Patient knowledge and views on the health impacts of climate change in primary care: a cross-sectional survey study

1 Introduction

Climate change poses growing risks to human health, prompting increased attention to the role of primary care providers in addressing planetary health (Haq et al., 2023). Surveys of healthcare providers and patients alike suggest growing awareness of its health impacts. For example, a 2021 multinational study of nearly 4,000 healthcare providers found that 77% of clinicians believed climate change would cause either a moderate or great deal of harm to their patients (Kotcher et al., 2021). Studies in India, Nepal, and Portugal found that healthcare providers largely believe in and are concerned about the health implications of climate change (Chandra et al., 2023; Ponte et al., 2024; Rai et al., 2025). In a sample of 250 hospitalized patients in the United States, 84% were aware of environmental threats to their health (Cerceo et al., 2025).

However, many physicians report barriers to addressing climate change in clinical encounters, including insufficient knowledge, time constraints, and a perceived lack of patient interest (Kircher et al., 2022). Some providers also worry about generating feelings of hopelessness or guilt in patients, or about straining the physician-patient relationship given the perceived political nature of climate conversations (den Boer et al., 2021; Kotcher et al., 2021; Müller et al., 2024; Sanderson and Galway, 2021).

Emerging evidence suggests these conversations may strengthen, rather than undermine, the therapeutic relationship. In a recent qualitative study of primary care patients in Germany, many participants reported conversations about climate change could have a positive effect on trust and communication (Griesel et al., 2023). A study of patient and family responses to climate change counseling from pediatricians in Wisconsin found that parents responded favorably despite their self-described political leaning (Lewandowski et al., 2021). Patients in other settings have also identified physicians as among their most trusted sources of information about climate change, second only to climate scientists and scientific journals (Boland and Temte, 2019).

Together, these findings highlight an important knowledge gap in the effort to inform patients about climate change and health. While providers see value in addressing the health impacts of climate change and patients view physicians as credible messengers, uncertainties remain about how patients view climate change, what adaptation resources they seek, and how climate discussions may affect the therapeutic relationship.

To address this gap, we conducted a cross-sectional survey of primary care patients to assess knowledge and attitudes regarding climate change, perceived barriers for climate action, and perspectives on how climate-related discussions with clinicians might influence trust and communication. We hypothesized that primary care patients possess a wide range of prior knowledge of the connections between climate change and health, the majority express interest in climate-related discussions that pertain directly to their health with their providers.

2 Methods

2.1 Study population

Participants aged 18 years and older were recruited from three University of Michigan Family Medicine clinics: Ypsilanti Health Center (Ypsilanti, Michigan), Briarwood Family Medicine (south Ann Arbor, Michigan), and Family Medicine at Domino's Farms (north Ann Arbor, Michigan). Medical student study team members approached patients in clinic waiting rooms and informed them that participation was voluntary and would not affect their care. The number of patients who declined initial participation was not recorded, and respondent names or identifiers were not collected to maintain confidentiality. After providing verbal consent, respondents completed the survey on their personal device (e.g., smartphone) or on a study-provided laptop computer. Data collection occurred from February 21, 2025, to June 6, 2025.All available responses were included in the analysis.

2.2 Survey development

The survey included questions about: (1) knowledge and attitudes about climate change and health, (2) experiences and attitudes about climate change discussions with healthcare providers, (3) barriers and motivations for climate change-related behavior change, and (4) demographic information. Survey content was developed in consultation with a faculty expert from the University of Michigan Survey Research Center. Draft questions were pilot tested with four non-medical colleagues of the research team to ensure clarity and readability. Pilot testing indicated a median completion time of 6 min. The final survey instrument is provided in the Supplementary materials. The study was reviewed and deemed exempt by the University of Michigan Institutional Review Board on January 20, 2025 (HUM00266416).

2.3 Data analysis

Descriptive statistics were used to summarize respondent characteristics and survey responses. Two key survey items asked whether respondents believed climate change affects the area where they live and whether they believed it was a threat to their long-term health. Both items were rated on a Likert scale. Responses were then averaged to create a composite “Attitude Score,” ranging from 1 to 5. A score of 1 reflected no alignment with the view that climate change and health are related and legitimate, while a score of 5 indicated strong alignment. The Attitude Score was used as a primary variable in subsequent analyses.

Kruskal-Wallis testing was performed to examine the relationship between participants' interest in learning about climate change and participants' familiarity with climate change-related topics. Dunn's testing was then performed to determine the difference in topics participants were familiar with between each group by interest in learning about climate change. Kruskal-Wallis and Dunn's testing were also used to test associations between participant attitudes and their perceptions of how climate change discussions might affect the patient-provider relationship. Chi-square tests were used to determine if there were differences between interest in resource type between demographic groups.

Analyses were performed with SAS software version 9.4 (SAS Institute).

3 Results

3.1 Survey respondents

Demographics for the 289 survey participants are presented in Table 1.

Table 1. Respondent demographics.

3.2 Knowledge of and attitudes toward climate change

Among 262 respondents, a majority (70.6%) agreed or strongly agreed that climate change poses a risk to their long-term health. Approximately one in five (19.1%) were neutral, while 10.3% disagreed or strongly disagreed. A similar pattern was observed when respondents were asked whether climate change affects the area where they live. Three quarters (76%) agreed or strongly agreed, 17.2% were neutral, and 6.9% disagreed or strongly disagreed. Representative free-text comments illustrating common respondent viewpoints on climate change are shown in Table 2.

Table 2. Selected patient opinions on climate change and health.

Respondent awareness and interest in discussing climate-related topics with their healthcare provider are summarized in Figure 1. Respondent awareness of climate change-related health issues was evaluated with “yes” or “no” questions (Supplementary Table 1). Among those who answered each question, most patients reported awareness of climate change impacts on environmental allergies (N = 222 of 254, 87.4%), lung disease (N = 214 of 253, 84.6%), and food shortages (N = 196 of 251, 78.1%). Awareness was lower for medication stability and availability (N = 116 of 248, 46.8%), heart disease (N = 96 of 244, 39.3%), and injury (N = 90 of 243, 37%).

Respondent interest in learning about climate change-related issues was measured using a three-point scale including “very interested”, “somewhat interested”, and “not very interested” (Supplementary Table 2). Among those who answered each question, a majority of respondents expressed being very or somewhat interested in discussing all the prompted issues with their provider. The areas of greatest interest were environmental allergies (N = 190 of 214, 88.8%), mental health issues (N = 188 of 213, 88.3%), and lung disease (N = 186 of 212, 87.7%).

The number of climate change-related issues respondents were already aware of differed significantly by level of interest in learning more about climate change (Chi-Square = 25.8, df = 4, p < 0.0001, N = 230). Respondents who were strongly interested in discussing climate change reported awareness of 3.84 more topics (p = 0.001) compared with those who were disinterested in discussing climate change (Supplementary Tables 3 and 4).

3.3 Barriers to and resources for climate change adaptation

Of 258 total responses, only one-quarter (25.4%) of respondents indicated they knew how to adapt to the health effects of climate change. Of 236 responses, most (69%) indicated they were somewhat or very likelyto change their perspective on climate change if they were to learn more from their healthcare provider. Of 233 respondents, three-quarters (75.6%) indicated they were somewhat or very likely to change their behaviors. Barriers to behavior change are summarized in Table 3. Among 228 respondents, the most reported barriers included uncertainty about what actions would make a difference (42.5%), lack of knowledge about climate change (31.6%), and concerns about cost (28.5%).

Table 3. Barriers to lifestyle changes in response to climate change.

Among 244 respondents who answered these questions, most expressed interest in engaging with climate-related health resources. Specifically, 78.3% of respondents reported being somewhat or very likely to engage with conversations about climate change with their provider, 78.6% self-reported as somewhat or very likely to read educational materials, and 89.8% indicated they were somewhat or very likely to use practical tools to adapt to climate change (e.g., discounts for fans, home air filters). Interest in these resources was examined by household income, education level, and age (Supplementary Table 5). No statistically significant differences were found across these demographic groups.

3.4 Impacts on the patient-provider relationship

When asked about the impact of climate change discussions on their relationship with their provider, 27.4% of respondents agreed or strongly agreed these conversations would have a positive effect, 54.3% were neutral, and 18.3% disagreed or strongly disagreed.

A statistically significant difference in Attitude Score was observed between respondents who believed their physician relationship would be positively impacted by climate change discussions and those who did not (Chi-Square = 37.18, df = 4, p < 0.0001, N = 255). Respondents who strongly agreed their relationship would improve had an average Attitude Score 3.06 points higher (p = 0.019) compared with those who strongly disagreed (Supplementary Tables 6 and 7).

4 Discussion

This study adds to the growing body of literature on how patients in the primary care setting understand and engage with the health impacts of climate change. We found that most respondents recognized climate change as a health concern and expressed interest in learning more from their providers. Awareness was greatest for climate-related respiratory illness, allergies, and food shortages and lowest for less visible but clinically important areas such as medication stability, climate-associated injuries, and cardiovascular impacts.

Compared with prior studies that have placed a larger emphasis on provider insights (den Boer et al., 2021; Kircher et al., 2022; Kotcher et al., 2021; Müller et al., 2024), our work broadens the understanding of patient-reported attitudes and knowledge. Our findings parallel those of a 2025 study of parents of pediatric patients in New Jersey, which found that air pollution and allergens and pollen were among the environmental threats of greatest parental concern (Lin et al., 2025). Patients who reported greater interest in climate health education were already familiar with more climate-related health topics, suggesting that baseline knowledge may be associated with receptiveness to further counseling.

A subset of respondents in our study expressed disinterest or skepticism about climate change health effects. Those with lower Attitude Scores acknowledged knowing fewer climate-health connections and were also less likely to express that discussing climate change with their provider would strengthen their relationship. These results highlight both the opportunity and challenges for clinicians in climate education: while many patients may be receptive, a minority may view these discussions as politically charged or irrelevant.

Our study mirrors prior work showing that physicians often hesitate to discuss climate change due to fears of inducing hopelessness or harming the patient-provider relationship (den Boer et al., 2021; Kotcher et al., 2021; Müller et al., 2024). A 2022 survey of 103 primary care physicians conducted in Michigan reported more than 60% of responding providers were concerned about the possible negative effects on their patient relationships if they were to discuss climate change (Müller et al., 2024). However, our work suggests that providers may benefit from a baseline assessment of patient beliefs regarding climate change before attempting to discuss the topic if they are concerned about maintaining the therapeutic relationship.

We also found that nearly half of respondents reported uncertainty about which individual actions would make a difference, and qualitative responses included language like “inevitable” and “disheartened.” These sentiments underscore the importance of framing climate conversations around actionable, personalized steps. Even patients skeptical of anthropogenic climate change may recognize tangible environmental hazards (high heat days, periods of higher air pollution) and adopt protective behaviors when the advice is framed around their personal health.

4.1 Future directions

Previous work has suggested disease-state-specific and actionable counseling on the health impacts of climate change, such as weather-related guidance on hospital discharge paperwork, could be effective educational measures (den Boer et al., 2021; Kotcher et al., 2024). Future research should evaluate implementation of patient-centered resources such as brochures, practical adaptation tools (e.g., air filters, cooling devices), and structured conversation guides. Additionally, patient awareness of systemic protections, such as emergency alert systems and air quality indices, may also impact behavior change and could be integrated into discussions within the clinic. Since over 75% of our study respondents reported a willingness to change behaviors if counseled by their provider, interventions linking education with concrete adaptation strategies could be highly impactful. Studies should also explore communication strategies to offer evidence-based guidance for clinicians seeking to navigate the clinical and political sensitivities of climate discussions.

4.2 Strengths and limitations

This study has several strengths. The sample size provided adequate power to detect statistically significant associations, including differences in knowledge and attitudes by interest level. Additionally, patients were recruited in-person from three diverse family medicine clinics, ensuring that participants were engaged in ongoing primary care at the same sites likely to implement future interventions.

However, there are also limitations. First, not all survey respondents completed the entire survey, likely in part due to its length. In addition, one set of topic-specific items may have been skipped more often because it followed a similarly structured question. Analyses therefore included all available data, with item-specific sample sizes reported. Although non-response was greater for later questions, attrition bias remains possible if respondents who did not complete the survey differed systematically from those who did. Second, the total number of patients approached and reasons for non-participation were not recorded, preventing calculation of a survey response rate and limiting assessment of non-response bias while introducing potential selection bias. Third, we were unable to screen for duplicative responses, as some participants used personal devices to complete the survey. Fourth, the timing of data collection (February to June) may have influenced responses as it preceded Michigan's peak summertime exposure to wildfire smoke and extreme heat (Michigan Air Quality Annual Report, 2025). Finally, these findings may not be generalizable to other patient populations with different political, cultural, or environmental contexts.

4.3 Conclusions

Our study suggests primary care providers are well positioned to support patients with both adaptation and resilience to the expanding health effects of climate change. By tailoring discussions to individual conditions and focusing on pragmatic strategies, providers may strengthen rather than strain therapeutic relationships.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fclim.2026.1930073/full#supplementary-material

Supplementary Data and Patient Survey. Supplementary material at the source

Footnotes

Edited by: Adugna Woyessa, Ethiopian Public Health Institute, Ethiopia

Reviewed by: Pouné Saberi, Philadelphia Veterans Health Administration, United States Department of Veterans Affairs, Philadelphia, Pennsylvania, United States

Adrian Cois, Oregon Health and Science University, United States