Beyond the Imodium, a One Health Discussion on Diarrhea and the Impact of Climate Change

Abstract

Our ability to tackle the looming human, animal, and global ecosystem health threats arising from the issues of climate change and extreme weather events will require effective and creative cross-disciplinary collaboration. There is a growing national and international interest in equipping the next generation of clinicians and health scientists for success in facing these important challenges by providing interprofessional training opportunities. This paper describes how we assembled an interdisciplinary team of experts to design and deliver a case-based discussion on a cross-species illness outbreak in animals and humans using a One Health framework. The small group, case-based approach highlighted the impact of climate change-driven extreme weather events on human and animal health using a diarrhea outbreak associated with a contaminated community water supply precipitated by extreme flooding. Post-activity survey data indicated that this team-taught learning activity successfully engaged a cross-disciplinary cohort of medical, veterinary, and public health students in the issues of environmental public health threats and helped them understand the importance of an integrative, cross-functional, team-based approach for solving complex problems. The data from this study is being used to plan similar interprofessional, One Health learning activities across the health sciences curriculum in our institution.

Background

According to the World Health Organization and World Economic Forum, climate change and its associated adverse weather events represent the single biggest health threat facing humanity [1, 2] while also endangering animal and ecosystem health. Since the human health effects of climate change disproportionately impact vulnerable and disadvantaged populations, they are powerful exemplars of various social determinants of health, such as livelihood, clean water, and food security [3]. Given the complexity and universal impact of climate change across different health sectors, the investigators determined that a cross-species adverse health event would be an ideal backdrop for an interprofessional One Health learning activity.

One Health is a framework that emphasizes the interconnectedness of human, animal, and ecosystem health [4]. The devastating impact of the COVID-19 pandemic has refocused the world’s attention on the serious threat of emergent zoonotic infectious diseases and the importance of adopting an interdisciplinary approach to understand the complex interactions between human, animal, and environmental health [5]. In addition to zoonotic diseases, the challenges of increasing antimicrobial resistance and the associated and complex interactions of microorganisms that affect humans, animals, and ecosystems can also be explored through the One Health framework [6].

In view of the intricate overlap and interdependence of these complex, looming health threats, it is important that we train our future health professionals and social scientists to adopt a collaborative and interdisciplinary approach to problem-solving and in the design and implementation of effective, evidence-based, sustainable solutions. While most health professional programs recognize the need and benefit [7] for interprofessional educational (IPE) interactions, it is often difficult to assemble an interdisciplinary team of educators and to simultaneously identify a cross-disciplinary group of learners that would benefit from such an activity. This paper briefly describes an innovative approach to integrating climate change through interdisciplinary education. In this study, a team of educators representing the University of Illinois Colleges of Medicine, Veterinary Medicine, Applied Health Sciences, and the Champaign-Urbana Public Health District (CUPHD) designed, delivered, and evaluated an authentic interprofessional learning experience of One Health-based activity to provide early curricular exposure of healthcare learners to the interactions between animal, human, and ecosystem health [8]. The educational approach of including three university-based academic departments with the recruitment of a diverse, cross-disciplinary phenotype of learners continues to add to the emerging experience of a case-based, multidisciplinary approach of developing and emphasizing the benefits of these partnerships for health professional students [9, 10]. The novelty of our approach was the inclusion of a community-based public health organization that took a prominent role in the case development and deployment, adding authenticity to the IPE activity [8] and increasing collaboration between community partners and academic institutions. In this study, we were able to construct and coordinate this One Health activity to match the content and timetable of delivery to relevant courses in several health science colleges. We were able to include students from medicine, veterinary medicine, and public health disciplines.

Methods

Starting in September 2021, faculty from Carle Illinois College of Medicine, University of Illinois College of Veterinary Medicine, College of Applied Health Sciences, and a representative from the CUPHD met monthly virtually to create a case-based discussion on a common clinical sign in animals and humans through a One Health framework that highlighted the impact of climate change and extreme weather events. The case study was based on a diarrhea outbreak due to a contaminated water supply from a manure lagoon precipitated by extreme flooding in a rural community and was developed so that students from each discipline could share their expertise and learn about health risks. In March 2022, a pilot was done with seven medical students, ten veterinary medical students, and thirty-two Master of Public Health Students. IRB approval was received from the University of Illinois Urbana-Champaign, protocol #22,619. The discussions were over two 90-min video conference sessions. During each session, the students were split into three breakout groups facilitated by faculty from each of the three departments. Groups were designed to have at least one student from each discipline and no more than ten total students in each group. Facilitators used a common guide created by the collaboration of faculty in different disciplines and a public health representative who used their expertise to create relevant questions about the case portrayal as it unfolded, as well as providing relevant reference materials for pre-reading. The scenario was deployed using PowerPoint slides that depicted images of key stakeholders (care recipients (farmer and livestock), physician, veterinarian, and public health professional) conversing with dialogue and short video clips. In the end, the small groups reconvened, and representatives from each small group shared what they learned and ways to solve some of the issues they discussed.

We assessed student learning via an optional Qualtrics (https://www.qualtrics.com) survey administered at the end of the discussion utilizing a retrospective pre-post-test design. This design was used to help reduce response-shift bias often seen in traditional pre-test-post-test designs [11]. Students were asked to evaluate their awareness of five factors related to the case study before and after participating in the discussion. The questions asked about awareness of risk factors for infectious diseases, strategies to address contaminated water sources, consequences of flooding on animal, human, and community health, strategies to build resilience against future climate threats, and the interprofessional nature of this type of case. The full questions are provided in Table 1. Students provided a response representing their pre- and post-activity level of awareness using a Likert scale (1 to 5), where 1 represented “not at all aware” and 5 represented “extremely aware.”

Table 1.

Survey questions

a	How aware were/are you of the infectious causes and risk factors that contribute to diarrhea in human and animal outbreaks?
b	How aware were/are you about public health initiatives for mitigation of contaminated water sources?
c	How aware were/are you of consequences of flooding due to extreme weather on animal, human and community health?
d	How aware were/are you of strategies to build resilience against future climate threats?
e	How aware were/are you of the interprofessional nature of this type of case?

Statistical Analysis

We assessed differences in the pre-test and post-test mean responses using the paired t-test [12]. Significance was assessed at α = 0.05. Because the paired t-test assumes normality in the differences between paired responses, we checked this assumption visually using histograms. We also examined differences in the distribution of responses using the Wilcoxon signed rank test (a non-parametric test). Conclusions using the Wilcoxon signed rank test were not different from the paired t-test, so we present only the results of the parametric paired t-test below.

Results

Of the 48 students who participated in the activity, 26 (54%) agreed to participate in the survey, and 25 (52%) completed the questionnaire. There was a significant increase (paired t-test at α = 0.05) in awareness across all questions after the exercise when compared to before the exercise (Fig. 1). The largest increase in mean scores (pre- to post-activity) was for the question about awareness of the interprofessional nature of the exercise, where average scores increased by 1.5 (standard deviation = 1) points, suggesting we successfully engaged students in an interdisciplinary manner. Additionally, 96% of respondents said they were interested in more One Health case activities in the future.

Fig. 1.

Differences in the average Likert scale response for each of the five questions included in our survey. Scores of 1 indicated “not at all aware” of the issue presented and 5 represented “extremely aware.” Error bars indicate standard deviations. *Paired t-test is significant at α = 0.05

Discussion

Climate change poses multiple challenges to human, animal, and ecosystem health and threatens the foundational rights to a clean and safe environment for planetary life [13]. Given the multiple sectors that are impacted, a variety of health professionals will be at the forefront of addressing these issues. The results from this pilot support the importance of introducing an interprofessional framework for understanding the impact of climate change in various dimensions of healthcare. Guiding this discussion with interprofessional faculty introduces learners to the complexity and collaboration needed in addressing the global health threats related to climate change. The One Health framework provides a successful model for a collaborative approach to addressing these challenges.

As a pilot interprofessional experience across three colleges within the University of Illinois, there were several limitations. This was a voluntary activity for the Colleges of Medicine and Veterinary Medicine, so there is inherent self-selection of those who participated. The experience was virtual, which may have limited the interactions possible between student participants. The survey was kept relatively short, limiting what could be analyzed from the experience, but it may have helped in having a higher response rate. We did not collect data on student programs, limiting our ability to assess student learning outcomes by academic discipline. Assessment only happened as a cross-sectional survey, so no longitudinal analysis could be performed to assess the retention of the new concepts from the experience.

This collaborative strategy, employing expertise and perspectives from various experts in the One Health paradigm, has been shown to improve health systems performance at the international level and benefit all institutions involved [14]. This approach is also generalizable across multiple topics related to the impacts of climate change on human and planetary health that arise throughout the training of healthcare professionals. The Network for Ecohealth and One Health (NEOH) proposes core competencies for a One Health workforce. To this end, case scenarios can be customized to the educational needs of the trainees in their core curriculum, such as addressing specific organ systems or infectious diseases, as well as, justice, effective communication, and collective learning, which reflect the NEOH competencies [15]. Demonstration of an understanding of One Health concepts is already a required competency for students graduating from Council on Education for Public Health programs. Our pilot project demonstrates how such learning could be integrated into medical and veterinary medical education as well. This has fostered increased interest by the various stakeholders in the university to integrate these interprofessional discussions within the curriculum. This case will be utilized in the first year of the curriculum for veterinary medical and medical students moving forward correlating with gastrointestinal disease units and as part of the environmental health core course for the Master of Public Health students to meet the One Health competency. We will continue to create and facilitate cases using the One Health framework that will highlight the impact of climate change and extreme weather events on animal, human, and ecosystem health.

Author Contribution

Authors’ contributions are as follows: Grace L. Park, conception and design of the work, data collection, drafting, critical revision, and final approval of the article; William E. Sander, conception and design of the work, data collection, drafting, critical revision, and final approval of the article; Sheena E. Martenies, design of the work, data collection, data analysis, and interpretation, drafting, critical revision, and final approval of the article; Holly Rosencranz, design of the work, drafting, critical revision, and final approval of the article; Laura Rice, design of the work and final approval of the article; Japhia Jayasingh-Ramkumar, design of the work and final approval of the article; Sarah Michaels, design of the work, critical revision, and final approval of the article; Brian Aldridge, design of the work, critical revision, and final approval of the article.

Data Availability

Material for the activity is available per request.

Declarations

Ethical Approval

IRB approval was received from the University of Illinois Urbana-Champaign, protocol #22619.

Consent for Publication

All authors have reviewed the manuscript and given consent for publication.

Competing Interests

The authors declare no competing interests.