Climate Change Adaptation and Mitigation Opportunities and Strategies in Primary Health Care: Perspectives of Pharmacists in Ontario, Canada

Abstract

Background: Health care work contributes significantly to greenhouse gas emissions. Primary health care is community-based and focused on wellness and disease prevention. Within primary health care, pharmacists are most frequently the stewards of medicines, supplies, and other tangible products that contribute to carbon footprints. Pharmacists are in a unique position to help adapt to and mitigate climate change-related issues. Objective: To examine pharmacists’ perspectives on climate adaptation and mitigation strategies in primary health care delivery in interprofessional settings. Methods: Semi-structured qualitative interviews with primary care pharmacists were undertaken. Constant-comparative data analysis was used to code and categorize findings. The COREQ system was applied to ensure rigor and quality of research. Results: A total of 21 primary care pharmacists participated in this research. Several core themes emerged as follows: (a) universal agreement that climate change is real and primary health care needs to evolve rapidly to address it; (b) recognition that primary health care is time-pressured and resource constrained so successful solutions need to be pragmatic and work within realities of practice; (c) identification of actionable priorities with high potential for mitigation impact; and (d) mobilization of a coalition to develop system-wide initiatives that could be implemented in primary health care. Conclusions: Collaborative approaches and those that focus on the implementation of regulatory requirements were identified as being most productive in this setting.

1. Introduction

Health care work is thought to contribute close to 5% of all global greenhouse gas (GHG) emissions [1]. Recent research suggests that prescribed and over-the-counter medications alone account for somewhere between 1 and 2% of all GHG emissions [2]; this figure does not take into account downstream pharmaceutical pollution-related climate consequences associated with unsafe disposal of unused pharmaceuticals or release of polluting or contaminating pharmaceutical residues through wastewater. Pharmaceutical and medical waste is a significant contributor to antibiotic resistance, which drives further use of polluting medications and medical supplies [3]. Health care work—in the community and in specialized institutions and hospitals—consumes an enormous amount of single-use products (such as alcohol swabs, disposable needles and syringes, gloves, masks, and sterile packaging), which cannot be recycled and are ultimately disposed of in landfills or through incineration—further adding to the carbon footprint of health care work [4,5].

It is with sanguine resignation and some irony that an increasing number of health professionals—physicians, nurses, pharmacists, dentists, and others—note that, in the name of trying to heal the sick, the actual work of health care is contributing meaningfully to disease burden and illness [6,7]. Increasing rates of asthma and other respiratory diseases [8,9], decreases in fertility linked to estrogenification of water tables [9], growing numbers of allergic and atopic conditions [10,11], and increasing antimicrobial resistance [12] are all ways in which polluting outputs of health care work are acting to make individual patients sicker.

Across many health professions, this reality has driven individual professionals to affirm commitments to “climate conscious practice” [13]. Climate-conscious practice emphasizes the daily practice of frontline, patient-facing practitioners (including doctors, nurses, pharmacists, and dentists) and is focused on the myriad choices made each hour they work that may have climate-related impacts [14]. Climate-conscious practice is less focused on large employers (such as hospitals), organizations (such as academic health centers), or health systems, and instead prioritizes individual awareness-building and action to reduce the climate burdens of health care work [13].

The scope of “health care” is vast and covers a range of organizations, settings, professionals, and objectives. Primary health care (PHC) is most frequently described as the first (or primary) point of contact for individuals seeking health or wellness services [15]. Management of common illnesses or minor ailments (such as “pink eye”, urinary tract infections, or “athlete’s foot”), chronic disease management (for conditions such as diabetes, asthma, or arthritis), and disease prevention (through, for example, blood pressure and cholesterol monitoring) are all examples of PHC [16]. PHC also often deals with non-emergency injuries and acute medical problems [15,16]. PHC is part of the broader network of health care and connects with secondary and tertiary services through referrals to specialists and specialized institutions/clinics with advanced capabilities. Primary health care is rooted in comprehensive service provided by health professionals that is built upon long-term relationships [16]. It is most frequently delivered in an interprofessional manner, bringing together the talents and unique capabilities of diverse professionals, including physicians, nurses, nurse practitioners, pharmacists, and others [17,18]. Typical activities in primary care include regular “check-ups”, periodic health reviews, medication reviews, chronic disease management services, and preventative screening [13]. Primary care focuses on both physical and psychosocial care and is patient-centered in its orientation [13,18].

Primary care teams of diverse professionals function interdependently and reinforce one another’s skills, competencies, and scopes of practice. Within these teams, pharmacists are most frequently viewed as stewards of resources, ensuring rational, appropriate, and cost-effective use of medications and other medical supplies within the context of the care and services provided [19]. Pharmacy has historically been focused on the procurement, storage, monitoring, distribution, effective use, and safe disposal of medications and other medical supplies used for patient care by a health care team [20]. As the quartermaster of the primary care system, pharmacists are often the health care professionals most directly connected to the use of the supplies that drive the carbon footprint of health care work. In recent years, in many jurisdictions, the scope of practice of pharmacists has evolved considerably [20]. Scope of practice refers to the legally allowed activities a profession may perform, aligned with their education and expertise [21]. In Canada, the scope of practice for pharmacists has evolved to include the administration of vaccinations, the prescribing of medications for minor/common ailments, and adapting/modifying/renewing prescriptions written by other health care professionals (such as physicians) [21]. Pharmacists are also leading initiatives related to “de-prescribing”, the process of reducing or stopping medications that are no longer of benefit or may actually be causing harm due to side effects or drug interactions [21].

Given the scope of practice of pharmacists in primary care and their quartermaster responsibilities associated with stewardship of medications and medical supplies, they are uniquely positioned to champion climate-conscious practice. Through their independent scope of practice (e.g., prescribing and de-prescribing activities) and through their role as a primary care team member (advising physicians, educating patients, reviewing medications), there are opportunities for pharmacists to positively impact the carbon footprint of primary health care.

The objective of this research was to examine climate adaptation and mitigation options and opportunities in primary health care team settings from the perspective of primary care pharmacists working in Canadian health care teams. This study is novel in focusing on the day-to-day practice and experience of non-specialist frontline primary care professionals without specific training or expertise in climate science; these are the individuals who, through their daily clinical decisions and actions, are having the most direct impact on climate-conscious health care practice, yet their experiences and perspectives have not been widely reported in the literature. As an exploratory study, the research itself was pragmatic in its orientation, focused on eliciting and documenting the activities and experiences of pharmacists without specialty training in climate science. Findings from this study would be useful in shaping the climate-conscious practice of individual professionals and primary health care pharmacy practitioners, as well as informing organizational policies and practices around climate breakdown and change.

2. Materials and Methods

The potential role of primary health care teams and professionals in reducing climate impacts of their work has not been widely reported. As a result, an exploratory, qualitative research method for this study was selected as being most appropriate given the relative lack of available evidence on this topic [22]. Semi-structured interviews with pharmacists were identified as a useful initial research approach, given the pharmacist’s role and scope of practice in primary health care delivery. Semi-structured interviews have been used previously to support authentic engagement with research participants while still maintaining a focus on a central research theme or objective [22].

In undertaking exploratory qualitative research of this sort, it is essential to ensure the quality, indicativeness, and trustworthiness of both the research method and the interpretation of data. The consolidated criteria for reporting quality research (COREQ) checklist is a widely used method in qualitative research to ensure adherence to high-quality methods throughout the research process [23]. It provides reassurance that researchers’ own subjectivities and biases do not disproportionately influence research design, analysis, or reporting. For this study, the COREQ process was used to guide research design, research conduct, data collection, data storage and management, data analysis, analysis and synthesis of findings, and reporting of outcomes.

For this research, pharmacists working in primary health care team settings were the focus of the study. Inclusion criteria for this study were as follows: (i) licensed/registered practicing pharmacist; (ii) working in a primary health care team setting for a minimum of 3 years (to ensure participants were sufficiently well-integrated into their interprofessional teams and practices and more comfortable in exercising their own profession-specific mandates); (iii) English-speaking (due to the linguistic capabilities of the researchers involved).

In Canada’s universally accessible health care system, primary health care is a government-funded initiative [15]. All Canadians are eligible for access to primary health care services; patients are required to pay for any expenses associated with primary health care services, but private insurance plans are not required. Primary health care teams maintain a visible web presence in order to engage with their communities; through these websites, it was possible to identify primary health care team pharmacists and to contact them directly via email to participate in this study. Ontario is the largest of Canada’s provinces, home to over 15 million people. Like the rest of Canada, there are rural communities, small towns, larger cities, and global metropolises in Ontario. As of June 2025, there were 330 interprofessional, team-based primary health care practices in the province [24]. The locations and catchment areas for these practices were analyzed in order to allocate each team based on geographic or demographic focus. Five cohort groupings were identified for this study based on catchment: large urban area (population >1,000,000), suburban/adjacent large urban area, mid-size community (population between 50,000 and 1,000,000), small town (population less than 50,000), and Aboriginal/Indigenous catchment (community with >50% First Nation, Aboriginal or Indigenous population) [24]. The 330 identified primary health care team practices were allocated to one of these five groups to ensure adequate sampling of different kinds of primary care practices across the provinces.

Emails were sent to the pharmacists identified at each of the 330 practices, with an explanation of the rationale for the study and an invitation to contact the researchers to learn more and to participate.

Individuals who agreed to participate were required to complete informed consent pursuant to a research protocol approved by the University of Toronto. A semi-structured interview protocol was developed and pilot-tested (see Appendix A). Four individuals participated in the pilot testing process and provided their feedback to ensure the protocol was clear, concise, and on-topic. Modifications to the initial protocol were made iteratively during the pilot testing process. The final version of the interview protocol was designed to be sufficiently open-ended to facilitate free and honest dialog but focused enough to ensure the central research objective of this study was achieved. The initial draft of the protocol consisted of 14 questions/prompts and sub-prompts; the final version used in this study contained 9 prompts. Approximate time required for completion of the interview was estimated as 35–45 min, based on pilot data—depending on the interest and talkativeness of individual participants, interviews could last longer or go more quickly, so one-hour interview time slots were booked with each participant to ensure sufficient time was available to facilitate in-depth conversations.

Informed consent for participation was obtained from all subjects involved in the study. Interviews with participants would be undertaken to the point of thematic saturation, a theoretical construct describing the point in a qualitative research project where the research team believed no new, meaningful, or important additional information that would result in new codes, categories, or themes being identified during data analysis would be derived from conducting additional interviews [25]. Given the relatively small number of participants within each of the five cohorts identified above, thematic saturation for this study was defined based on the entire participant pool. This decision was pragmatic but also justified based on the reality that each primary care pharmacist—regardless of their cohort or geographic location—performed substantially similar work in their interprofessional team setting. At the point where the research team concluded thematic saturation had occurred based on the lack of new themes/ideas being generated, an additional two participant interviews were undertaken to confirm this conclusion prior to suspending enrollment in the study.

All interviews were undertaken virtually using the Zoom (Zoom Communications Inc., San Jose, CA, USA) platform. With informed consent from the participant, interviews were recorded and verbatim transcripts generated using Zoom’s automatic transcript function. Subsequent review and “cleaning” of these automatically generated transcripts by the interviewer were required to ensure accuracy and clarity and to help adjudicate discrepancies between verbal comments and non-verbal cues of participants during the interview. Each participant was offered the opportunity to review their individual transcript, once cleaned, if they wished to do so.

All transcripts were reviewed by two researchers who undertook independent coding and categorization of data using the constant comparative data analysis method [26]. Data were managed and analyzed using NVivo v15.3 (Lumivero, Burlington, MA, USA), a widely used qualitative data management package. This version includes an artificial intelligence (AI) assistant that can be engaged to summarize documents, suggest codes, and provide AI-generated summaries for analytical frameworks and coding structures. This functionality was used during initial data analysis, but all final decisions regarding interpretation, coding, categorizing, and theming were made by the research team itself. As a result, while AI was used to support the research and to enhance operational efficiency, human-in-the-loop AI methods were relied upon to ensure all final decisions were made by human researchers. For this research, AI assistance was used to provide summaries of interview transcripts and to provide initial recommendations for coding and categorizing themes for analysis. Throughout this process, specific transcript data were referred to in order to ensure a clear evidentiary basis for the identified codes, categories, and themes. The 32-item COREQ checklist was used to ensure all research processes and methods conformed to quality expectations for this kind of participant-focused, interview-based, qualitative research study.

This study received ethics board approval from the University of Toronto Canada (protocol number 45420 approved 10 October 2023). It was deemed as low-risk research given the relatively low threat of vulnerability faced by participants, all of whom were highly educated, autonomous health care professionals. Informed consent for participation was obtained from all subjects involved in the study. No patient-identifying data or disclosure of details related to vulnerable individuals was included in the study protocol or in the study itself. The research team were both experienced pharmacy practice and health services researchers with combined experience of over 50 years and more than 150 research manuscripts published. The primary author (ZA) is a registered pharmacist with over 35 years experience in the profession. Neither member of the research team have particular expertise in climate science, though both authors have strong interests in advancing climate-conscious pharmacy practice. This manuscript reporting findings of the study was entirely generated by human researchers with no assistance from AI, other than superficial text editing for grammar, spelling, punctuation, and formatting.

3. Results

A total of 40 individuals responded to the initial email invitation to consider participation in this study; follow-up information was provided by email, with an opportunity to speak directly to a researcher to discuss further. Of these 40, 24 indicated an interest in continuing the process and participated in the research, including semi-structured interviews. During the start-up period for this project, three individuals who had agreed to participate were forced to withdraw due to illness, organizational constraints/changes, or other factors. A total of 21 individuals completed informed consent and were enrolled as study participants. Demographic characteristics of participants are presented in Appendix B. Key themes that emerged from this research, followed by sample verbatim transcript excerpts from participant interviews to support the identified theme, are presented below.

• Universal agreement that climate change is real, and primary health care needs to evolve rapidly to address it: All participants in this research demonstrated both awareness and understanding of climate science and accepted the realities associated with climate breakdown. All participants were aware of technical concepts such as “adaptation” and “mitigation” strategies and accepted that, without intervention and work to reduce carbon emissions, climate breakdown would be irreversible, leading to significant consequences for humanity. All participants were also aware of the polluting effects of health care work itself, though individual participants demonstrated varying degrees of depth of this awareness. Of the 21 participants, 9 indicated that in their particular primary health care practice, they (as the only, primary, or one of several pharmacists on the team) were identified as the key “point person” to consider how the team and practice could manage climate-related issues. This provided some confirmation of the initial supposition of this study that primary care pharmacists, as stewards of medicines and medical supplies, were well-positioned to lead primary care initiatives related to adaptation and mitigation strategies. Six of the participants indicated that in their primary care practices/teams, there had been no formal discussion or job assignments related to management of climate-related issues; despite this, these individuals had assumed some personal responsibility to build awareness of this issue within the team, provide support and education to other professionals, and initiate informal conversations and activities aimed at heightening awareness of the issue. The remaining six participants indicated that in their primary care team practices, there had been no or very limited conversation or action related to climate-conscious practice. All participants in this research indicated their own personal commitment to addressing climate breakdown, both in their professional and personal lives, and agreed that the issue itself was important and required further attention in health care. The researchers noted—and many participants confirmed—a high degree of self-selection bias in these results: the level of commitment and interest demonstrated by these participants related to this issue was a driver of their interest in participating in this kind of study in the first place.

“This is an issue I have really strong feelings about, so I was really happy to [hear] you’re doing a study like this. In my [primary health care team], I guess I’m the one people look to about this issue. My administrator has actually asked me to be active—you know, provide continuing education, develop information sheets for patients and the rest of the team, that sort of thing—to try to get the word out and provide really concrete and practical guidance on how to reduce climate impact of the work we do. It’s really one of the highlights of my job right now.”

“This is something I really take seriously not just at work. I try to cycle to work instead of drive whenever possible, I’m a fiend about recycling, you know that sort of thing. At [my clinic], most everyone agrees about the importance of climate change—I don’t think anyone is a skeptic of climate denier—but everyone is just really busy and doesn’t have time or bandwidth to do anything about it. Well, except insist on LED light bulbs and things like that. So I’d say the intentions are good but the system doesn’t provide enough time or space for these good intentions to translate into any real action.”

“I know in some [primary care teams] they actually make it a job, give someone the assignment to take on the climate change role. Unfortunately, we don’t do that in [my practice], there’s not enough, I don’t know, for us to be able to actually do this. So it ends up being something a few of us just do off the side of our desk because, well, we know its important and believe in it, and you just have to try your best even if the system doesn’t seem to be able to support it all the time.”

2.

Recognition that primary health care is time-pressured and resource-constrained, so successful solutions need to be pragmatic and work within realities of practice: A strong and common theme related to pragmatic workplace pressures negatively impacting good intentions and desires to embed climate-conscious practice into primary health care emerged amongst all study participants. They noted that the reality of primary health care work is that it is fast-paced, crisis-driven, and resource-constrained. Demands on the primary care system demonstrate strong seasonal variations: for example, in the fall and winter months, peak workloads will emerge due to cough, cold, and flu season, yet additional staffing is not available to manage patient volume surges. As a result, most primary care health professionals describe their work in terms of intense demands and high levels of workload, which requires them to make ruthlessly pragmatic choices as to what priorities need attention. Within this context of primary care work, participants in this study indicated that managing climate change-related issues often times “fell off the radar” or became deprioritized in light of other, seemingly more urgent medical and health priorities. Several participants expressed understanding but also frustration regarding this reality. They noted that the long time horizons for actual climate change-related impacts created the illusion that action to address climate breakdown could be deferred indefinitely, while (in comparison) a person suffering an acute asthma attack in a primary health care team must be managed immediately. Many participants highlighted the challenges they personally faced, but also primary health care in general faces, by raising the profile of climate change and the climate impacts of primary health care work so that it became more of a priority or focus of attention. They acknowledged that the work of primary care is sometimes so stressful that they themselves, consciously, were forced to abandon climate-conscious practice in order to address an acute medical situation. They also noted that this cycle perpetuated negative climate impacts of primary health care work and that some kind of system to break this downward negative spiral would be essential…but it was unlikely that the answer could or would come from overburdened primary health care professionals themselves. These participants noted that the greatest successes they had found in trying to implement climate-conscious practice in primary care teams came from highly formulaic and algorithm-driven practice changes. All participants noted the success of recent guidance focused on replacing older, more polluting inhalers (used to treat asthma) with newer, less polluting devices that are equally capable of managing the medical condition of asthma but with a much smaller carbon footprint. Implementing a prescribing change such as this was facilitated by explicit guidance from professional associations and an algorithm to support changing patients from one asthma device to another. This example was cited by many participants in this study as a successful case study to emulate. It made climate-conscious practice easy to implement due to the algorithm-driven nature of the process, which minimized the need for individual professionals to undertake additional work to determine the most appropriate pathways for change themselves. Making climate-conscious practice decisions more pragmatic through the use of similar algorithm-driven practice-change pathways, such as this, was strongly endorsed as the best, and perhaps only practical, way forward to expand climate-conscious primary health care practice beyond asthma inhalers.

“Look, you have to make it easy for people. Unless you’ve worked in primary care you have no idea how chaotic, how busy, how stressful it really is. Everyone wants a piece of you and you literally sometimes don’t have time for lunch, or to even go to the [toilet] especially when it’s flu season. So that’s why [primary health care professionals] need to be told what they should do. They know it’s important, they would like to be more climate conscious but they don’t have time to figure out how to do this themselves. So give us an algorithm, give us a prescribing guideline and we will just follow it. Make it mandatory, make it easy, and we will happily do it. But honestly, you just can’t expect we have the time to figure this out for ourselves, one [professional] at a time.”

“I think the best example is asthma and inhalers. I’m old enough, been in pharmacy long enough to remember all the old-style CFC inhalers. They worked great, they worked fast, but in those days we had no idea that each puff was punching a hole in the ozone layer. Now there are the newer dry powder inhalers. So much less polluting. Might not work quite as fast but still work really well. When [the professional association] published guidelines on how to switch patients, and how much this helped the environment—well, that made it easy. Everyone now is mindful of this issue, and everyone has an algorithm they just have to follow. This is what I mean—you need to make it easy for the [primary health care professionals]. It sounds bad but we don’t have time to think and problem solve stuff like this—but we will do what we are told if you lay it out clearly enough.”

“You know, I feel so strongly about this issue and really want to make a change, a positive impact. But even me, when it gets really busy, when we are short staffed, when it’s ‘flu season…you just have to get through the shift, just get through the next hour. So anything climate related gets forgotten. It has too. Our priority, well, we are all health care professionals right, so we have to focus on the patient that’s right in front of us right now who has an acute medical need. It’s not, it’s never going to be realistic, and this is what bugs me about this climate conscious practice stuff—you can’t put the burden on already over burdened [health care professionals] to problem solve how to reduce climate change. They don’t have the bandwidth. If you tell them how to do it, they’ll do it—I don’t know anyone I work with who is one of those climate change skeptics. They want to do the right thing of course, but you can’t expect them to figure this out on their own.”

3.

Identification of actionable priorities with high potential for mitigation impact: All participants in this study were superficially aware of the distinction between “adaption” and “mitigation” in the context of climate-conscious health care practice, though none of them demonstrated in-depth awareness of theoretical/conceptual distinctions as articulated by (for example) the Intergovernmental Panel on Climate Change or other international organizations. For participants in this study and in their specific practice-focused (rather than research-centered) context, “adaptation” was usually described as finding ways to help patients deal with the actual consequences of climate change on their personal health (for example, how to store medicines safely in the event of a climate change-related power outage or how to manage during a heat wave to minimize health impacts). In contrast, “mitigation” was usually described as techniques designed to actually reduce polluting or other climate-impacting actions associated with the delivery of primary health care (for example, emphasizing the purchase of recyclable medical supplies, reducing the use of certain medications, or cleaning and reusing items rather than relying on single-use disposables). Rather than rely upon external guidance from international organizations, these practical, practice-focused understandings of the terms “adaptation” and “mitigation” were more relevant in guiding participants in their day-to-day decisions and behaviors in primary care. Participants in this study highlighted how, already, most primary care professionals focus more readily on adaptation strategies in their work with patients. For example, advising patients how to avoid dehydration during heat waves, which may amplify side effects of certain medications, was described as part of the routine patient education provided in primary care. Most primary health care teams maintained lists of locations of “cooling” or “warming” centers they could make available to patients and their communities to manage wide temperature variations that negatively impact health. Adaptation strategies such as those above were frequently mentioned and generally focused on individual patients and their unique health care and medical needs, rather than communities or population-based adaptation. Participants noted that there was less emphasis in primary care on mitigation strategies, in part because of the time required to do so. Most participants expressed optimism that there was untapped potential in advancing mitigation strategies in primary care and that the climate footprint reductions this could engender could be significant. Several participants noted that, within their own primary care teams, the emphasis on mitigation was primarily focused on administrative and office-based opportunities; for example, using LED lightbulbs, providing more bins and opportunities to recycle paper, leasing clinic space from LEED-certified developers, or making conscious decisions to only purchase equipment and supplies from sustainable sources. While helpful, they noted that such options did not fully capture the range of mitigation opportunities available to individual primary health care professionals. The most frequently identified, under-utilized mitigation strategy in this study was a more robust and structured approach to “deprescribing”. Deprescribing is the process of reviewing medications and medical supplies/equipment used by a patient to identify opportunities to remove drugs or supplies that are no longer beneficial. There is abundant literature that highlights the effectiveness of primary health care professionals in starting patients on medications/supplies/equipment in response to an acute health or medical problem. Unfortunately, the nature of primary health care practice means that in many cases a patient is started on an important and necessary new treatment, but then that treatment continues indefinitely long after the acute problem has resolved. Not only is this wasteful (and polluting), it also exposes the patient to unnecessary risk of side effects, expenses, or potential interactions with other medications. One common example cited by participants involved the use of anxiolytic/hypnotic agents (“sleeping pills”). Amongst the most commonly prescribed medications in primary health care, these agents are effective and needed for the management of short-term insomnia or other sleep-related disorders. Unfortunately, they are sometimes forgotten as time passes, and even when the short-term problem has resolved, the medication continues. Side effects (including the risk of falling in the elderly) can be significant, as is the carbon footprint associated with taking an unnecessary medication. Deprescribing in this case would involve gradual withdrawal of the unneeded medication in order to prevent side effects and to reduce the carbon footprint of the patient’s medical treatments. Deprescribing has emerged as a primary role for primary health care pharmacists. Participants in this study noted that framing deprescribing as both a patient-centered initiative and a climate mitigation strategy could be an effective way of encouraging greater spread of this important practice. In this way, busy primary care professionals would be convinced more easily of the value of performing climate-conscious (mitigation) practice and overcome associated time- and resource-related barriers to this work because ultimately it is actually in the patient’s best medical/health interest. Participants in this study noted that attempting to prioritize mitigation strategies for their own sake and for climate-change purposes alone was unlikely to be successful. Busy primary care professionals prioritize their patients’ needs and well-being over all else—including climate change. The example of deprescribing, which has both patient-specific benefits and positive climate change mitigation advantages, provided a useful and frequently described exemplar of a pathway to achieve both important objectives.

“It just all seems so vast and so therefore not likely to ever succeed. I think this is the problem with trying to convince [primary care professionals] to think and act on climate change. It needs to be broken down into bite sized, digestible actions, steps. And the focus, it has to be, it must be—what’s best for your patient. In the middle of a busy clinic with all the chaos and stress and acuity—that’s all you have time to think about, the patient in front of you and what they need here and now. That’s how priorities are established.”

“Deprescribing is a great example, a case study for what can work in primary care for climate change mitigation. It’s in the best interest of the patient and it reduces consumption—a win for the climate. But it’s the fact that it is in the best interest of the patient, that’s what is going to convince a bush [health care professional] to invest the time and energy into it.”

“We’ve done the easy stuff—you know, changed the light bulbs, got the blue-bins [recycling bins] out everywhere. And honestly, that wasn’t even us, the health professionals, right? It was the office administrators. So what can the [primary health care team] do that’s important. Well, the first “R” of the three “Rs” is “reduce”, isn’t it? Does the patient need this medication, do they really benefit from this intervention or using this equipment, these supplies? Prioritizing this question and incorporating it into day to day practice is not just about climate conscious practice, it’s about patient centred care. That is what will work.”

4.

Mobilization of a coalition to develop system-wide initiatives that could be implemented in primary health care: An overarching theme of this research was that busy, time- and resource-constrained primary health care professionals do not have the time or bandwidth to fully engage in climate-conscious primary health care practice, despite their best intentions and awareness of the seriousness of the issue. Participants in this research were unanimous and clear on this point, describing attempts to “guilt” practitioners into climate-conscious practice as being both unhelpful and unsuccessful. Instead, participants in this study highlighted the importance of mobilizing other arms of health professions and other organizations to support primary health care providers in achieving the twin objectives of optimizing patient care and reducing climate impacts of their work. Key groups to mobilize that were identified by participants included: (a) licensing/regulatory bodies who register professionals, as these organizations have legal tools that can compel/require practitioners to engage in more climate-conscious practice; (b) educators of pre-professional students, in order to better embed climate-conscious practice principles into curriculum to make it more natural and effortless to implement in practice; (c) continuing education providers, to enhance both quality and quantity of practice development programming; and (d) unions and employer groups, to undertake workplace reforms to provide better support for climate-conscious practice. Participants in this research noted that, currently, the burden to practice a profession in a more climate-conscious way falls entirely on the overburdened professional. This results in both unsuccessful inaction and guilt, neither of which is productive. Instead, professions and the primary health care sector as a whole need to work more collaboratively using educational, regulatory, and workplace management approaches in a more coordinated and strategic manner in order to not simply encourage climate-conscious primary health care but enable it to happen. Without these supports, participants expressed pessimism that meaningful change would ever be possible. With this sort of coalition mobilized and focused on supporting overburdened primary care professionals, the possibility of real and sustainable change towards climate-conscious practice was possible and would build more effectively upon the goodwill and good intentions that already exist.

“It comes down to this: are we serious about climate change or not? If we are, then the people who work in primary care are ready—they want to be part of the solution, they know they are part of the problem and they don’t like that. But they just don’t have the time and wherewithal themselves to make the changes that are needed. That’s where the rest of the system needs to step up to help them. If they step up—this could work.”

“I don’t think it’s realistic—feasible—that we, I mean the primary care team, we just won’t ever have the time or the capacity to make climate conscious practice work if we have to do it by ourselves. If the regulatory bodies made it a requirement, then, well, the employers they’d have to provide resources, structure to make it happen. Then the universities, they’d have to embed this in their curriculum so everyone graduates ready to practice in this way. It’s all connected, right? It has to work as a system and be coordinated or its just gonna flop. Which—sadly—it’s kind of flopping right now.”

“I think if we can get our act together, and we should be able to, then climate conscious practice could really take off. I mean it’s such a common sense good idea to be mindful of the climate impact of what we do, just like we have to be mindful of the cost implications of what we do. But right now the whole burden of this falls on us, on people who are just way to stressed and busy and don’t have any space left on our plate to take on one more thing like this no matter how important it is.”

4. Discussion

Action towards climate-conscious practice, particularly in primary health care, has not been widely reported or well researched. This study is amongst the first to examine this issue from the perspective and lived experience of primary care practitioners themselves. Findings from this study can be viewed optimistically: there is significant awareness and good intentions towards the value of climate-conscious practice. All participants in this study demonstrated a strong degree of personal and professional commitment, and there were no climate change skeptics or deniers who negated the foundational need for change. This research also highlighted the potential value of promising emerging practices, including deprescribing or algorithm-driven prescribing tools aimed at reducing carbon impacts of primary health care work. Less optimistically, however, are the realities identified by participants regarding structural barriers that impose a high burden on already overburdened primary care practitioners themselves to assume primary or full responsibility to implement climate-conscious practice. From this perspective, the results of this study could be interpreted to suggest that everyone keeps “pointing the finger” at everyone else to take responsibility for change, and in such a situation, no one ever takes responsibility and nothing ever changes.

This optimistic-pessimistic dichotomy reflects, in many ways, the general current state of change with respect to addressing climate change through adaptation and mitigation strategies. These participants noted that adaptation strategies are generally more highly prioritized in primary care, as they are more directly connected to acute medical and health needs; for example, the risk of dehydration during a heat wave could lead to significant medical complications, and as a result, primary care providers find time and ways of integrating adaptation strategies into their practice as a priority. It is less clear how more impactful and necessary mitigation strategies can be prioritized and added to the work of primary care providers. Participants in this study indicated that deprescribing provided a useful template to consider. To them, the unique feature of deprescribing that makes it worthy of replication and emulation is that it is simultaneously a way of optimizing and providing better primary health care to individual patients and has, at the same time, value in reducing carbon footprints of primary health care work, which serves as an important mitigation strategy. Finding other options and opportunities to achieve these twin objectives will be important. However, as noted by participants in this study, it is essential that better patient care and optimizing medical outcomes for individual patients will always take precedence and be prioritized by primary health care professionals, and so this must be the starting place for any climate-conscious practice initiatives.

There are important limitations to consider with this research. The study was framed as an exploratory qualitative exploration of a topic about which little had been previously published or known. The qualitative nature of this study and its participant recruitment process likely yielded a participant pool that is not representative of the primary care professional population. Participants in this study were already well informed and committed to climate change work (“enthusiastic early adopters”)—many of them noted that the reason they agreed to participate and were interested in this study was because they had already bought into the importance of the work itself. A more skeptical or unaware group of participants never volunteered or emerged to engage in this research, and as a result, these voices were not represented in this data. Further, the response rate to the initial request for participants was low (<15%), which may compromise the generalizability of findings. The focus on primary care pharmacists as stewards of the potentially polluting resources of the primary health care system was justified, but also therefore excluded other professional voices, including those of physicians and nurses. Clearly, there is scope to examine this issue from these other professional perspectives as well to complement the analysis presented here. The geographic focus on a single Canadian province (Ontario) limits the generalizability of this work beyond that jurisdiction. The participant inclusion criteria related to 3+ years’ experience working in primary care as a pharmacist, and being English-speaking, may also have inadvertently excluded some individuals from participating in this study. The pragmatic orientation of this study may also be viewed as a limitation: since the participant pool was non-specialists in climate science, the research itself was focused on their experience as pharmacists (not as climate scientists). As a result, direct connections to climate science theories and methods were not explicitly made or established; instead, practical connections to the daily work of primary care pharmacists were the focus of this study.

Strengths of this study include adherence to the COREQ checklist to ensure quality and rigor in qualitative research; indeed, it was adherence to COREQ that signaled to the research team the potential skew in the participant pool noted above. The qualitative nature of this study gave voice to the perspectives and lived experiences of these primary health care professionals; this has not been widely reported in the literature prior to this study. The use of independent coding by two researchers enhances both the trustworthiness and indicativeness of this research.

Additional research examining the perspectives of primary health care providers with respect to climate change is required. Health care is a large and important component of our society, and primary health care is its most visible, accessible, and largest sub-element. The scale and dimensions of the climate change problem are enormous, meaning all citizens and all parts of society will need to engage and become involved in identifying appropriate adaptation and mitigation strategies. This study is amongst the first of its kind to explore the issue from the perspective of primary care health professionals themselves and has, as a result, provided some important insights for consideration. First amongst these is the perception that it cannot be left to primary health care providers themselves, alone, to implement climate-conscious practices. They are overburdened and overwhelmed, and despite the best of intentions, do not have time or bandwidth to creatively problem-solve in this space. Instead, as noted by these participants, they are eager to be provided with tools—algorithms, checklists, guidelines—that they only need to apply and implement, rather than actually create. This opens up important opportunities for coalitions or partnerships with other groups—including researchers, educators, regulators, employers, unions, and others. Relying on primary health care providers to implement change, rather than create that change, may be a more successful pathway forward. Second, this study has identified promising emerging climate-conscious practices that warrant further study and dissemination, including the role of deprescribing and the value of algorithms in changing behaviors. Finally, this study has provided important insights into the different ways in which climate change “adaptation” and “mitigation” strategies are prioritized and valued by frontline primary health care professionals.

5. Conclusions

Primary health care is a large and important sector within the large and important health care sector. The polluting impacts of health care work have been established, yet progress towards addressing these impacts has not been as fast as hoped. The complexities and realities of health care work are significant. In particular, the prioritization of patients’ medical/health needs over all else must be respected, even in the context of climate change work. This study of primary health care professionals has provided insights to help guide future research, work, policy development, and coalition building to support busy and dedicated practitioners in achieving their prime directive of optimizing care for their patients. Identifying pathways to ensure this prime directive is achieved in the most climate-conscious way possible will be the next important step.