Mar 10, 2026
Version 2
Eco-responsible practices in adult diabetes care: a scoping review protocol V.2
- Marie Michelle Milord1,2,
- Jonathan Bichon2,
- Nathalie Clavel1,2,
- Jonathan Bichon3
- 1School of Public Health, Université de Montréal (ESPUM), Montréal, Québec, Canada;
- 2CHUM Research Centre, Montréal, Québec, Canada;
- 3Centre de recherche du CHUM
Protocol Citation: Marie Michelle Milord, Jonathan Bichon, Nathalie Clavel, Jonathan Bichon 2026. Eco-responsible practices in adult diabetes care: a scoping review protocol. protocols.io https://dx.doi.org/10.17504/protocols.io.x54v9bz9ql3e/v2Version created by Marie Michelle Milord
License: This is an open access protocol distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Protocol status: Working
We use this protocol and it's working
Created: March 02, 2026
Last Modified: March 10, 2026
Protocol Integer ID: 244266
Keywords: diabetes, self-management, environmental sustainability, eco-responsible care, healthcare waste, sharps, safety, costs, scoping review, healthcare waste, waste management in healthcare setting, medical waste management report, medical waste, waste generation, waste management, estimates of waste generation, carbon footprint of personal protective equipment, environmental footprint, waste reduction strategy, syntheses on medical waste management report, tonnes of waste, substantial volumes of waste, carbon footprint, hierarchy of waste reduction strategy, environmental sustainability, public health agency of canada, responsible practices in diabetes, reducing environmental harm, sustainable logistic, disposal system, plastic, waste, diabetes care, hospitals in canada, responsible practices in adult diabetes, impacts on the environment, climate degradation, based medical supply, major public health challenge, substantial material production, national greenhouse gas emission, public health agency, recycle, environmental
Disclaimer
This protocol represents the methodological plan for a scoping review conducted as part of a graduate research project. The content reflects the authors’ work and does not necessarily represent the views of affiliated institutions.
Abstract
Background : Climate degradation represents a major public health challenge and places health systems under ethical and organizational pressure: to provide care while reducing environmental harm. In Canada, an analysis of the health system’s environmental footprint estimated that health care was responsible for approximately 33 MtCO2e, or 4.6% of national greenhouse gas emissions, underscoring the magnitude of this challenge for health organizations (Pichler et al., 2019). This footprint is also associated with substantial material production: hospitals in Canada generate approximately 200,000 to 300,000 tonnes of waste annually, representing about 0.8% of the waste disposed of nationwide, based on estimates of waste generation ranging from 6 to 8.2 kg per bed per day (Shi et al., 2024). A notable share of these flows includes plastic materials: syntheses on medical waste management report that plastics can account for approximately 35% of medical waste, which reinforces the relevance of approaches focused on source reduction and recovery/valorization when safe and compliant (Singh et al., 2022). In a context of increasing pressures, particularly during the pandemic, the rise in reliance on single-use equipment also illustrates the potential scale of these volumes: in England, the carbon footprint of personal protective equipment distributed over a six-month period was estimated at 106,478 tCO2e (Rizan et al., 2021). In parallel, health-care activities generate substantial volumes of waste, a fraction of which requires secure collection and disposal streams, particularly for sharps (World Health Organization, 2024).
In this context, diabetes represents a particularly relevant case, given its high and rapidly increasing global prevalence and the recurrent use of devices and consumables associated with self-management (e.g., glucose monitoring systems, insulin injections, and related supplies). According to the International Diabetes Federation, an estimated 537 million adults worldwide were living with diabetes in 2021, a number projected to reach 643 million by 2030 (International Diabetes Federation, 2021). In Canada alone, approximately 3.9 million individuals (9.7% of the population) were living with diabetes in 2023-2024 (Public Health Agency of Canada, 2024). This substantial and growing burden translates into significant and recurrent material flows, including sharps and plastic-based medical supplies, raising important safety and organizational challenges related to waste collection and disposal systems, particularly in home and ambulatory care settings (World Health Organization, 2018).
While eco-responsible initiatives are emerging and becoming more structured (optimization of device use, reusable approaches when appropriate, more sustainable logistics/supply chains, organization of collection and disposal streams), there is still, to our knowledge, no structured, integrated mapping synthesis that documents (1) the barriers and facilitators to implementing eco-responsible practices in diabetes care, and (2) their impacts on the environment, safety, and costs.
Methods and analysis: A scoping review will be conducted in accordance with recognized methodological recommendations for this type of evidence synthesis, in order to map the scope, nature, and characteristics of the literature (Arksey & O’Malley, 2005; Peters et al., 2020). Findings will be reported using the PRISMA-ScR checklist (Tricco et al., 2018). To address in a structured manner the research question on eco-responsible practices (Q1), the extraction and categorization of practices identified in the literature will be organized using a 5R framework (e.g., “Rethink/Refuse, Reduce, Reuse, Recycle”), which is commonly mobilized in the literature on circularity and the hierarchy of waste reduction strategies, and discussed in work focusing specifically on waste management in healthcare settings (Morseletto, 2020; Lattanzi et al., 2022). In parallel, the extraction and analysis of implementation determinants (barriers/facilitators) will be structured using an adapted version of the Consolidated Framework for Implementation Research (CFIR), to ensure a rigorous and comparable interpretation of factors influencing the adoption of practices (Damschroder et al., 2009). The integration of the 5R framework (practice description and typology) and the CFIR (implementation determinants) will enable the production of an integrated map linking, for each type of practice, the associated implementation conditions and the reported levers or barriers (Q2) (Kirchherr et al., 2017).
Ethics and dissemination: No ethics approval is required for this scoping review, as it relies exclusively on data that are already published and publicly accessible. It should be noted that the broader research project within which this work is embedded has undergone an ethics review process at the CHUM; however, the present review does not involve any data collection from participants nor access to identifiable data. Results will be disseminated in the form of a thesis, scientific communications (posters, presentations) and, where relevant, manuscripts submitted to peer-reviewed journals. Knowledge translation products may also be developed for decision-makers and managers. The objective is to support evidence-informed decision-making by identifying success conditions and gaps in the literature to guide research and practice transformation.
Strengths and limitations of this study: This scoping review will provide a structured mapping of eco-responsible practices and interventions related to diabetes care, by integrating dimensions that are often addressed separately (environment, safety, and costs). The use of an implementation framework will support an analysis that goes beyond a simple description of initiatives, by systematically identifying the organizational, professional, and contextual determinants that shape their implementation (Damschroder et al., 2009). Anticipated limitations include heterogeneity in interventions, impact measures, and contexts, as well as variability in operational definitions of eco-responsibility.
Keywords : diabetes; self-management; environmental sustainability; eco-responsible care; healthcare waste; sharps; safety; costs, scoping review.
Troubleshooting
General information
Title: Eco-responsible practices in adult diabetes care: a scoping review protocol
Subtitle: Mapping interventions, implementation factors, and environmental, economic, and safety impacts
Authors: Marie Michelle Milord [1,2], Jonathan Bichon [2], Nathalie Clavel [1,2]
Affiliations: [1] School of Public Health, Université de Montréal (ESPUM), Montréal, Québec, Canada.[2] CHUM Research Centre, Montréal, Québec, Canada.
Start date: July 1, 2025
End date: July 31, 2026
Introduction
Background and scientific rationale
Health systems face a dual imperative: meeting growing care needs while reducing their environmental footprint. In Canada, the delivery of health care contributes measurably to national greenhouse gas emissions: an analysis of the Canadian health system’s footprint estimated emissions at approximately 33 million tonnes of CO2, representing 4.6% of national emissions, underscoring the importance of more sustainable approaches in organization, procurement, and clinical practices (Pichler et al., 2019). Beyond environmental benefits, these approaches may also generate organizational and clinical co-benefits, including resource savings and cost optimization, while maintaining high standards for prevention and patient safety (Singh et al., 2022; Tseng & Miller, 2022). In parallel, the generation of care-related waste, particularly waste requiring safe management (e.g., sharps), reinforces the relevance of eco-responsible and resource-conserving strategies (World Health Organization, 2024).
In this context, diabetes represents a particularly relevant case study, given its high and increasing global prevalence and the material intensity of its long-term management. According to the International Diabetes Federation, an estimated 537 million adults worldwide were living with diabetes in 2021, with projections reaching 643 million by 2030 (International Diabetes Federation, 2021). Diabetes care relies heavily on repeated use of devices and consumables associated with self-management, including glucose monitoring systems, insulin delivery devices, injection supplies, and related materials. Moreover, diabetes management frequently occurs in home-based and outpatient settings, shifting responsibility for waste handling beyond institutional environments. This organization of care generates specific waste streams, including sharps and plastic-based medical products, and raises complex challenges related to collection, segregation, and safe disposal, particularly when responsibilities are shared among patients, caregivers, pharmacies, and health care organizations (World Health Organization, 2018).
However, the shift toward eco-responsible practices in health care does not depend solely on their environmental legitimacy; it hinges on implementation conditions, including acceptability, safety, supply constraints, upfront and recurring costs, infection prevention requirements, internal logistics, training, engagement of professionals and patients, the regulatory framework, and organizational capacity for monitoring. In the absence of a structured synthesis, organizations may multiply isolated initiatives that are difficult to compare, whose sustainability and transferability remain uncertain, and may underestimate the barriers and levers that shape their large-scale deployment. To our knowledge, no synthesis has yet mapped eco-responsible practices in diabetes care in an integrated manner by simultaneously linking environmental impacts, care safety, costs, and implementation conditions. A scoping review can precisely map the state of knowledge, identify gaps, and guide research and practice transformation (Arksey & O’Malley, 2005; Tricco et al., 2018).
Literature gaps and need for synthesis
Despite the growing body of work on sustainability in health care, the literature specifically focused on diabetes and eco-responsibility remains fragmented and heterogeneous: some studies focus on environmental indicators, while others address patient safety issues or economic impacts, often without an explicit articulation between these dimensions. Moreover, barriers and facilitators to implementing eco-responsible practices are described variably across care contexts, which limits the comparability and transferability of findings.
In this context, a scoping review appears particularly relevant, as it will make it possible to (1) identify and classify the types of eco-responsible initiatives reported, (2) describe the implementation contexts and settings, (3) map the impacts and indicators used in the literature, and (4) highlight gaps and imbalances in the existing evidence base, in order to inform future research and support the transformation of practices.
Methods and analysis
Study design
This study adopts a scoping review design aimed at mapping and synthesizing the current state of knowledge on eco-responsible practices in diabetes care among adults. The review will be conducted in accordance with the methodological framework proposed by Arksey and O’Malley, as further refined by the Joanna Briggs Institute, and will be reported in line with PRISMA guidelines for scoping reviews (PRISMA-ScR). The protocol is developed to ensure transparency, reproducibility, and methodological consistency, through explicit planning of the steps, source selection procedures, study inclusion criteria, and the analytic framework.
Methodological framework and reporting standards
The review will follow a recognized methodological approach for scoping reviews (a stepwise process: question formulation, study identification, selection, data extraction, and synthesis), and findings will be reported in accordance with the PRISMA-ScR checklist (Tricco et al., 2018). The overarching rationale is to prioritize a descriptive, mapping and analytical synthesis (what, where, how, in which context, and with what effects/indicators), rather than an effectiveness meta-analysis.
Step 1 : Identification of the objectives and research questions
Overall objective
The main objective of this scoping review is to synthesize the available evidence on eco-responsible practices reported in adult diabetes care, to examine the barriers and facilitators influencing their adoption and implementation across care settings, and to map their reported environmental, safety, and economic impacts.
Specific objectives
The specific objectives of this scoping review are to:
- Identify and describe eco-responsible practices reported in the literature related to adult diabetes care.
- Compile and analyze the barriers and facilitators associated with the adoption and implementation of these practices across different care settings.
- Describe the reported impacts and how they are measured (indicators/methods) in relation to the environment, care safety, and costs.
- Identify the main gaps in the literature on eco-responsible practices in adult diabetes care with regard to the three objectives above (practices studied, implementation determinants, and impacts/measures).
Step 2 : Identification of relevant studies
Information sources
A literature search will be conducted in biomedical, nursing, and interdisciplinary databases (MEDLINE, Embase, CINAHL, Web of Science, Google Scholar). A grey literature search will complement the strategy (reports from organizations, agencies, stewardship programs, guidelines, and institutional documents).
Due to the heterogeneous and non-indexed nature of grey literature sources, records will be identified through targeted institutional website searches and structured web-based searches. Rather than being managed exclusively through reference management software, grey literature records will be documented using a structured screening log that captures the source, search date, search terms used, and preliminary eligibility decision. Selection will follow the same predefined inclusion and exclusion criteria as for peer-reviewed studies. A second reviewer will independently verify eligibility decisions to ensure consistency and methodological rigor.
Covered period
The literature search covered the period from database inception to September 2025. Specifically, MEDLINE was searched from 1946 to September 19, 2025; Embase from 1974 to September 18, 2025; CINAHL Complete from its inception to September 2025; and Web of Science Core Collection from inception to September 2025. The final search was conducted between September 18 and September 19, 2025, depending on the database interface.
The scoping review will be conducted over several months and will include the following phases: development of the search strategy, literature searching, source selection, data extraction, and synthesis of findings.
Search strategy
The search strategy will combine terms related to diabetes (diabetes, type 2, insulin, glucose monitoring, lancets, syringes) and terms related to eco-responsibility/environmental sustainability (sustainab*, environmentally sustainable, carbon footprint, life cycle assessment/LCA, waste, reusable, recycling, circular economy, green healthcare, telehealth to reduce travel when the environmental link is explicit). The strategy will be adapted to each database and then validated using a high-sensitivity approach (prioritizing maximal retrieval of relevant records).
Eligibility criteria (PCC – Population / Concept / Context)
Population: The population includes adults (≥ 18 years) living with diabetes, as described in the included studies and documents. Sources addressing type 1 diabetes, type 2 diabetes, or both types will be considered.
Concept: The concept relates to eco-responsible practices in diabetes care, including, in particular, practices aimed at reducing the environmental footprint of care, medical waste management, the use of reusable or recyclable devices or consumables (or those with a lower environmental impact), as well as organizational or logistical practices associated with diabetes care from a perspective of reduced environmental impact.
Context: The context includes all care settings in which these practices are reported, namely home care, outpatient and clinic-based care, as well as hospital settings, with no geographic restrictions.
Types of documents
Documents presenting empirical data or a structured synthesis of relevant data on eco-responsible practices related to diabetes care will be considered eligible. This includes quantitative, qualitative, and mixed-methods studies, implementation studies, as well as program/intervention evaluations when they are based on data collected in a clear manner and analyzed using a described methodological approach. Economic analyses will also be eligible (e.g., cost studies, cost-effectiveness analyses), as will environmental analyses (e.g., life cycle assessment/LCA, carbon footprint, waste quantification, energy/water consumption), provided they relate to diabetes management. Finally, systematic reviews and scoping reviews will be included when they synthesize data directly related to the concept of eco-responsibility in diabetes care. Grey literature may be retained (e.g., institutional reports, agency reports, technology assessments) only if it is methodologically informative (explicit methods, usable data, described criteria).
Conceptual model
Figure 1. Integrated conceptual framework combining the 5R framework and the CFIR.
Source: Author’s adaptation based on Damschroder et al. (2009) and Kirchherr et al. (2017).
The analysis will be conducted using an integrated conceptual framework combining the 5R framework and the Consolidated Framework for Implementation Research (CFIR). On the one hand, the 5R framework, used as a hierarchy of actions in the circular economy (e.g., refuse/rethink, reduce, reuse/repair, recycle/recover/valorize, rot/compost), will be used to classify the nature of eco-responsible practices reported in the literature (i.e., “what” type of intervention/practice is described) (Kirchherr et al., 2017). In addition, practices categorized within the 5R framework will be examined according to their primary level of action, policy/system (e.g., procurement regulations, reimbursement policies), organizational (e.g., hospital waste management systems, logistics redesign, device reprocessing programs), or individual (e.g., clinician prescribing behaviors, patient self-management practices aimed at reducing waste). This multilevel characterization will help situate eco-responsible practices within the broader structure of diabetes care delivery. On the other hand, the CFIR, initially proposed by Damschroder et al. and widely used in implementation science research, will help explain the adoption, implementation, and sustainment of these practices by analyzing determinants (i.e., “how”: barriers and facilitating factors) in real-world care settings (Damschroder et al., 2009).
In this protocol, the term “eco-responsible” refers to interventions, programs, clinical practices, devices, policies, or organizational strategies that explicitly aim to reduce the environmental footprint of diabetes care, while taking into account safety requirements, costs, and organizational constraints (e.g., waste reduction and sorting, reusable or lower-impact devices, take-back/collection programs, logistics optimization, telehealth to reduce travel). Concretely, the extracted data will therefore make it possible (1) to identify and describe eco-responsible practices by positioning them within the 5R framework (Q1) and (2) to analyze the implementation determinants of these practices using the CFIR (Q2), while documenting reported impacts across key dimensions, namely environmental impacts (including GHG emissions, waste and resource use), care safety and costs (Damschroder et al., 2009; Kirchherr et al., 2017).
The CFIR will be used as a structuring framework to extract barriers and facilitating factors. CFIR constructs will be grouped into analytic domains adapted to the context of diabetes care (home/ambulatory/hospital) in order to facilitate charting and comparison of implementation factors:
- Description of the eco-responsible practice: nature, components, target population, categorization according to the 5R framework (refuse/rethink, reduce, reuse, recycle, recover/valorize) (Kirchherr et al., 2017) and primary level of action (policy/system, organizational, individual).
- Implementation setting: hospital setting, clinic/ambulatory setting, home.
- Stakeholders involved: patients, caregivers/relatives, professionals, managers, partners.
- Implementation determinants: barriers/facilitators (coded using the CFIR) (Damschroder et al., 2009).
- Reported impacts: environment (e.g., GHG emissions, waste, resource use), safety, and costs.
Implementation determinants will then be coded deductively according to CFIR domains and constructs to ensure comparability of results across studies (Damschroder et al., 2009). Coding will be organized around the five CFIR domains: intervention characteristics (e.g., complexity, adaptability, costs), outer setting (e.g., norms, regulations, market, stakeholder pressure), inner setting (e.g., culture, resources, logistics and waste flows, organizational priorities), characteristics of individuals (e.g., knowledge, risk perceptions, competencies, acceptability), and implementation process (e.g., planning, training, engagement of leaders/champions, feedback, iterations). When certain reported elements do not clearly align with an existing construct, they will be coded inductively and then discussed, and, when possible, linked to a CFIR domain during synthesis, in order to preserve the rigor and transparency of interpretation.
In addition, extraction will systematically distinguish (i) implementation determinants of eco-responsible practices (analyzed using the CFIR) and (ii) reported results/impacts. Impacts will be extracted and synthesized across three domains consistent with the study objective: (1) environmental impacts (e.g., waste, carbon footprint, resource consumption), (2) patient and staff safety (e.g., infection prevention, sharps-related safety), (3) economic impacts (e.g., acquisition costs, waste management costs, and economic analyses). This structure will make it possible to analytically link categories of practices (5R framework) with their reported effects, while connecting implementation conditions identified through the CFIR to observed or anticipated impacts in diabetes care.
Eligibility criteria
The Population/Concept/Context (PCC) framework will be used to guide the inclusion and exclusion criteria for this scoping review.
Population : The population of interest includes adults living with type 1 or type 2 diabetes. Studies including mixed chronic disease populations will be considered only if diabetes is the primary focus of the study or if data specific to individuals with diabetes can be clearly extracted and analyzed separately.
Concept : For the purposes of this review, a practice will be considered “eco-responsible” only if the document establishes an explicit link with environmental sustainability (e.g., waste reduction or management, carbon footprint, life cycle assessment [LCA], energy or water consumption, reuse/recycling, circularity, logistics or procurement practices) applied to the organization of care, technologies/devices, services, or material flows related to diabetes care.
Publications in which the terms “durable,” “sustainability,” or related concepts refer exclusively to health behaviours (e.g., a “sustainable” diet) without an environmental dimension applied to care delivery, technologies, services, or material flows will not be eligible.
Context : Eligible settings include clinical contexts (hospital, outpatient clinic, primary care, pharmacy, organized home care) and the home environment when the intervention or practice is directly related to the diabetes care pathway.
Types of sources : This review will include qualitative, quantitative, and mixed-methods empirical studies, as well as relevant grey literature documents (e.g., institutional reports, guidelines, standards, implementation frameworks, programme evaluations) that present explicit empirical data, implementation processes, determinants, or reported impacts.
Documents that do not report empirical data will be excluded. This includes editorials, letters to the editor, commentaries, opinion pieces, and position statements that do not present original data or describe an intervention, implementation process, or empirical analysis. Purely theoretical or conceptual papers lacking empirical evidence will also be excluded. Conference abstracts, proceedings, and preprints will not be retained.
Language and time period : Sources published in French and English will be included. The search will cover the period from database inception to the date of the last search.
Search strategy
A comprehensive search strategy will be conducted across multiple electronic databases to identify relevant evidence (for example: MEDLINE [Ovid], Embase [Ovid], CINAHL [EBSCO], Web of Science, and, as appropriate, Scopus and/or Global Health). Searches will be conducted primarily in English, with French equivalents used when necessary, combining controlled vocabulary (e.g., MeSH) and keywords related to (1) diabetes and diabetes care, (2) environmental sustainability/eco-responsibility, and (3) implementation and outcomes (costs, waste, carbon footprint, logistics, safety, etc.).
The search equations will combine:
1. Diabetes (e.g., Diabetes Mellitus / type 1 diabetes / type 2 diabetes, T1DM/T2DM, and text word equivalents).
2. Sustainability/eco-responsibility and medical waste management (e.g., controlled descriptors such as Sustainable Development, Environmental Sustainability, Medical Waste/Disposal), complemented by free-text keywords adapted to each interface with truncation and proximity operators: sustainab*; “green healthcare”; “eco-friendly”; “circular economy”; “waste management”; “biomedical/medical waste”; “sharps disposal”; “medical device reuse”, etc.
Databases searched and indicative results (prior to cross-deduplication)
Ovid MEDLINE ALL (1946 – September 19, 2025): S1 (controlled diabetes) 409,152; S2 (free-text diabetes) 465,069; S3 (controlled sustainability/waste) 18,774; S4 (free-text sustainability/waste) 263,974; combination (S1 OR S2) AND (S3 OR S4) = 1,715; FR/EN limit = 1,679.
Embase (Ovid) (<1974 – September 18, 2025): E1 1,272,837; E2 718,127; E3 85,479; E4 278,247; (E1 OR E2) AND (E3 OR E4) = 4,571; FR/EN limit = 4,487; after removing preprints/conference records = 2,327.
CINAHL Complete (EBSCO): S1 (diabetes headings) 169,750; S2 (free-text diabetes) 126,769; S3 (sustainability/waste headings) 15,931; S4 (free-text sustainability/waste) 39,059; (S1 OR S2) AND (S3 OR S4) = 771 (FR/EN limits and “equivalent subjects/proximity” as per the interface).
Web of Science Core Collection: 1,663 results (equivalent query on diabetes AND sustainability/waste management).
The search equations will integrate database-specific controlled vocabulary (MeSH, Emtree, CINAHL Headings) and free-text terms in titles/abstracts, using truncation and proximity operators (adj#, N#, W#) depending on the interface. Human/adult filters will be applied only at the screening stage, in accordance with the protocol (PCC). For information purposes, pilot searches yielded 8,600 records (including duplicates, preprints, and conference records); after removing preprints/conference records at the source, 6,440 records remained (including duplicates) before cross-deduplication. Reporting will follow PRISMA-ScR and the JBI Manual for Evidence Synthesis for a complete description of the search strategy (Tricco et al., 2018; Peters et al., 2020).
In parallel, grey literature will be searched in a structured manner using a three-component approach: (1) targeted searches of relevant organizations’ and agencies’ websites (e.g., health technology assessment agencies, public health organizations, professional associations, healthcare institutions, stewardship programs, sharps waste management documents, and take-back/collection initiatives), (2) searches in web search engines (Google) using standardized equations and advanced operators, limited to relevant formats (e.g., PDF reports and institutional documents), and (3) reference and related-document checking (snowballing). Grey literature records will be documented using a structured screening log, including the source consulted, search date, search terms or equations used, and preliminary eligibility decision. When feasible, relevant documents may also be imported into the reference management tool to facilitate organization and retrieval. Selection will follow the same predefined inclusion and exclusion criteria as for published studies, while taking into account the heterogeneous and non-indexed nature of grey literature sources.
The initial strategy will be developed in MEDLINE and then adapted for the other databases. It will be reviewed by a specialist librarian, based on research strategy validation principles (e.g., the PRESS approach), to strengthen its accuracy and comprehensiveness.
Table 1. Inclusion and exclusion criteria
| A | B | C | |
| Dimension | Inclusion criteria | Exclusion criteria | |
| Publication type | Peer-reviewed empirical studies (quantitative, qualitative, and mixed methods), including trials or quasi-experimental studies, cohort studies, cross-sectional studies, and case studies or case series. Systematic reviews and scoping reviews (used for secondary mapping). Relevant institutional grey literature (e.g., WHO, ministries of health, NHS) containing data, indicators, or operational recommendations in care settings. | Editorials, letters, commentaries, and expert opinions without empirical data. Protocols with no results. Marketing or industry documents without a scientific basis. Strictly technical device assessments with no environmental relevance. | |
| Population | Adults living with diabetes (type 1 and/or type 2). | Pediatric studies (children or adolescents). Animal studies. Populations unrelated to diabetes. | |
| Intervention/ context | Practices, policies, or strategies with an explicit environmental component applied to diabetes care, including waste management or waste reduction (needles, pens, pumps, sensors, test strips, etc.), reuse or reprocessing, reusable alternatives versus disposable options, recycling, eco-design, sustainable procurement and purchasing, green logistics, telehealth aimed at reducing travel, and self-management initiatives that incorporate environmental objectives. | Studies focusing only on the clinical effectiveness of a drug or device with no environmental dimension. Technical or engineering innovations with no explicit link to eco-responsibility. General environmental exposure (air, climate) unrelated to the organization or management of diabetes care. “Sustainable” lifestyle behaviors with no care-related component. | |
| Outcomes | Adoption and implementation of eco-responsible practices. Environmental impacts (GHG emissions or carbon footprint, waste, water or energy consumption, life cycle assessment). Care and occupational safety (e.g., infection prevention). Costs and economic outcomes (including cost–benefit analyses and economic evaluations). Patient experience and self-management when explicitly linked to eco-responsibility. | Strictly biomedical or technical outcomes (device performance, biomarkers) with no link to sustainability. Clinical outcomes not connected to environmental or eco-responsible impacts. | |
| Setting | Diabetes care or self-management contexts, including home, clinic, hospital, pharmacy, and community programs. | Laboratory-only studies. Device or product design without clinical validation or without relevance to patient or professional experience. Non-healthcare settings (industry, factory) unrelated to care delivery. | |
| Language | French or English. | Other languages with no available translation. |
Table 2. Concept map (search concepts)
| A | B | C | |
| Concepts | Type 1/2 diabetes | Sustainability/ eco-responsability | |
| Keywords | Type 2 diabetes; T2D; “type 2 diabetes mellitus”; T2DM; type 1 diabetes (if mixed); T1DM; insulin-dependent; non-insulin-dependent; adult-onset diabetes. | Sustainable healthcare; “green” healthcare; eco-responsibility; circular economy; reduction, reuse, recycling (3R/5R); biomedical or medical waste management; sharps waste; reuse of medical devices; telehealth to reduce travel; sustainable procurement and logistics; “sustainable healthcare / green healthcare / eco-friendly”; environmental sustainability; “medical/biomedical waste”; “sharps disposal”; “medical device reuse”. | |
| MEDLINE MeSH descriptors | MeSH: Diabetes Mellitus, Type 2; Diabetes Mellitus, Type 1 | Sustainable Development; Environmental Sustainability; Medical Waste Disposal; Recycling; Environmental Waste; Medical Waste. |
Step 3 : Selection of eligible studies
All identified references will be imported into a reference management software package (e.g., EndNote or Zotero) to remove duplicates, and then transferred to a screening management tool (e.g., Covidence or Rayyan).
Two reviewers will independently screen titles and abstracts using the predefined inclusion and exclusion criteria. A pilot phase will be conducted on a sample (for example, 10% of references) to ensure a shared understanding of the criteria and to improve inter-rater agreement. Disagreements will be resolved through discussion; if needed, a third reviewer will act as an adjudicator.
Full texts of the preselected references will then be independently assessed by two reviewers to confirm eligibility. Any persistent discrepancies will be resolved by consensus or adjudication
Step 4 : Data extraction
The source selection process will take place in two stages. First, titles and abstracts of identified references will be independently reviewed by two reviewers to assess eligibility against the predefined inclusion and exclusion criteria. Second, full texts of the retained references will be assessed to confirm inclusion.
Disagreements between reviewers will be resolved through discussion and adjudication. The selection process will be documented using a flow diagram consistent with PRISMA recommendations for scoping reviews.
Data extraction will be performed using a standardized charting form. Extracted data will include, in particular, the general characteristics of the sources, the care setting, a description of the eco-responsible practices, reported barriers and facilitators, and documented impacts on the environment, patient and staff safety, and costs.
Step 5 : Quality appraisal
In anticipation of the diversity of study designs and sources of evidence likely to be identified in this scoping review, different appraisal tools will be used according to the type of evidence. Empirical studies (qualitative, quantitative, and mixed methods) will be appraised using the Mixed Methods Appraisal Tool (MMAT) (Hong et al., 2018). Systematic reviews and scoping reviews will be appraised using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Systematic Reviews and Research Syntheses (Joanna Briggs Institute, n.d). Grey literature documents will be appraised using the AACODS checklist (Authority, Accuracy, Coverage, Objectivity, Date, Significance) (Tyndall, 2010).
In line with the JBI Manual for Evidence Synthesis (Aromatatis et al., 2020; Porritt et al., 2014) and PRISMA-ScR recommendations (Tricco et al., 2018), appraisal results will be used to support interpretation and contextualization of the findings. No source of evidence will be excluded based on appraisal results.
Step 6 : Structuring the synthesis of evidence
Extracted data will be synthesized using a descriptive and narrative approach, in line with the objectives of a scoping review. Characteristics of included sources and the types of identified eco-responsible practices will be presented using tables and simple descriptive statistics.
Barriers and facilitators to the integration of eco-responsible practices will be organized thematically. The narrative synthesis will also describe reported impacts on the environment, safety of care, costs, and will identify gaps in the existing literature.
Patient and public involvement
Depending on the project governance, patients and/or members of the public may be engaged in a targeted manner, notably to validate the relevance of the analytical categories, to help interpret selected findings related to home-based practices (e.g., management and disposal of sharps), and to identify priorities for action. If such involvement is retained, it will be described in detail in the final version (profile of participants involved, modalities of contribution, and timing of involvement).
Ethics and dissemination
As this scoping review will analyze only data drawn from publicly accessible documents, ethics approval is not required. Findings will be submitted to a peer-reviewed scientific journal and presented at relevant conferences (public health, health services, sustainability in health care, diabetology, waste management).
Beyond its academic contribution, the synthesis aims to generate practical implications for decision-makers and clinical teams by clarifying what facilitates or hinders the integration of eco-responsible practices in diabetes care and by identifying the types of impacts that have been measured (environmental, economic, safety, resilience). Dissemination to key stakeholders (health care organizations, professional bodies, collection and waste management programs) may be considered in the form of an executive summary or a policy brief.
Considerations and Implications
Patient and public involvement
Depending on the project governance, patients and/or members of the public may be engaged in a targeted manner, notably to validate the relevance of the analytical categories, to help interpret selected findings related to home-based practices (e.g., management and disposal of sharps), and to identify priorities for action. If such involvement is retained, it will be described in detail in the final version (profile of participants involved, modalities of contribution, and timing of involvement).
Ethics and dissemination
As this scoping review will analyze only data drawn from publicly accessible documents, ethics approval is not required. Findings will be submitted to a peer-reviewed scientific journal and presented at relevant conferences (public health, health services, sustainability in health care, diabetology, waste management).
Beyond its academic contribution, the synthesis aims to generate practical implications for decision-makers and clinical teams by clarifying what facilitates or hinders the integration of eco-responsible practices in diabetes care and by identifying the types of impacts that have been measured (environmental, economic, and safety). Dissemination to key stakeholders (health care organizations, professional bodies, collection and waste management programs) may be considered in the form of an executive summary or a policy brief.
Strengths, Limitations, and Conclusions
Strengths and limitations of this scoping review
This scoping review has several strengths, including a structured search strategy combining bibliographic databases and grey literature, a double-screening process with a pilot phase, a standardized data charting approach informed by JBI guidance, and a robust conceptual framework (adapted CFIR) to support coherent analysis of implementation determinants and reported impacts.
Some limitations are anticipated. Published literature may introduce publication bias, and initiatives that are unpublished or evaluated locally may be under-represented. In addition, the diversity of interventions, contexts, and indicators (waste, emissions, costs, safety) may generate substantial heterogeneity, limiting direct comparisons. Finally, restricting eligibility by language (French and English) may exclude relevant evidence produced in other languages.
Conclusion and Implications
This scoping review protocol addresses an important gap at the intersection of environmental sustainability and chronic disease management. By integrating the 5R framework with the Consolidated Framework for Implementation Research (CFIR) and mapping reported impacts across environmental, safety, and economic domains, the review aims to provide the first structured synthesis of eco-responsible practices in adult diabetes care.
Beyond documenting existing initiatives, this review will clarify implementation determinants and identify patterns across care settings, thereby contributing to the emerging field of sustainable health systems research. The findings are expected to inform clinicians, managers, policymakers, and researchers seeking to reconcile quality of care with environmental responsibility, and to support the development of more sustainable and resource-conscious diabetes care models.
Protocol references
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Acknowledgements
The author would like to thank Nathalie Clavel for her methodological guidance and supervision throughout the development of this protocol, and also acknowledge the contribution of Jonathan Bichon for his support in screening strategy.