Staff Attitudes Toward Healthcare Waste Separation: An Exploratory Survey from a Triple-Bottom-Line Perspective

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Based on 84 responses in on line survey the article wants to  show a gap between awareness and practical implementation of  ideal waste management in dermatology hospitals and clinics. The authors stated that while knowledge and motivation exist, structural barriers such as stress, time pressure, and logistical challenges hinder consistent sorting and subsequently, recycling.

The aim of the study was to reach healthcare professionals in hospital departments and private dermatological practices among “dermatology healthcare professionals in Germany” (line 94). However, the population targeted by email was much smaller and specific (“23 dermatology practices in Bavaria, participants were approached at ‘KoPra-kompakt+prax- isnah 2024’ in Wiesbaden and the ‘44th Erlanger Minisymposium’,” etc.). There is no reason to believe that the data obtained are representative of dermatology healthcare professionals in Germany.

The purpose of the study is unclear and was not presented, neither directly nor in the form of research questions. It is also difficult to consider the survey’s questions as being  unaffected by social desirability, as most of the questions cited are strongly influenced by it, especially in Germany ("I try to work in a way that saves resources" or "It is important to pay attention to the amount of waste generated in everyday working life").

The reviewer is not convinced that the obtained correlations are not coincidental, but – more importantly – the authors did not explain their rationale behind them or whether their measurement tools consisted of individual questionnaire questions or were intended to create scales (which they did not – hence they were analyzed as individual questions). Nor the construction of the measurement tool was presented, neither the idea of it. “The dependent variables measured self-reported data on “Personal stand on the topic of waste reduction”, “Current knowledge”, “Care with a focus on changing bandages” and  “Outcome and Quality Assurance”” (lines 119-120) – does not present the items and their creation and selection processes, neither the background for these 4 categories.

So major concern is the questionnaire itself as it looks like strongly influence by social desirability, not using the scales of psychological attitudes.

Some minor comments:

• “We aimed for a maximum number of participants, deeming 100 respondents feasible for further analysis” (lines 97-98) –incomprehensible, there were no 100 valid responses
• UKR dermatology employees – unexplained abbreviation
• 31 university hospitals were asked to forward it – the potential population size was not given
• “Approximately 3,500 individuals were reached (≈3,000 from 30 104 university dermatology departments, ≈230 from 23 practices, and 300 via QR codes at conferences). With 100 completed surveys, the estimated response rate is about 3%.” – with such an estimated population, the number of responses (return rate) is too small
• Research questions are not described and not connected to actual scientific research, so conclusion section is very weak
• Several limitations were not presented – geographical bias in sample, self-selection of more educated in (or oriented to) sustainability participants, understanding of questions, declaration rather than fact bias,  

Author Response

 

Point 1: Based on 84 responses in online survey the article wants to show a gap between awareness and practical implementation of ideal waste management in dermatology hospitals and clinics. The authors stated that while knowledge and motivation exist, structural barriers such as stress, time pressure, and logistical challenges hinder consistent sorting and subsequently, recycling.

 

Response: We would like to thank the reviewer for their interest in our work. Based on the 84 responses to our online survey, the aim of the article was to highlight the discrepancy between awareness of optimal waste management practices and their practical implementation in dermatology hospitals and clinics. While staff are generally knowledgeable and motivated, our results suggest that structural barriers such as stress, time constraints, and logistical challenges substantially impede consistent waste sorting and, consequently, recycling. It is important to understand these barriers as systemic issues rather than as a lack of individual commitment.

 

Point 2: The aim of the study was to reach healthcare professionals in hospital departments and private dermatological practices among “dermatology healthcare professionals in Germany” (line 94). However, the population targeted by email was much smaller and specific (“23 dermatology practices in Bavaria, participants were approached at ‘KoPra-kompakt+praxisnah 2024’ in Wiesbaden and the ‘44th Erlanger Minisymposium’,” etc.). There is no reason to believe that the data obtained are representative of dermatology healthcare professionals in Germany.

 

Response: We sincerely thank the reviewer for this valuable and important comment. We fully agree that the study population represents a limited and specific subset of dermatology healthcare professionals in Germany, meaning that the data cannot be considered nationally representative. Accordingly, we consider this study to be exploratory in nature and aimed at providing initial insights. This limitation has been clarified more explicitly in the Methods and Conclusion sections, as can be seen from the revisions in the manuscript highlighted in green.

 

Point 3: The purpose of the study is unclear and was not presented, neither directly nor in the form of research questions.

 

Response: We appreciate the reviewer’s comment regarding the clarity of the study’s purpose. The Introduction has been revised to clearly state the study’s aim and the underlying research questions (p. 3, lines 86–94). The study is now explicitly described as exploratory and addresses three research questions: (1) staff perceptions of the importance and practicability of sustainable waste management in dermatology, (2) the relationship between the perceived potential for waste reduction and its actual practical implementation, and (3) the evaluation of increased recycling as a waste reduction strategy. These revisions clarify the scope and focus of the study.

 

Point 4: It is also difficult to consider the survey’s questions as being unaffected by social desirability, as most of the questions cited are strongly influenced by it, especially in Germany ("I try to work in a way that saves resources" or "It is important to pay attention to the amount of waste generated in everyday working life").

 

Response: We appreciate the reviewer’s comment regarding the potential for social desirability bias. As explained in the revised manuscript (p. 4, lines 146–149), the study is based on self-reported data, reflecting declared attitudes rather than objectively measured behavior; therefore, it is susceptible to reporting bias. The anonymous survey design was intended to mitigate this effect. Given the exploratory nature of the study, the focus lies on identifying perceptions, attitudes, and practical barriers rather than on absolute behavioral levels; this supports the interpretation of the findings as hypothesis-generating.

 

Point 5: The reviewer is not convinced that the correlations obtained are not coincidental

 

Response: We acknowledge the reviewer’s concern that some of the correlations may be coincidental. Given the exploratory nature of the study and its small sample size, the findings should be interpreted with caution. All reported correlations were tested for statistical significance, which reduces - but does not eliminate - the likelihood of random associations. These preliminary results provide initial insights and underscore the need for further research in the form of larger, more controlled studies to confirm and expand upon these potential relationships.

 

Point 6: but – more importantly – the authors did not explain their rationale behind them

 

Response: The rationale for reporting specific correlations has been clarified. Given the exploratory nature of the study, correlations were examined to identify potential relationships between knowledge, perceived feasibility, stress, and reported sustainable behavior. Only those correlations that were directly relevant to these questions, statistically significant, and conceptually interpretable were reported in the manuscript. This selective approach was chosen to focus on meaningful patterns rather than presenting an exhaustive list of isolated associations.

 

Point 7: or whether their measurement tools consisted of individual questionnaire questions or were intended to create scales (which they did not – hence they were analyzed as individual questions).

 

Response: Thank you for your comment. The questionnaire items were analyzed individually rather than combined into scales, as they were designed to address distinct aspects of sustainable waste management rather than a single underlying construct. This approach is consistent with the exploratory nature of the study and the absence of a validated scale structure. Practical considerations, including the limited sample size and available resources, meant that it was better to analyze the items separately. The manuscript has been revised to clarify this point (p. 4, lines 157–158).

 

Point 8: Nor the construction of the measurement tool was presented, neither the idea of it. “The dependent variables measured self-reported data on “Personal stand on the topic of waste reduction”, “Current knowledge”, “Care with a focus on changing bandages” and “Outcome and Quality Assurance”” (lines 119-120) – does not present the items and their creation and selection processes, neither the background for these 4 categories.

 

Response: Thank you very much for this helpful comment. The manuscript has been revised to clarify the conceptual rationale and construction of the measurement tool (p. 4, lines 141–146). The questionnaire was developed a priori to address sustainable waste management in dermatology using dressing changes as a concrete, routine, and particularly waste-intensive clinical process. Based on this focus, four thematic domains were defined to capture distinct aspects of the topic: general attitudes toward waste reduction, self-assessed current knowledge, practices related to dressing changes, and perceptions regarding outcomes, quality assurance, and organizational measures.

The items were developed based on practical clinical experience and designed to address these domains individually, rather than forming validated scales. This is in line with the exploratory and pilot nature of the study. The aim of these revisions is to improve transparency regarding item selection and category development.

 

Point 9: So major concern is the questionnaire itself as it looks like strongly influence by social desirability, not using the scales of psychological attitudes.

 

Response: We thank the reviewer for this important overarching comment. We fully acknowledge that the questionnaire is susceptible to social desirability bias because it does not rely on validated psychological attitude scales. This was a deliberate decision, in line with the exploratory, practice-oriented nature of the study and the need for a short, feasible survey in a time-limited clinical setting. While the anonymous design may reduce this bias, it cannot eliminate it, which we now clearly acknowledge as a limitation. Accordingly, the results should be interpreted as preliminary and descriptive rather than as precise measurements of attitudes. We agree that future studies should build on these findings using validated scales and more robust methodological designs.

 

Some minor comments:

Point 10:“We aimed for a maximum number of participants, deeming 100 respondents feasible for further analysis” (lines 97-98) –incomprehensible, there were no 100 valid responses

 

Response: We apologize for the unfortunate wording and the resulting misunderstanding. Our intention was not to imply that 100 valid responses were achieved, but rather that we aimed to obtain up to 100 responses overall, which we considered a feasible target for an exploratory survey in this setting. We have revised the wording to clarify this point (page 4, lines 153–155) and hope that our intention is now stated more clearly.

 

Point 11: UKR dermatology employees – unexplained abbreviation

 

Response: We thank the reviewer for drawing our attention to the unexplained abbreviation “UKR dermatology employees.” This has been corrected in the revised manuscript, and the abbreviation is now fully explained (page 3, lines 103–105).

 

Point 12: 31 university hospitals were asked to forward it – the potential population size was not given

 

Response: We have revised the manuscript to clarify the potential population size. Originally, we stated that 31 university hospitals were asked to forward the survey, but the estimated number of recipients was not clearly indicated. We hope that the updated text now makes this issue clearer (page 3, lines 107–109).

 

Point 13: “Approximately 3,500 individuals were reached (≈3,000 from 30 104 university dermatology departments, ≈230 from 23 practices, and 300 via QR codes at conferences). With 100 completed surveys, the estimated response rate is about 3%.” – with such an estimated population, the number of responses (return rate) is too small

 

Response: We thank the reviewer for pointing this out. The originally stated estimate that ≈3,000 individuals from university dermatology departments were reached was indeed overly optimistic. In reality, based on responses and feedback, it is more plausible that only around 300 individuals were effectively reached. We acknowledge this error and have corrected the calculation of the estimated response rate in the revised manuscript (page 3, lines 117–120). This emphasizes the exploratory nature of the survey and the limited generalizability of the results.

 

Point 14: Research questions are not described and not connected to actual scientific research, so conclusion section is very weak

 

Response: The manuscript has been revised to more clearly articulate the research questions and to explicitly link the Conclusion to these questions and to the relevant scientific literature. The Conclusion now systematically addresses Research Question 1 (p. 10, line 281), Research Question 2 (p. 11, lines 304), and Research Question 3 (p. 11, line 325), and relates the findings to existing research on sustainability and waste management in healthcare. In addition, the overarching study aim is revisited (p. 12, lines 353-398) to contextualize the results and to highlight implications and directions for future research. These revisions strengthen the scientific grounding and coherence of the Conclusion.

 

Point 15: Several limitations were not presented – geographical bias in sample, self-selection of more educated in (or oriented to) sustainability participants, understanding of questions, declaration rather than fact bias

 

Response: Thank you for your comment. All limitations mentioned have been addressed in the revised manuscript. The text highlights geographical bias, potential self-selection of more educated or sustainability-oriented participants, possible misunderstandings of questions, and the reliance on self-reported rather than actual behavior several times throughout the text to avoid any misinterpretation (green markings). For clarity, these points are also summarized again at the end of the manuscript. We hope this comprehensive reporting alleviates any concerns.

 

Reviewer 2 Report

Comments and Suggestions for Authors

• The research would be an added contribution to medical waste management in the field. however, the following suggestions and comments are needed to improve upon the quality of the manuscript. Attached also, an highlighted version of the manuscript for authors' attention
•  
• Summary of Comments on Type of the Paper (Article
• Page: 1
• Lines 17-31: why is the abstract lacking any result? The result should be presented. Abstract should should provide the summary of the entire result.
• Page: 3
•  
• Lines 99-106: this is a survey, it requires ethical clearance. These are not provided. sample size should also be determined using appropriate sample size calculation formula
• Line 97-98: "We aimed for a maximum number of participants, deeming 100 respondents feasible for further analysis", how did you determine this? This is not science, sample size should be calculated using appropriate formula. If you have used convenience sample size, it should be stated.
• In addition, is 100 representative of dermatology healthcare professionals in Germany? There is a serious technical error in the design.
• Therefore, this article should be taken as a preliminary result considering the only 3% response rate.
• Lines 122-123: the supplementary material is not accessible for review. It should be made available for review
• Page: 4
• Line 141: format table 1 accordingly, avoid direct output from SSPS. For decimal point, use ".", not ","
• Page: 5
• Lines 143-184: rather relying on frequency analysis, the Likert scales can be converted to numeric data for ANOVA analysis.

Author Response

Point 1: The research would be an added contribution to medical waste management in the field. however, the following suggestions and comments are needed to improve upon the quality of the manuscript. Attached also, an highlighted version of the manuscript for authors' attention

 

Response: We would like to thank the reviewer for the constructive and encouraging assessment of our manuscript. All suggestions and comments have been carefully considered and addressed in the revised version. The corresponding changes have been incorporated throughout the manuscript and are indicated in the highlighted version that is provided for reference.

 

Point 2: Page 1 Lines 17-31: why is the abstract lacking any result? The result should be presented. Abstract should provide the summary of the entire result.

 

Response: We thank the reviewer for this valuable comment. The abstract has been revised to include the key results of the study, ensuring that it now provides a concise summary of the main findings and outcomes of the research.

 

Point 3: Page 3 Lines 99-106: this is a survey, it requires ethical clearance. These are not provided. sample size should also be determined using appropriate sample size calculation formula

 

Response: We thank the reviewer for this important comment. Information on ethical clearance for the survey has been included in the Methods section (Page 3, Lines 121-125) to improve clarity. This information is also provided in the Declarations section, as in the previous version of the manuscript.

 

We appreciate the reviewer’s suggestion regarding the sample size determination. As noted in the statistical analysis, a suitable power analysis was not feasible for this study (Page 4, Line 153). To ensure transparency, we have now explicitly stated the resulting limitations for the interpretation of the findings, both in the Methods section (Page 3, Lines 102–103) and in the Analysis section (Page 4, Lines 153-155), to make things clearer for the reader.

 

Point 4: Page 3 Line 97-98: "We aimed for a maximum number of participants, deeming 100 respondents feasible for further analysis", how did you determine this? This is not science, sample size should be calculated using appropriate formula. If you have used convenience sample size, it should be stated.

 

Response: The manuscript now explicitly states that a convenience sampling approach was used. The target of approximately 100 participants was not based on a formal sample size calculation, but rather chosen as a pragmatic and feasible number for this exploratory pilot study, given the absence of prior reference data and the practical constraints of the study setting. This clarification has been added to the Methods and Statistical Analysis sections (p. 3, line 103-103; p. 4, line 153-158) to ensure transparency regarding the sampling strategy and its limitations.

 

Point 5: In addition, is 100 representative of dermatology healthcare professionals in Germany? There is a serious technical error in the design.

 

Response: We thank the reviewer for raising this important point. The sample size of this study is not intended to be representative of dermatology healthcare professionals in Germany. This limitation is inherent in the exploratory design and the use of convenience sampling and is now explicitly stated throughout the manuscript. The study is therefore presented as a pilot investigation, aimed at generating initial insights and hypotheses, rather than generalizable conclusions. The limitations regarding sample size and representativeness have been clearly highlighted in the Methods, Discussion, and Conclusion sections, as indicated by the revisions marked in green.

 

Point 6: Therefore, this article should be taken as a preliminary result considering the only 3% response rate.

 

Response: We thank the reviewer for highlighting the low response rate. Although the estimated response rate was calculated based on the number of participants who were reached at the university hospitals (p. 3, lines 117–120), we fully acknowledge that this figure is low. Accordingly, the exploratory and preliminary nature of the results has been emphasized throughout the manuscript; the text passages are marked green.

 

Point 7: Page 3 Lines 122-123: the supplementary material is not accessible for review. It should be made available for review

 

Response: We regret that the supplementary material was not available to the reviewer, despite it being submitted with the manuscript. It has been reattached for review. To ensure the manuscript is clear even without the supplementary material, the relevant text has also been revised (Page 4, Lines 150-151). Additionally, as stated in the Declarations, the supplementary material will be made publicly available on Zenodo upon publication.

 

Point 8: Page 4 Line 141: format table 1 accordingly, avoid direct output from SSPS. For decimal point, use ".", not ","

 

Response: Thank you for this valuable suggestion. We have revised all tables and figures accordingly, ensuring that decimal points are now consistently presented as “.” instead of “,”.

 

Point 9: Page 5 Lines 143-184: rather relying on frequency analysis, the Likert scales can be converted to numeric data for ANOVA analysis.

 

Response: We thank the reviewer for this valuable suggestion. We have revised the manuscript to explain why the Likert-scale data were analyzed descriptively rather than being converted into numeric data for ANOVA (Page 4, Lines 164-168). Specifically, given the small sample size, the exploratory and pilot nature of the study, and the absence of assumptions regarding normal distribution and homogeneity of variance, it would not have been statistically appropriate to apply ANOVA. In addition, since the data are ordinal, converting them into numeric values for parametric testing could result in misleading interpretations. Therefore, we focused on descriptive and correlation analyses to provide a reliable overview of the observed patterns while avoiding overinterpretation.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Based on 84 responses in on line survey the article wants to  show a gap between awareness and practical implementation of  ideal waste management in dermatology hospitals and clinics. The authors stated that while knowledge and motivation exist, structural barriers such as stress, time pressure, and logistical challenges hinder consistent sorting and subsequently, recycling. The Authors emphasized that  although sustainable waste management in dermatological practice is widely regarded as important, it remains difficult to implement consistently in daily clinical routines. The main finding of this study is the gap between high awareness and limited practicability, indicating that sustainability is constrained less by lack of knowledge than by social, organizational, and economic barriers.

As the reviewer previously emphasized, both the sample (small and incidental) and the survey instrument (biased by social desirability) undermine the generalizability of the study results. He also emphasized that the text is a „survey report”, not a scientific article, as neither the literature review nor the conclusions draw are grounded on a broad range of research or scientific theories. Despite expanding the reference list to 21 items, clarifying uncertainties, and clarifying the instrument description, these reviewer comments remain valid.

 

It is not the reviewer's responsibility to decide whether a report from a pilot study with an unclear scope, yet written correctly, can be published in this scientific journal.

 

However, the reviewer noted that the research questions are still not presented before the description of the research methodology, nor are they grounded in the scientific literature.

The only description of the questionnaire's development appears on page 4.  lines 138-143 „The dependent variables measured self-reported data on “Personal stand on the topic of waste reduction”, “Current knowledge”, “Care with a focus on changing bandages”, and “Outcome and Quality Assurance” using a Likert scale (strongly agree to strongly 140 disagree).These categories were defined a priori to capture awareness, perceived importance, the practicability of sustainable waste management, and the evaluation of  increased recycling during dressing changes; the study also assessed the perceived need for training and awareness programs across all four areas.” And it is supplemented by the statement not gounded in the literature – ​​“As no validated instrument was available for this specific clinical context,” (line 144) without any discussion of tools measuring such variables in areas other than the Department of Dermatology at the University Medical Center Regensburg (or Bavarian dermatology practices).

The authors rightly point out that their study can only be treated as a pilot study, but they do not summarize it in a way that shows what further steps should be implemented to obtain results that can be used in practice and what they learned from carrying out their pilot study.

Neither the Limitation nor the Conclusion sections meet the minimum standards of a scientific text. The statement, "Recruiting larger and more diverse samples could also improve generalizability," demonstrates that the authors do not understand the problem with their sample, nor does the Limitation section provide a broader discussion of the issue of "social desirability" and approaches to overcome it.

The Conclusion section repeats the term "training" as a precept that there is no lack of knowledge, suggesting specific and undiscussed training ideas, without presenting any findings or conclusions derived from the pilot study for the main study for this specyfic training itself.

Author Response

We sincerely thank the reviewers for their valuable and constructive feedback. A detailed point-by-point response has been provided in a separate Word document.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have revised the manuscript as suggested and the revision is impressive.

However, the supplementary material was not made available for review. It was another version of the manuscript that was provided as supplementary material. Authors should ensure all necessary files are made available. 

Please watch out for punctuation error in line 296.

Putting these together, the manuscript is suitable for publication. Congratulations to the authors.

Author Response

Thank you very much for your decision and for the time and effort dedicated to the review process.

 

We would like to respectfully note that, within the scope of a minor revision and due to time constraints, a complete major revision was not possible. Nevertheless, we have carefully addressed all previous comments from Reviewer 1.

 

We have also thoroughly considered the new comments and implemented the corresponding revisions accordingly. We sincerely hope that the revised manuscript meets the expectations and improves the quality of the work.

 

Thank you again for your consideration.

 

Kind regards,

 

Julia Sturm

 

 

 

 

 

 

 

 

 

 

 

 

 

Round 3

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for your effords. I still have doubts about the value of the study, however you can put some informations about lessons learnt from your study for further research including:

• how to obtain a proper sample for the study
•  how to construct a questionaire with no problems odf social desirability
• how to check if the data and conclussion from the data are valid

Author Response

We thank the reviewer for the helpful comments and the effort invested in reviewing our manuscript. A detailed point-by-point response is provided in the revised document.

Author Response File: Author Response.docx