Barriers to Sustainable Healthcare Waste Management: A Grey Method Approach for Barrier Ranking

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The article presents a comprehensive exploration of barriers to sustainable healthcare waste management (HCWM) through an integrated methodology combining a literature review, expert consultations, and the Grey Method for barrier ranking. This approach enables the categorization and ranking of key barriers across economic, social, technical, and regulatory dimensions, providing insightful findings on the primary issues hindering HCWM. Notable barriers identified include the lack of standardized guidelines, ineffective waste segregation, and significant gaps in training. The manuscript is well-organized and employs suitable methodologies, offering a solid foundation for discussing HCWM challenges.
The combination of Grey Relational Analysis (GRA) and expert qualitative data creates a robust foundation for identifying and prioritizing HCWM barriers, ensuring a well-rounded understanding of the topic. The paper’s organization and flow enhance its readability, and the results are clearly delineated, making it accessible even to readers unfamiliar with advanced analytical techniques. The background and literature review sections are thorough, effectively setting the stage for the study and supporting the categorization of barriers. The study concludes with well-defined suggestions for policymakers and healthcare administrators, highlighting practical actions for improving HCWM.

Given the environmental impact of waste management decisions, the inclusion of Life Cycle Assessment (LCA) theme in the introduction would provide a valuable perspective on how different HCWM policies compare in terms of sustainability. LCA is increasingly recognized as a decision-support tool in waste management policy, allowing for a systematic evaluation of environmental impacts associated with different treatment and disposal methods (e.g., incineration, gasification). Recommended references for this addition include:

• 10.1016/j.jclepro.2024.144174
• 10.1016/j.scitotenv.2023.162083

Here are some other specific comments.
Data collection and expert selection: While the selection of experts is explained, additional details about the experts’ geographical diversity or field specialization would enhance the generalizability and robustness of the study’s findings.

Discussion of results sensitivity: The sensitivity analysis effectively shows how variations in ranking sensitivity can affect prioritization. Further discussion on how these shifts might influence policy recommendations or practical implementation could add more applied value to the analysis.

Limitations: The article could benefit from a more explicit discussion of limitations, particularly regarding how regional differences in HCWM practices may affect the applicability of the findings across diverse healthcare settings.

I also advise including more visual aids, such as flowcharts or decision-making diagrams, which could make the methodology more accessible to readers unfamiliar with GRA.

Comments on the Quality of English Language

Minor grammatical errors and awkward phrasing need revision. A thorough proofreading would improve clarity and readability.

Author Response

We sincerely thank you for your valuable feedback and constructive comments on our manuscript. We have addressed your suggestions and made revisions where necessary to improve the clarity and robustness of the study. Below are our responses to your specific comments:

1. Quality of English:
• We have thoroughly proofread the manuscript and corrected minor grammatical errors and awkward phrasing to improve clarity and readability. We hope that the revised version now reads more fluently.
2. Regional Diversity in Expert Selection:
• As per your suggestion, we have added details regarding the geographical diversity and specialization of the experts consulted in the study. Experts were selected from a range of regions (Africa, Asia, and Europe), ensuring that the findings reflect a wide array of HCWM challenges and practices across different healthcare settings. We also highlighted the experts' specialization in healthcare waste management, environmental health, regulatory bodies, and academic research.
3. Discussion of Findings in Relation to Literature:
• In the Discussion section, we have expanded the comparison of our findings with past studies, particularly focusing on HCWM challenges in Ethiopia and Uganda, as you suggested. This comparison underscores the consistency of barriers across regions, while also identifying regional variations.
4. Practical Implications:
• We have incorporated practical recommendations for hospitals and policymakers, including the development of standardized guidelines, enhanced training programs, and better resource allocation. These recommendations are clearly presented in the Practical Implications subsection of the Discussion.
5. Visual Aids:
• We have added a bar chart and a flowchart (Figures 1 and 2) to make the findings more accessible and visually engaging for readers. These figures illustrate the ranking of barriers and the study process, respectively.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

1. First of all authors must use the proper and adequate citations style given by the journal at its website under instructions for authors.

2. Abstract must be in structured format i.e. background, aims, material & methods, results, conclusions

3. Section 2 Methodology must be replaced with heading literature review

4. Add section 3.3. sample questions at the end of the introduction

5. Section 3.4 first sentence "we will conduct... should be in the past tense as the study has been conducted already

6. Tables format must match the journal format

7. Align the research questions with statistical results

8. Rearrange the discussion section as follows: discussion section must answer the research questions/objectives based on the findings, and findings must be compared with past studies. 

9. Moreover, add practical implications and recommendations for researchers as well as hospitals on the basis of findings

Author Response

Thank you for your thoughtful review and insightful suggestions. We have made the following revisions based on your comments:

1. Abstract Structure:
• As per your recommendation, we have restructured the abstract into a more standard format with clearly defined sections: Background, Aims, Methods, Results, and Conclusions. This change improves the flow and clarity of the abstract.
2. Methodology Section:
• We have renamed Section 2 to "Literature Review and Methodology" to align with your suggestion. This change ensures that the structure is clearer to the reader. Additionally, we have included a brief section on the expert selection criteria and their geographical diversity.
3. Sample Questions:
• We have added a new subsection titled "Sample Questions" at the end of the Introduction to provide readers with a clearer understanding of the interview framework used in expert consultations.
4. Reorganization of the Discussion Section:
• We have reorganized the Discussion section into subsections, as suggested. The sections are now clearly structured into:
• Alignment with Objectives
• Comparison with Literature
• Practical Implications
  This reorganization enhances the flow of the discussion and ensures that each aspect of the findings is addressed systematically.
5. References and Formatting:
• We have reviewed and updated the references to ensure they follow the journal’s citation style. Additionally, we have formatted the tables according to the journal’s requirements.

 

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The article discusses the topic: Barriers to Sustainable Healthcare Waste Management: A Grey Method Approach for Barrier Ranking.

The issues raised are important and the authors' efforts should be emphasized. The article is written in a substantively correct manner and meets the quality requirements of the journal. After taking into account the comments of the reviewer(s), the article can be published.

Issues for improvement:

1. The editorial guidelines should be checked and the sections required by the publisher should be used.

2. The methodological assumptions of the research should be described in more detail - the aim, scope of the research, research problems, and also an indication of the added value of the selected research approach (what distinguishes these analyses from other such studies), it is worth adding the study scheme.

3. The number of cited sources should be increased - this can be done by adding a Literature review section.

4. What is currently in the Discussion section constitutes a deeper analysis within the study, and references and comparisons to studies and analyses by other authors should be included here.

5. A description of the limitations of the research and future studies should be in the Conclusions.

Author Response

We appreciate your detailed and thoughtful comments on the manuscript. Your suggestions have helped improve the overall clarity and depth of the study. Below are the changes made in response to your comments:

1. Editorial Guidelines and Section Headers:
• We have carefully reviewed the manuscript to ensure that the section headers and content comply with the journal’s editorial guidelines. Specifically, we have renamed Section 2 to "Literature Review and Methodology" and added a new subsection on Sample Questions as per your suggestion.
2. Methodological Assumptions and Research Scope:
• As recommended, we have provided more details about the research scope, the expert selection process, and the added value of the Grey Relational Analysis (GRA) approach. This additional information is now included in the Methodology section, which highlights how our methodology uniquely contributes to understanding HCWM barriers.
3. Comparison with Past Studies:
• We have expanded the Comparison with Literature subsection in the Discussion to include a more comprehensive comparison of our findings with previous studies, including those conducted in Ethiopia and Uganda. This comparison highlights the consistency of barriers across different regions and healthcare systems.
4. Limitations and Future Studies:
• In the Limitations and Future Work section, we have addressed the potential limitation regarding regional differences in HCWM practices and how these may limit the generalizability of the findings. We also suggest further research on region-specific studies and the integration of emerging technologies in HCWM practices, which we believe will help refine and scale up the solutions identified in this study.
5. Practical Implications:
• We have emphasized actionable recommendations for hospitals and policymakers to improve HCWM, as suggested. These recommendations focus on standardized guidelines, training, and resource allocation to overcome the identified barriers.

 

General Response

We greatly appreciate the time and effort each of you took to review our manuscript. The feedback provided has significantly improved the quality of our work, and we believe the revisions made have strengthened the manuscript. We look forward to hearing your thoughts on the revised version.