Lifecycle of surgical devices: Global, environmental, and regulatory considerations.

BACKGROUND: Technological advancements, improved surgical access, and heightened demand for surgery have fueled unprecedented device and supply turnover impelling wealthy hospitals to upgrade continually and sell, donate, recycle, or dispose of used, expired, antiquated, or surplus goods. This paper reviews the issues related to device and supply lifecycles and discusses the opportunities and challenges they present for sustainable surgical growth in low- and middle-income (LMICs) countries. OBSERVATIONS: This review found, in LMICs countries, regulatory disparities persist that limit effective harmonization secondary to highly variable national policies and a lack of prioritized enforcement. Heterogeneity in the regulatory landscape, specifically in the classification, nomenclature, and identification of medical devices, encumbers effective regulation and distribution. Once devices are sold, donated, or reused in LMICs countries, complexities arise in regulatory compliance, maintenance, and appropriate use of these technologies. At the end of the lifecycle, waste management poses significant obstacles with limited resources hindering the implementation of best practices. CONCLUSION: There are major disparities in access to quality surgical equipment and supplies around the world. Improved communication between relevant stakeholders and harmonization of manufacture and disposal regulations will be needed to ensure adequate and appropriate responses to these challenges. TRIAL REGISTRATION NUMBER: Not applicable.

Sustainable waste management solutions for the foodservice industry: A Delphi study.

Foodservice businesses influence the sustainability of their natural environment by producing significant amounts of waste. Yet, research has, thus far, been dominated by studies that limit their scope to food waste alone. Few studies have taken a broader look at sustainable waste initiatives, including innovative waste processing techniques, with a view to constructing management indicators for foodservices. This study combines management innovation practices related to resource management, waste prevention, processing and disposal techniques, and stakeholder involvement to offer sustainable standards. It primarily adopts the Delphi technique to propose specific solutions pertaining to waste management. Experts from government, industry, and academia reveal that potential waste management initiatives comprise three facets - service, process (operational), and organisational practices and innovations, 15 sub-facets and 41 indicators. This study thus establishes a catalogue of solutions for food, packaging and other 'non-food' waste that foodservice establishments can implement. In addition to its practical implications, an important contribution is its focus on management systems to establish waste management standards for hospitality, food and beverage (F&B) services, restaurants, and non-commercial catering.

Determinants of Unsafe Plastic Waste Disposal among Households in the Tamale Metropolitan Area, Ghana.

Background: The global discourse on plastic waste generation and disposal has over the last two decades, gained traction with the aid of research-based evidence. Though observed globally, the situation is quickly deteriorating in developing countries such as Ghana. In Ghana and Africa as a whole, rapidly increasing population and rural to urban migration have been cited as factors that exacerbate the existing struggles with plastic pollution. This study aimed at identifying the determinants of unsafe plastic waste disposal among households. Methods: The study was carried out in three communities in Tamale in the Northern Region of Ghana. Data were collected from 270 randomly selected households through household surveys, key informant interviews, and direct field observations. Results: The study revealed that the majority (63.3%) of the total respondents used and disposed of their plastic waste "unsafely." The analysis showed that the education level and household wealth were significant determinants of unsafe plastic disposal. Conclusion: The study concludes that challenges of plastic waste management are not limited to economic, technical, and institutional factors, but social factors such as human behavior are key aspects of waste management that need attention. The study, therefore, recommends strict enforcement of sanitation by-laws, promotion of education, and provision of alternatives to plastics that will minimize the need for importing and manufacturing plastics, as potential steps towards addressing unsafe disposal of plastics in the domestic environment.

The role of Environmental Health in preventing antimicrobial resistance in low- and middle-income countries.

Antimicrobial resistance (AMR) is increasingly becoming a threat to global public health, not least in low- and middle-income countries (LMICs) where it is contributing to longer treatment for illnesses, use of higher generation drugs, more expenditure on antimicrobials, and increased deaths attributed to what should be treatable diseases. Some of the known causes of AMR include misuse and overuse of antimicrobials in both humans and animals, unnecessary use of antimicrobials in animals as growth promoters, and lack of awareness among the public on how to protect antimicrobials. As a result, resistant organisms are circulating in the wider environment, and there is a need to consider the One Health approach to minimise the continuing development of AMR. Environmental Health, specifically water, sanitation and hygiene (WASH), waste management, and food hygiene and safety, are key components of One Health needed to prevent the spread of antimicrobial-resistant microorganisms particularly in LMICs and reduce the AMR threat to global public health. The key Environmental Health practices in the prevention of AMR include: (1) adequate WASH through access and consumption of safe water; suitable containment, treatment and disposal of human excreta and other wastewater including from health facilities; good personal hygiene practices such as washing hands with soap at critical times to prevent the spread of resistant microorganisms, and contraction of illnesses which may require antimicrobial treatment; (2) proper disposal of solid waste, including the disposal of unused and expired antimicrobials to prevent their unnecessary exposure to microorganisms in the environment; and (3) ensuring proper food hygiene and safety practices, such as sale and consumption of animal products in which adequate antimicrobial withdrawal periods have been observed, and growing vegetables on unpolluted soil. Environmental Health is therefore crucial in the prevention of infectious diseases that would require antimicrobials, reducing the spread of resistant organisms, and exposure to antimicrobial residues in LMICs. Working with other professionals in One Health, Environmental Health Practitioners have a key role in reducing the spread of AMR including health education and promotion, surveillance, enforcement of legislation, and research.

Ambiência - Manuseio de resíduos e material de descarte em Bancos de Leite Humano e Postos de Coleta de Leite Humano / Ambientación - Manejo de residuos y material de descarte en Bancos de Leche Humana y Centros de Recolección de Leche Humana / Ambience - Handling of waste and disposal material in Human Milk Banks and Human Milk Collection Stations

Esta Norma Técnica tem por objetivo estabelecer as medidas para manipulação de resíduos e materiais de descarte em Bancos de Leite Humano e Postos de Coleta de Leite Humano, visando a garantia da qualidade nestes serviços e sua certificação.

Esta Norma Técnica tiene por objetivo establecer las medidas para el manejo de residuos y materiales de descarte en los Bancos de Leche Humana y Centros de Recolección de Leche Humana, con el fin de asegurar la calidad de estos servicios y su certificación.

Initiatives to broaden safety concerns in anaesthetic practice: The green operating room.

The health sector is a major contributor to climate change through its large carbon footprint. Hospitals are highly energy and resource intensive. Operating rooms (ORs) contribute to a major part of these emissions because of anaesthetic gases, energy-intensive equipment and waste. Besides initiatives aimed to mitigate hospitals' climate footprints, health care professionals need to be involved in this process by changing their professional and personal behaviours without compromising the quality of care. Education on metrics (greenhouse gases), concepts (life cycle) and strategies to reduce the health care footprint would help professionals to commit themselves to the issue. The 5R's rule (reduce, reuse, recycle, rethink and research) used to promote an environmentally friendly way of life can be applied to the medical field and especially to the operating room and anaesthesia. When applied in the ORs, these strategies help question the use of disposable devices, attires and packaging, as well as our professional and personal behaviour. Greening the ORs requires the engagement of all professionals as well as other departments (pharmacy, hygiene) and management. Economic and social co-benefits are expected from this process.

The role of Environmental Health in preventing antimicrobial resistance in low- and middle-income countries

Antimicrobial resistance (AMR) is increasingly becoming a threat to global public health, not least in low- and middle-income countries (LMICs) where it is contributing to longer treatment for illnesses, use of higher generation drugs, more expenditure on antimicrobials, and increased deaths attributed to what should be treatable diseases. Some of the known causes of AMR include misuse and overuse of antimicrobials in both humans and animals, unnecessary use of antimicrobials in animals as growth promoters, and lack of awareness among the public on how to protect antimicrobials. As a result, resistant organisms are circulating in the wider environment, and there is a need to consider the One Health approach to minimise the continuing development of AMR. Environmental Health, specifically water, sanitation and hygiene (WASH), waste management, and food hygiene and safety, are key components of One Health needed to prevent the spread of antimicrobial-resistant microorganisms particularly in LMICs and reduce the AMR threat to global public health. The key Environmental Health practices in the prevention of AMR include: (1) adequate WASH through access and consumption of safe water; suitable containment, treatment and disposal of human excreta and other wastewater including from health facilities; good personal hygiene practices such as washing hands with soap at critical times to prevent the spread of resistant microorganisms, and contraction of illnesses which may require antimicrobial treatment; (2) proper disposal of solid waste, including the disposal of unused and expired antimicrobials to prevent their unnecessary exposure to microorganisms in the environment; and (3) ensuring proper food hygiene and safety practices, such as sale and consumption of animal products in which adequate antimicrobial withdrawal periods have been observed, and growing vegetables on unpolluted soil. Environmental Health is therefore crucial in the prevention of infectious diseases that would require antimicrobials, reducing the spread of resistant organisms, and exposure to antimicrobial residues in LMICs. Working with other professionals in One Health, Environmental Health Practitioners have a key role in reducing the spread of AMR including health education and promotion, surveillance, enforcement of legislation, and research.

Perceived risk and associated factors of healthcare waste in selected hospitals of Kathmandu, Nepal.

BACKGROUND: Healthcare waste management is the subject of a neglected issue in many developing countries. Health care facilities are facing a major challenge in handling healthcare wastes and reducing their potential risks to human health and the environment. Insufficient understanding of the risk associated with healthcare waste by health workforce can contribute to poor waste management practices. The main aim of this study is to assess risk perception towards healthcare waste among hospital attendants and to identify associated factors. METHODOLOGY: We carried out a cross-sectional hospital-based study among 120 attendants of a private and public hospital in Kathmandu, Nepal. We used two-stage random sampling for the selection of hospital and participants. We conducted a face-to-face interview with the participants using semi-structured questionnaires. Based on the mean score, we classified risk perception as good and poor. Bivariate and multivariate analysis was carried out to determine associates of risk perception towards healthcare waste. RESULTS: Approximately 51.0% of hospital attendants had poor risk perception of healthcare waste. Nearly half of the participants (49.2%) had inadequate knowledge and 43.0% had a negative attitude. Factors such as healthcare waste management training (p = 0.028), housekeeping department (p = 0.036) and attitude (p = 0.001) were associated with risk perception of healthcare waste. CONCLUSION: Hospital attendants had a poor understanding of risk perception of healthcare waste. Periodic training on healthcare waste management and edification on the risk associated with healthcare waste is essential to boost awareness among all healthcare workers. Communication on behavioral improvements for appropriate waste management must be prioritized to change the perception of health workers.

Greenhouse gas, water, and land footprint per unit of production of the California dairy industry over 50 years.

Food production including dairy has been associated with environmental impacts and resource use that has been steadily improving when adjusted per unit of product. The objective of this study was to conduct a cradle-to-farm gate environmental impact analysis and resource inventory of the California dairy production system to estimate the change in greenhouse gas emissions and water and land use over the 50-yr period between 1964 and 2014. Using a life cycle assessment according to international standards and the Food and Agriculture Organization of the United Nations guidelines, we analyzed contributions from dairy production in California to global environmental change. Production of 1 kg of energy- and protein-corrected milk (ECM) in California emitted 1.12 to 1.16 kg of CO2 equivalents (CO2e) in 2014 compared with 2.11 kg of CO2e in 1964, a reduction of 45.0 to 46.9% over the last 50 yr, depending on the model used. Greater reductions in enteric methane intensity (i.e., methane production per kilogram of ECM) were observed (reduction of 54.1 to 55.7%) compared with manure GHG (reduction of 8.73 to 11.9%) in 2014 compared with 1964. This was mainly because manure management in the state relies on lagoons for storage, which has a greater methane conversion factor than solid manure storage. Water use intensity was reduced by 88.1 to 89.9%, with water reductions of 88.7 to 90.5% in crop production, 55.3 to 59.2% in housing and milking, and 52.4 to 54% in free water intake. Improved crop genetics and management have contributed to large efficiencies in water utilization. Land requirements for crop production were reduced by 89.4 to 89.7% in 2014 compared with 1964. This was mainly due to dramatic increases in crop yields in the last 50 yr. The increases in milk production per cow through genetic improvements and better nutrition and animal care have contributed to reductions in greenhouse gas emissions and land and water usage when calculated per unit of production (intensity) basis.

City to city learning and knowledge exchange for climate resilience in southern Africa.

Southern African cities face several challenges including management of rapid urbanization, rising populations, expanding informal settlements; adequate water and other service provision, and a host of governance challenges. Climate change and variability add a compounding effect to this complex, multi stressor context. Addressing the complexity requires an understanding of urban ecosystems functioning and interactions amongst the built and natural environment (climate) and human systems. In this paper we argue that learning is essential for cities to be resilient to current and future challenges. We profile the Future Resilience for African CiTies And Lands (FRACTAL) project which contributed towards climate resilient development by providing relevant climate information for decision-making at the city regional scale in southern Africa. Following FRACTAL's city-to-city learning approach of sharing good practices, knowledge and experiences framed around transdisciplinary research, the study cities of Harare, Lusaka, Windhoek and Durban conducted city learning exchange visits between 2017 and 2018. We used a mixed methods approach to collect and analyze historical climate and hydrological data and current socio-economic and development data among the cities. A qualitative, in-depth, case study comparative analysis was used to identify similarities and differences as well as lessons drawn from the learning process during the city exchanges and these were complimented by desktop studies. Results showed water scarcity, large informal settlements, reliance on external water and energy sources, inadequate protection of ecologically sensitive resources and service provision as some of the common complications in the cities. Several lessons and transferable practices learnt from the cities included effective water conservation and waste management and the use of public-private partnerships in Windhoek, community engagements in Durban and Lusaka while lessons on decisive leadership in dealing with informal settlements emanated from Harare's limited informal settlements. Lastly, Durban's Adaptation Charter and integrated climate planning provided lessons for biodiversity protection and mainstreaming climate change at city governance level. While we recognize that cities are context-specific we consider these good practices as being broadly transferable to other southern African cities. We conclude that social, experiential and structured learning can be an innovative way of multi-stakeholder engagement and a useful approach to increase city resilience planning across southern Africa and cities that face similar developmental challenges.

Identifying and Prioritizing Effective Factors on Outsourcing in Public Hospitals Using Fuzzy BWM.

The outsourcing of health services has gained prominence over the past decades. Because numerous factors affect outsourcing in the field of health services, identifying and prioritizing these factors is specifically important. This study sought to identify and prioritize the factors affecting outsourcing, and to propose a model for the effective outsourcing of hospital services in Shiraz, Iran. The study drew on an exploratory mixed research method. In the first stage, all the criteria affecting the outsourcing of activities in hospitals were identified through the theoretical framework, a literature review, and interviews with hospital experts. Next, the criteria were finalized and prioritized using the fuzzy best-worst method (BWM). Following the literature review, 34 criteria for outsourcing were identified based on the studies explored and the interviews with the experts; the criteria were categorized into seven dimensions including "strategy", "management", "economy", "quality", "security and keeping patients' records", "service", and "agility." These dimensions formed the final outsourcing model of hospitals in Shiraz. Finally, the fuzzy BWM analysis revealed that "security and keeping patient's records" had the highest priority in outsourcing-related decision-making. The findings can help hospital managers make the right decision concerning the outsourcing of hospital services. The dimensions found in this research might also have been identified in other models, although this study was different in that it concentrated on the criteria in the specialized area of hospital management, while identifying the importance and weights of all the criteria involved.

Adherence to safety practices and risks associated with health care waste management at an academic hospital, Pretoria, South Africa.

BACKGROUND: Adequate knowledge on hazards of healthcare waste and proper handling methods can result in its safe disposal and protection of workers and communities. The study assessed perceptions of healthcare workers on the adherence and risks associated with the practices of healthcare waste management. METHODS: A total of 126 questionnaires were administered in selected wards at an academic hospital to establish training and knowledge on legislations regarding healthcare waste and health hazards associated with such waste. RESULTS: Sixty nine percent (69.0%) of participants had received training on healthcare waste handling. The highest number of cleaning staff (85.7%) received training from work while 34.8% of the doctors also received training from work. Only 44.1% of the nurses had knowledge about policies on healthcare waste. The majority of the participants (82.0%) had knowledge on the risks associated with handling of healthcare waste. However, only 20.0% of the participants re-capped needles after use and of these 43.5% were doctors. Most of the nurses (64.0%) had been exposed to needle pricks. CONCLUSION: Even though 82.0% of the participants believed there were enough management practices enforced with regards to the healthcare waste, it was recommended that there should be more education on the handling of healthcare waste.

A Scientometric Review of Resource Recycling Industry.

With rapid economic development and urbanization, a large number of primary resources are consumed and accumulate in society as recyclable resource, which causes great pressure on the environment. The development of the resource recycling industry (RRI) can reduce environmental impacts and achieve sustainable development and green growth. Scholars are paying more attention to the resource recycling industry (RRI), and the related literature continues to increase. There are over 7041 publications covering RRI in the Web of Science database from 1996 to 2018. This paper analyzes the time distribution characteristics of the literature and the status of the scientific research cooperation network using the visualization analysis software CiteSpace. The number of documents increased from 94 in 1996 to a peak of 963 in 2018. There is no relatively stable core author group. The number of papers published by "Chinese Acad Sci" ranks first among all research institutions. Document co-citation analysis and burst detection are adopted to assess the status and emerging trends in the RRI research domain. A publication by M.C. Monte on waste management is the most cited paper. Additionally, "green and sustainable and technology" and "science and technology-other topics" are the latest emerging subject categories in RRI research. Furthermore, "e-waste", "reverse logistics" and "lean manufacturing" are emerging research trends for RRI, and "carbon emissions", "policy", "demolition waste", "supply chain management" and "compressive strength" have become hot topics. These findings may provide inspiration for scholars to search for new research directions and ideas.

Influencing factors behind inappropriate solid waste management of small clinics in a resource-constrained country.

Appropriate clinical waste management is a critical concern in today's era. Resource-constrained countries agonize greatly over this issue in order to mitigate inappropriate clinical waste management practices. The goal of this study is to assess factors behind inappropriate waste management of small clinics in resource-constrained countries. We tested the hypothesis that negligence of government, knowledge and awareness, and financial burden are three key factors behind inappropriate solid waste management of small clinics. A two-phase survey including a pilot study and a main study was conducted for exploratory factor analysis and confirmatory factor analysis, respectively, in the fourth largest city of Pakistan, i.e., Hyderabad. One sample t test was used to validate the hypothesis, the correlation between the three key factors, and the location of the clinics were established. These factors were found to have a contribution to inappropriate waste management of small clinics. The hypothesis was then validated, and all three factors were found to have no significant variation in responses with the contrast of three types of clinic locations, namely, low-, medium-, and high-income areas. Responses were almost identical and bear equal significance from all locations, the financial burden factor is at the highest, the second factor is the negligence of government, and the third factor is that of knowledge and awareness. This study highlights the factors that are usually neglected and can help to improve solid waste management of small clinics in resource-constrained countries.

Assessment of status of solid waste management in Asella town, Ethiopia.

BACKGROUND: Improper solid waste management (SWM) is a major public health and environmental concern in the urban areas of many developing countries such as Asella Town. The aim of this study was to assess the status of SWM in Asella town. METHODS: A community-based cross-sectional study design was used to assess the status of improper SWM and associated factors in Asella town. From the total of eight kebeles (smallest administrative unit in Ethiopia) four kebeles were randomly selected using lottery method. The sample size was 413 households. The households were proportionally allocated to each randomly selected kebeles. The data was collected by pretested questionnaire in the local language. Data was entered using statistical software Epi Info version seven and transferred to SPSS version 21. Descriptive data analysis was done to summarize the socioeconomic status of the respondents. Chi-square was used to show the association between the status of solid waste management and different variables. Binary logistic regression was used to determine the potential factors for improper SWM. RESULT: 332 (82.8%), had improper solid waste management practice. Lack of adequate knowledge about solid waste management and not having access to door to door solid waste collection could have contributed to the reported improper solid waste practice. Participants who didn't have access to door to door solid waste collection service were about three times more likely to practice improper solid waste management when compared to those who had access (AOR = 2.873, 95 CI (1.565,5.273) P = 0.001). CONCLUSION: The study finding showed that, the majority of the residents practiced improper solid waste management. Lack of adequate knowledge about solid waste management and not having access to door to door solid waste collection could have contributed to the reported improper solid waste practice. Therefore, there is a need to enhance the awareness of the community about proper SWM and to improve the door to door solid waste collection service by the town municipality.

Efficiency of Health Care Risk Waste Management in Rural Healthcare Facilities of South Africa: An Assessment of Selected Facilities in Vhembe District, Limpopo Province.

Waste generated form healthcare facilities is a potential source of health risks to the public, if it is not properly handled from the point of generation to disposal. This study was conducted to assess the efficiency of healthcare risk waste (HCRW) management in Vhembe District of Limpopo Province, South Africa. Fifteen healthcare facilities were selected in Vhembe District for this study. Data were obtained through in-depth interviews, semi-structured questionnaires, observation and pictures. Qualitative data were thematically analyzed, while the quantitative data were analyzed using the Statistical Package for the Social Sciences, version 25. In all the healthcare facilities; mismanagement of HCRW was noted at different points along the management chain. Poor segregation, overfilling of waste bins, inappropriate transportation and storage of waste in substandard storage rooms were observed in the facilities. All the waste from the district are transported to a private-owned treatment facility outside the district, where they are mainly incinerated. Enforcement of healthcare risk waste guidelines, provision of standardized equipment for temporary storage, empowerment of each healthcare facility to treat at least some of the waste, and employment of non-burn techniques for treatment of waste are recommended for more efficient management of healthcare risk waste in Vhembe District.

Agent-Based Modelling for Simulation-Based Design of Sustainable Faecal Sludge Management Systems.

Re-using faecal sludge (FS) to generate value has the potential to contribute towards solving the issue of long term sanitation solutions in growing urban areas across sub-Saharan Africa; however, hitherto, no design tools have been available that are capable of simulating a system involving economic factors, complex social issues and environmental circumstances. We hypothesized that Agent-Based Modelling (ABM), when deployed with appropriate rigour, can provide such a tool. Extensive field work was carried out in a Malawian city, investigating the adoption of Skyloo above-ground composting toilets by households, and the operation of the municipal FS site. 65 semi-structured interviews and 148 household interviews, together with observations, were carried out to characterize these processes, with the data acquired being used to construct two separate ABMs. The Skyloo ABM was run for various scenarios of start-up capital for business and payback of loans against the toilet cost to households. The municipal FS Site ABM was run for different patterns of dumping fee and enforcement structure. The field work demonstrated that there is potential for further expansion of FS reuse, with a market for agricultural application. The Skyloo ABM identified the significance of start-up capital for a business installing the toilet technology; the municipal FS Site ABM showed that existing fees, fines and regulatory structure were insufficient to reduce illegal dumping of FS to any useful degree, but that a monthly permit system would provide enhanced revenue to the city council compared with per-visit charging of disposal companies at the municipal FS site. Whilst each ABM ideally requires some additional data before full application, we have, for the first time, shown that ABM provides a basis for the simulation-based design of FS management systems, including complex social, economic and environmental factors.

Health care waste management among health workers and associated factors in primary health care facilities in Kampala City, Uganda: a cross-sectional study.

BACKGROUND: Healthcare wastes (HCWs) are one of the most hazardous wastes globally; second to only radiation waste. HCW management needs to be prioritized because of the devastating effects on human health and environment if not well managed. Health workers play a crucial role in management of HCWs. This study investigated the management of HCWs among health workers and associated factors in primary health care facilities in Kampala City, Uganda. METHODS: We conducted a cross-sectional health facility survey in 8 primary health care facilities in Kampala City from March to April 2017. We interviewed health workers who provided data on socio-demographic characteristics, knowledge, attitudes and practices on HCW management. Prevalence ratios (PRs) and their corresponding 95% confidence intervals were used as a measure of association between HCW management and associated factors. The PRs were obtained using a multivariable modified Poisson regression using a generalized linear model of Poisson family with a logarithm as the canonical link function, with robust standard errors while applying a forward elimination method. RESULTS: A total of 200 health workers responded to the survey; Knowledge of HCW management  was high 143 (71.5%, 95% CI (65.2-77.8)). About 160 (80.0%) wore appropriate personal protective wear when handling HCWs. Overall, 148 (74.0%, 95% CI (67.8-80.1) had satisfactory HCW management practices. Health workers with diploma education (Adjusted PR = 1.49, 95% CI (1.13-1.96), working in the teenage corner (Adjusted PR = 1.10, 95% CI (1.01-1.29), previous training on HCW management (Adjusted PR = 1.19, 95% CI (1.01-1.42) and those who thought HCW management was important (Adjusted PR = 2.81, 95% CI (1.22-6.47) were more likely to have satisfactory HCW management practices. CONCLUSION: The practices of health workers on HCW management were largely satisfactory. Higher odds of HCW management were determined among health workers with diploma education, previous HCW management trainings and among those who perceived HCW management as important. There is need to organize HCW management trainings in order to improve their HCW management practices among health workers.

Environmental assessment in health care organizations.

The aim of this research is to design a multi-criteria model for environmental assessment of health care organizations. This is a model which guarantees the objectivity of the results obtained, is easy to apply, and incorporates a series of criteria, and their corresponding descriptors, relevant to the internal environmental auditing processes of the hospital. Furthermore, judgments were given by three experts from the areas of health, the environment, and multi-criteria decision techniques. From the values assigned, geometric means were calculated, giving weightings for the criteria of the model. This innovative model is intended for application within a continuous improvement process. A practical case from a Spanish hospital is included at the end. Information contained in the sustainability report provided the data needed to apply the model. The example contains all the criteria previously defined in the model. The results obtained show that the best-satisfied criteria are those related to energy consumption, generation of hazardous waste, legal matters, environmental sensitivity of staff, patients and others, and the environmental management of suppliers. On the other hand, those areas returning poor results are control of atmospheric emissions, increase in consumption of renewable energies, and the logistics of waste produced. It is recommended that steps be taken to correct these deficiencies, thus leading to an acceptable increase in the sustainability of the hospital.

Litter impacts on beach/dune systems along the Atlantico Department, the Caribbean Coastline of Colombia.

Eight beach/dune systems located along the Atlantico Department, Caribbean coast of Colombia were surveyed to determine litter influences over its scenic quality. Application of the Coastal Scenic Evaluation System (CSES) categorized these systems into two of the five available classes. Five of the investigated beach/dune systems belong to Class IV, while three systems correspond to V. Classes I, II and III were not found. Along these beach/dune systems, a total amount of 1908 litter items were collected with average abundances of 4.2 items/m2. Currently, 82% of surveyed sites are under an unacceptable condition of cleanness. User's habits as well as bad litter management practices are directly responsible for the decline of scenic quality of the Atlantico Department beach/dune systems. Litter management must be centered on strategies to eliminate or minimize litter sources. Specific remedial actions need to be defined and developed.