Assessing medical biochemistry professionals’ knowledge, attitudes, and behaviors regarding green and sustainable medical laboratory practices in Türkiye

Introduction

The environmental crisis has escalated to the extent that it now poses a global health emergency [1]. With the world’s inaction, the climate crisis is inflicting a heavy toll on a global scale [2]. Sustainable development refers to implementing practices that meet present needs without jeopardizing the ability of future generations to meet their own, which has recently gained significant attention [3].

Hospitals, operating 24/7, have substantial environmental footprints [4], [5], [6]. Medical laboratories are significant energy consumers contributing significantly to carbon emissions. However, they also have the potential to impact sustainability significantly. By implementing sustainable practices, such as energy-efficient equipment, waste recycling, and water conservation, medical laboratories have achieved notable reductions in carbon emissions, with some reporting an annual decrease in energy consumption exceeding 30 % [7]. This potential for energy savings and emission reduction should inspire hope and motivate action.

The European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Green Laboratories Task Force was initiated to lead the adoption of sustainable practices in European medical laboratories under the EFLM. EFLM, as a guiding force, aims to lead the laboratory medicine community towards carbon neutrality. The Task Force has published a guideline for medical laboratories to improve their sustainability performance, focusing on energy, water, waste, and chemical management [8].

The primary goal of this study is to perform a situational analysis by assessing the knowledge, attitudes, and behaviors of medical biochemistry professionals in Türkiye concerning Green and Sustainable Medical Laboratory (GSML) practices. Furthermore, another objective is to identify the most common and challenging barriers to becoming a GSML in Türkiye. This study, the first of its kind in Türkiye on this subject, aims to raise general awareness about GSML practices. It was conducted according to the ‘EFLM guidelines for GSML.’

Materials and methods

Results

This study included 130 medical biochemistry professionals (28.5 % academicians, 48.5 % specialists, and 23.1 % residents) with a median age of 38.5 (18) years. 60 % of the participants were female. 45.4 % of the participants worked in a training and research hospital (TRH), 24.6 % in a university hospital (UH), 23.8 % in a state hospital (SH), and 6.2 % in private hospitals (PH). Data on the responses obtained through “Google Forms” are given in Supplementary material.

Education and knowledge levels

A significant portion of medical biochemistry professionals in Türkiye lack education and knowledge about GSML practices. Only 10.8 % of participants received education on sustainability during their medical specialty education. No statistically significant difference existed between residents, specialists, and academicians (p=0.139). 76.2 % have heard of the concept of sustainability, but 74.6 % are unaware of green chemistry principles [9]. The awareness of green chemistry principles among academicians was twice as high as among residents and specialists (p=0.043).

Most respondents believe that regulations in all four areas can contribute to sustainability (Figure 1). The proportion is higher among academicians than specialists and residents (p=0.025).

Figure 1:

The percentage of the answers to question 2 (Section 2): regulations in which areas in medical laboratories contribute to sustainability? You can select more than one option.

A notable portion needs more awareness regarding the significance of managing chemicals, energy, waste, and water in medical laboratories (Supplementary Table 1, Section 2). The knowledge levels are similar among academicians, specialists, and residents (Table 1, Section 2) and participants working in different types of hospitals (Table 2, Section 2).

Table 1:

The comparison of total scores of multiple-choice questions with more than one answer in Sections 2, 3, and 4 between academicians, specialists, and residents.

	Total scores				p-Values
	All	Academicians	Specialists	Residents
Section 2. The level of knowledge of the participants regarding green laboratories Main question: Which or which of the following information do you know? Please mark them.
Q4: Chemical management (highest score: 3)	1 (2)	1 (2)	1 (2)	1 (1)	0.969
Q5: Energy management (highest score: 4)	2 (1)	2 (2)	1 (1)	2 (1)	0.265
Q6: Waste management (highest score: 4)	1 (2)	1 (3)	1 (2)	1 (2)	0.508
Q7: Water management (highest score: 3)	1 (1)	2 (2)	1 (1)	1 (1)	0.113
Section 3. The individual attitudes and behaviors of the participants in the laboratory regarding the environment and green laboratories Main question: Which or which of the following practices do you individually apply frequently in the laboratory?
Q1: Chemical management (highest score: 3)	2 (2)	2 (2)	2 (1)	1.5 (1)	0.026a
Q2: Energy management (highest score: 8)	5 (2)	5 (3)	5 (2)	5 (2)	0.464
Q3: Waste management (highest score: 3)	1 (1)	2 (1)	1 (1)	1 (1)	0.617
Q4: Water management (highest score: 3)	3 (1)	3 (1)	2 (1)	3 (1)	0.258
Section 4. The practices regarding the environment and green laboratories in the biochemistry laboratories where the participants work. Main question: Which or which of the following applications are included in your laboratory?
Q1: Chemical management (highest score: 4)	3 (2)	3 (3)	3 (1)	3 (2)	0.008a
Q2: Energy management (highest score: 4)	1 (2)	1 (2)	1 (1)	1 (1)	0.056
Q3: Waste management (highest score: 3)	2 (1)	2 (1)	2 (2)	1 (1)	0.282
Q4: Water management (highest score: 3)	1 (1)	1 (2)	1 (1)	0 (1)	0.125

1. Total scores for each question are represented as median (interquartile range) value. Q, question. All of the data are nonparametric. ^ap<0.05 is statistically significant (Kruskal–Wallis test).

Table 2:

The comparison of total scores of multiple-choice questions with more than one answer in Sections 2, 3, and 4 between people who work in different types of hospitals.

	Total scores					p-Values
	All	TRH	UH	SH	PH
Section 2. The level of knowledge of the participants regarding green laboratories Main question: Which or which of the following information do you know? Please mark them.
Q4: Chemical management (highest score: 3)	1 (2)	1 (2)	1 (2)	0 (1)	1.5 (2)	0.350
Q5: Energy management (highest score: 4)	2 (1)	2 (2)	2 (2)	1 (1)	1.5 (2)	0.456
Q6: Waste management (highest score: 4)	1 (2)	1 (3)	1 (3)	1 (2)	0.5 (2)	0.947
Q7: Water management (highest score: 3)	1 (1)	1 (1)	2 (1)	1 (1)	2 (2)	0.609
Section 3. The individual attitudes and behaviors of the participants in the laboratory regarding the environment and green laboratories Main question: Which or which of the following practices do you individually apply frequently in the laboratory?
Q1: Chemical management (highest score: 3)	2 (2)	1 (1)	2 (2)	1 (0)	2 (1)	0.15
Q2: Energy management (highest score: 8)	5 (2)	5 (2)	5 (3)	5 (2)	6 (2)	0.94
Q3: Waste management (highest score: 3)	1 (1)	1 (1)	1 (1)	1 (1)	1 (1)	0.77
Q4: Water management (highest score: 3)	3 (1)	3 (1)	3 (1)	2 (1)	3 (1)	0.63
Section 4. The practices regarding the environment and green laboratories in the biochemistry laboratories where the participants work. Main question: Which or which of the following applications are included in your laboratory?
Q1: Chemical management (highest score: 4)	3 (2)	3 (2)	2 (3)	4 (1)	3 (1)	0.007a
Q2: Energy management (highest score: 4)	1 (2)	1 (2)	1 (2)	1 (2)	1 (2)	0.255
Q3: Waste management (highest score: 3)	2 (1)	2 (1)	2 (2)	2 (1)	2 (1)	0.758
Q4: Water management (highest score: 3)	1 (1)	1 (1)	0,5 (1)	1 (1)	1 (2)	0.554

1. Total scores for each question are represented as median (interquartile range) value. PH, private hospital; SH, state hospital; TRH, training and research hospital; UH, university hospital; Q, question. All of the data are nonparametric. ^ap<0.05 is statistically significant (Kruskal–Wallis test).

Awareness about the EFLM guidelines for green and sustainable medical laboratories

Sixty percent of the participants had never heard of the GSML guidelines published by EFLM. Only 6.06 % of the participants said they had implemented practice in their laboratory using this guide. These practices include turning off unused devices and lights to save energy, defrosting refrigerators, promoting saving and recycling through conferences, and reducing electricity and water consumption.

Academicians (59.46 %) were more likely to have heard of this guide than specialists (30.16 %) and residents (36.67 %) (p=0.014) (Supplementary Table 2).

Figure 2:

Evaluation of the most common (A) and most difficult (B) barriers to becoming a GSML (green and sustainable laboratory) in Türkiye (Section 5, questions 7–8, n=130).

Discussion

This study aims to analyze the situation regarding GSML in Türkiye. According to this study, a notable portion of medical biochemistry professionals in Türkiye lack education and knowledge about GSML practices. Despite the low level of formal education, many participants exhibit environmentally conscious behaviors in their laboratories. Although significant gaps are found in GSML practices, particularly in energy and water management, participants strongly desire to improve GSML practices.

Formal education on global warming, climate change, and sustainability in medical biochemistry training programs is inadequate. The lack of difference between residents with the most up-to-date training and specialists or academicians indicates the need for further improvement.

Education and knowledge levels, individual environmental practices and attitudes, and inadequacies in GSML practices were similar between the different groups except for a few points. Academicians had higher levels of knowledge about green chemistry and sustainability. Individual environmental practices and attitudes of the residents were inadequate in terms of chemical management. This inadequacy is likely attributed to the residents’ lack of professional experience and education. These findings underscore the critical role of education.

GSML practices in chemical substance management are better in laboratories where specialists work. It is also better for training and research hospitals than university hospitals. When these results are evaluated together, the reasons for the inadequacy of university hospitals, where academicians and residents are more concentrated, should be investigated.

In the study by McAlister S. et al., the carbon footprint of testing was mainly associated with blood sample collection (including test tube plastics) rather than reagents or energy use [9]. While individual biochemistry tests may not have a substantial carbon footprint, the cumulative impact of numerous daily tests is substantial. Establishing a minimal retest interval for medical tests has the potential to reduce resource wastage, carbon footprint, and patient risk [10]. According to our survey, only half of the laboratories where respondents work audit unnecessary test orders. Medical biochemistry professionals should take the initiative to reduce unnecessary test orders. For example, implementing retest intervals or rational test ordering [11].

The EFLM guideline highlights that a lack of knowledge and awareness of sustainability practices among medical laboratory professionals is a significant barrier to sustainability in the healthcare sector [8]. Our survey findings align with this. Participants identify education and awareness as the most common and challenging barriers to adopting GSML. Integrating GSML training into the formal education program of medical biochemistry is an important step that can be taken in this regard.

According to the survey results, the second most common and challenging barrier to adopting GSML is the continuity/sustainability of the steps taken on this path. According to EFLM guidelines [8], the only way to gain real momentum on sustainability is to campaign for change and educate about environmental benefits and cost-effectiveness. Also, once a system for sustainability is established, people follow and implement it. Therefore, it is essential to establish a workable system to overcome this barrier.

The third common and challenging barrier is cost. While sustainable health systems may have an initial financial burden, efficient resource use can lead to long-term cost savings [8]. Ross et al. [12] demonstrated saving over eight hundred thousand Australian dollars by implementing the ISO14001 Environmental Management System. Overcoming the cost barrier requires convincing vital decision-makers, such as the Ministry of Health, hospital administrations, and budget providers, about the long-term benefits. The cost barrier can be achieved through education, awareness, and legislative regulations.

The survey identifies motivation as another common and challenging barrier. Raising awareness about the EFLM Green Laboratory Certificate [13], a motivation source, is suggested to overcome this obstacle. EFLM aims to drive environmental improvement motivated by a desire for excellence, not just regulatory compliance [8]. Besides the certificate, additional sources of motivation can be explored through further studies on what inspires employees.

The final common and challenging barrier among the top five is communication. Similarly, the EFLM guidance notes that communication poses a hurdle due to the involvement of various stakeholders such as patients, contractors, colleagues, hospital administrations, and government. Convincing test requesters of the necessity of their requests can be challenging [8]. O’Neil et al. underscores the importance of effective communication across disciplines for creating a safer and more sustainable culture, emphasizing that green chemistry is a multidisciplinary effort involving all researchers, not exclusively chemists [14]. This aligns with a technical briefing by Procaccianti G. et al., highlighting sustainability as a multidisciplinary process [15].

Our study’s strength lies in the diversity of participants, encompassing residents, specialists, and academicians, working across various hospital types, including university hospitals, state hospitals, training and research hospitals, and private hospitals. The limitation of our study is that only medical biochemistry professionals from medical laboratories were included; medical microbiology and medical pathology professionals were not included. One of the most significant environmental issues in laboratory medicine is the problem of liquid waste or wastewater. Another limitation of our study is the lack of attention to this important topic.

In the future, studies can be planned to investigate what can be done to remove the obstacles to becoming a GSML in Türkiye, and committees can be formed to do so. Strategies can be identified to eliminate these obstacles, and their effectiveness can be measured after the planned initiatives.

Conclusions

A significant portion of medical biochemistry professionals in Türkiye lack education and knowledge about GSML practices. Despite the low level of formal education, many participants exhibit environmentally conscious behaviors in their laboratories. There are significant gaps in GSML practices, particularly in energy and water management. Education and awareness are the most common barriers to becoming a GSML, followed by sustainability, cost, motivation, and communication. Education and awareness are highlighted as the most significant obstacles and potential solutions to other challenges. There is an intense desire among participants to improve GSML practices.