Abstract
Objective
This study aimed to assess levels of awareness, knowledge, attitudes and behaviors related to climate change and sustainability in health care among final-year medical students (intern doctors), and to examine the relationships between these domains.
Methods
This descriptive, cross-sectional study was conducted between 12 August and 24 October 2025 among intern doctors enrolled at Gaziantep University Faculty of Medicine. Data from 167 interns who agreed to participate and completed the questionnaire in full were analyzed. Data were collected via an online questionnaire developed by the researchers based on a literature review, consisting of sections on sociodemographic characteristics, awareness, objective knowledge, attitudes and behaviors related to climate change and sustainability in health care. Total scores were calculated for the awareness, knowledge, attitude and behavior sections. Descriptive statistics, t tests, one-way analysis of variance, Pearson correlation and hierarchical multiple linear regression were used for data analysis. Internal consistency of the questionnaire sections was assessed using Cronbach’s alpha coefficients.
Results
The mean age of participants was 24.03 ± 1.36 years, and 52.1% were female. While perceived knowledge was mostly rated as low or moderate, objective knowledge scores indicated that 44.9% of students had moderate and 53.3% had good knowledge levels. Mean awareness scores were high (6.04 ± 1.27), attitude scores reflected moderately positive attitudes (6.38 ± 1.18), and behavior scores were lower, particularly in daily-life and clinical practice domains (overall behavior score 10.31 ± 3.89). Only 7.8% of participants reported discussing climate change with most of their patients; the most frequently reported barriers were lack of time (75.4%), perceived patient disinterest (69.5%) and insufficient knowledge (60.5%). Cronbach’s alpha coefficients for the awareness, attitude and behavior sections were 0.65, 0.70 and 0.78 respectively, indicating acceptable internal consistency, whereas the coefficient for the knowledge section was 0.40. Higher perceived knowledge and greater involvement in sustainability initiatives within the hospital were associated with significantly higher scores in some behavior domains. There was a weak but statistically significant positive correlation between knowledge and attitude scores (r = 0.172, p = 0.026), whereas no significant relationships were observed between knowledge or awareness scores and behavior scores.
Conclusion
Although intern doctors demonstrated relatively high levels of awareness and knowledge regarding climate change and sustainability in health care, these did not fully translate into corresponding changes in clinical and everyday behaviors. The weak relationship between knowledge and behavior suggests that information alone is insufficient to drive behavior change, and that motivational, institutional and structural support mechanisms are needed. Medical education should therefore be restructured to strengthen the climate-health nexus through both theoretical content and the promotion of environmentally sustainable clinical practices.
Trial registration
Not applicable. This study did not involve a health care intervention or clinical trial.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12875-026-03338-x.
Keywords: Climate change, Sustainable healthcare, Medical education, Intern doctors, Knowledge-attitude-behavior
Introduction
Climate change is one of the most important environmental problems currently threatening global public health [1]. In its 2021 special report The Health Argument for Climate Action, the World Health Organization (WHO) emphasizes that climate change is “the greatest health threat facing humanity” [2]. The COVID-19 pandemic has clearly demonstrated that the protection and maintenance of human health are closely linked to vegetation, animal health and the integrity of ecosystems as a whole [3].
In recent years, a marked increase has been observed in the frequency of climate-related disasters [4]. In addition, the climate crisis poses serious threats to human health and well-being through multiple pathways, including air pollution associated with fossil fuel use; increases in respiratory diseases due to wildfires; waterborne infections arising from flooding and environmental contamination; shifts in the geographic range and migration patterns of vectors such as mosquitoes, facilitating the spread of infectious diseases; zoonotic infections; and an elevated risk of future pandemics [3]. Previous studies and reviews have documented the multiple health impacts of climate change, including heat-related morbidity and mortality, food insecurity leading to undernutrition, and health problems driven by social and political instability [5].
Climate change is also anticipated to have both direct and indirect effects on mental health [6]. Thus, it is not merely an environmental or economic issue but a phenomenon that profoundly affects public health [7].
The health sector is directly impacted by climate change, while simultaneously contributing to this adverse transformation through the environmental footprint of healthcare production and delivery processes [8]. Although awareness of environmental issues within the health sector has increased in recent years, substantial variability persists in how health professionals and students understand and implement environmentally responsible practices. Evidence suggests that when attitudes toward sustainability are supported by effective leadership and educational initiatives, they can lead to positive changes in individual behaviors [9].
In this context, a noteworthy development is the June 2023 update of the European Definition of General Practice/Family Medicine by the European Council of WONCA (World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians). This document explicitly emphasizes three core concepts: One Health, Planetary Health and the Sustainable Development Goals (SDGs). The common premise underlying these three components is that human health is fundamentally dependent on the holistic health of natural ecosystems [3].
Similarly, other medical specialties have begun to incorporate environmental sustainability into their agendas - for example, by integrating climate-related content into internal medicine residency training, developing climate-sensitive models of care for older adults in geriatrics, and addressing cardiovascular disease in conjunction with environmental determinants in cardiology [10–12].
Although awareness of the health impacts of climate change has increased in recent years, the current body of knowledge regarding the adverse environmental footprint of healthcare delivery remains limited [8]. Therefore, medical education should train future physicians not only in clinical competencies but also as professionals who are responsive to environmental health threats. To our knowledge, the existing literature provides only limited evidence from multi-domain studies that simultaneously assess the awareness, knowledge, attitudes and behaviors of intern doctors, who are on the brink of entering independent medical practice and will play a primary role in responding to climate-health challenges. The aim of this study was to assess the levels of knowledge, attitudes and behaviors related to the climate crisis and sustainability in health care among intern doctors, who represent the future medical workforce.
Methods
This descriptive, cross-sectional study was conducted between 12 August and 24 October 2025 among final-year medical students (intern doctors) at Gaziantep University Faculty of Medicine. Before data collection, students were informed about the study, and only those who provided consent were included. The questionnaire was administered anonymously via Google Forms. No personally identifiable information, including names, email addresses or IP addresses, was collected. Access to the dataset was restricted to the research team, and data were stored in a password-protected environment in accordance with the approved ethical procedures. Participation was voluntary; students who did not provide consent or who submitted incomplete questionnaires were excluded from the analysis.
The minimum required sample size was calculated as 111 participants, assuming a prevalence of 50% for the primary outcome, a 95% confidence level and a 5% margin of error. As no prior study using a comparable instrument and outcome definition was available in the target population, a prevalence of 50% was selected as a conservative estimate to maximise sample size. In this study, the primary outcome variable used for the sample size calculation was the overall behavior score related to climate-friendly practices. During the 2025–2026 academic year, 204 intern doctors were enrolled; 171 (83.8%) responded to the survey. After exclusion of 4 respondents due to lack of consent or invalid responses, data from 167 participants were included in the final analysis.
The questionnaire items were developed by the authors based on a narrative review of the literature focusing on climate change, sustainability in health care, and health professionals’ knowledge, attitudes and behaviors and do not correspond to any previously published scale. Relevant studies were identified through searches of PubMed and Google Scholar, and questionnaire items were selected and adapted to reflect key domains identified in the literature. The literature search used to inform questionnaire development was conducted in May 2025. The search strategy included combinations of the following keywords: ‘climate change’, ‘climate and health’, ‘sustainable healthcare’, ‘medical students’, ‘health professionals’, ‘climate-health education’, ‘knowledge’, ‘attitudes’, and ‘behaviors’. Boolean operators (AND/OR) were used to combine search terms. Articles published in English that examined climate change, sustainability in healthcare, or climate-health education among health professionals or medical students were considered. No date restrictions were applied to the search to ensure a comprehensive overview of the evidence from database inception until May 2025. Studies not related to healthcare professionals or not addressing knowledge, attitudes, or behaviors were excluded. The identified literature was reviewed narratively to identify key domains for questionnaire item generation. To enhance content relevance, the preliminary questionnaire was reviewed by two faculty members with experience in public health and family medicine who were familiar with climate-health research. Minor revisions were made to improve clarity and wording of several items. Because the instrument was intended for exploratory use and no previously validated scale covering all domains of interest was available, formal psychometric validation procedures such as exploratory or confirmatory factor analysis were not conducted. The questionnaire was therefore used as an exploratory instrument to capture multiple dimensions of climate-health awareness, knowledge, attitudes and behaviors. The instrument was structured to assess participants’ levels of knowledge, attitudes and behaviors related to climate change and sustainability in health care. It consisted of four main sections: sociodemographic characteristics, awareness, objective knowledge, attitudes and behaviors. Each section included multiple-choice items, open-ended questions and closed-ended questions (e.g. yes/no or similar response formats). The questionnaire was intended for exploratory use, and no formal pre-testing or psychometric validation was performed.
Objective knowledge section
This section comprised 15 items covering different content areas related to the causes, consequences and health impacts of climate change. The knowledge items in the questionnaire were designed to cover multiple dimensions of climate change and healthcare sustainability, including causes, health impacts, and mitigation strategies. Therefore, the knowledge domain was conceptualized as a formative construct rather than a reflective unidimensional scale. In formative constructs, items represent different components of a broader concept and are not necessarily expected to be highly correlated with each other. Consequently, internal consistency measures such as Cronbach’s alpha may underestimate reliability in heterogeneous knowledge domains. For this reason, the knowledge score was treated as an exploratory composite indicator of objective knowledge rather than a psychometrically validated scale. (Taber KS. The use of Cronbach’s alpha when developing and reporting research instruments in science education. Res Sci Educ. 2018;48:1273–1296.) The objective knowledge section consisted of heterogeneous items covering multiple aspects of climate change and healthcare sustainability; therefore, this domain was treated as an exploratory composite score rather than a psychometrically validated unidimensional scale. Each correct answer was scored as 1 point. Based on the total score, knowledge level was categorised as very low (≤ 3 points), low (4–7 points), good (8–10 points) and very good (≥ 11 points). The total knowledge score was used in the study as a summary indicator of participants’ objective knowledge level.
Attitude section
The attitude section consisted of 7 statements rated as Yes/No/Unsure. Five items reflected positive attitudes and two reflected negative attitudes. For scoring, positive responses were assigned 2 points, “Unsure” responses 1 point and negative responses 0 points.
Behavior section
The behavior section included multiple-choice, multiple-response, open-ended and frequency-based questions. Items were grouped under three domains: Daily Individual Lifestyle Habits, Transportation and Climate-Friendly Mobility, and Sustainable Practices in the Clinical Setting. In this section, each pro-environmental / climate-friendly option was coded as 1 point. Separate subtotal scores were calculated for Daily Individual Lifestyle Habits, Transportation and Climate-Friendly Mobility, and Sustainable Practices in the Clinical Setting; the sum of these subtotals constituted the overall Behavior score.
Awareness section
The awareness section consisted of 7 items assessing participants’ subjective awareness of the health impacts of climate change. Items were answered in a Yes/No format. The awareness score was calculated as a total score ranging from 0 to 7, with each “Yes” response scored as 1 point.
Ethical approval
Ethical approval for this study was obtained from the Dean’s Office of Gaziantep University Faculty of Medicine (dated 12.08.2025, No. 699009) and the Gaziantep University Clinical Research Ethics Committee (dated 06.08.2025, No. 2025/199). The study was conducted in full accordance with the principles of the latest Declaration of Helsinki.
Statistical analysis
Data analysis was performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Questionnaire section scores were calculated, and skewness and kurtosis coefficients were examined to assess the normality of score distributions. All skewness and kurtosis values were within the range of − 3 to + 3, indicating approximate normality; therefore, parametric test procedures were applied. Independent-samples t tests were used to analyse categorical variables with two groups, and one-way ANOVA was employed for variables with more than two groups. Pearson correlation analysis was conducted to examine relationships between questionnaire section scores and behavior scores. Hierarchical multiple linear regression was used to identify predictors of the total Behavior score. Internal consistency of the questionnaire sections was evaluated using Cronbach’s alpha coefficients. A p value of < 0.05 was considered statistically significant.
Results
Descriptive characteristics
A total of 167 intern doctors were analyzed in the study. Participants’ ages ranged from 21 to 29 years, with a mean age of 24.03 ± 1.36 years; 64.1% were aged 24 years or older. Just over half of the sample were female (52.1%), and the vast majority (98.2%) were living in urban areas. Only 10.2% reported having previously received any education specifically on “climate change and health” (Table 1).
Table 1.
Sociodemographic and climate-health related characteristics of participants (n = 167)
| Variable | n | % |
|---|---|---|
| Age group | ||
| ≤ 23 years | 60 | 35.9 |
| ≥ 24 years | 107 | 64.1 |
| Gender | ||
| Female | 87 | 52.1 |
| Male | 80 | 47.9 |
| Current place of residence | ||
| Urban | 164 | 98.2 |
| Rural | 3 | 1.8 |
| Have you ever received any training on “climate change and health”? | ||
| Yes | 17 | 10.2 |
| No | 150 | 89.8 |
| How much knowledge do you have about the health impacts of climate change? | ||
| No knowledge | 14 | 8.4 |
| A little | 79 | 47.3 |
| Moderate | 72 | 43.1 |
| A lot | 2 | 1.2 |
| How much knowledge do you have about sustainability in health care? | ||
| No knowledge | 21 | 12.6 |
| A little | 88 | 52.7 |
| Moderate | 56 | 33.5 |
| A lot | 2 | 1.2 |
| I discuss the health impacts of climate change with my patients | ||
| With every patient | 0 | 0.0 |
| With most of my patients | 13 | 7.8 |
| Rarely | 93 | 55.7 |
| Never | 61 | 36.5 |
| I have contributed to sustainability initiatives in my hospital | ||
| Yes | 62 | 37.1 |
| No | 105 | 62.9 |
| Barriers to discussing this topic with patientsa | ||
| Time constraints | 126 | 75.4 |
| Lack of knowledge | 101 | 60.5 |
| Topic perceived as irrelevant | 70 | 41.9 |
| Patients’ lack of interest | 116 | 69.5 |
| No barriers | 10 | 6.0 |
aMultiple responses allowed
Regarding the frequency of discussing the health impacts of climate change with patients, none of the participants reported talking about this issue with every patient; only 7.8% reported discussing it with most of their patients, 55.7% did so rarely and 36.5% stated that they never discussed it. The proportion of participants who reported having contributed to sustainability initiatives within their hospital was 37.1%. The most frequently reported barriers to discussing climate-related health risks with patients were “lack of time” (75.4%), “patients’ lack of interest” (69.5%) and “insufficient knowledge” (60.5%), whereas only 6.0% reported having no barriers (Table 1).
When the distribution of objective knowledge scores was examined, the vast majority of participants were found to have either “moderate” or “good” levels of knowledge. Specifically, 75 participants (44.9%) had a moderate level of knowledge and 89 (53.3%) had a good level, whereas only 3 participants (1.8%) fell into the low knowledge category (Table 2).
Table 2.
Descriptive statistics for questionnaire domains and scores
| Questionnaire domain / score | n | Minimum | Maximum | Median | Mean | SD |
|---|---|---|---|---|---|---|
| Awareness total | 167 | 1 | 7 | 7 | 6.04 | 1.28 |
| Knowledge total score | 167 | 2 | 14 | 10 | 9.61 | 1.85 |
| Attitude score | 167 | 4 | 10 | 6 | 6.38 | 1.19 |
| Daily Individual Behavior total | 167 | 1 | 8 | 4 | 4.53 | 1.82 |
| Transportation and Climate-Friendly Behavior total | 167 | 1 | 4 | 2 | 1.93 | 0.94 |
| Clinical Setting total | 167 | 1 | 8 | 3 | 3.85 | 1.95 |
| Overall Behavior total | 167 | 3 | 20 | 10 | 10.31 | 3.90 |
In comparisons by age group, a statistically significant difference was observed only in awareness scores (p = 0.002). Participants aged 24 years and older had higher awareness scores (6.26 ± 1.15) than those aged 23 years and younger (5.63 ± 1.39), and this difference represented a medium effect size.
When questionnaire scores were compared by gender, no statistically significant differences were found in awareness, knowledge, attitude or behavior subscale scores (p > 0.05).
Cronbach’s alpha coefficients for the awareness, attitude and behavior sections were 0.65, 0.70 and 0.78, respectively, indicating acceptable internal consistency. The alpha coefficient for the knowledge section was 0.40, suggesting limited internal consistency and reflecting the heterogeneous and multidimensional content of the knowledge items; therefore, knowledge scores represent an approximate indicator of overall knowledge level.
Perceived knowledge level and ANOVA analyses
According to the one-way ANOVA conducted by perceived knowledge of the health impacts of climate change, awareness scores differed significantly between groups (p < 0.001). Participants who reported having no knowledge had lower awareness scores (M = 4.71 ± 1.68) than those who reported having little knowledge (M = 6.06 ± 1.01) and those who reported having moderate or high knowledge (M = 6.26 ± 1.30), with a medium effect size (η²=0.104) (Table 3).
Table 3.
Questionnaire scores by perceived knowledge of the health impacts of climate change (ANOVA and post-hoc Tukey results)
| Questionnaire domain / score | Perceived knowledge of the health impacts of climate change | n | Mean | SD | F | p | Post-hoc Tukeyᵃ | Effect size (η²) |
|---|---|---|---|---|---|---|---|---|
| Awareness total | No knowledge | 14 | 4.71 | 1.684 | 9.542 | 0.000* | 1,2 | 0.104 |
| A little | 79 | 6.06 | 1.017 | 1,3 | ||||
| Moderate or a lot | 74 | 6.26 | 1.304 | |||||
| Knowledge total score | No knowledge | 14 | 8.36 | 1.692 | 4.048 | 0.019* | 1,3 | 0.047 |
| A little | 79 | 9.59 | 1.843 | |||||
| Moderate or a lot | 74 | 9.86 | 1.816 | |||||
| Attitude score | No knowledge | 14 | 6.36 | 1.216 | 0.063 | 0.939 | 0.047 | |
| A little | 79 | 6.42 | 1.105 | |||||
| Moderate or a lot | 74 | 6.35 | 1.276 | |||||
| Daily Individual Behavior total | No knowledge | 14 | 3.57 | 1.869 | 4.027 | 0.020* | 1,3 | 0.029 |
| A little | 79 | 4.35 | 1.762 | |||||
| Moderate or a lot | 74 | 4.91 | 1.799 | |||||
| Transportation and Climate-Friendly Behavior total | No knowledge | 14 | 2.07 | 0.917 | 2.448 | 0.090 | 0.015 | |
| A little | 79 | 1.76 | 0.866 | |||||
| Moderate or a lot | 74 | 2.08 | 1.004 | |||||
| Clinical Setting total | No knowledge | 14 | 3.14 | 1.875 | 1.246 | 0.290 | 0.032 | |
| A little | 79 | 3.81 | 1.657 | |||||
| Moderate or a lot | 74 | 4.03 | 2.227 | |||||
| Overall Behavior total | No knowledge | 14 | 8.79 | 4.282 | 2.716 | 0.069 | 0.001 | |
| A little | 79 | 9.92 | 3.296 | |||||
| Moderate or a lot | 74 | 11.01 | 4.311 |
ᵃNumbers in the Post-hoc Tukey column refer to perceived knowledge groups: 1 = No knowledge; 2 = A little; 3 = Moderate or a lot
*p < 0.05
Total objective knowledge scores also differed significantly across perceived knowledge groups (p = 0.019). Participants who stated that they had no knowledge (M = 8.36 ± 1.69) had lower objective knowledge scores than those reporting little knowledge (M = 9.59 ± 1.84) and those reporting moderate/high knowledge (M = 9.86 ± 1.81) (η²=0.047) (Table 3).
Significant differences in daily individual behavior scores were also observed across perceived knowledge groups (p = 0.020). Participants who reported having no knowledge had lower daily individual behavior scores (M = 3.57 ± 1.86) than those reporting little knowledge (M = 4.35 ± 1.76) and those reporting moderate/high knowledge (M = 4.91 ± 1.79) (η²=0.047) (Table 3).
When groups were compared according to perceived knowledge of sustainability in health care, awareness scores differed significantly (p = 0.037, η²=0.039). Total knowledge scores (p = 0.024, η²=0.044), daily individual behavior scores (p = 0.007, η²=0.059) and total behavior scores (p = 0.025, η²=0.044) also showed significant differences between groups. For all three variables, higher perceived knowledge was associated with higher scores. No significant differences were found for attitude, transportation or clinical setting scores (Table 3).
A one-way ANOVA based on how often participants discussed the health impacts of climate change with their patients showed a significant difference in clinical setting scores across groups (p = 0.017, η²=0.048). Participants who reported discussing this topic with their patients “most of the time” had higher clinical setting scores (M = 4.85 ± 2.61) than those who reported discussing it rarely (M = 4.03 ± 1.99) or never (M = 3.36 ± 1.59).
Total behavior scores also differed significantly according to how often participants discussed climate change with their patients (p = 0.048, η²=0.036). Those who reported raising the topic “most of the time” had higher total behavior scores (M = 11.69 ± 5.85) than those who discussed it rarely (M = 10.72 ± 3.92) or never (M = 9.39 ± 3.18). No significant group differences were observed for awareness, knowledge, attitude, daily individual behaviors or transport-related behaviors.
When participants were grouped according to whether they had contributed to sustainability initiatives in their hospital, significant differences were found in daily individual behavior, clinical setting and total behavior scores (p < 0.05). Interns who reported contributing to sustainability initiatives had higher daily individual behavior scores (M = 5.02 ± 1.83) than those who had not (M = 4.25 ± 1.76), with a small-to-medium effect size (d = 0.43). Similarly, clinical setting scores were higher among contributors (M = 4.42 ± 2.15) than non-contributors (M = 3.51 ± 1.75), representing a medium effect (d = 0.48). Total behavior scores were also significantly higher in the contributor group (M = 11.52 ± 4.22) compared with non-contributors (M = 9.60 ± 3.53), with a medium effect size (d = 0.51).
The hierarchical multiple linear regression analysis showed that demographic variables together with awareness, knowledge and attitude scores did not have a significant predictive effect on the total Behavior score.
Correlation analysis
There was a positive, weak but statistically significant correlation between attitude scores and total knowledge scores (r = 0.172, p = 0.026). A positive, moderate correlation was found between the Transportation and Climate-Friendly Behavior score and the Daily Individual Behavior score (r = 0.353, p < 0.001). The Clinical Setting score was positively and strongly correlated with the Daily Individual Behavior score (r = 0.639, p < 0.001), and positively and moderately correlated with the Transportation and Climate-Friendly Behavior score (r = 0.398, p < 0.001) (Table 4).
Table 4.
Pearson correlation coefficients (r) and p values between questionnaire domains and scores
| Questionnaire domain / score | Awareness total | Knowledge total score | Attitude score | Daily Individual Behavior total | Transportation and Climate-Friendly Behavior total | Clinical Setting total | Overall Behavior total |
|---|---|---|---|---|---|---|---|
| Awareness total | r | 1 | 0.108 | 0.110 | 0.075 | −0.008 | 0.099 |
| p | 0.165 | 0.156 | 0.337 | 0.920 | 0.203 | ||
| Knowledge total score | r | 1 | 0.172* | −0.081 | −0.002 | −0.016 | |
| p | 0.026 | 0.298 | 0.976 | 0.835 | |||
| Attitude score | r | 1 | −0.025 | 0.041 | 0.046 | ||
| p | 0.744 | 0.599 | 0.557 | ||||
| Daily Individual Behavior total | r | 1 | 0.353** | 0.639** | |||
| p | 0.000 | 0.000 | |||||
| Transportation and Climate-Friendly Behavior total | r | 1 | 0.398** | ||||
| p | 0.000 | ||||||
| Clinical Setting total | r | 1 | |||||
| p | |||||||
| Overall Behavior total | r | ||||||
| p |
* p < 0.05; ** p < 0.01
With respect to the total Behavior score, a very strong positive correlation was observed with the Daily Individual Behavior score (r = 0.871, p < 0.001). Similarly, there was a very strong positive correlation between the total Behavior score and the Clinical Setting score (r = 0.894, p < 0.001), and a strong positive correlation between the total Behavior score and the Transportation and Climate-Friendly Behavior score (r = 0.605, p < 0.001) (Table 4).
Discussion
In this study, intern doctors were found to have high levels of awareness and relatively high levels of knowledge regarding climate change and sustainability in health care, whereas climate-friendly behaviors-particularly in daily life and clinical settings-were at comparatively lower levels. The frequency with which participants discussed climate and health with their patients was quite limited, and the most commonly reported barriers were lack of time, insufficient knowledge and perceived patient disinterest. A weak but statistically significant association was observed between knowledge and attitude scores, while no significant relationship was found between knowledge level and behavior scores.
Climate change is a major global health challenge in which health professionals occupy a frontline position. Strengthening this frontline should begin early in medical training to ensure that future health workers develop the capacity to recognize and manage the health impacts of climate change [13]. Heydari et al. reported that medical students had inadequate understanding and awareness of the health impacts of climate change in a study assessing their perceptions of climate-health links [14]. Similarly, Bharadwaj and Jannavada found low levels of knowledge, attitudes and practices related to climate change among medical students in India [15]. In contrast, in our study 44.9% of participants had a moderate and 53.3% had a good level of objective knowledge. This discrepancy may be explained by contextual factors such as differences in curriculum content, the extent of students’ engagement in voluntary environmental activities and faculty-level awareness-raising initiatives.
In our sample, only 7.8% of intern doctors reported discussing the health impacts of climate change with most of their patients, whereas 55.7% did so rarely and 36.5% reported never discussing this topic. The most frequently cited barriers to discussing climate-related health risks were lack of time (75.4%), perceived patient disinterest (69.5%) and insufficient knowledge (60.5%), while only 6% reported having no barriers. In a study among primary care physicians, Andre et al. similarly found that the majority of respondents perceived limited consultation time (70%), lack of clinical guidance (62%) and knowledge gaps (57%) as barriers to addressing climate and health in practice [16]. A study from Minnesota examining health professionals’ knowledge, attitudes and practices regarding climate change and health reported that only 4% of participants discussed climate change with all or most of their patients, and identified lack of knowledge (57%), lack of time (40%) and perceived patient disinterest (29%) as the most common barriers [17]. In another study conducted in primary care clinics, Wiskel et al. found that 36.2% of clinicians discussed climate-related health risks with patients, and noted competing clinical priorities and time constraints as key barriers to such discussions [18]. Taken together, these findings suggest that health professionals across different settings face similar challenges in addressing climate-health issues with patients. Consistent with this literature, time pressure, limited knowledge and perceived lack of patient interest were also the most frequently reported barriers in our study. These results indicate that gaps in time management, effective communication and counselling skills within health systems are experienced not only locally but also globally, and underscore the need for targeted interventions to strengthen these areas.
In our study, awareness and knowledge levels were relatively high and overall attitudes were positive, whereas climate-friendly behaviors-particularly those related to daily life and the clinical setting-were observed at lower levels. Examination of the behavioral subdomains showed that daily individual and transportation-related behaviors, and especially behaviors within the clinical environment, remained lower than awareness and knowledge levels, and that the total behavior score was consistent with this pattern. In a study evaluating clinicians’ knowledge and attitudes on climate change and health following a quality improvement programme, educational interventions were reported to be effective in increasing knowledge [19]. Similarly, Kircher et al. found that although 60% of participating health professionals were aware that climate change directly or indirectly affects the health of their patients or community members, only 4% reported discussing climate change with all or most of their patients [17]. Thus, the finding in our study that intern doctors’ behavior scores remained low despite high awareness and knowledge levels is in line with the literature [17, 19] and suggests that additional barriers hinder the translation of knowledge into clinical practice. This underscores the need to investigate potential mediating factors such as attitudes, motivation and system-level constraints. Participation in hospital sustainability initiatives was associated with higher pro-environmental behavior scores among intern doctors. Importantly, this finding highlights the role of institutional and organisational factors in shaping sustainable practices within medical training environments.
Müller et al. found that, among primary care clinicians, those belonging to the “Generation X” cohort discussed global warming more frequently with friends and family and were more likely to believe that global warming would harm U.S. residents compared with younger clinicians [20]. In Ayalon’s study, older adults were more likely than younger individuals to state that climate change is real and to express concern about its effects on their own lives and on the lives of both younger and older family members [21]. In contrast to these findings, which support a role for age, Luque-Alcaraz et al. reported a different pattern in a study of nurses, in which younger age was strongly associated with pro-environmental behavior and understanding of climate change [22]. Similarly, a study conducted in the Czech Republic found that approximately 80% of participants-particularly adolescents-had greater knowledge about climate change than adult participants [23]. In our study, awareness scores were significantly higher among intern doctors aged 24 years and older, suggesting that age may influence environmental risk perception and climate awareness. However, the inconsistency of age-related findings in the literature indicates that this relationship may vary depending on context and study population.
Sambath et al. reported that, among health workers in India, knowledge levels were high whereas behavior/practice levels remained limited [24]. In a study of French health professionals examining knowledge, behaviors, practices and expectations related to climate change and environmental sustainability, most participants recognised the adverse effects of climate change on human health, yet only about 25% reported having initiated environmental sustainability actions within their hospitals [25]. In our study, although higher knowledge levels were associated with greater awareness, consistent with these findings the increase in knowledge appeared to translate only modestly into behavioral change. Overall, these results suggest that higher levels of knowledge were not consistently associated with corresponding changes in behavior. Given the cross-sectional design and the exploratory nature of the knowledge measure, these findings should be interpreted as correlational rather than causal, and suggest that multiple factors-such as motivation, behavioral skills and systemic support-may influence sustainable practice.
In our study, there was a positive, weak but statistically significant correlation between attitude scores and total knowledge scores (r = 0.172, p = 0.026). This finding suggests that as participants’ level of knowledge about climate change increases, their attitudes tend to become slightly more favourable. The literature similarly supports the role of knowledge as an important determinant of environmental attitudes. For example, in a study of health workers in India, Sambath et al. reported that the majority of participants acknowledged that the health sector contributes to climate change (80.8%), felt that they have a responsibility to address it (85.4%) and believed that health professionals should play an active role in mitigation efforts (81.5%) [24]. Likewise, in a study by Odonkor et al., 71.4% of respondents reported having knowledge about climate change and more than half (50.1%) indicated that they engaged in adaptive behaviors, supporting a link between knowledge and environmental action [26]. In the Ismailia region of Egypt, Hussein et al. found that nearly three-quarters of the population supported mitigation strategies such as afforestation, reducing greenhouse gas emissions and transitioning to low-carbon energy sources [27]. Consistent with these findings, Hurst, Loo and Walker reported that increased knowledge about the causes and effects of climate change facilitates the development of pro-environmental attitudes and behaviors [28]. Taken together, these studies suggest that the weak but significant association observed in our research indicates that knowledge alone does not sufficiently drive attitude formation, but may constitute an important starting point for more favorable attitudes. This gap between knowledge and behavior may be interpreted within established behavior-change frameworks such as the Theory of Planned Behavior or the COM-B model, which emphasise that knowledge alone is insufficient and that motivation and opportunity are critical determinants of behavioral change [29]. Consequently, the limited impact of knowledge on changes in attitudes and behaviors implies that information provision alone may not be adequate within health education programs, and that targeted interventions are needed to actively support attitude and behavior change. Future longitudinal and intervention-based studies are needed to better elucidate causal pathways between knowledge, attitudes, and behavior in the context of climate change and sustainable healthcare.
Strengths and limitations
This study also has several strengths. First, the sample included all intern doctors from a single medical faculty and achieved a high response rate (83.8%), which increases the representativeness of the sample. Focusing on intern doctors is particularly important, as they are about to enter independent medical practice and will play a central role in responding to climate-related health challenges. Second, the study did not limit its focus to knowledge alone, but examined climate change and sustainability in health care across multiple domains, including awareness, attitudes and different behavioral areas (daily life, transportation and clinical setting). This approach provides a multidimensional perspective on the topic. In addition, the concurrent assessment of both subjective (self-perceived) and objective knowledge allowed for a more detailed examination of the knowledge-attitude-behavior relationship. The combined use of ANOVA, correlation and hierarchical regression analyses is another methodological strength, as it enabled a comprehensive depiction of the current situation of intern doctors in the context of climate change and sustainability in health care.
This study has some limitations. First, its single-center and cross-sectional design restricts the ability to infer causal relationships and limits the generalizability of the findings to other medical schools and primary care training settings. In addition, the predominantly urban composition of the study population and potential differences in curricula and institutional sustainability policies across medical faculties may further limit the transferability of the results. Second, the use of self-reported data introduces the risk of social desirability and recall bias. In the context of environmental sustainability, this may have led participants to overreport pro-environmental behaviors, potentially resulting in an overestimation of behavioral scores. In addition, the internal consistency of the knowledge section of the questionnaire, which was developed by the researchers, was low (Cronbach’s alpha = 0.40), indicating that scores from this section should be interpreted as an approximate indicator of knowledge level. Consequently, associations involving knowledge scores-particularly comparisons with attitudes and behaviors-should be interpreted with caution, and should not be taken as evidence of causal relationships. Moreover, the absence of formal construct validation limits confidence in domain-level interpretations, particularly for behavioral outcomes. Given the cross-sectional design of the study, the relationships observed between knowledge, attitudes and behaviors should be interpreted as associations rather than causal effects.
Conclusıon
This study provided a comprehensive assessment of knowledge, attitudes and behaviors related to climate change and sustainability in health care among final-year medical students. Although participants generally demonstrated high levels of awareness and knowledge, these did not fully translate into corresponding changes in clinical practice or everyday behaviors. In particular, the absence of a significant association between knowledge and behavior suggests that various barriers hinder the transformation of cognitive awareness into practical action.
The findings suggest that, among intern doctors, positive attitudes towards environmental sustainability were not consistently associated with corresponding changes in behavior, indicating that information alone may not be sufficient to support behavioral change. In this context, medical education needs to be structured in a way that not only strengthens theoretical understanding of the climate-health nexus but also actively promotes environmentally sustainable clinical practices.
Moreover, the results highlight the need for more in-depth investigation of intermediary factors influencing climate-related behavior change, such as motivational drivers, systemic constraints, role modelling and organizational support. Intervention-based approaches that explicitly target these domains should be evaluated. For a meaningful transition towards environmental sustainability in health systems, climate change and planetary health ought to be given priority within health education policies.
Supplementary Information
Acknowledgements
The authors would like to thank all intern doctors who participated in this study.
Authors’ contributions
YBA: design of the work, acquisition and analysis of the data, drafting the work, revising it critically for important intellectual content and final approval of the version to be published.İD: design of the work, acquisition and analysis of the data, drafting the work, revising it critically for important intellectual content and final approval of the version to be published.SDY: design of the work, acquisition and analysis of the data, drafting the work, revising it critically for important intellectual content and final approval of the version to be published.TS: design of the work, acquisition and analysis of the data, drafting the work, revising it critically for important intellectual content and final approval of the version to be published.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
Ethics Committee approval was obtained from Gaziantep University (Approval No: 2025/199, Date: 06.08.2025) The ethical principles stated in the latest revision of the Declaration of Helsinki and good clinical practice standards were applied.
Informed consent was obtained from all individual participants included in the study.
Consent for publication
Not applicable. The manuscript does not contain any individual person’s data in any form (including images, videos or identifiable quotations) that would require consent for publication.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.