Using the Behaviour Change Wheel and Theoretical Domains Framework in the Co-Design of a Recycling Intervention Implemented in a Rural Australian Public Hospital

Using the Behaviour Change Wheel and Theoretical Domains Framework in the Co-Design of a Recycling Intervention Implemented in a Rural Australian Public Hospital | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Using the Behaviour Change Wheel and Theoretical Domains Framework in the Co-Design of a Recycling Intervention Implemented in a Rural Australian Public Hospital Alexander Letts, Kay Knight, Daniel Halliday, Judith Singleton This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4392610/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Healthcare waste is growing annually at a rate of 2–3% globally with negative implications for environmental and population health. Improving recycling of non-contaminated healthcare waste can reduce carbon emissions and landfill use with consequent financial and health co-benefits. This paper reports the development of a co-designed behavioural change recycling intervention in a small, rural hospital in Queensland, Australia. The aim was to reduce the amount of potentially recyclable or reusable non-contaminated waste currently ending up in landfill. Methods This study utilised co-design to develop a behavioural change intervention informed by an evidence-based, theoretical framework – the integrated Behaviour Change Wheel (BCW) and Theoretical Domains Framework (TDF). This study was undertaken in a 20-bed rural Queensland Health hospital and included hospital staff in the co-design of a recycling intervention. The waste streams chosen were commingled recycling stream and waste accepted by the Containers-for-Change recycling scheme. Two co-design workshops were held onsite at the hospital on 2nd June (n = 8) and 3rd August 2023 (n = 6) followed by a visit to the hospital on 31st August 2023 to implement the recycling intervention. Final data collection was undertaken at the end of November 2023. Results The co-designed intervention comprised placing commingled bins (grey with yellow lids) and CFC bins (grey with white lids) at points of recyclable waste generation with signage and ‘train-the-trainer’ education sessions with the green champions. Over the 3-month post-intervention data collection period there was a reduction of 1.25t for the general waste stream, 0.1042t of recyclable waste was recycled through the newly introduced CFC scheme, and an increase of 0.07t of commingled recyclable waste after the intervention. In summary, across a three-month period, this co-designed recycling intervention reduced CO 2 e by 2t. This equates to a reduction of 13,652 km of car travel in an Australian sedan or light SUV. Importantly, it also diverted approximately 3,000 plastic bottles and 866 aluminium cans from landfill. Conclusions Despite the small number of participants in the two co-design workshops, combining co-design with an evidence-based theoretical framework (BCW + TDF) produced a robust, fit-for-purpose, recycling intervention that led to behaviour change (recycling). Hospitals rural Co-design healthcare waste recycling carbon Behaviour Change Wheel (BCW) Theoretical Domains Framework (TDF) Figures Figure 1 Background As the global population increases so does the demand for healthcare services 1 and with this increased demand comes an increased generation of healthcare waste. 2 , 3 In 2018, high-income countries generated approximately 0.5kg of waste on average per hospital bed per day compared with low-income countries which generated approximately 0.2kg of waste per hospital bed per day. 4 Globally, the rate of healthcare waste generation is growing annually at a rate of 2–3%. 5 This is concerning as healthcare waste has a significant impact on the environment. 6 – 8 WHO categorises healthcare waste into eight categories. 9 The first seven waste categories – infectious, pathological, sharps, chemical, pharmaceutical, cytotoxic, and radioactive waste - are all considered clinical and related waste with the last category deemed general, non-hazardous waste. 9 In the hospital setting this general waste stream comprises a large variety of waste types some of which are potentially recyclable. 3 , 7 Interventions to reduce hospital waste and improve recycling and reuse of waste can have financial benefits for the hospital and reduce carbon emissions which in turn benefits population health. 10 , 11 There has been much research on how to improve employees’ workplace pro-environmental behaviours (PEBs) including recycling 12 – 17 with researchers noting that pro-environmental behaviours can differ significantly between the home and the workplace. 17 Whilst a significant amount of previous research into behavioural change has focussed on Ajzen’s Theory of Planned Behavior 18 , 19 and Stern’s Value-Belief-Norm model, 20 these models have still demonstrated a significant percentage of unexplained variance between intention to behave and actual behaviour. 13 , 14 , 21 – 25 This corroborates Blake’s Value-Action-Gap Theory 26 which argues that pro-environmental attitudes and intentions do not necessarily lead to pro-environmental action. These theories also do not consider those organisational factors that may influence employees’ intention to undertake a PEB. Organisational factors recognised as influencing employees’ workplace PEBs are organisational focus or commitment, 21 , 27 – 32 structure, 30 , 31 , 33 – 35 organisational size and type, 36 – 38 departmental size and type, 39 , 40 culture, 40 – 43 and organisational climate. Lack of adequate infrastructure (e.g. recycling facilities) 32 and environmental information 30 , 32 have both been identified as barriers to workplace PEBs in Australia’s public healthcare sector. 43 , 44 Workplace PEBs such as recycling can only take place if the necessary infrastructure is provided e.g. clearly labelled recycling bins. 45 Prior experience with recycling (i.e. individual recycles at home) has been found to be a predictor of workplace recycling but only where the waste streams are the same. 21 , 31 , 32 , 46 , 47 These earlier behavioural change models’ inability to predict actual recycling behaviour also could be due to the fact that they were not designed to assist in the implementation of behavioural interventions. 48 Building on Lindenberg’s Goal-framing theory, 49 – 51 Unsworth et al argue that on a daily basis people are juggling numerous, competing goals. 13 Personal environmental goals (e.g., recycling, reducing energy use at work) tend to be pushed to the background due to competing workplace pressures and time constraints. 13 Background goals are more likely to be attained when not attached to urgent organisational deadlines. Therefore, when designing a workplace recycling intervention, it is necessary to minimise goal conflict arising from structural and organisational workplace barriers to ensure recycling can take place. Also, to ensure the recycling is sustained after the conclusion of the intervention, the intervention itself must be concordant with the employee’s personal environmental goals. 13 Therefore, to ensure a recycling intervention is successful long-term, employees should be included in the development and design of the intervention. Business research has highlighted the value of participatory design practice that involves the consumers of a good or service in the design process. 52 – 54 However, healthcare interventions typically implement a top-down approach that does not involve stakeholder consultation. 54 This is despite the potential for improved engagement and compliance with the intervention by empowering stakeholders through consultation in the intervention design. Whilst previous research into participatory designs in the healthcare sector has aimed to improve patient outcomes 55 – 57 or improve the efficacy of research when implemented in healthcare settings, 58 , 59 there is a paucity of research exploring co-designed PEB interventions in healthcare settings. With a co-designed intervention there is active collaboration between stakeholders to solve a pre-existing, recognised problem. 60 This paper reports the development and implementation of a co-designed behaviour change intervention to improve the waste recycling behaviours of staff working in a small, rural hospital in Queensland, Australia. A previous waste audit at this site conducted by the research team identified a large amount of potentially recyclable or reusable waste that was ending up in landfill. Having identified potential for improving waste disposal at this rural hospital site with its financial and environmental co-benefits, the research team worked with hospital staff to co-design a recycling intervention. Methods The reporting of this intervention follows the checklist developed by Albrecht et al 61 to assess the quality of reporting of knowledge translation interventions using the Workgroup for Intervention Development and Evaluation Research (WIDER) recommendations. Theoretical Framework for Intervention Development Literature tells us that theories such as the TPB and the VBN whilst somewhat successful in predicting intention to behave, do not lead to actual recycling behaviours when used to design recycling interventions. 14 , 26 This failure is possibly due to the fact they do not cover the full range of possible influences on recycling behaviours and therefore exclude potentially important variables. 62 They also fail to consider the workplace context of the recycling behaviour. 62 Therefore this recycling intervention was designed around the question posed by Michie et al , 63 “What conditions internal to individuals and in their social and physical environment need to be in place for a specified behavioural target to be achieved?” The theoretical frameworks underpinning this intervention were the Behaviour Change Wheel (BCW) integrated with the Theoretical Domains Framework (TDF). The BCW was developed from 19 frameworks of behaviour change identified from a systematic literature review 62 It comprises three layers; at the centre is the COM-B model of behaviour which identifies the sources of behaviours which the intervention could target. 64 In this model Capability, Opportunity, and Motivation interact to generate Behaviour which in turn influences each of these three components. Capability is an individual’s psychological and physical capacity (including having the requisite knowledge and skills) to undertake the targeted activity. 62 Opportunity refers to all those factors in the individual’s social and physical environment that enable the behaviour or prompt it. 62 Motivation refers to those brain processes that propel an individual to engage in a goal-directed behaviour. 62 The middle layer of the BCW comprises nine intervention functions, the choice of which depends on the COM-B analysis. 64 The outer layer comprises seven policy types that can be used to ensure the effectiveness of the intervention. 64 Each domain of the TDF relates to one of these COM-B components. The TDF is an “integrated theoretical framework synthesised from 128 theoretical constructs from 33 theories” 63 , p.2 of behaviour and behaviour change clustered into 14 domains. 63 These 14 domains are ‘knowledge’, ‘skills’, ‘’social/professional role and identity’, ‘beliefs about capabilities’, ‘optimism’, ‘beliefs about consequences’, ‘reinforcement’, ‘intentions’, ‘goals,’ ‘memory, attention and decision processes’, ‘environmental context and resources’, ‘social influences’, ‘emotion’, and ‘behavioural regulation’. When linked with the BCW, the TDF enables a deeper understanding of psychological capability and reflective motivational processes (the C and M from the COM-B model). 48 Following the example of Gainforth et al , 48 this study also used the integrated BCW + TDF framework to develop an evidenced-based intervention to improve recycling behaviours. However, a key difference between the two studies is that this study also utilised co-design in the development of the recycling intervention. Study Site and Scope This study was undertaken in a 20-bed Queensland Health hospital servicing a small rural town. Two co-design workshops were held onsite at the hospital on 2nd June and 3rd August 2023 followed by a visit to the hospital on 31st August 2023 to implement the recycling intervention. Final data collection was undertaken at the end of November 2023. Ethical approval was obtained from the Darling Downs Health and Hospital Service HREC (LNR/2023/QTDD/95112) and administrative ethical approval from Queensland University of Technology (QUT Approval No. 7206). The waste streams chosen for this intervention were the local council’s commingled recycling stream (accepts dry and clean recyclables such as rigid plastics, paper, cardboard, steel, and aluminium) and waste accepted by the Containers-for-Change recycling scheme (accepts most aluminium, glass, plastic, steel, and liquid paperboard beverage containers between 150ml and 3L). Disposal of waste streams that fall outside these two streams are problematic for rural and remote Queensland hospitals. The researchers contacted a number of third-party recycling firms and pharmaceutical companies in June 2023 regarding collection of other potentially recyclable waste streams but were informed that collection from rural sites was not feasible due to economies of scale and logistical issues. Participant Recruitment Prior to each co-design workshop, the project’s hospital sponsor was emailed information about the workshop with an attached participant information sheet. This email was then forwarded to the hospital’s sustainability champions inviting them to participate. Staff who agreed to participate signed an Informed Consent document prior to the workshop. Participants (n = 8) for the first workshop comprised five nurses working in different areas of the hospital, one pharmacist, and two doctors. There were two researchers - the Chief Investigator (CI) facilitated the workshop with the second researcher (RA) taking field notes. For the second workshop, two of the original participants (the two doctors) were on leave so participants (n = 6) comprised the pharmacist and five nurses. Co-Design Workshop 1 The CI and the RA used a semi-structured discussion guide (Supplementary File 1) to facilitate discussion between participants. Session 1 of the workshop explored recycling in the hospital utilising five pre-determined questions. Session 2’s questions were developed after the research team analysed the participants’ responses to the questions asked in Session 1. Each question was put to each of the participants as they all worked in different areas of the hospital. Each session’s discussions were digitally recorded and transcribed by the RA. All comments were anonymous – the RA ensured that participants’ names or any identifying information were not recorded. After the workshop the RA transcribed all comments and discussion into a single document (Supplementary File 2) which was checked for accuracy by the CI. This summary document was not circulated to the workshop’s participants afterwards as they indicated at the workshop’s completion that workload pressures due to staff shortages meant they would not have time to read it. The participants were agreeable for the research team to design an intervention based on the BCW and TDF framework and present to participants in the second co-design workshop. The text in Supplementary File 2 was then analysed using content analysis. Content analysis enabled the research team to quantify comments and link to the BCW. Co-Design Workshop 2 In this workshop, the CI and RA presented the recycling intervention to participants. This intervention was examined and discussed in depth by the participants with the CI facilitating the workshop and the RA taking field notes. The field notes from this workshop were transcribed (Supplementary File 3) and this data informed adjustments to the intervention. Implementation of Recycling Intervention and Post-Implementation Data Collection On 31st August the CI visited the hospital and implemented the recycling intervention. The data collection period was 1/9/2023–30/11/2023. At the end of this period, waste data were obtained from the hospital’s waste services manager for the general, commingled, and Containers-For-Change waste streams. The short time period for data collection (3 months) was dictated by the timeline of the grant funding for this project. Results Development of Intervention Content analysis of the field notes from co-design Workshop 1 are presented in Table 1 . Table 1 Content Analysis of Field Notes from Co-Design Workshop 1 (refer Supplementary File 1 – Co-Design workshop 1 Discussion Guide) Source of Behaviour (BCW) TDF Domains Representative Quotations Capability Psychological Capability Knowledge “…there are obviously a few things which need a little bit more education towards staff, and just letting them know what can be recycled and what can’t be.” – B17 “I think the area of plastics is very confusing…some is recyclable, some isn’t, some is return to store, some is thrown away, so I think that’s a complex space for people. You can’t assume that all plastics are recyclable.” – G05 “So we would need identification posters I guess or point of care posters to say this is what goes in this bin, this is what goes in this bin, maybe on a lid or on a wall, whatever style of bin you have.” – G17 “I would need some guidance and some education around what we can put and where.” – G29 “…I would want guidance on a document or a poster or on the bins.” – P21 “I’m unsure of the co-mingled bins, what can go in there.” – A034 “Yeah down in our little office. So people are still taking the lids off and there’s a separate containers for lids.” – A034 “I think it’s interesting that what we need is more peer support and peer – because I will catch people and say ‘no no, don’t do that.’ I think we need to set up some system of peer support or education…Train the trainers.” – H303 Beliefs about capabilities “…at this point in time, I wouldn’t say that I’ve got enough knowledge to know what I could and couldn’t put in a bin.” – P12 Opportunity Physical Opportunity Environmental Context Lack of a bank account “We used to take bottles home as well, some people, but not anymore, we’re not allowed to.” – G07 Physical Opportunity Environmental Context Lack of recycling bins “…which unfortunately, because we don’t have a recycling program, ends up with our general waste.” – B17 On the lack of a compost bin for food waste in the kitchen: “It broke, and I think it’s something to do with Queensland Health regulations that we can't get them anymore.” – G07 On bottles going in Containers for Change bins: “They used to, but not anymore.” – G07 Physical Opportunity Environmental Context Containers for Change bins are full (post introduction of intervention) “I don’t know whose job it is to empty them so they just overflow, and then you think just put them in the bin. Sometimes people are just putting them back in the bin, because they’re all overflowing.” – L033 Motivation Motivation to recycle “Another thing that I would like to raise – bring forward, is batteries. I also think most of them do end up in general waste as well…which is horrible.” – B17 “…recently we’ve had a few events and a few things that happened at the hospital and since then I’ve seen a lot of people show more interest towards recycling, towards wanting – well, pretty much asking for recycling facilities... there are a lot of people that I can think of, that would be open to the idea of recycling appropriately.” – B17 “We are most definitely in it like to help you guys.” – G07 On using appropriate recycling bins if provided : “Absolutely, everybody would I think, yeah.” – G17 “Yes.” – G29 “Absolutely.” – P12 “Yes.” – P21 “I think probably we don’t recycle enough.” – G29 “…the team would be very happy to [receive appropriate recycling education], as long as they’re told what they can and can’t put in there.” – P12 “I mean I'd love to have provision for recycling of cardboard and hard plastics…” – P21 “We’re all excited that it [the recycling intervention] is happening. I know we’ve been groaning for years.” – L033 “It’s hugely great. Those containers are chokkers. To think that what we were doing – just chucking them out because we weren’t allowed to recycle them.” – M083 Motivation to recycle was high among hospital staff across several departments, particularly since this community was experiencing the impacts of climate change such as droughts and bushfires. However, participants reported that recycling was impeded by three main factors. Firstly, the hospital was unable to establish a Containers-for-Change (CFC) scheme collection as they did not have an appropriate bank account into which the reimbursement funds could be deposited. This scheme reimburses 10c for each plastic bottle recycled. 65 As the hospital only supplies water to patients and staff in plastic water bottles, this waste stream is significant and was previously being disposed of in general waste bins destined for landfill. Secondly, a lack of recycling bins at points of waste generation throughout the hospital was identified as a physical barrier. Thirdly, staff members’ psychological capability to recycle was impeded by a lack of knowledge, as well as a lack of confidence around their knowledge, about what waste could be recycled. The first barrier was resolved through the efforts of the project’s sponsor who followed up continually with senior management until a bank account number was provided. The remaining two barriers were then mapped to the BCW + TDF framework (Supplementary File 2) to identify an evidence-based co-designed behaviour change intervention (Fig. 1). The barrier ‘lack of recycling bins’ mapped to ‘Opportunity’ (Physical Opportunity) of the COM-B model and the ‘Environmental Context and Resources’ domain of the TDF. The TDF defines ‘Environmental Context and Resources’ as those environmental circumstances which may facilitate or hinder skills development and adaptive behaviour. 64 Therefore, ‘Physical Opportunity’ may be achieved through interventions that focus on ‘Environmental Restructuring’ and ‘Enablement’. 62 ‘Environmental Restructuring’ interventions involve changing the physical context and ‘Enablement’ refers to interventions which reduce barriers to increase opportunity. 62 Therefore the intervention required adding objects to the environment and providing prompts and cues to guide the behaviour change (Fig. 1). Workshop participants agreed that purchasing two types of recycling bins – commingled recycling with yellow lids and CFC bins with green lids - which were clearly labelled with infographics of the waste types to put in them - would encourage recycling behaviours. Bins were also provided for battery waste (one of the participants converted one of these bins to one for electrical cable waste, again labelled with infographics). Laminated signs would also be provided to affix to the wall above the bins. Convenient location of bins at the point of waste segregation was highlighted in Workshop 1 discussions as necessary to achieve recycling. However, in Workshop 2 three of the nurse participants also raised the issue of space restrictions in some treatment rooms and nursing stations. Therefore, the location of the purchased bins was left to the hospital’s green champion to decide upon subject to discussions with nurses working in the various areas. The barrier ‘lack of knowledge about what waste can be recycled and in which bin’ mapped to ‘Capability’ (Psychological) of the COM-B model and to the ‘Knowledge’ domain of the TDF. The TDF ‘Knowledge’ domain encompasses the theoretical constructs of knowledge of condition or rationale, procedural knowledge, and knowledge of the task environment. 64 The BCW links ‘Knowledge’ with interventions that focus on ‘Education’, ‘Training’ and ‘Enablement’. ‘Enablement’ was enhanced through the provision of clearly labelled bins for the different recycling streams and signage. Workshop 2 participants all agreed that education and training were needed as a component of the intervention. Types of training that were canvassed included a webinar, a recorded training session to be uploaded to the hospital’s intranet, and onsite training in staff meetings. Various organisational barriers were identified to uploading recorded training materials to the hospital’s intranet and therefore it was decided that the research team would provide face-to-face training for the hospital’s green champions and operational services staff. Educating the operational services staff was identified as important because they would be ultimately responsible for collecting these bins. They therefore needed to be educated on the different recycling waste streams and their correct bins, and where the main collection bins for the different waste streams would be located. Training of the green champions would utilise a train-the-trainer approach so that the green champions could in turn train other staff in staff meetings and continue to run ongoing training sessions after the project concluded to ensure its continuance. Intervention Description The final co-designed intervention comprised placing commingled and CFC bins in identified work areas at points of recyclable waste generation. These bins comprised commingled recycling bins (grey with yellow lids) and two sizes of CFC bins to suit the work area’s requirements (larger grey bins with white lids which had the words 10c containers on them and small white containers with the CFC logo on the front). Laminated signs with clear infographics depicting types of waste which could be recycled in that waste bin were placed on walls directly above these bins. Education was provided to the green champions face-to-face using a ‘train-the-trainer’ approach and they in turn educated colleagues in staff meetings. Written educational material was provided by the research team for inclusion in hospital-wide staff newsletters and emails. The research team sent follow-up emails and SMS messages to the hospital green champions to remind them to continue to spread the word about the recycling intervention. Pre- and Post-Intervention Waste Data Waste data were compared for the pre-intervention period June-August 2023 with the post-intervention period September-November 2023 (Table 2 ). Table 2 Final Waste Data Collection General Waste (tonnes) Commingled Waste (tonnes) Containers for Change waste (tonnes) tCO 2 e Pre-Intervention: June-Aug 2023 10.84 0.065 Nil 17.35 Post-intervention: Oct -Dec 2023 9.59 0.135 0.1042 15.35 *General waste stream: 1.6 tCO 2 e/t 66 General Waste There was a reduction of 1.25t for this stream which not only reduced CO 2 e but also reduced waste collection fees. Commingled Recycling Waste Prior to the intervention only kitchen staff had access to the hospital’s commingled recycling bins. Post-intervention, with the availability of more commingled recycling bins at points of waste generation there was an increase of 0.07t of commingled recyclable waste after the intervention. Containers-For-Change Scheme Waste Once a bank account was allocated to the hospital to receive payment for recycling through this scheme, staff recycled 0.1042t of recyclable waste (Table 3 ). Approximately 3,000 plastic bottles and 866 aluminium cans were diverted from landfill. The total tCO 2 e saved by diverting this waste from landfill was 0.167t which equates to a saving of 1,140 km of car travel for an Australian sedan or light SUV. Table 3 Containers for Change Data Post-Intervention (3-months) Waste stream Glass Aluminium PET – Clear (polyethylene terephthalate) PET – Coloured (polyethylene terephthalate) High-Density polyethylene (HDPE) Tetra-paks Totals (tonnes) Total Number 19 866 2,914 17 14 12 Total Weight (tonnes) 0.0087 0.01212 0.0816 0.00048 Weight unknown 0.0013 0.1042 tCO 2 e* saved by diverting from landfill 0.014 0.019 0.131 0.00077 unknown 0.0021 0.167 *General waste stream: 1.6 tCO 2 e/t 66 Overall Outcomes of Intervention In a three-month period, this co-designed recycling intervention reduced CO 2 e by 2t (Table 3 ). This equates to a reduction of 13,652 km of car travel in an Australian sedan or light SUV. Importantly, it also diverted approximately 3,000 plastic bottles and 866 aluminium cans from landfill. Discussion This co-design workshop resulted in a multi-faceted recycling intervention designed by staff for staff. To strengthen the chance of the intervention’s success, its development was guided by researchers utilising an integrated BCW + TDF theoretical framework. This framework has been developed to overcome the limitations of the many behavioural change theories and theoretical constructs upon which it is based. It also incorporates context. 48 Context is extremely important when the behaviour in question is a pro-environmental behaviour such as recycling. Literature shows that people tend to recycle less at work compared with at home due to infrastructural and other organisational barriers. 67 , 68 As with the recycling intervention developed by Gainforth et al 48 which integrated the BCW and the TDF framework, behavioural analysis of participants’ comments in this study identified that most were motivated to recycle; however, lack of ‘physical opportunity’ had a negative influence on motivation. Since the co-design workshop participants in this study were members of the hospital’s green champions team, it was expected that their motivation to recycle would be high and potentially higher than other members of staff. The integrated BCW + TDF framework’s suggested interventions linked to ‘Motivation’ include ‘incentivisation’, ‘persuasion’ and ‘coercion’. 62 Behavioural analysis in both studies also identified that poor engagement with recycling behaviour was linked to a lack of ‘psychological capability’ to recycle in their workplace contexts. Therefore, it was decided to frame the intervention in this study around the sources of behaviour ‘physical opportunity’ and ‘psychological capability’. However, to address ‘motivation’ some ‘incentivisation’ was provided by offering hospital staff a say in what the money raised from the Containers-for-Change programme would be spent on. An important difference between this study and the study conducted by Gainforth et al , 48 is that our study included staff who would be undertaking the recycling intervention in its co-design. We believe this combination of co-design with an evidence-based theoretical framework to inform the intervention design is the true strength of this study. Staff were able to describe barriers to recycling which the research team would never have been aware of e.g., lack of access to a bank account. Logistics of bin collections in the hospital (who would collect bins from where and when) and bin locations was also an area where the research team relied on the corporate knowledge of staff to inform the intervention design. A limitation of the study was the small number of participants in the co-design workshops. The hospital site for this research project is a small 20-bed facility and the number of participants was limited by staff shortages at this time due to a COVID-19 outbreak at the hospital as well as the usual ongoing chronic staff shortages experienced by rural hospitals. 69 However, despite the small number of participants, the workshops generated enthusiastic, lively discussion with the outcome being a robust, fit-for-purpose, recycling intervention. Conclusion This study demonstrated that combining co-design with an evidence-based theoretical framework (BCW + TDF) to inform a behavioural intervention was successful in bringing about behaviour change (recycling) – at least over the three-month post-intervention data collection period. Declarations Ethics Approval and Consent to Participate Ethical approval was obtained from the Darling Downs Health and Hospital Service HREC (LNR/2023/QTDD/95112) and administrative ethical approval from Queensland University of Technology (QUT Approval No. 7206). Consent for publication Not applicable Availability of data and material The interview transcripts and analyses are available from the corresponding author on reasonable request. Competing interests The authors declare there are no competing interests to report. Funding This research study was funded by Queensland University of Technology through the Charles Selby Endowment Fund. Authors' contributions AL contributed to the research design, co-facilitated the co-design workshops with JS, collected, analysed, and interpreted the data with JS, and was a major contributor to writing and revising the manuscript. KN contributed to the conception of the project, data collection, and contributed to manuscript revision. DH contributed to data collection and manuscript revision. JS conceived the project and was the recipient of the grant funding to support it, and made substantial contributions to research design, data collection, data analysis and interpretation, contributed to drafts of manuscript and undertook the final revision of manuscript. All authors read and approved the final manuscript. Acknowledgements The research team acknowledges with grateful thanks the support of the Darling Downs Hospital and Health Service and the many hospital staff who helped in various ways with this project, in particular Ms Vanessa Rolph and Mr. Manroop Singh. References Thakur V, Mangla SK and Tiwari B. Managing healthcare waste for sustainable environmental development: A hybrid decision approach. Business Strategy and the Environment 2021; 30: 357-373. Windfeld E and Brooks M. Medical waste management - A review. Journal of Environmental Management 2015; 163: 98. 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Normative, Gain and Hedonic Goal Frames Guiding Environmental Behavior. Journal of Social Issues 2007; 63: 117-137. DOI: 10.1111/j.1540-4560.2007.00499.x. Terblanche NS. Some theoretical perspectives of co-creation and co-production of value by customers. Acta Commercii 2014; 14: 1-8. Prahalad CK and Ramaswamy V. Co-creation experiences: The next practice in value creation. Journal of interactive marketing 2004; 18: 5-14. Leask CF, Sandlund M, Skelton DA, et al. Framework, principles and recommendations for utilising participatory methodologies in the co-creation and evaluation of public health interventions. Research involvement and engagement 2019; 5: 1-16. Leask CF, Sandlund M, Skelton DA, et al. Framework, principles and recommendations for utilising participatory methodologies in the co-creation and evaluation of public health interventions. Research involvement and engagement 2019; 5: 1-16. Lazo-Porras M, Perez-Leon S, Cardenas MK, et al. Lessons learned about co-creation: developing a complex intervention in rural Peru. Global Health Action 2020; 13: 1754016. Raeside R, Partridge SR, Singleton A, et al. Cardiovascular disease prevention in adolescents: eHealth, co-creation, and advocacy. Medical Sciences 2019; 7: 34. Greenhalgh T, Jackson C, Shaw S, et al. Achieving research impact through co‐creation in community‐based health services: literature review and case study. The Milbank Quarterly 2016; 94: 392-429. Jackson CL and Greenhalgh T. Co-creation: a new approach to optimising research impact. Med J Aust 2015; 203: 283-284. Vargas C, Whelan J, Brimblecombe J, et al. Co-creation, co-design, co-production for public health – a perspective on definitions and distinctions. Public Health Research & Practice . Albrecht L, Archibald M, Arseneau D, et al. Development of a checklist to assess the quality of reporting of knowledge translation interventions using the Workgroup for Intervention Development and Evaluation Research (WIDER) recommendations. Implementation Science 2013; 8: 52. DOI: 10.1186/1748-5908-8-52. Michie S, van Stralen MM and West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation science : IS 2011; 6: 42-42. DOI: 10.1186/1748-5908-6-42. Atkins L, Francis J, Islam R, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Science : IS 2017; 12. DOI: 10.1186/s13012-017-0605-9. Michie S, Atkins L and West R. The behaviour change wheel: A guide to designing interventions. Great Britain: Silverback Publishing, 2014, p.1010. Containers For Change. How it Works, https://www.containersforchange.com.au/qld/how-it-works?gad_source=1&gclid=CjwKCAiAvJarBhA1EiwAGgZl0K66PXiL-mv5QzP6Vf6ATBACuYaAaGwsdM9Z6aZd_MomFCCcs0DK1hoChbAQAvD_BwE&gclsrc=aw.ds (2020, accessed 29 November 2023). Department of Climate Change Energy the Environment and Water. Australian National Greenhouse Accounts Factors: For individuals and organisations estimating greenhouse gas emissions. Canberra, Australia: Australian Government, 2023, p. 53. Dunphy JL. Healthcare professionals' perspectives on environmental sustainability. Nursing Ethics 2014; 21: 414-425. DOI: 10.1177/0969733013502802. Whitmarsh LE, Haggar P and Thomas M. Waste reduction behaviors at home, at work, and on holiday: What influences behavioral consistency across contexts? Frontiers in Psychology 2018; 9: 2447. Whiteing N, Barr J and Rossi DM. The practice of rural and remote nurses in Australia: A case study. Journal of Clinical Nursing 2022; 31: 1502-1518. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1CodesignWorkshopDiscussionGuide.pdf SupplementaryFile2CoDesignWorkshop1FieldNotes.pdf SupplementaryFile3CoDesignWorkshop2FieldNotes.pdf SupplementaryFile4ALbrechtetalChecklist.png Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4392610","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308125701,"identity":"b5476f26-fbc7-4ea7-ad0f-effd6756a2a8","order_by":0,"name":"Alexander Letts","email":"","orcid":"","institution":"Queensland University of Technology","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Letts","suffix":""},{"id":308125702,"identity":"036542ae-267f-489f-ab8a-818211e5c795","order_by":1,"name":"Kay Knight","email":"","orcid":"","institution":"Queensland Health","correspondingAuthor":false,"prefix":"","firstName":"Kay","middleName":"","lastName":"Knight","suffix":""},{"id":308125703,"identity":"4bf84411-73bf-414f-b80a-557657438878","order_by":2,"name":"Daniel Halliday","email":"","orcid":"","institution":"Queensland Health","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Halliday","suffix":""},{"id":308125704,"identity":"1bd06292-605e-4251-8ab7-f292b44df180","order_by":3,"name":"Judith Singleton","email":"data:image/png;base64,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","orcid":"","institution":"Queensland University of Technology","correspondingAuthor":true,"prefix":"","firstName":"Judith","middleName":"","lastName":"Singleton","suffix":""}],"badges":[],"createdAt":"2024-05-09 05:00:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4392610/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4392610/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57867673,"identity":"5cf63950-8530-4508-912f-d202dd392e31","added_by":"auto","created_at":"2024-06-06 16:06:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":69561,"visible":true,"origin":"","legend":"\u003cp\u003eIdentification of Target Behaviour and Development of Behaviour Intervention based on the Behaviour Change Wheel (BCW) and Theoretical Domains Framework (TDF)\u003csup\u003e48, 64\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e* PEB = pro-environmental behaviour\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4392610/v1/3b28d88327075a9a94c6a3d6.png"},{"id":57916157,"identity":"f26a5842-69ef-4ac0-b9bf-d42caf2a2ac7","added_by":"auto","created_at":"2024-06-07 12:09:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":763112,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4392610/v1/9b3e1ded-4074-42d0-b1c0-7c8173a227a6.pdf"},{"id":57868332,"identity":"2f53cf91-b711-4dc9-99cb-ad6f4434b6fe","added_by":"auto","created_at":"2024-06-06 16:14:32","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":47912,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1CodesignWorkshopDiscussionGuide.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4392610/v1/85b5fb4917cea687805fe5f0.pdf"},{"id":57867674,"identity":"725b1cea-1934-4f94-a10a-1674ad26d4e8","added_by":"auto","created_at":"2024-06-06 16:06:32","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":151909,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile2CoDesignWorkshop1FieldNotes.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4392610/v1/faf065ec950e644962a8c055.pdf"},{"id":57868334,"identity":"a76f10be-a01f-49cb-a7fa-a2a715d80973","added_by":"auto","created_at":"2024-06-06 16:14:32","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":40843,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile3CoDesignWorkshop2FieldNotes.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4392610/v1/ed2111eaf7486a7b26fba50b.pdf"},{"id":57867676,"identity":"7cdeb13f-742e-46c3-ad10-d9a84eed813b","added_by":"auto","created_at":"2024-06-06 16:06:32","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":411031,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile4ALbrechtetalChecklist.png","url":"https://assets-eu.researchsquare.com/files/rs-4392610/v1/e519e94ec4ff930c43f13c17.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"Using the Behaviour Change Wheel and Theoretical Domains Framework in the Co-Design of a Recycling Intervention Implemented in a Rural Australian Public Hospital","fulltext":[{"header":"Background","content":"\u003cp\u003eAs the global population increases so does the demand for healthcare services\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e and with this increased demand comes an increased generation of healthcare waste.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e In 2018, high-income countries generated approximately 0.5kg of waste on average per hospital bed per day compared with low-income countries which generated approximately 0.2kg of waste per hospital bed per day.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Globally, the rate of healthcare waste generation is growing annually at a rate of 2\u0026ndash;3%.\u003csup\u003e5\u003c/sup\u003e This is concerning as healthcare waste has a significant impact on the environment.\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e WHO categorises healthcare waste into eight categories.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e The first seven waste categories \u0026ndash; infectious, pathological, sharps, chemical, pharmaceutical, cytotoxic, and radioactive waste - are all considered clinical and related waste with the last category deemed general, non-hazardous waste.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e In the hospital setting this general waste stream comprises a large variety of waste types some of which are potentially recyclable.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Interventions to reduce hospital waste and improve recycling and reuse of waste can have financial benefits for the hospital and reduce carbon emissions which in turn benefits population health.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere has been much research on how to improve employees\u0026rsquo; workplace pro-environmental behaviours (PEBs) including recycling\u003csup\u003e\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e with researchers noting that pro-environmental behaviours can differ significantly between the home and the workplace.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Whilst a significant amount of previous research into behavioural change has focussed on Ajzen\u0026rsquo;s Theory of Planned Behavior\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e and Stern\u0026rsquo;s Value-Belief-Norm model,\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e these models have still demonstrated a significant percentage of unexplained variance between intention to behave and actual behaviour.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22 CR23 CR24\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e This corroborates Blake\u0026rsquo;s Value-Action-Gap Theory\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e which argues that pro-environmental attitudes and intentions do not necessarily lead to pro-environmental action. These theories also do not consider those organisational factors that may influence employees\u0026rsquo; intention to undertake a PEB. Organisational factors recognised as influencing employees\u0026rsquo; workplace PEBs are organisational focus or commitment,\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28 CR29 CR30 CR31\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e structure,\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e organisational size and type,\u003csup\u003e\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e departmental size and type,\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e culture,\u003csup\u003e\u003cspan additionalcitationids=\"CR41 CR42\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e and organisational climate. Lack of adequate infrastructure (e.g. recycling facilities)\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e and environmental information\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e have both been identified as barriers to workplace PEBs in Australia\u0026rsquo;s public healthcare sector. \u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e Workplace PEBs such as recycling can only take place if the necessary infrastructure is provided e.g. clearly labelled recycling bins.\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e Prior experience with recycling (i.e. individual recycles at home) has been found to be a predictor of workplace recycling but only where the waste streams are the same.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e These earlier behavioural change models\u0026rsquo; inability to predict actual recycling behaviour also could be due to the fact that they were not designed to assist in the implementation of behavioural interventions.\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eBuilding on Lindenberg\u0026rsquo;s Goal-framing theory,\u003csup\u003e\u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e Unsworth \u003cem\u003eet al\u003c/em\u003e argue that on a daily basis people are juggling numerous, competing goals.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Personal environmental goals (e.g., recycling, reducing energy use at work) tend to be pushed to the background due to competing workplace pressures and time constraints.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Background goals are more likely to be attained when not attached to urgent organisational deadlines. Therefore, when designing a workplace recycling intervention, it is necessary to minimise goal conflict arising from structural and organisational workplace barriers to ensure recycling can take place. Also, to ensure the recycling is sustained after the conclusion of the intervention, the intervention itself must be concordant with the employee\u0026rsquo;s personal environmental goals.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Therefore, to ensure a recycling intervention is successful long-term, employees should be included in the development and design of the intervention.\u003c/p\u003e \u003cp\u003eBusiness research has highlighted the value of participatory design practice that involves the consumers of a good or service in the design process.\u003csup\u003e\u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e However, healthcare interventions typically implement a top-down approach that does not involve stakeholder consultation.\u003csup\u003e\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e This is despite the potential for improved engagement and compliance with the intervention by empowering stakeholders through consultation in the intervention design. Whilst previous research into participatory designs in the healthcare sector has aimed to improve patient outcomes\u003csup\u003e\u003cspan additionalcitationids=\"CR56\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e or improve the efficacy of research when implemented in healthcare settings,\u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e there is a paucity of research exploring co-designed PEB interventions in healthcare settings. With a co-designed intervention there is active collaboration between stakeholders to solve a pre-existing, recognised problem.\u003csup\u003e\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e This paper reports the development and implementation of a co-designed behaviour change intervention to improve the waste recycling behaviours of staff working in a small, rural hospital in Queensland, Australia. A previous waste audit at this site conducted by the research team identified a large amount of potentially recyclable or reusable waste that was ending up in landfill. Having identified potential for improving waste disposal at this rural hospital site with its financial and environmental co-benefits, the research team worked with hospital staff to co-design a recycling intervention.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe reporting of this intervention follows the checklist developed by Albrecht \u003cem\u003eet al\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e to assess the quality of reporting of knowledge translation interventions using the Workgroup for Intervention Development and Evaluation Research (WIDER) recommendations.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTheoretical Framework for Intervention Development\u003c/h2\u003e \u003cp\u003eLiterature tells us that theories such as the TPB and the VBN whilst somewhat successful in predicting intention to behave, do not lead to actual recycling behaviours when used to design recycling interventions.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e This failure is possibly due to the fact they do not cover the full range of possible influences on recycling behaviours and therefore exclude potentially important variables.\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e They also fail to consider the workplace context of the recycling behaviour.\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e Therefore this recycling intervention was designed around the question posed by Michie \u003cem\u003eet al\u003c/em\u003e,\u003csup\u003e\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e \u0026ldquo;What conditions internal to individuals and in their social and physical environment need to be in place for a specified behavioural target to be achieved?\u0026rdquo; The theoretical frameworks underpinning this intervention were the Behaviour Change Wheel (BCW) integrated with the Theoretical Domains Framework (TDF).\u003c/p\u003e \u003cp\u003eThe BCW was developed from 19 frameworks of behaviour change identified from a systematic literature review\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e It comprises three layers; at the centre is the COM-B model of behaviour which identifies the sources of behaviours which the intervention could target.\u003csup\u003e\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e In this model Capability, Opportunity, and Motivation interact to generate Behaviour which in turn influences each of these three components. Capability is an individual\u0026rsquo;s psychological and physical capacity (including having the requisite knowledge and skills) to undertake the targeted activity.\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e Opportunity refers to all those factors in the individual\u0026rsquo;s social and physical environment that enable the behaviour or prompt it.\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e Motivation refers to those brain processes that propel an individual to engage in a goal-directed behaviour.\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e The middle layer of the BCW comprises nine intervention functions, the choice of which depends on the COM-B analysis.\u003csup\u003e\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e The outer layer comprises seven policy types that can be used to ensure the effectiveness of the intervention.\u003csup\u003e\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e Each domain of the TDF relates to one of these COM-B components.\u003c/p\u003e \u003cp\u003eThe TDF is an \u0026ldquo;integrated theoretical framework synthesised from 128 theoretical constructs from 33 theories\u0026rdquo;\u003csup\u003e\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, p.2\u003c/sup\u003e of behaviour and behaviour change clustered into 14 domains.\u003csup\u003e\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e These 14 domains are \u0026lsquo;knowledge\u0026rsquo;, \u0026lsquo;skills\u0026rsquo;, \u0026lsquo;\u0026rsquo;social/professional role and identity\u0026rsquo;, \u0026lsquo;beliefs about capabilities\u0026rsquo;, \u0026lsquo;optimism\u0026rsquo;, \u0026lsquo;beliefs about consequences\u0026rsquo;, \u0026lsquo;reinforcement\u0026rsquo;, \u0026lsquo;intentions\u0026rsquo;, \u0026lsquo;goals,\u0026rsquo; \u0026lsquo;memory, attention and decision processes\u0026rsquo;, \u0026lsquo;environmental context and resources\u0026rsquo;, \u0026lsquo;social influences\u0026rsquo;, \u0026lsquo;emotion\u0026rsquo;, and \u0026lsquo;behavioural regulation\u0026rsquo;. When linked with the BCW, the TDF enables a deeper understanding of psychological capability and reflective motivational processes (the C and M from the COM-B model).\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e Following the example of Gainforth \u003cem\u003eet al\u003c/em\u003e,\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e this study also used the integrated BCW\u0026thinsp;+\u0026thinsp;TDF framework to develop an evidenced-based intervention to improve recycling behaviours. However, a key difference between the two studies is that this study also utilised co-design in the development of the recycling intervention.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Site and Scope\u003c/h2\u003e \u003cp\u003eThis study was undertaken in a 20-bed Queensland Health hospital servicing a small rural town. Two co-design workshops were held onsite at the hospital on 2nd June and 3rd August 2023 followed by a visit to the hospital on 31st August 2023 to implement the recycling intervention. Final data collection was undertaken at the end of November 2023. Ethical approval was obtained from the Darling Downs Health and Hospital Service HREC (LNR/2023/QTDD/95112) and administrative ethical approval from Queensland University of Technology (QUT Approval No. 7206). The waste streams chosen for this intervention were the local council\u0026rsquo;s commingled recycling stream (accepts dry and clean recyclables such as rigid plastics, paper, cardboard, steel, and aluminium) and waste accepted by the Containers-for-Change recycling scheme (accepts most aluminium, glass, plastic, steel, and liquid paperboard beverage containers between 150ml and 3L). Disposal of waste streams that fall outside these two streams are problematic for rural and remote Queensland hospitals. The researchers contacted a number of third-party recycling firms and pharmaceutical companies in June 2023 regarding collection of other potentially recyclable waste streams but were informed that collection from rural sites was not feasible due to economies of scale and logistical issues.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Recruitment\u003c/h2\u003e \u003cp\u003ePrior to each co-design workshop, the project\u0026rsquo;s hospital sponsor was emailed information about the workshop with an attached participant information sheet. This email was then forwarded to the hospital\u0026rsquo;s sustainability champions inviting them to participate. Staff who agreed to participate signed an Informed Consent document prior to the workshop. Participants (n\u0026thinsp;=\u0026thinsp;8) for the first workshop comprised five nurses working in different areas of the hospital, one pharmacist, and two doctors. There were two researchers - the Chief Investigator (CI) facilitated the workshop with the second researcher (RA) taking field notes. For the second workshop, two of the original participants (the two doctors) were on leave so participants (n\u0026thinsp;=\u0026thinsp;6) comprised the pharmacist and five nurses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eCo-Design Workshop 1\u003c/h2\u003e \u003cp\u003eThe CI and the RA used a semi-structured discussion guide (Supplementary File 1) to facilitate discussion between participants. Session 1 of the workshop explored recycling in the hospital utilising five pre-determined questions. Session 2\u0026rsquo;s questions were developed after the research team analysed the participants\u0026rsquo; responses to the questions asked in Session 1. Each question was put to each of the participants as they all worked in different areas of the hospital. Each session\u0026rsquo;s discussions were digitally recorded and transcribed by the RA. All comments were anonymous \u0026ndash; the RA ensured that participants\u0026rsquo; names or any identifying information were not recorded. After the workshop the RA transcribed all comments and discussion into a single document (Supplementary File 2) which was checked for accuracy by the CI. This summary document was not circulated to the workshop\u0026rsquo;s participants afterwards as they indicated at the workshop\u0026rsquo;s completion that workload pressures due to staff shortages meant they would not have time to read it. The participants were agreeable for the research team to design an intervention based on the BCW and TDF framework and present to participants in the second co-design workshop. The text in Supplementary File 2 was then analysed using content analysis. Content analysis enabled the research team to quantify comments and link to the BCW.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eCo-Design Workshop 2\u003c/h2\u003e \u003cp\u003e In this workshop, the CI and RA presented the recycling intervention to participants. This intervention was examined and discussed in depth by the participants with the CI facilitating the workshop and the RA taking field notes. The field notes from this workshop were transcribed (Supplementary File 3) and this data informed adjustments to the intervention.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eImplementation of Recycling Intervention and Post-Implementation Data Collection\u003c/h2\u003e \u003cp\u003eOn 31st August the CI visited the hospital and implemented the recycling intervention. The data collection period was 1/9/2023\u0026ndash;30/11/2023. At the end of this period, waste data were obtained from the hospital\u0026rsquo;s waste services manager for the general, commingled, and Containers-For-Change waste streams. The short time period for data collection (3 months) was dictated by the timeline of the grant funding for this project.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eDevelopment of Intervention\u003c/h2\u003e \u003cp\u003eContent analysis of the field notes from co-design Workshop 1 are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eContent Analysis of Field Notes from Co-Design Workshop 1 (refer Supplementary File 1 \u0026ndash; Co-Design workshop 1 Discussion Guide)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSource of Behaviour (BCW)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTDF Domains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRepresentative Quotations\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCapability\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePsychological Capability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;there are obviously a few things which need a little bit more education towards staff, and just letting them know what can be recycled and what can\u0026rsquo;t be.\u0026rdquo; \u0026ndash; B17\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think the area of plastics is very confusing\u0026hellip;some is recyclable, some isn\u0026rsquo;t, some is return to store, some is thrown away, so I think that\u0026rsquo;s a complex space for people. You can\u0026rsquo;t assume that all plastics are recyclable.\u0026rdquo; \u0026ndash; G05\u003c/p\u003e \u003cp\u003e\u0026ldquo;So we would need identification posters I guess or point of care posters to say this is what goes in this bin, this is what goes in this bin, maybe on a lid or on a wall, whatever style of bin you have.\u0026rdquo; \u0026ndash; G17\u003c/p\u003e \u003cp\u003e\u0026ldquo;I would need some guidance and some education around what we can put and where.\u0026rdquo; \u0026ndash; G29\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;I would want guidance on a document or a poster or on the bins.\u0026rdquo; \u0026ndash; P21\u003c/p\u003e \u003cp\u003e\u0026ldquo;I\u0026rsquo;m unsure of the co-mingled bins, what can go in there.\u0026rdquo; \u0026ndash; A034\u003c/p\u003e \u003cp\u003e\u0026ldquo;Yeah down in our little office. So people are still taking the lids off and there\u0026rsquo;s a separate containers for lids.\u0026rdquo; \u0026ndash; A034\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think it\u0026rsquo;s interesting that what we need is more peer support and peer \u0026ndash; because I will catch people and say \u0026lsquo;no no, don\u0026rsquo;t do that.\u0026rsquo; I think we need to set up some system of peer support or education\u0026hellip;Train the trainers.\u0026rdquo; \u0026ndash; H303\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBeliefs about capabilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;at this point in time, I wouldn\u0026rsquo;t say that I\u0026rsquo;ve got enough knowledge to know what I could and couldn\u0026rsquo;t put in a bin.\u0026rdquo; \u0026ndash; P12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOpportunity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical Opportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnvironmental Context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLack of a bank account\u003c/p\u003e \u003cp\u003e\u0026ldquo;We used to take bottles home as well, some people, but not anymore, we\u0026rsquo;re not allowed to.\u0026rdquo; \u0026ndash; G07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical Opportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnvironmental Context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLack of recycling bins\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;which unfortunately, because we don\u0026rsquo;t have a recycling program, ends up with our general waste.\u0026rdquo; \u0026ndash; B17\u003c/p\u003e \u003cp\u003eOn the lack of a compost bin for food waste in the kitchen: \u0026ldquo;It broke, and I think it\u0026rsquo;s something to do with Queensland Health regulations that we can't get them anymore.\u0026rdquo; \u0026ndash; G07\u003c/p\u003e \u003cp\u003eOn bottles going in Containers for Change bins: \u0026ldquo;They used to, but not anymore.\u0026rdquo; \u0026ndash; G07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical Opportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnvironmental Context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eContainers for Change bins are full (post introduction of intervention)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I don\u0026rsquo;t know whose job it is to empty them so they just overflow, and then you think just put them in the bin. Sometimes people are just putting them back in the bin, because they\u0026rsquo;re all overflowing.\u0026rdquo; \u0026ndash; L033\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMotivation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMotivation to recycle\u003c/p\u003e \u003cp\u003e\u0026ldquo;Another thing that I would like to raise \u0026ndash; bring forward, is batteries. I also think most of them do end up in general waste as well\u0026hellip;which is horrible.\u0026rdquo; \u0026ndash; B17\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;recently we\u0026rsquo;ve had a few events and a few things that happened at the hospital and since then I\u0026rsquo;ve seen a lot of people show more interest towards recycling, towards wanting \u0026ndash; well, pretty much asking for recycling facilities... there are a lot of people that I can think of, that would be open to the idea of recycling appropriately.\u0026rdquo; \u0026ndash; B17\u003c/p\u003e \u003cp\u003e\u0026ldquo;We are most definitely in it like to help you guys.\u0026rdquo; \u0026ndash; G07\u003c/p\u003e \u003cp\u003e\u003cb\u003eOn using appropriate recycling bins if provided\u003c/b\u003e: \u0026ldquo;Absolutely, everybody would I think, yeah.\u0026rdquo; \u0026ndash; G17\u003c/p\u003e \u003cp\u003e\u0026ldquo;Yes.\u0026rdquo; \u0026ndash; G29\u003c/p\u003e \u003cp\u003e\u0026ldquo;Absolutely.\u0026rdquo; \u0026ndash; P12\u003c/p\u003e \u003cp\u003e\u0026ldquo;Yes.\u0026rdquo; \u0026ndash; P21\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think probably we don\u0026rsquo;t recycle enough.\u0026rdquo; \u0026ndash; G29\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;the team would be very happy to [receive appropriate recycling education], as long as they\u0026rsquo;re told what they can and can\u0026rsquo;t put in there.\u0026rdquo; \u0026ndash; P12\u003c/p\u003e \u003cp\u003e\u0026ldquo;I mean I'd love to have provision for recycling of cardboard and hard plastics\u0026hellip;\u0026rdquo; \u0026ndash; P21\u003c/p\u003e \u003cp\u003e\u0026ldquo;We\u0026rsquo;re all excited that it [the recycling intervention] is happening. I know we\u0026rsquo;ve been groaning for years.\u0026rdquo; \u0026ndash; L033\u003c/p\u003e \u003cp\u003e\u0026ldquo;It\u0026rsquo;s hugely great. Those containers are chokkers. To think that what we were doing \u0026ndash; just chucking them out because we weren\u0026rsquo;t allowed to recycle them.\u0026rdquo; \u0026ndash; M083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMotivation to recycle was high among hospital staff across several departments, particularly since this community was experiencing the impacts of climate change such as droughts and bushfires. However, participants reported that recycling was impeded by three main factors. Firstly, the hospital was unable to establish a Containers-for-Change (CFC) scheme collection as they did not have an appropriate bank account into which the reimbursement funds could be deposited. This scheme reimburses 10c for each plastic bottle recycled.\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e As the hospital only supplies water to patients and staff in plastic water bottles, this waste stream is significant and was previously being disposed of in general waste bins destined for landfill. Secondly, a lack of recycling bins at points of waste generation throughout the hospital was identified as a physical barrier. Thirdly, staff members\u0026rsquo; psychological capability to recycle was impeded by a lack of knowledge, as well as a lack of confidence around their knowledge, about what waste could be recycled. The first barrier was resolved through the efforts of the project\u0026rsquo;s sponsor who followed up continually with senior management until a bank account number was provided. The remaining two barriers were then mapped to the BCW\u0026thinsp;+\u0026thinsp;TDF framework (Supplementary File 2) to identify an evidence-based co-designed behaviour change intervention (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eThe barrier \u0026lsquo;lack of recycling bins\u0026rsquo; mapped to \u0026lsquo;Opportunity\u0026rsquo; (Physical Opportunity) of the COM-B model and the \u0026lsquo;Environmental Context and Resources\u0026rsquo; domain of the TDF. The TDF defines \u0026lsquo;Environmental Context and Resources\u0026rsquo; as those environmental circumstances which may facilitate or hinder skills development and adaptive behaviour.\u003csup\u003e\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e Therefore, \u0026lsquo;Physical Opportunity\u0026rsquo; may be achieved through interventions that focus on \u0026lsquo;Environmental Restructuring\u0026rsquo; and \u0026lsquo;Enablement\u0026rsquo;.\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e \u0026lsquo;Environmental Restructuring\u0026rsquo; interventions involve changing the physical context and \u0026lsquo;Enablement\u0026rsquo; refers to interventions which reduce barriers to increase opportunity.\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e Therefore the intervention required adding objects to the environment and providing prompts and cues to guide the behaviour change (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eWorkshop participants agreed that purchasing two types of recycling bins \u0026ndash; commingled recycling with yellow lids and CFC bins with green lids - which were clearly labelled with infographics of the waste types to put in them - would encourage recycling behaviours. Bins were also provided for battery waste (one of the participants converted one of these bins to one for electrical cable waste, again labelled with infographics). Laminated signs would also be provided to affix to the wall above the bins. Convenient location of bins at the point of waste segregation was highlighted in Workshop 1 discussions as necessary to achieve recycling. However, in Workshop 2 three of the nurse participants also raised the issue of space restrictions in some treatment rooms and nursing stations. Therefore, the location of the purchased bins was left to the hospital\u0026rsquo;s green champion to decide upon subject to discussions with nurses working in the various areas.\u003c/p\u003e \u003cp\u003eThe barrier \u0026lsquo;lack of knowledge about what waste can be recycled and in which bin\u0026rsquo; mapped to \u0026lsquo;Capability\u0026rsquo; (Psychological) of the COM-B model and to the \u0026lsquo;Knowledge\u0026rsquo; domain of the TDF. The TDF \u0026lsquo;Knowledge\u0026rsquo; domain encompasses the theoretical constructs of knowledge of condition or rationale, procedural knowledge, and knowledge of the task environment.\u003csup\u003e\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e The BCW links \u0026lsquo;Knowledge\u0026rsquo; with interventions that focus on \u0026lsquo;Education\u0026rsquo;, \u0026lsquo;Training\u0026rsquo; and \u0026lsquo;Enablement\u0026rsquo;. \u0026lsquo;Enablement\u0026rsquo; was enhanced through the provision of clearly labelled bins for the different recycling streams and signage. Workshop 2 participants all agreed that education and training were needed as a component of the intervention. Types of training that were canvassed included a webinar, a recorded training session to be uploaded to the hospital\u0026rsquo;s intranet, and onsite training in staff meetings. Various organisational barriers were identified to uploading recorded training materials to the hospital\u0026rsquo;s intranet and therefore it was decided that the research team would provide face-to-face training for the hospital\u0026rsquo;s green champions and operational services staff. Educating the operational services staff was identified as important because they would be ultimately responsible for collecting these bins. They therefore needed to be educated on the different recycling waste streams and their correct bins, and where the main collection bins for the different waste streams would be located. Training of the green champions would utilise a train-the-trainer approach so that the green champions could in turn train other staff in staff meetings and continue to run ongoing training sessions after the project concluded to ensure its continuance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eIntervention Description\u003c/h2\u003e \u003cp\u003eThe final co-designed intervention comprised placing commingled and CFC bins in identified work areas at points of recyclable waste generation. These bins comprised commingled recycling bins (grey with yellow lids) and two sizes of CFC bins to suit the work area\u0026rsquo;s requirements (larger grey bins with white lids which had the words 10c containers on them and small white containers with the CFC logo on the front). Laminated signs with clear infographics depicting types of waste which could be recycled in that waste bin were placed on walls directly above these bins. Education was provided to the green champions face-to-face using a \u0026lsquo;train-the-trainer\u0026rsquo; approach and they in turn educated colleagues in staff meetings. Written educational material was provided by the research team for inclusion in hospital-wide staff newsletters and emails. The research team sent follow-up emails and SMS messages to the hospital green champions to remind them to continue to spread the word about the recycling intervention.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePre- and Post-Intervention Waste Data\u003c/h2\u003e \u003cp\u003eWaste data were compared for the pre-intervention period June-August 2023 with the post-intervention period September-November 2023 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFinal Waste Data Collection\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral Waste\u003c/p\u003e \u003cp\u003e(tonnes)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommingled Waste (tonnes)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eContainers for Change waste (tonnes)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003etCO\u003csub\u003e2\u003c/sub\u003ee\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-Intervention: June-Aug 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-intervention: Oct -Dec 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*General waste stream: 1.6 tCO\u003csub\u003e2\u003c/sub\u003ee/t\u003csup\u003e66\u003c/sup\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eGeneral Waste\u003c/h2\u003e \u003cp\u003eThere was a reduction of 1.25t for this stream which not only reduced CO\u003csub\u003e2\u003c/sub\u003ee but also reduced waste collection fees.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCommingled Recycling Waste\u003c/h2\u003e \u003cp\u003ePrior to the intervention only kitchen staff had access to the hospital\u0026rsquo;s commingled recycling bins. Post-intervention, with the availability of more commingled recycling bins at points of waste generation there was an increase of 0.07t of commingled recyclable waste after the intervention.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eContainers-For-Change Scheme Waste\u003c/h2\u003e \u003cp\u003eOnce a bank account was allocated to the hospital to receive payment for recycling through this scheme, staff recycled 0.1042t of recyclable waste (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Approximately 3,000 plastic bottles and 866 aluminium cans were diverted from landfill. The total tCO\u003csub\u003e2\u003c/sub\u003ee saved by diverting this waste from landfill was 0.167t which equates to a saving of 1,140 km of car travel for an Australian sedan or light SUV.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eContainers for Change Data Post-Intervention (3-months)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWaste stream\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGlass\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAluminium\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePET \u0026ndash; Clear (polyethylene terephthalate)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePET \u0026ndash; Coloured (polyethylene terephthalate)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh-Density polyethylene\u003c/p\u003e \u003cp\u003e(HDPE)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTetra-paks\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotals\u003c/p\u003e \u003cp\u003e(tonnes)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Number\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e866\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,914\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Weight (tonnes)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.0087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.01212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0816\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.00048\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWeight unknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.1042\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003etCO\u003c/b\u003e\u003csub\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sub\u003e\u003cb\u003ee* saved by diverting from landfill\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.00077\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eunknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.167\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e*General waste stream: 1.6 tCO\u003csub\u003e2\u003c/sub\u003ee/t\u003csup\u003e66\u003c/sup\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eOverall Outcomes of Intervention\u003c/h2\u003e \u003cp\u003eIn a three-month period, this co-designed recycling intervention reduced CO\u003csub\u003e2\u003c/sub\u003ee by 2t (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). This equates to a reduction of 13,652 km of car travel in an Australian sedan or light SUV. Importantly, it also diverted approximately 3,000 plastic bottles and 866 aluminium cans from landfill.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis co-design workshop resulted in a multi-faceted recycling intervention designed by staff for staff. To strengthen the chance of the intervention\u0026rsquo;s success, its development was guided by researchers utilising an integrated BCW\u0026thinsp;+\u0026thinsp;TDF theoretical framework. This framework has been developed to overcome the limitations of the many behavioural change theories and theoretical constructs upon which it is based. It also incorporates context.\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e Context is extremely important when the behaviour in question is a pro-environmental behaviour such as recycling. Literature shows that people tend to recycle less at work compared with at home due to infrastructural and other organisational barriers.\u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u003c/sup\u003e As with the recycling intervention developed by Gainforth \u003cem\u003eet al\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e which integrated the BCW and the TDF framework, behavioural analysis of participants\u0026rsquo; comments in this study identified that most were motivated to recycle; however, lack of \u0026lsquo;physical opportunity\u0026rsquo; had a negative influence on motivation. Since the co-design workshop participants in this study were members of the hospital\u0026rsquo;s green champions team, it was expected that their motivation to recycle would be high and potentially higher than other members of staff. The integrated BCW\u0026thinsp;+\u0026thinsp;TDF framework\u0026rsquo;s suggested interventions linked to \u0026lsquo;Motivation\u0026rsquo; include \u0026lsquo;incentivisation\u0026rsquo;, \u0026lsquo;persuasion\u0026rsquo; and \u0026lsquo;coercion\u0026rsquo;.\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e Behavioural analysis in both studies also identified that poor engagement with recycling behaviour was linked to a lack of \u0026lsquo;psychological capability\u0026rsquo; to recycle in their workplace contexts. Therefore, it was decided to frame the intervention in this study around the sources of behaviour \u0026lsquo;physical opportunity\u0026rsquo; and \u0026lsquo;psychological capability\u0026rsquo;. However, to address \u0026lsquo;motivation\u0026rsquo; some \u0026lsquo;incentivisation\u0026rsquo; was provided by offering hospital staff a say in what the money raised from the Containers-for-Change programme would be spent on.\u003c/p\u003e \u003cp\u003eAn important difference between this study and the study conducted by Gainforth \u003cem\u003eet al\u003c/em\u003e,\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e is that our study included staff who would be undertaking the recycling intervention in its co-design. We believe this combination of co-design with an evidence-based theoretical framework to inform the intervention design is the true strength of this study. Staff were able to describe barriers to recycling which the research team would never have been aware of e.g., lack of access to a bank account. Logistics of bin collections in the hospital (who would collect bins from where and when) and bin locations was also an area where the research team relied on the corporate knowledge of staff to inform the intervention design.\u003c/p\u003e \u003cp\u003eA limitation of the study was the small number of participants in the co-design workshops. The hospital site for this research project is a small 20-bed facility and the number of participants was limited by staff shortages at this time due to a COVID-19 outbreak at the hospital as well as the usual ongoing chronic staff shortages experienced by rural hospitals.\u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e However, despite the small number of participants, the workshops generated enthusiastic, lively discussion with the outcome being a robust, fit-for-purpose, recycling intervention.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrated that combining co-design with an evidence-based theoretical framework (BCW\u0026thinsp;+\u0026thinsp;TDF) to inform a behavioural intervention was successful in bringing about behaviour change (recycling) \u0026ndash; at least over the three-month post-intervention data collection period.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics Approval and Consent to Participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Darling Downs Health and Hospital Service HREC (LNR/2023/QTDD/95112) and administrative ethical approval from Queensland University of Technology (QUT Approval No. 7206).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and material\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interview transcripts and analyses are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare there are no competing interests to report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research study was funded by Queensland University of Technology through the Charles Selby Endowment Fund.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors' contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAL contributed to the research design, co-facilitated the co-design workshops with JS, collected, analysed, and interpreted the data with JS, and was a major contributor to writing and revising the manuscript. KN contributed to the conception of the project, data collection, and contributed to manuscript revision. DH contributed to data collection and manuscript revision. JS conceived the project and was the recipient of the grant funding to support it, and made substantial contributions to research design, data collection, data analysis and interpretation, contributed to drafts of manuscript and undertook the final revision of manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team acknowledges with grateful thanks the support of the Darling Downs Hospital and Health Service and the many hospital staff who helped in various ways with this project, in particular Ms Vanessa Rolph and Mr. Manroop Singh.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eThakur V, Mangla SK and Tiwari B. 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The practice of rural and remote nurses in Australia: A case study. \u003cem\u003eJournal of Clinical Nursing\u003c/em\u003e 2022; 31: 1502-1518.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hospitals, rural, Co-design, healthcare waste, recycling, carbon, Behaviour Change Wheel (BCW), Theoretical Domains Framework (TDF)","lastPublishedDoi":"10.21203/rs.3.rs-4392610/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4392610/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHealthcare waste is growing annually at a rate of 2\u0026ndash;3% globally with negative implications for environmental and population health. Improving recycling of non-contaminated healthcare waste can reduce carbon emissions and landfill use with consequent financial and health co-benefits. This paper reports the development of a co-designed behavioural change recycling intervention in a small, rural hospital in Queensland, Australia. The aim was to reduce the amount of potentially recyclable or reusable non-contaminated waste currently ending up in landfill.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study utilised co-design to develop a behavioural change intervention informed by an evidence-based, theoretical framework \u0026ndash; the integrated Behaviour Change Wheel (BCW) and Theoretical Domains Framework (TDF). This study was undertaken in a 20-bed rural Queensland Health hospital and included hospital staff in the co-design of a recycling intervention. The waste streams chosen were commingled recycling stream and waste accepted by the Containers-for-Change recycling scheme. Two co-design workshops were held onsite at the hospital on 2nd June (n\u0026thinsp;=\u0026thinsp;8) and 3rd August 2023 (n\u0026thinsp;=\u0026thinsp;6) followed by a visit to the hospital on 31st August 2023 to implement the recycling intervention. Final data collection was undertaken at the end of November 2023.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe co-designed intervention comprised placing commingled bins (grey with yellow lids) and CFC bins (grey with white lids) at points of recyclable waste generation with signage and \u0026lsquo;train-the-trainer\u0026rsquo; education sessions with the green champions. Over the 3-month post-intervention data collection period there was a reduction of 1.25t for the general waste stream, 0.1042t of recyclable waste was recycled through the newly introduced CFC scheme, and an increase of 0.07t of commingled recyclable waste after the intervention. In summary, across a three-month period, this co-designed recycling intervention reduced CO\u003csub\u003e2\u003c/sub\u003ee by 2t. This equates to a reduction of 13,652 km of car travel in an Australian sedan or light SUV. Importantly, it also diverted approximately 3,000 plastic bottles and 866 aluminium cans from landfill.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e Despite the small number of participants in the two co-design workshops, combining co-design with an evidence-based theoretical framework (BCW\u0026thinsp;+\u0026thinsp;TDF) produced a robust, fit-for-purpose, recycling intervention that led to behaviour change (recycling).\u003c/p\u003e","manuscriptTitle":"Using the Behaviour Change Wheel and Theoretical Domains Framework in the Co-Design of a Recycling Intervention Implemented in a Rural Australian Public Hospital","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-06 16:06:27","doi":"10.21203/rs.3.rs-4392610/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a85df07b-c0bd-4be7-a042-992a559f4722","owner":[],"postedDate":"June 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-13T17:08:24+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-06 16:06:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4392610","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4392610","identity":"rs-4392610","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}