The Effectiveness of Educational Interventions in Improving Waste Management Knowledge, Attitudes, and Practices among Healthcare Workers: A Systematic Review and Meta-Analysis

Round 1

Reviewer 1 Report

The work addresses an important and practical issue in healthcare, contributing valuable insights on how educational interventions can improve waste management practices.

The paper is well-structured, presenting a clear methodology, results, and discussion. However, further clarity in some sections could enhance comprehensibility.

The systematic review and meta-analysis are conducted rigorously, adhering to PRISMA guidelines, providing a robust scientific basis for the conclusions drawn.

The paper cites relevant literature, showing a comprehensive understanding of the field and situating its contributions effectively within existing research. However, also complementary subjects like The University role in developing the human capital for a sustainable bioeconomy could be addressed.

The paper is generally well-written in clear and understandable English, with minor errors that do not significantly hinder comprehension.

In conclusion, the study assesses the effectiveness of educational interventions on waste management knowledge, attitudes, and practices among healthcare workers globally. Thus, the study encompasses international research findings rather than being limited to a particular national context.

The work addresses an important and practical issue in healthcare, contributing valuable insights on how educational interventions can improve waste management practices.

The paper is well-structured, presenting a clear methodology, results, and discussion. However, further clarity in some sections could enhance comprehensibility.

The systematic review and meta-analysis are conducted rigorously, adhering to PRISMA guidelines, providing a robust scientific basis for the conclusions drawn.

The paper cites relevant literature, showing a comprehensive understanding of the field and situating its contributions effectively within existing research. However, also complementary subjects like The University role in developing the human capital for a sustainable bioeconomy could be addressed.

The paper is generally well-written in clear and understandable English, with minor errors that do not significantly hinder comprehension.

In conclusion, the study assesses the effectiveness of educational interventions on waste management knowledge, attitudes, and practices among healthcare workers globally. Thus, the study encompasses international research findings rather than being limited to a particular national context.

Author Response

Dear reviewer, we are very grateful for the time you spent reviewing our manuscript. All your comments have been carefully considered, and, where possible, the manuscript has been amended accordingly. We appreciate your commitment and hope that this second version improves the overall quality of the manuscript.

We have provided a point-by-point response to your comments:

Comments and Suggestions for Authors

The work addresses an important and practical issue in healthcare, contributing valuable insights on how educational interventions can improve waste management practices.

Thank you for your positive feedback, we are aware that waste management is an important issue in the healthcare sector, and the fact that you have recognized our work as a valuable contribution in this field made us proud of it.

The paper is well-structured, presenting a clear methodology, results, and discussion. However, further clarity in some sections could enhance comprehensibility.

Thank you for your appreciation for the overall structure of our manuscript. We have tried to improve the comprehensibility; in case you have identified some awkward sentences, we would kindly ask you to specify what sections/sentences are not fully comprehensible and we could try to make them more understandable.

The systematic review and meta-analysis are conducted rigorously, adhering to PRISMA guidelines, providing a robust scientific basis for the conclusions drawn.

Thank you for your positive feedback on the methodological standards that we have followed.

The paper cites relevant literature, showing a comprehensive understanding of the field and situating its contributions effectively within existing research. However, also complementary subjects like The University role in developing the human capital for a sustainable bioeconomy could be addressed.

Thank you for your feedback on the relevance of our findings. In relation to your suggestion, we have more deeply highlighted the importance of University, and less specifically of continuing education initiatives, in the discussion.

Page 5, Lines 512-515. “In this sense, for the achievement of beneficial public health and economic standards, healthcare institutions and Universities should work in synergy for the provision of training and continuing education of a sustainability-oriented workforce.”

The paper is generally well-written in clear and understandable English, with minor errors that do not significantly hinder comprehension.

Thank you for your positive comments on the understandability of the English language throughout the text.

In conclusion, the study assesses the effectiveness of educational interventions on waste management knowledge, attitudes, and practices among healthcare workers globally. Thus, the study encompasses international research findings rather than being limited to a particular national context.

Thank you for underlining the sense of our study. We really appreciated your feedback.

Reviewer 2 Report

Thank you for the opportunity to review this paper. I have just three minor comments.

Could you clarify that the review does not (or does it?) include interventions with personal care/support workers who manage medical waste in the home?

Consider mentioning in the abstract that the articles evaluated are almost all from low income countries and that none of them include interventions for recycling, reuse or reduction of medical waste.

The first paragraph defines medical waste and then the next paragraph refers to healthcare waste. Both terms appear throughout the paper. Are the terms being used interchangeably? Please clarify.

Author Response

Dear reviewer, we are very grateful for the time you spent reviewing our manuscript. All your comments have been carefully considered, and, where possible, the manuscript has been amended accordingly. We appreciate your commitment and hope that this second version improves the overall quality of the manuscript.

We have provided a point-by-point response to your comments:

Comments and Suggestions for Authors

Thank you for the opportunity to review this paper. I have just three minor comments.

Thank you for your positive feedback. We had amended the manuscript following your comments.

Could you clarify that the review does not (or does it?) include interventions with personal care/support workers who manage medical waste in the home?

Thank you for your question. The home care setting was an inclusion criteria. Nevertheless, we have not identified any manuscript focusing on such setting. The most similar to the home care setting are the community centers, but we are aware that the waste management at home could represent a greater issue for the healthcare policies. We have provided a sentence to underline the lack of research in this particular setting, and the need for conducting more research on it in the limitations and conclusions.

Page 6, Lines 577-579. “Finally, although the home care contexts could potentially be included in this review, no articles were identified in the selected databases.”

Page 7, Lines 612-613. “[…] directed at HCWs at the global level and in specific contexts such as long-term care and home care, […]”

Consider mentioning in the abstract that the articles evaluated are almost all from low income countries and that none of them include interventions for recycling, reuse or reduction of medical waste.

Thank you for your suggestion. We have amended the abstract accordingly.

The first paragraph defines medical waste and then the next paragraph refers to healthcare waste. Both terms appear throughout the paper. Are the terms being used interchangeably? Please clarify.

Thank you for your question. The international literature used these terms interchangeably; indeed, the articles we have included in the review both used the terms “healthcare waste” and “medical waste”. However, since we have followed the theoretical underpinning of the WHO throughout the text, which uses the term “healthcare waste”, we have now amended the terms accordingly to this definition. We hope this could provide some consistency to the readers.

Reviewer 3 Report

It would better to add the line number in this manuscript.

The year of publication of Ashtari et al. is missing in the paragraph starting with “Despite the clear need…”.

What is “PRISMA” criteria? You need to give a brief introduction about it.

What are the definitions of “systematic review” and “meta-analysis” in this study? What is the major difference between them?

Author Response

Dear reviewer, we are very grateful for the time you spent reviewing our manuscript. All your comments have been carefully considered, and, where possible, the manuscript has been amended accordingly. We appreciate your commitment and hope that this second version improves the overall quality of the manuscript.

We have provided a point-by-point response to your comments:

Comments and Suggestions for Authors

It would better to add the line number in this manuscript.

Thank you for your suggestion. The line numbers have been provided as part of the Sustainability journal template; you can find them on the left side of the page.

The year of publication of Ashtari et al. is missing in the paragraph starting with “Despite the clear need…”.

Thank you for your suggestion. The year of publication has now been provided.

What is “PRISMA” criteria? You need to give a brief introduction about it.

Thank you for your suggestion. We have added a sentence to describe these criteria.

Page 3, Lines 130-131. “These consist of a series of reporting recommendations reflecting the methods of identification, selection, evaluation, and evidence synthesis.”

What are the definitions of “systematic review” and “meta-analysis” in this study? What is the major difference between them?

Thank you for your suggestion. We have provided more information in the text.

Page 3, Lines 126-131. “A systematic literature review (intended as a comprehensive synthesis of the existing literature) with meta-analysis (intended as a statistical technique used to combine the results of primary studies to obtain cumulative evidence) has been conducted in accordance with the updated Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria [30].”

Reviewer 4 Report

The manuscript submitted to sustainability is a reasonable piece of work and has been carefully carried out. The authors have addressed most of the relevant factors related to medical waste management. Three factors, i.e., knowledge, attitude and practices are elaborated with support of literature from some countries. The language of the paper is fluent and clearly understandable with negligible errors. This reviewer has no major concerns against the article however the following suggestions are given for improvement purposes. 

1. Change font color in figures to make the text prominent. 

2. In certain places citations are given in clusters, if possible reduce the number to an optimum level through out the text.

3. I would suggest the authors to add a section about relevant policies in the countries from where the data is reported. I assume that most of the countries discussed in the instant review article do not have clear policies and if exist, then the implementation is a major barrier in proper waste management. 

4. Some recent and most relevant papers are recommended to be studied and summarized for instance, (1) 10.1007/s10163-023-01728-2 (2) 10.3390/su15032397 (3) 10.1177/0734242X23118444 (4) 10.12968/bjhc.2019.0041 etc. 

Author Response

Dear reviewer, we are very grateful for the time you spent reviewing our manuscript. All your comments have been carefully considered, and, where possible, the manuscript has been amended accordingly. We appreciate your commitment and hope that this second version improves the overall quality of the manuscript.

We have provided a point-by-point response to your comments:

Comments and Suggestions for Authors

The manuscript submitted to sustainability is a reasonable piece of work and has been carefully carried out. The authors have addressed most of the relevant factors related to medical waste management. Three factors, i.e., knowledge, attitude and practices are elaborated with support of literature from some countries. The language of the paper is fluent and clearly understandable with negligible errors. This reviewer has no major concerns against the article however the following suggestions are given for improvement purposes. 

Thank you for your positive feedback, we are very satisfied we have met your expectations and that the comprehensibility and fluency of the text have been appreciated. We had amended the manuscript following your comments.

1. Change font color in figures to make the text prominent. 

Thank you for your suggestion. The font color in the figures presented in the text has been changed to improve readability for the readers.

2. In certain places citations are given in clusters, if possible, reduce the number to an optimum level throughout the text.

Thank you for your feedback. We have considered and tried to reduce the number of clusters of citations. Unfortunately, especially for the results of our review, we are concerned that we cannot reduce the number of citations, because it would mean to reduce the number of the studies included or to limit the possibility for readers of checking for potential interventions that could be performed in their context and their effectiveness. In the other parts of the manuscript, some clusters of citations have been reduced.

3. I would suggest the authors to add a section about relevant policies in the countries from where the data is reported. I assume that most of the countries discussed in the instant review article do not have clear policies and if exist, then the implementation is a major barrier in proper waste management.

Thank you for your suggestion. A specific section has been provided in the discussion to present the problem arising from the lack of clear waste management policies, especially in the low-income countries. At this regard, we have examined the waste management policies of the countries most represented in our review (India and Pakistan).

Page 6, Lines 612-616. “In fact, in many low-income countries, healthcare waste management policies are absent or poorly implemented [79,80]. For example, Pakistan has entire districts in which healthcare waste is dumped in open areas or landfills [79], while India has a regulation since 2016 mandating the incineration of healthcare waste but not enough facilities to treat and dispose of them [80].”

4. Some recent and most relevant papers are recommended to be studied and summarized for instance, (1) 10.1007/s10163-023-01728-2; (2)10.3390/su15032397; (3) 10.1177/0734242X23118444; (4) 10.12968/bjhc.2019.0041etc.

Thank you for your suggestion. We have carefully read the recommended studies and inserted two of them in the discussion section (citations #83 and #85).

Round 2

Reviewer 3 Report

The originality of this study has been largely explained in the revised MS. This provides a strong ground for this study. 

One minor amendment:

- the last column of the table on Pages 11-15 is not shown completely. Pls adjust.

Author Response

Dear Reviewer, we are very grateful for the time you spent reviewing our manuscript. We have considered your comment and amended the table accordingly. We appreciate your commitment and hope that this third version improves the overall quality of the manuscript.