# paper.pdf ## Metadata - PDFFormatVersion=1.6 - Language=en - IsLinearized=false - IsAcroFormPresent=false - IsXFAPresent=false - IsCollectionPresent=false - IsSignaturesPresent=false - Author=Zineb Bentounsi; Ikbal Humay Arman; Carolina Cordovil; Ana Cristina Franco Spinola; Lukasz Reczek; Ozden Gokdemir - CreationDate=D:20260629060317+05'30' - Creator=Servigistics Arbortext Advanced Print Publisher 11.1.4546/W-x64 - Custom.EPSprocessor=PStill version 1.84.42 - Keywords=climate change; curriculum; family practice; general practitioners; health knowledge; attitudes; practice; primary health care - ModDate=D:20260629144710+05'30' - Producer=PDFlib+PDI 9.0.7p3 (C++/Win64) - Subject=DOI: 10.1093/fampra/cmag047; Family Practice, 43, 4, 2026-06-30.; Abstract: Background: The healthcare sector contributes substantially to greenhouse gas emissions, and family doctors are well placed to reduce this impact, but their preparedness depends on adequate education in sustainable healthcare. Objectives: The objective of this study was to describe self-reported knowledge of sustainable healthcare and perceived educational gaps among family doctors and trainees affiliated with the European Young Family Doctors Movement (EYFDM) network. Methods: A cross-sectional, web-based survey was distributed through EYFDM. The instrument comprised one open-ended question, five knowledge items (four single-best-answer and one multiselect), and two yes/no items. Open-ended responses were scored independently by three authors using a rubric anchored to the World Health Organization definition of environmentally sustainable health systems. Data were analysed in SPSS v27. Results: A total of 130 family doctors and trainees from 15 European countries responded; 83.8% came from three countries (the Netherlands, Türkiye, and the UK). Of those who answered, 64.7% (75/116) reported no prior experience with sustainable healthcare, and 72.5% (58/80) had received no related teaching during training. The median total knowledge score was 3/5 [interquartile range (IQR) 2]. Scores were higher in participants aged under 45 years (P < .001), in female respondents (P = .014), and in trainees (P < .001). Nearly everyone who responded agreed that planetary health should be included in the family medicine curriculum. Conclusions: Within this EYFDM sample, prior formal education in sustainable healthcare was uncommon, and interest in further training was high. Findings are exploratory and not generalizable to all European family doctors, but they support the development of validated instruments and the integration of planetary health into family medicine curricula. - Title=Sustainable healthcare knowledge, experience and curricular perspectives: a cross-sectional survey within the European Young Family Doctors Movement network - dc:format=application/pdf - dc:identifier=10.1093/fampra/cmag047 - dc:lang=en - dc:publisher=Oxford University Press - dc:title=Sustainable healthcare knowledge, experience and curricular perspectives: a cross-sectional survey within the European Young Family Doctors Movement network - dc:creator=Zineb Bentounsi; Ikbal Humay Arman; Carolina Cordovil; Ana Cristina Franco Spinola; Lukasz Reczek; Ozden Gokdemir,Ikbal Humay Arman,Carolina Cordovil,Ana Cristina Franco Spinola,Lukasz Reczek,Ozden Gokdemir - dc:description=DOI: 10.1093/fampra/cmag047; Family Practice, 43, 4, 2026-06-30.; Abstract: Background: The healthcare sector contributes substantially to greenhouse gas emissions, and family doctors are well placed to reduce this impact, but their preparedness depends on adequate education in sustainable healthcare. Objectives: The objective of this study was to describe self-reported knowledge of sustainable healthcare and perceived educational gaps among family doctors and trainees affiliated with the European Young Family Doctors Movement (EYFDM) network. Methods: A cross-sectional, web-based survey was distributed through EYFDM. The instrument comprised one open-ended question, five knowledge items (four single-best-answer and one multiselect), and two yes/no items. Open-ended responses were scored independently by three authors using a rubric anchored to the World Health Organization definition of environmentally sustainable health systems. Data were analysed in SPSS v27. Results: A total of 130 family doctors and trainees from 15 European countries responded; 83.8% came from three countries (the Netherlands, Türkiye, and the UK). Of those who answered, 64.7% (75/116) reported no prior experience with sustainable healthcare, and 72.5% (58/80) had received no related teaching during training. The median total knowledge score was 3/5 [interquartile range (IQR) 2]. Scores were higher in participants aged under 45 years (P < .001), in female respondents (P = .014), and in trainees (P < .001). Nearly everyone who responded agreed that planetary health should be included in the family medicine curriculum. Conclusions: Within this EYFDM sample, prior formal education in sustainable healthcare was uncommon, and interest in further training was high. Findings are exploratory and not generalizable to all European family doctors, but they support the development of validated instruments and the integration of planetary health into family medicine curricula. - dc:subject=climate change,curriculum,family practice,general practitioners,health knowledge,attitudes,practice,primary health care - dc:rights=© The Author(s) 2026. Published by Oxford University Press. - pdf:keywords=climate change; curriculum; family practice; general practitioners; health knowledge; attitudes; practice; primary health care - pdf:producer=PDFlib+PDI 9.0.7p3 (C++/Win64) - pdfuaid:part=1 - pdfx:epsprocessor=PStill version 1.84.42 - prism:aggregationtype=Journal - prism:copyright=© The Author(s) 2026. Published by Oxford University Press. - prism:doi=10.1093/fampra/cmag047 - prism:elssn=1460-2229 - prism:endingpage=8 - prism:issn=0263-2136 - prism:number=4 - prism:publicationname=Family Practice - prism:startingpage=1 - prism:url=https://doi.org/10.1093/fampra/cmag047 - prism:volume=43 - xmp:createdate=2026-06-29T06:03:17+05:30 - xmp:creatortool=Servigistics Arbortext Advanced Print Publisher 11.1.4546/W-x64 - xmp:metadatadate=2026-06-29T14:47:10+05:30 - xmp:modifydate=2026-06-29T14:47:10+05:30 - xmpmm:documentid=uuid:50E50532-EE66-441F-4304-A2CDC0B25487 - xmpmm:instanceid=uuid:a7ee9e7c-e905-4611-b42d-9ed81c317719 - xmprights:marked=True - pdfaextension:schemas=http://www.aiim.org/pdfua/ns/id/pdfuaidPDF/UA Universal Accessibility SchemainternalIndicates, which part of ISO 14289 standard is followedpartInteger ## Contents ### Page 1 Family Practice, 2026, 43, 1–8Published: 30 June 2026 ![Logo]() Health service research # Sustainable healthcare knowledge, experience and curricular perspectives: a cross-sectional survey within the European Young Family Doctors Movement network Zineb Bentounsi,, Ikbal Humay Arman,,, Carolina Cordovil, Ana Cristina Franco Spinola, Lukasz Reczek, Ozden Gokdemir Watling Street Practice, The Health Center, Market Square, Stony Stratford, Milton Keynes, MK11 1YA, United Kingdom Department of Family Medicine, Faculty of Medicine, Istanbul Medipol University, İstanbul, 34810, Türkiye Department of Public Health, Institute of Graduate Studies in Health Sciences, Istanbul University, İstanbul, 34126, Türkiye European Young Family Doctors Movement, Lisbon, Portugal Centro de Saúde de Bom Jesus, SESARAM EPERAM, Funchal, 9004-514, Portugal College of Family Physicians, Krakow, 31-061, Poland Department of Family Medicine, Faculty of Medicine, Izmir University of Economics, İzmir, 35330, Türkiye ‡Co-first author. Corresponding author. Department of Family Medicine, Faculty of Medicine, Istanbul Medipol University Kavacık Campus, Kavacık Mah. Ekinciler Cad. No:19 Kavacık Kavşağı 34810 Beykoz, İstanbul, Türkiye. Email: Abstract Background The healthcare sector contributes substantially to greenhouse gas emissions, and family doctors are well placed to reduce this impact, but their preparedness depends on adequate education in sustainable healthcare. Objectives The objective of this study was to describe self-reported knowledge of sustainable healthcare and perceived educational gaps among family doctors and trainees affiliated with the European Young Family Doctors Movement (EYFDM) network. Methods A cross-sectional, web-based survey was distributed through EYFDM. The instrument comprised one open-ended question, five knowledge items (four single-best-answer and one multiselect), and two yes/no items. Open-ended responses were scored independently by three authors using a rubric anchored to the World Health Organization definition of environmentally sustainable health systems. Data were analysed in SPSS v27. Results A total of 130 family doctors and trainees from 15 European countries responded; 83.8% came from three countries (the Netherlands, Türkiye, and the UK). Of those who answered, 64.7% (75/116) reported no prior experience with sustainable healthcare, and 72.5% (58/80) had received no related teaching during training. The median total knowledge score was 3/5 [interquartile range (IQR) 2]. Scores were higher in participants aged under 45 years (P < .001), in female respondents (P = .014), and in trainees (P < .001). Nearly everyone who responded agreed that planetary health should be included in the family medicine curriculum. Conclusions Within this EYFDM sample, prior formal education in sustainable healthcare was uncommon, and interest in further training was high. Findings are exploratory and not generalizable to all European family doctors, but they support the development of validated instruments and the integration of planetary health into family medicine curricula. Keywords climate change, curriculum, family practice, general practitioners, health knowledge, attitudes, practice, primary health care Key messages - • Most surveyed family doctors had received no training in sustainable healthcare. - • Younger respondents and trainees scored higher than older or qualified colleagues. - • A total of 92.5% of those answering supported including planetary health in curricula. - • Findings reflect a self-selected EYFDM-network sample, not all European family doctors. - • Validated tools and multilingual surveys are needed for fu-ture research. © The Author(s) 2026. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com. ### Page 2 ## Introduction The European Definition of Family Medicine was revised in 2023 by the World Organization of Family Doctors (WONCA) Europe []. One Health, Planetary Health, and Sustainability were added to the discipline's context to create the bedrock for a new inte-grated approach. Sustainable healthcare is defined by the World Health Organization (WHO) as a health system that maintains, improves, or restores health while minimizing negative environmental im-pacts and leverages opportunities to improve it for the benefit of the health of current and future generations []. The health-care sector itself contributes an estimated 4%–5% of global greenhouse gas emissions and a comparable share of air pollu-tant emissions in many high-income countries [,]. Primary care has been identified as a key setting in which clinicians can both reduce environmental impact and prepare patients for climate-related health risks [,]. Surveys of general practitioners and trainees in different coun-tries have consistently reported limited formal education in planetary health and a high level of interest in receiving such training []. Family doctors are in a unique position to pro-mote knowledge about One Health, Planetary Health, and Sustainability, to encourage changes in behaviour, and to inform policy and educational change []. Building on a pilot survey and a peer dialogue at the WONCA Europe Conference in 2023 [], both indicating a need for wider exploration, this paper describes self-reported knowledge of sus-tainable healthcare among family doctors and trainees within the EYFDM network, identifies perceived educational gaps, and explores preferences for further education. ## Materials and methods ### Study design and reporting We conducted a cross-sectional, web-based, self-administered survey. The manuscript is reported in line with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for cross-sectional stud-ies []. A completed STROBE checklist is provided as. ### Setting and sampling frame The accessible population was family doctors/general practi-tioners (GP) and family medicine trainees affiliated with the European Young Family Doctors Movement (EYFDM), a subnet-work of WONCA Europe, which includes predominantly early- career family doctors. We used a convenience, nonprobability sampling approach: an open invitation was distributed within the EYFDM network through e-mail lists, EYFDM-related WhatsApp groups, and two issues of the EYFDM newsletter. Several follow-up reminders were sent through the same chan-nels, and additional invitations were e-mailed directly to national EYFDM country representatives, who were asked to forward the survey to their national networks. The data was collected from September 2023 to January 2024. No formal sample-size calculation was performed; we aimed to maximize responses across as many European countries as possible within this net-work. Participation was voluntary and anonymous, and re-sponses were collected through Google Forms. No IP addresses or other identifiers were recorded, and no incentives were offered. ### Survey content and variables The survey was designed by the authors based on the WHO def-inition of environmentally sustainable health systems [] and on topics highlighted in WONCA position statements [] and prior literature [,]. It was reviewed for face validity by all coauthors before distribution and administered in English only; formal pilot testing and psychometric validation were not performed. The survey contained, in order, the following: an open-ended ques-tion (‘In your opinion, what is sustainable healthcare?’); five knowledge items covering healthcare's contribution to global carbon emissions, deaths from climate-sensitive diseases, the benefit-to-cost ratio of climate action, actions to reduce health-care's carbon emissions (multiselect), and healthcare waste (identify the false statement); a repeat of the open-ended ques-tion; two nonmandatory closed questions on inclusion of planet-ary health in the curriculum and awareness of national initiatives; and nonmandatory demographics (age category, gen-der, country, training status, prior experience, and prior teach-ing). Verbatim wording, response options, and sources for each knowledge item are provided as. The nonmandatory placement of demographic and closed items explains the variation in denominators reported in thesection. ### Scoring Each single-best-answer item (Q1, Q2, Q3, and Q5) was scored 1 point for the correct answer and 0 points otherwise. Question 4 was a multiselect item in which respondents could identify all correct statements from a list of four and an ‘other’ option and was scored proportionally (0.2 per correct statement, including adding one more correct item for a total maximum of 1.0). Open-ended responses were scored from 1 (very poor) to 5 (very competent) using a rubric developed a priori and anchored to the five components of the WHO definition of environmentally sustainable health systems [] (maintaining or improving health, minimization of environmental impact, responsibility towards current and future generations, systems-level thinking, and clinician-level actions). Three authors (Z.B., C.C., and Ö.G.) scored each response independently; discrepancies were resolved by averaging the three scores. Formal interrater reliability statistics (intraclass correlation coefficient) were not calculated; this is ac-knowledged as a limitation. When a participant's second open- ended response was ‘same as before’, the first score was carried over. Fourteen responses (one in Turkish and 13 in Dutch) were translated into English by bilingual members of the author team before scoring; two participants left both open-ended questions blank and were excluded from the open-ended ### Page 3 analysis (n = 128 for the paired open-ended comparison; n = 130 for the knowledge score). ### Statistical analysis Data were analysed with IBM SPSS Statistics version 27. Categorical variables are reported as frequencies and percen-tages, with the denominator stated for each variable. Continuous variables were tested for normality using histograms and the Kolmogorov–Smirnov and Shapiro–Wilk tests. Normally distributed variables are reported as mean ± standard deviation; nonnormally distributed variables are reported as median and interquartile range (IQR). The Mann–Whitney U test and Kruskal–Wallis test were used to compare nonnormally distrib-uted continuous variables between two and more than two inde-pendent groups, respectively. The chi-square test was used to compare categorical variables. Spearman's rank correlation and Pearson's correlation were used to assess the relationship between the total knowledge score and continuous independent variables. A linear regression model with age (three categories), gender, training status, prior experience, prior teaching during training, and awareness of national sustainability efforts as inde-pendent variables was used to explore predictors of the total knowledge score. A two-sided P value of <.05 was considered statistically significant. Given the limited sample size and the ex-ploratory nature of the study, all subgroup analyses and regres-sion results are interpreted as hypothesis generating. ### Missing data and handling of partial responses Because the demographic items and the two closed (yes/no) ques-tions were not mandatory, some items have a smaller denomin-ator than the overall sample of 130. Denominators are reported for every variable in. We did not impute missing values, and analyses were performed on complete cases for each item. ### Ethical considerations Ethical approval for this study was obtained from Izmir University of Economics, Ethics Committee for Health Sciences Research (Date: 11.09.2023, No: B.30.2.İ EÜSB.0.05.05-20-260). Participation was voluntary and anonymous. The first page of the online survey contained an information statement describ-ing the purpose of the study, the voluntary nature of participa-tion, the absence of identifiers, and contact details of the research team. Submission of the completed survey was taken as informed consent. The study was conducted in accordance with the principles of the Declaration of Helsinki. ## Results ### Participants and descriptive data A total of 130 participants completed the survey. A total of 61.5% were female, 34.6% were male, and 3.9% preferred not to say. The mean age was 39.9 ± 11.2 years (median 35; range 26–65). A total of 64.6% were qualified family doctors, and 35.4% were trainees. Participants came from 15 countries in Europe. The top three contributing countries were the Netherlands (57.7%, n = 75), ### Page 4 Türkiye (16.9%, n = 22), and the UK (9.2%, n = 12); together these accounted for 83.8% of the sample. The remaining 12 countries each contributed five or fewer respondents (). Most participants had no prior experience in sustainable healthcare (64.7%, 75/116), and the majority of participants did not receive any teaching about it as part of their family medicine training (72.5%, 58/80) (). ### Knowledge score and item-level performance The median total knowledge score was 3 of 5 (IQR 2–4; mean 2.97 ± 1.14; range 0–5). Ten per cent of participants achieved a perfect score, and 1.5% scored zero (). The frequency of correct answers varied markedly between items (): Question 5, on healthcare waste, was the most frequently an-swered correctly (76.9%, 100/130), whereas Question 1 (rank of healthcare as a global carbon emitter) and Question 2 (climate- sensitive deaths) were the least frequently answered correctly (26.2% and 27.7%, respectively). For the multiselect Question 4 (actions to reduce healthcare's carbon emissions), the mean pro-portional score was 0.67 ± 0.20 (median 0.80; IQR 0.20). ### Knowledge score by demographic and contextual variables Univariate associations between the total knowledge score and demographic or contextual variables are shown in. Knowledge scores were significantly higher in participants aged under 45 years than in those aged 45 and above (Kruskal–Wallis, P < .001;). Spearman's rank correlation be-tween age category and total score was rho −0.352 (P < .001), and Pearson's correlation between continuous age and total score was r −0.340 (95% CI −0.485 to −0.176; P < .001). ### Page 5 Female respondents scored higher than male respondents (P = .014), trainees higher than qualified family doctors (P < .001), respondents who had received teaching about sus-tainable healthcare during training higher than those who had not (P = .011), and respondents aware of national initiatives higher than those who were not (P = .005). Prior personal experi-ence was associated with a slightly nonsignificant trend (P = .052). No significant difference was observed between high- income and upper–middle-income countries (P = .383). In an exploratory linear regression including age, gender, training sta-tus, prior experience, prior teaching during training, and aware-ness of national efforts, age category (P = .001) and awareness of national efforts (P = .030) were the strongest independent pre-dictors of the total knowledge score (overall model P = .007; R2 = 0.262). Given the limited sample size, these results are inter-preted as hypothesis generating. ### Attitudes towards inclusion of planetary health in the curriculum Eighty participants answered the question ‘Do you think it is im-portant to include planetary health in the family medicine curric-ulum?’, and 92.5% (74/80) said ‘yes’. This question was placed at the end of the survey and was nonmandatory, which explains the smaller denominator compared with the 130 respondents who answered the knowledge questions. Of the 117 respondents who answered the corresponding question, 71.8% (n = 84) re-ported being aware of initiatives in their country aimed at mak-ing healthcare more sustainable. ### Open-ended responses: ‘what is sustainable healthcare?’ Of 130 respondents, two participants left both open-ended ques-tions blank and were excluded from the open-ended analysis. Fourteen responses written in a language other than English (one in Turkish and 13 in Dutch) were translated into English by bilingual members of the author team before scoring, so that 128 paired open-ended responses contributed to the com-parison. The mean score for the first iteration of the question (at the start of the survey) was 2.66 of 5; the mean score for the second iteration (at the end of the survey) was 2.26. A total of 43.9% of participants gave the same answer to both iterations, 10.6% obtained a higher score in the second iteration, while the remainder obtained a similar or lower score. The decline among the latter group most often reflected a shift from describing the concept of sustainable healthcare to commenting on its import-ance after exposure to the closed-ended items, rather than any actual loss of knowledge. The absence of a control group pre-vents any causal inference about a learning effect. As an example, one answer that scored 4 of 5 from the rubric-based scoring was: ‘In my view, healthcare should aim for minimal environmental impact, fostering a harmonious coex-istence between hygiene and climate preservation. This necessi-tates a transformative journey, where new innovations drive sustainability, reducing post-surgery waste, ensuring the respon-sible disposal of medications to safeguard natural and drinking water, and promoting the use of reusable medical products’. ## Discussion In this convenience sample of 130 family doctors and family medicine trainees affiliated with the EYFDM network, most re-spondents reported limited prior education in sustainable healthcare. The median knowledge score was 3 of 5, and scores were higher in younger respondents, in female respondents, and in trainees than in their respective comparator groups. Among the 80 respondents who answered the curriculum question, 92.5% supported the inclusion of planetary health in the family medicine curriculum. These findings are exploratory and apply primarily to the surveyed network; they should not be inter-preted as a representative description of European family doc-tors as a whole. ![Box-and-whisker plot comparing total knowledge scores out of 5 across three age categories \(below 30 years, 30-44 years, and 45 years or above\). The medians for the below-30 and 30-44 groups are approximately 2.8, while the median for the 45-or-above group is approximately 2.2; the 45-or-above box shows a wider spread towards lower scores.]() ### Page 6 The finding that participants aged under 45 years scored high-er than those aged 45 and above is consistent with reports from other primary care contexts. In an Australian survey of general practitioner registrars, 61.8% agreed that climate change con-tent should be integrated into their training programme []. Several plausible mechanisms could contribute to this age-related pattern: more recent undergraduate and postgradu-ate curricula increasingly include planetary health content [,]; younger clinicians may have greater exposure to climate change as a salient public health issue through media and pro-fessional networks []; and self-selection into surveys distrib-uted through early-career networks (such as the EYFDM) may have produced a particularly engaged group of younger respond-ents. The finding that trainees scored higher than qualified family doctors is consistent with these mechanisms. These hypotheses cannot be tested with the present data and should be examined in future studies with broader sampling and validated instruments. Continuing professional development for more experienced colleagues is also important, both because they currently care for the largest share of patients and because the climate–health intersection has emerged within their working lifetime rather than during their training. Highlighting the link between planet-ary health and patient outcomes, e.g. through the lens of climate-sensitive infectious diseases, heat-related morbidity, and air pollution-driven respiratory and cardiovascular disease, may be a particularly effective entry point for clinicians whose primary professional motivation is patient care [,]. Encouragingly, our survey found a high level of interest in fur-ther education on this topic. The 92.5% supporting planetary health inclusion in the curriculum represents 74/80 respondents to a nonmandatory item rather than 92.5% of all 130 participants, which is consistent with findings in other surveys of primary care clinicians already engaged with the topic []. Some training bodies, such as the Royal College of General Practitioners in the UK, have begun to integrate planetary health and sustainability into the workplace-based assessment framework [], and a scop-ing review is currently mapping the integration of planetary health into family medicine training across Europe []. ### Limitations This study has several important limitations that constrain how its findings should be interpreted. #### Sampling frame and representativeness The survey was distributed predominantly through the EYFDM net-work, an early-career subnetwork of WONCA Europe, so the access-ible population was a specific subgroup rather than European family doctors. The sample size (n = 130) is small relative to the tar-get population; the geographical distribution is uneven (83.8% from three countries; several countries contributing a single re-spondent); and although 32.3% of participants were aged over 45 years, the EYFDM is structured around early-career doctors. The findings should therefore be interpreted as descriptive of an engaged, self-selected subgroup connected to the EYFDM. #### Selection bias The voluntary, self-selected nature of participation is likely to have overrepresented respondents with a preexisting interest in sustainable healthcare; baseline knowledge is therefore likely to be overestimated. #### Instrument validity and reliability The instrument was developed by the authors using the WHO definition and prior literature but was not piloted and not sub-jected to formal psychometric validation, and Cronbach's al-pha was not calculated; construct validity therefore cannot be confirmed. The rubric-based scoring of open-ended re-sponses was performed independently by three raters, but for-mal interrater reliability statistics (Fleiss’ kappa or intraclass correlation coefficient) were not calculated, and discrepancies were resolved by averaging rather than through structured consensus discussion; this may have introduced interrater variability. #### Open-ended analysis The analysis of open-ended responses relied on rubric-based scoring rather than on a formal qualitative method. Comparisons between the open-ended score and the total knowledge score should be interpreted cautiously as the two in-struments measure different constructs. #### Language The survey was administered in English only, which may have affected both who chose to participate and the depth of free-text responses among nonnative English speakers. Non-English open-ended responses (one in Turkish and 13 in Dutch) were translated into English by bilingual members of the author team and included in the analysis; however, trans-lation by the same team that designed and scored the rubric is a potential source of bias, and a fully independent translation pipeline would be preferable in future work. Future studies should also administer multilingual versions of the instrument from the outset. ## Conclusion Among family doctors and trainees engaged with the EYFDM net-work, self-reported knowledge of sustainable healthcare was modest, prior formal training was uncommon, and there was strong interest in including planetary health in the family medi-cine curriculum. These findings are exploratory and not general-izable to all European family doctors, but they support the development and validation of standardized educational tools, the integration of planetary health into family medicine curric-ula, and the design of larger, multilingual, and more representa-tive studies of European primary care clinicians. ## Acknowledgements The authors thank the EYFDM and all participants who com-pleted the survey. We would like to express our sincere gratitude to our Dutch colleague, Dr Sabine Kloprogge, for her exceptional collaboration in disseminating the survey. The preliminary re-sults of this work were presented as an oral communication at the WONCA Europe Conference, Brussels, 2023. ### Page 7 ## Author contributions All authors contributed to the conception and design of the study. Z.B., I.H.A., C.C., A.C.F.S., L.R., and O.G. were involved in survey design and distribution. Z.B., C.C., and O.G. independently scored the open-ended responses. I.H.A. analysed all quantita-tive data. Z.B. and I.H.A. drafted the manuscript. All authors crit-ically revised the manuscript and approved the final version. ## Supplementary material Supplementary material is available at online. ## Conflicts of interest The authors declare that they have no conflicts of interest. ## Funding No specific funding was received for this study. ## Data availability The data underlying this article will be shared on reasonable re-quest to the corresponding author. ## Ethical approval This study was approved by Izmir University of Economics, Ethics Committee for Health Sciences Research (Date: 9 November 2023, No: B.30.2.İEÜSB.0.05.05-20-260). Submission of the online survey was taken as informed consent. ## Use of artificial intelligence No generative AI tools were used to draft, analyse, or interpret the content of this manuscript. Standard spell-check and grammar-check tools were used during preparation. ## References Allen J, Gay B, Crebolder H et al. The European Definition of General Practice/Family Medicine. WONCA Europe 2023 Edition. Ljubljana: WONCA Europe. 2023. (21 May 2026, date last accessed). World Health Organization Regional Office for Europe.Environmentally Sustainable Health Systems: A Strategic Document. Copenhagen: WHO Regional Office for Europe, 2017. (21 May 2026, date last accessed). Karliner J, Slotterback S, Boyd R et al. Health Care's Climate Footprint: How the Health Sector Contributes to the Global Climate Crisis and Opportunities for Action. Reston, VA: Health Care Without Harm, 2019. (21 May 2026, date last accessed). Romanello M, Walawender M, Hsu S-C et al. The 2024 report of the lancet countdown on health and climate change: facing record-breaking threats from delayed action. Lancet 2024;404: 1847–96. Global Centre for Sustainable Healthcare. (21 May 2026, date last accessed). Pencheon D, Wight J. Making healthcare and health systems net zero. BMJ 2020;368:m970. Wild K, Tapley A, Fielding A et al. Climate change and Australian general practice vocational education: a cross- sectional study. Fam Pract 2023;40:435–41. Tun SYM, Wellbery C, Teherani A. Faculty development and partnership with students to integrate sustainable health-care into health professions education. Med Teach 2020;42: 1112–8. Schwerdtle PN, Maxwell J, Horton G et al. 12 tips for teaching environmental sustainability to health professionals. Med Teach 2020;42:150–5. Maxwell J, Blashki G. Teaching about climate change in med-ical education: an opportunity. J Public Health Res 2016;5: 673. The WONCA Working Party on the Environment. WONCA Statement on Planetary Health and Sustainable Development Goals. Brussels, Belgium: World Organization of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians (WONCA), 2017. (21 May 2026, date last accessed). Spínola ACF, Arman IH, Bentounsi Z et al. WONCA Europe's new family medicine definition and sustainable healthcare knowledge. Anatol J Fam Med 2024;7:44–5. von Elm E, Altman DG, Egger M et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007;370:1453–7. Shaw E, Walpole S, McLean M et al. AMEE consensus state-ment: planetary health and education for sustainable health-care. Med Teach 2021;43:272–86. Walpole SC, Pearson D, Coad J et al. What do tomorrow's doctors need to learn about ecosystems? A BEME systematic review: BEME guide no. 36. Med teach. Med Teach 2016;38: 338–52. Watts N, Amann M, Arnell N et al. The 2020 report of the lan-cet countdown on health and climate change: responding to converging crises. Lancet 2021;397:129–70. Costello A, Abbas M, Allen A et al. Managing the health effects of climate change. Lancet 2009;373:1693–733. Haines A, Ebi K. The imperative for climate action to protect health. N Engl J Med 2019;380:263–73. ### Page 8 Royal College of General Practitioners. Planetary Health and Sustainability in WPBA. (21 May 2026, date last accessed). Bates OB, Freeman N, Sala-Ivars P et al. Integrating planetary health into the continuing professional development and training in family medicine: protocol for a scoping literature review. HRB Open Res 2025;8:39.