environmental data to aggregated cancer data to examine general associations. Exposures and outcomes are generally grouped to a geographic area, such as a census tract, for comparison. Individual exposures are not included in an ecological analysis. Ecological studies are most often done initially to explore potential associations but alone cannot determine causality. Epidemiologists must use caution when interpreting this type of analysis because the association with a particular environmental contaminant might not be true for individual cases, especially if there is heterogeneous distribution of the exposure over the geographic area. The related bias is known as ecological inference fallacy and could result in exposure misclassification.
• Cross-sectional study : A cross-sectional study is another descriptive study that measures health outcomes and exposure factors during a specific point in time. This type of study is helpful in describing the frequency of different characteristics in a study population during the time frame of interest. However, it may not be the ideal study design for investigating unusual patterns of cancer because this type of study design only looks at data distributions in a specific time frame, and temporal patterns cannot be established. In instances when biomarker data are available, a cross-sectional study may provide insights about key exposures among the population.
• Case-control study : Consider a case-control study when the etiology of the cancer is unknown. This type of analytical study can also be used to assess the association between cancer and a presumed exposure while being able to control for confounding factors. A case-control study collects information from cancer cases meeting the case-definition and controls within the same study area. Exposures and risk factors are compared between the two groups, for example using regression analysis methods. Case-control studies are suggested for rare cancer outcomes. Unlike the ecological study, case-control studies allow for the collection of individual-level data and risk factors to assess within the analyses. The primary disadvantages of a case-control study are the inability for individuals to recall historic events (e.g., exposures) and the difficulty of providing a direct estimate of risk. Risk is often estimated as an odds ratio, showing the odds for a particular cancer to have occurred given a particular exposure, compared to odds of the same cancer without the exposure. For this type of study, the sample size needed should be calculated ahead of time considering the power needed to detect statistical differences between the populations ( Appendix A ).
• Cohort (retrospective or prospective) : Consider a cohort study when the exposure source is known or being investigated. Select people who have varying levels of exposure for the study. Prospective cohort studies, while one of the strongest types of studies to examine exposure-disease relationships, are very time consuming and expensive. Depending on the latency of the cancer(s) of concern, a prospective cohort study may need to be 10–20 years or longer to collect enough data for analyses. The length of time needed often must account for study attrition and thus require a very large sample size. A retrospective cohort study may be feasible, but also is reliant on time-related information. For example, a cohort study may want to compare a population exposed to chemicals from Factory X, which was operating in the early 1990s. To establish a study cohort, a population within that community would have to have been in the study area ~30 years previously. Because of the length of time needed for these studies, some challenges may arise that need to be accounted for within the study design. For example, a community may have experienced a substantial percentage of movement or migration. Also, as previously mentioned, the latency of the cancer will also need to be accounted for within the study design. For example, the average latency for mesothelioma is generally thought to be decades 7 . More recently, data from the World Trade Center Health Program suggests that the minimum latency for mesothelioma is about 11 years and the minimum latency for thyroid cancer is 2.5 years 4 . Studies assessing these types of cancers would have to account for the number of years that specific types of cancers develop following exposures. Additionally, limitations exist with quantifying historic exposures for retrospective cohort studies.

Ongoing technical and scientific advancements in areas such as data science, analytic and geospatial methods, and cancer genomics may be available in the future (e.g., genomic research, gene-environment interaction).

Other considerations for your study

When evaluating the feasibility of different epidemiologic studies, consider the following:

• Funding : Funding may be needed to help with the investigation. Seek state and federal opportunities to assist with funding the investigation or with providing technical assistance. In addition, academic partnerships may help to support the investigation.
• Outreach : For more robust analyses, reach out to other states to discuss case-finding and/or environmental sampling activities, specifically in neighboring states if suspected environmental contaminants cross state borders.
• Communication : Ultimately, the goal of an epidemiologic investigation of unusual patterns or excesses of cancer is to understand the potential relationship between environmental and other risk factors identified and observed cases of cancer. Some epidemiologic investigations have identified potential associations between certain cancers and risk factors including exposures to certain chemicals 8 9 10 . However, methodological limitations and data limitations (such as unknown levels of exposure) often limit the ability to demonstrate that such relationships exist. Regardless of the outcome of an epidemiologic investigation, continuing to communicate with individuals most concerned about exposures and health outcomes is important.
• Merrill R. Environmental Epidemiology, Principles and Methods. Sudbury, MA: Jones and Bartlett Publishers, Inc.; 2008.
• Lanphear B, Buncher C. Latent period for malignant mesothelioma of occupational origin – PubMed. J Occup Med [Internet]. 1992 [cited 2022 Jan 7];34(7):718–21. Available from: https://pubmed.ncbi.nlm.nih.gov/1494965/
• Urayama KY, Von Behren J, Reynolds P, Hertz A, Does M, Buffler PA. Factors associated with residential mobility in children with leukemia: implications for assigning exposures. Ann Epidemiol [Internet]. 2009 Nov [cited 2022 Jan 7];19(11):834–40. Available from: https://pubmed.ncbi.nlm.nih.gov/19364662/
• CDC. World Trade Center Health Program [Internet]. Available from: https://www.cdc.gov/wtc/pdfs/policies/WTCHP-Minimum-Cancer-Latency-PP-01062015-508.pdf
• Gordis L. Epidemiology. Philadelphia, PA: Elsevier Saunders; 2014.
• Dicker R, Coronado F, Koo D, Parrish R. Principles of Epidemiology in Public Health Practice: An Introduction to Applied Epidemiology and Biostatics. CDC Office of Workforce and Career Development; 2006.
• Frost G. The latency period of mesothelioma among a cohort of British asbestos workers (1978–2005). Br J Cancer. 2013 Oct 29;109(7):1965–73.
• Costas K, Knorr RS, Condon SK. A case-control study of childhood leukemia in Woburn, Massachusetts: The relationship between leukemia incidence and exposure to public drinking water. Sci Total Environ. 2002;300(1–3):23–35.
• Massachusetts Department of Public Health. The Wilmington Childhood Cancer Study: An Epidemiologic Investigation of Childhood Cancer from 1990–2000. 2021.
• Vieira VM, Hoffman K, Shin HM, Weinberg JM, Webster TF, Fletcher T. Perfluorooctanoic acid exposure and cancer outcomes in a contaminated community: A geographic analysis. Environ Health Perspect. 2013;121(3):318–23.

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