Climate change mitigation: Qualitative analysis of environmental impact-reducing strategies in German primary care

Abstract

Background

The German healthcare system is responsible for 5,2% of the national emissions of greenhouse gases. Therefore, mitigation actions to reduce the carbon footprint are crucial. However, there have been few approaches to achieve this in German primary care.

Objectives

This study aimed to identify environmental impact-reducing strategies of German primary care practices.

Methods

During the summer of 2021, a qualitative study was conducted using interviews and focus groups with experts in primary care across Germany, such as physicians, medical assistants, health scientists and experts on the health system level. Verbatim transcribed data were analyzed using Thematic Analysis.

Results

The sample comprised 26 individual interviews and two focus groups with a total of N = 40 participants. Findings provide a first overview of pursued mitigation strategies and contextual factors influencing their implementation. Strategies referred to the use of water and energy, recycling and waste management, supply chains and procurement, digitisation, mobility, patient care, behavioural changes and system level. Implementing sustainable actions in daily care was considered expensive and often unfeasible due to lack of staff, time and restrictive hygiene regulations. Participants called for more instruction on implementing mitigating actions, for example, through websites, podcasts, guidelines or quality indicators.

Conclusion

This study’s findings can support the development of future environmental impact-reducing strategies in primary care. Potential options for guidance and support should be considered to facilitate sustainability.

KEY MESSAGES

• Sustainable measures and actions are perceived as challenging to implement because of time, staff and financing shortages.

• The potential for sustainable environmental impact-reducing strategies is limited due to strict hygiene regulations.

• Primary care practitioners wish for practical and specific guidance to make their practice more sustainable.

Introduction

The direct and indirect impacts of climate change are far-reaching for the health of populations and societies [1]. The Lancet Commission proposed to track and work on the complex association between health and climate change. They address climate change mitigation, including ways to reduce the carbon footprint to minimise its impact [1]. The WHO defines climate-resilient and environmentally sustainable healthcare facilities to ‘anticipate, respond to, cope with, recover from and adapt to climate-related shocks and stresses while minimising negative impacts on the environment and leveraging opportunities to restore and improve it’ [2,3].

The health sector is an essential sector of society and one of the largest employers and consumers of energy [4]. The average contribution of a healthcare system to its national carbon emissions varies from 3% in England to 10% in the U.S. [5]. The German healthcare system is responsible for 5.2% of national greenhouse gas emissions [6]. This presents the health sector with both a responsibility and an opportunity to be at the forefront of achieving climate neutrality in its own operations [5]. Therefore, the Lancet Commission claimed climate change mitigation is ‘the greatest global health opportunity of the twenty-first century’ [1].

Institutions like ‘Health Care Without Harm’ have developed guidelines to make the health sector more sustainable with so-called ‘green hospitals’ [7]. Scientific research focuses on clinical care and shows actions or guidelines for hospitals [7].

The project RESILARE (building resilience against crises of primary care practices by developing and evaluating quality indicators) was initiated to enhance resilience against different crises, such as climate change in primary healthcare [8]. The project consists of three study phases: (1) Identification of starting points for deriving quality indicators via literature research and qualitative data collection. (2) Prioritisation and evaluation of quality indicators. (3) Piloting developed indicators in primary care practices [8]. Based on data generated in phase one, this present study aimed to identify climate change mitigation measures and factors influencing their implementation in German primary care practices with a focus on carbon footprint-reducing measures.

Methods

A qualitative exploratory study design was chosen to explore expert perspectives on climate change mitigation measures in primary care within the first phase of the project RESILARE [8]. An integrating approach with semi-structured guide-based interviews and focus groups with primary care experts was pursued to generate the width of topics, enhance data richness and enable a comprehensive understanding of discussed themes [9]. Reporting of this study follows the COREQ checklist [10].

Sampling strategy

A purposive sampling strategy was applied to contact experts in German primary care, such as primary care physicians, medical assistants, quality or practice managers, scientists, and health politicians and invite them to participate. The invitation could be forwarded to other interested parties. The following inclusion criteria were defined: Expertise in the German primary care system and quality indicators or climate change mitigation, age 18 years and older, fluency in reading and speaking German, and ability to give informed consent. Invitations were sent in June 2021 by mail or e-mail via networks of the project partners using personal contacts, existing e-mail lists, or newsletters. When interest in participation was expressed through e-mail, mail or phone, the study team contacted potential participants via phone or e-mail. If more than one person showed interest within a large practice or practice network, all practice team members were invited to participate in a focus group. After data collection, participants were asked to forward the interview invitation to others who might express interest in this study. To guarantee content saturation and to include as many stakeholders as possible, a large sample size (N = 40) was planned [11]. Information referring to non-participants was not documented. Due to the partial snowball recruitment approach, a response rate cannot be calculated.

Data sources

Qualitative interviews and focus groups were conducted using a self-developed semi-structured interview guide (Appendix). Focus groups were intended to cover team dynamics, idea generation, group opinions and individual knowledge as well as opinions assessed throughout interviews. The interview guide was based on a previously conducted scoping review within the overall project RESILARE and covered three main topics: (1) general crisis resilience (preparedness, knowledge, coping and response strategies, recovery and lessons learned); (2) climate change adaptation (knowledge and preparedness, adaptation strategies); (3) climate change mitigation (awareness, attitudes and beliefs, mitigation strategies and identification of barriers and facilitators for implementation).

Data collection

All qualitative data were collected between July and October 2021. No modifications were introduced to the interview guide. Interviews and focus groups were conducted by NL, a doctoral candidate and VF, a graduate student. Both are speech-language therapists and trained in interprofessional health care and health services research and implementation science. Data was collected via telephone (interviews), or video conference (focus groups). Interviews were audio recorded, focus groups were audio and video recorded. Interviews were transcribed verbatim and pseudonymised. In the focus groups, nonverbal reactions like nodding, were also transcribed. Transcripts were not returned to participants for comments or correction, no repeated interviews were carried out. Prior to data collection, all participants filled in a paper-based sociodemographic questionnaire (age, sex, profession, work experience, workplace). All participants gave their written informed consent prior to the interviews and focus groups. Ethical approval was obtained by the Ethics Committee of the Medical Faculty Heidelberg (S-456/2021).

Data analysis

The software MAXQDA Analytics Pro 2020 was used for data coding, IBM SPSS Statistics Version 26 was used to analyse the sociodemographic data. After transcription, data were coded inductively following the Thematic Analysis by VF [12].

Data was primarily analysed inductively to identify relevant themes related to climate change mitigation by VF and NL. For in-depth analysis, deductive coding was applied based on the Consolidated Framework for Implementation Science (CFIR) [13] for the themes ‘contextual factors and attitudes,’ ‘awareness,’ and ‘beliefs and knowledge.’ Two additional frameworks by ‘Health Care Without Harm’ and ‘KLUG’ were used to map discussed mitigation strategies [7,14]. Both organisations previously investigated ideas and strategies to reduce carbon emissions in healthcare, mainly in a clinical setting.

During data analysis, VF discussed and reflected on coding and transcript passages was reflected and discussed with experienced qualitative researchers (NL, AW, RPD) in regular project team meetings and a junior research group to reach a consensus. To facilitate a holistic perspective on the width of topics, data generated in the individual interviews and focus groups were triangulated in an integrating approach and statements were checked against the findings of comprehensive literature research.

Results

The sample comprised 26 individual interviews and two focus groups with six and eight participants (total of N = 40 experts). All but two directly contacted experts could be included. One focus group was conducted with team members of a medical care centre and one with members of a physicians’ network. Individual interviews were conducted with individual experts who had accepted the interview invitation.

Participating experts were mostly female (60%), between 25 and 59 years old (77.5%), and had a median work experience ranging from 4 to 20.5 years. Participants predominantly worked in primary care practices (see Table 1). The duration of individual interviews ranged from 39 to 76 min, duration of the focus groups was 80 and 91 min each. Two interviews and the two focus groups were conducted first, and all other interviews followed. Climate change mitigation was one of several topics discussed during data collection. The amount of time spent talking about this topic was not recorded.

Table 1.

Sociodemographic data of the study population.

	N	%
Total	40	100
Sex
Male	16	40.0
Female	24	60.0
Age
18–24 years	1	2.5
25–39 years	14	35.0
40–59 years	17	42.5
60 years or older	8	20.0
Professional activity (multiple answers allowed)
Working in a primary care practice as:
Physician	14	35.0
Medical assistant	16	40.0
With additional training	11	68.8
Other*	3	7.5
Working in health system
Research	3	7.5
Health system (Politics/ health insurance/…)	4	10.0
Others**	9	22.5
Location of practice
Big city (>1000.001 residents)	12	30.0
Medium city (20.001–100.000 residents)	10	25.0
Small city (5.001–20,000 residents)	7	17.5
Village (<5.000 residents)	5	12.5
Not mentioned	6	15.0

^*other includes practice managers and hygiene managers.

^**others include staff in pharmacy, physician network management, quality management, education, environment and health department.

Regarding climate change mitigation, three main themes were identified from the data: a) mitigation strategies for reducing the environmental impact of German primary care practices; b) contextual factors influencing the implementation of mitigation strategies; c) attitudes, awareness, beliefs and knowledge about climate change and sustainability in health care (see Tables 2 and 3). Findings are reported referring to these themes, illustrated with diligently translated quotes, indicated data source (focus group = FG; interview = Int) and transcript position.

Table 2.

Overview of codes regarding mitigation strategies.

Mitigation strategies
Real estate	Energy management Water management Sustainable building materials
Recycling and waste management	Reducing waste Using recyclable/reusable materials Waste separation Adequate waste disposal Sustainable work clothes
Procurement	Buying from sustainable distributors Local production Needs-assessment
Digitisation	Remote training for staff Digital patient care Digital practice organisation
Mobility	Patients Staff
Sustainable patient care	Patient Care Using materials resourcefully Reducing/ avoiding single-use plastic Sustainable drug use Patient counselling about climate change and sustainable behaviour

Table 3.

Overview of codes regarding contextual factors.

Contextual factors for implementation
Incentives	Financial subsidies for mitigation measures Investing in sustainability Subsidies of sustainable alternatives
Politics / system level	Guidelines for sustainable actions Supporting sustainable actions financially Making sustainability mandatory for primary care practices
Centralisation and networking	Sharing rooms or equipment with other medical practices
Structural characteristics	Practice organisation Practice equipment Hygiene standards vs. sustainability
Implementation climate for mitigation strategies	Sustainable organisational development Access to information and knowledge about sustainable measures Available resources   Sustainable material   Money   Staff   Time for implementation Leadership engagement Tension for Change   Aspects regarding high tension   Aspects regarding low tension
Costs	Higher costs of sustainable measures Additional costs of implementation
Miscellaneous	Integrating sustainability on various levels Talking about sustainability in different media formats
Attitudes, awareness, beliefs and knowledge	Attitudes of primary care stakeholders   towards change processes   towards climate change   high/low motivation for sustainability
	Awareness of primary care stakeholders   of climate change   of sustainability
	Beliefs of primary care stakeholders   about climate change   about sustainability
	Knowledge of primary care stakeholders   about climate change   about sustainability

Mitigation strategies in German primary care practices

When asked about mitigation strategies, some participants had to take a few seconds to think, needed examples or asked counter questions. After consideration and reflection, all participants came up with measures to reduce the carbon-footprint of medical practices. Included were already practised strategies as well as ideas for future mitigation strategies (Tables 4–7 lists all mitigation strategies as supplementary material).

Table 4.

Real estate.

Real estate
Sub-category:	Mitigation strategies
Energy	Using green electricity Using renewable energy (e.g. solar) Saving energy:   turning off lights when leaving the room   turning off devices when consultation is over   turning off all devices on lunch break   having only one main printer for the practice   instead of having a printer in every room   only using the heating when in the room   using LED lights   using energy-saving devices Not using air conditioning
Water	Using water-saving systems in toilets and sinks
Building materials	Climate-neutral paint Secure heat supply Install insulating windows

Table 5.

Recycling, waste and procurement.

Recycling, waste and procurement
Category	Mitigation strategies
Recycling and waste	Reducing waste Separating waste Disinfecting the treatment couch instead of using paper rolls Using paper rolls made of recycled paper Using recycled paper Reusing paper Using recycled toilet paper Using recycled paper towels Using recyclable and reusable printing material Printing double-sided Using digital documentation Using electricity-run devices instead of battery-run devices Cutting back on single-use materials Using reusable materials (e.g. paper or glass) Buying water in glass bottles or a giant water dispenser instead of plastic bottles Using spray disinfection instead of wiping disinfection Using materials that are packaged in paper instead of plastic Avoiding product samples to save plastic, e.g. by talking to suppliers to stop sending samples Using reusable containers instead of foil for storing lunch Using reusable dishware instead of plastic dishware Using glass bottles instead of plastic bottles Preparing food at home instead of buying or ordering in Ordering food from local restaurants that use paper packaging Washing work clothes only when they need to be washed Wearing clothes longer when they are still clean Searching for recyclable material for work clothes
Procurement	Ordering in small vessels Try not to let medication expire, e.g. with tables Being able to use big containers instead of several small ones Ordering reusable dispensers instead of single-use dispensers Ordering from one supplier Ordering office materials as well as medical materials from one big supplier Ordering in big packages Locally produced pills, medicines and creams from the nearby pharmacist

Table 6.

Digitisation and mobility.

Digitisation and mobility
Category	Mitigation strategies
Education and training	Using online classes for further education and training
Patient care	Sending digital prescriptions directly to the pharmacy Using video or telephone consultations Issuing sick notes via phone and sending them via mail instead of the patient driving to practice Putting information for patients on the practices’ website or using a TV in the waiting area
Practice organisation	Only using digital documentation and communication systems to create a paper-free practice Using applications to communicate with other practices instead of sending letters or CDs Using e-referrals Using digital letters Using digital documentation systems
Mobility for patients	Offering electric charging stations close to the medical practice Talking with patients about sustainable commuting, healthier lifestyles and getting more exercise
Mobility for staff	Commuting by foot Commuting by bike Commuting by public transport Using home office, where possible Supporting tickets for public transport as an employer Supporting rental bikes as an employer Using e-cars for home consultations Using bikes for home consultations Using e-bikes for home consultations Forming carpools Driving hybrid cars personally Driving smaller cars instead of SUVs personally

Table 7.

Sustainable patient care and mitigation measures on system level.

Sustainable patient care and mitigation measures on system level
Category	Mitigation strategies
Sustainable patient care	Using less medical material that is nevertheless sufficient for good patient care   using expired sterile bandages as non-sterile bandages e.g. for external applications for wound care   using fewer sugar test strips   thoughtful use of disposable gloves Avoiding drugs that are harmful to the environment, such as   Diclofenac   X-ray contrast agents   Asthma/ COPD medicines with propellants   Avoiding disinfection that is not degradable Using video or telephone consultation for minor issues Cleaning and sterilising medical devices in the practice instead of using single-use devices Avoiding overtreatment   conservative care instead of surgery   reasonable use of treatments Lifestyle interventions instead of prescribing medication (for diabetic patients) Avoiding prescribing antibiotics Supporting prevention Prescribing smaller packages first to test the medication so it won’t go to waste
Sustainable patient counselling	Advising patients on a healthy lifestyle, such as a meatless diet and going by bike or walk Putting information for patients on the practices’ website, using a TV in the waiting area or giving verbal recommendation Using the role of a physician as an educational mandate to inform about climate change and its negative consequences
Politics/system level	Adopt information on sustainability and waste separation into obligatory hygiene training Taking education classes in sustainability for the medical practice Education in sustainable health care, e.g. via podcasts or classes Talking about a sustainable medical practice in team meetings Creating special waste disposals for medications so they don’t end up in residual waste Expanding the durability of medications and medical devices Promoting sustainable healthcare in the media Handing out information on sustainable measures and actions for medical practices Implementing sustainable measures and actions mandatory for medical practices

Concerning the practice infrastructure, participants mentioned actions referring to energy supply, water saving, sustainable buildings, and water management. Most statements referred to sustainable energy, e.g. saving energy or using renewable sources.

First, the significant topic energy. We want our network members to switch to green electricity across the board. FG_1, Pos.110

Some participants said, they regretted that often devices still ran on batteries instead of electricity or the energy consumption could be reduced drastically with sustainable habits. One example was shutting off medical devices such as ultrasounds when not in use. Implementing water-saving systems in toilets and sinks, and planning to use sustainable building materials, e.g. climate-neutral wall paint or properly insulating windows, were also named.

Regarding recycling and waste, participants mentioned strategies to reduce waste and single-use plastic, as well as waste separation and reusing medical items. Most participants considered it necessary to reduce (plastic) waste. Some suggested switching to reusable or plastic-free materials and most were outraged about individual packaging of medical products. Some were unsure whether hygiene standards would be met with reusable items. For instance, vaccines were deemed to have excessive packaging, and the expiry dates of medical products such as wound bandages were considered too short. Participants stated that a revision was needed to balance hygiene standards and sustainability. Waste separation was seen as barely working in some practices, even though that would make the workplace more sustainable.

It’s also about practice waste, even on a small scale, simple waste separation, even that doesn’t work. FG1, Pos.127

Other suggested mitigation strategies were buying items in bigger containers to reduce plastic and ordering from less different suppliers to reduce packaging materials and delivery distances. It was proposed to actively search for more sustainable products or suppliers, e.g. paper packaging suppliers. Some suggested reducing medical waste by ordering smaller product packages and keeping expiration dates in practice storage in mind. It was mentioned that free samples from medical companies are often thrown away unused, so asking if needed before sending would also reduce waste. It was suggested that patients should first be prescribed a small pack of medication when starting a new treatment and a large pack if the medication is to be continued. Some participants mentioned that some medications are harmful to the environment because they are not biodegradable, such as Diclofenac and X-ray contrast agents and it therefore was important to find alternatives for them.

Or through other things like prescriptions, that I do not take inhalants that work on propellants for asthma COPD medications, things like that. Int_2, Pos.72

Regarding actions concerning digitized practice organization, digital patient care and online education were mentioned. Participants discussed the idea of using e-health for patient care, such as video or phone consultations and sending e-referrals to patients. In their opinion, this could save many carbon emissions by decreasing patient travels and decreasing paper use. Participants discussed digital networking with other medical practices or pharmacies to use less paper.

[…] Yes, we consume a lot of material, just prescriptions, sick notes, referrals but that’s what we have to do […] as I said we write digital letters and so, we do not send as much by mail as before. Int_7, Pos. 82

Mobility was often mentioned as a starting point to reduce the carbon-footprint of medical staff and patients. Using electric cars or bikes for home consultations and commutes were often suggested, as well as offering public transport tickets to the staff.

[For example] do I support something like a job ticket or similar to get to work CO2-free or CO2-reduced? Int_2, Pos.90

Especially in rural areas, cars were often described as the only option due to insufficient public transport. It was also mentioned that patients should be advised to adopt sustainable mobility, such as cycling or walking, to promote a healthy lifestyle.

Various specific ideas for actions concerning sustainable healthcare itself were discussed. Participants indicated that it is possible to prefer lifestyle interventions instead of prescribing medication or be more frugal with prescribing medications and medical items. Avoiding overprovision was also mentioned as an approach.

Participants stated that physicians should actively educate patients on climate change and its impact on their health and consult them about a sustainable lifestyle that can benefit their health, e.g. planetary health diet and sustainable mobility.

[…] who are trying to educate patients about what lifestyle can do to you, go meatless and things like that. Int_5, Pos.178

Other ideas included reducing the use of medical products such as gloves or bandages as much as possible. Here again, discussions about hygiene standards were brought up.

Some participants mentioned they practised sustainable behaviours at home but failed to implement these in their workplaces. Ideas of sustainable behaviour included using reusable containers instead of plastic wrap for lunch at work, drinking out of glass bottles and tap water instead of buying plastic bottles, reasonable laundry intervals for work clothes and finding sustainable materials for work clothes, e.g. avoiding single-use plastic gowns.

Contextual factors

Participants stated that politics also needed to provide guidelines about sustainable measures for primary care practices. Actions such as mandatory carbon-footprint calculation and easy access to information about sustainable practice management were discussed. Also considered important were positive incentives, such as financial support for practices when implementing sustainable measures or negative incentives for non-sustainable actions such as higher waste disposal charges. It was stated that switching to more sustainable measures should not be more expensive than currently used methods or materials.

Participants perceived that access to electric cars and bikes needed to be easier and more attractive for practices and employees, and political digitising efforts were to be followed through more consistently.

If you want to have VERAH Mobile as an e-car, there is a one-year waiting period, yes, but I need the car now to make home consultations and not in a year’s time, no, so the availability simply must be much greater, much faster, much better. That doesn’t do me any good if I want to think ecologically but don’t have the resources. Int_9, Pos.104

Dispensing rights for pharmacists were discussed, which could allow them to dispense medicines individually in the right quantities so that there was no need to throw medications away unnecessarily.

Participants talked about hygienic preparation of reusable medical devices which was often considered as less economic than buying single-use plastic items. They shared the perception that this should be changed by the industry. The contradiction between hygiene and sustainability was frequently represented throughout the interviews. Most participants talked about strict restrictions, instructions and laws considering hygiene in patient care. They stated that reducing waste was not possible if they still wanted to meet hygiene standards mostly set by external policies and hard to circumvent.

Participants stated leadership engagement was important and management needed to ensure all staff was properly educated about sustainability to make implementing changes easier and facilitate new ideas.

For example, with the paper rolls, um, we have three bosses, one of them thinks it’s totally great, says ‘I'll do it right away’, the next one says ‘Oh, I don’t know, […]’ so, as I said, I have to get the bosses on board. Int_19, Pos.105

Some said the general workflow did not yet consider sustainability or resourcefulness. Participants found it hard to break familiar routines and rethink these to act more sustainable. Staff would accept new measures if they worked but the acceptance period might take some time. If further measures meant less comfort for patients, medical staff might be hesitant to implement them for fear of negative feedback from patients. It was also mentioned that staff shortages and time-consuming work routines made it difficult to implement sustainable measures.

It was discussed that the public often judged healthcare professionals, so being more sustainable was considered important. Patients showed awareness towards sustainability more often, so it was more likely they would accept new sustainable measures in the medical practice. A positive example for this was reusing paper bags for transporting medicine that got positive reactions from patients or was even initialised by patients.

Participants perceived the general tension for change in German medical practices as low. Decisions about acting against climate change were seen as being realised very slowly and information about sustainability was considered not easily provided by physicians’ organisations and networks. Participants themselves showed a high ‘tension for change’, for example, by demanding to act faster on behalf of the wellbeing of the younger generation, showing political statements in the office, supporting environmental unions like ‘health for future’ and working with other professions such as pharmacists, electricians, suppliers, etc. Participants who showed a lower tension for change explained that it was difficult to implement changes due to the current Covid pandemic and the resulting high workload.

Attitudes, awareness, beliefs and knowledge about climate change and sustainability in healthcare

Many participants stated that sustainability was a political issue, such as expanding public transport. Others felt that physicians’ attitude towards sustainability was generally negative.

So sure, climate change, yes, but I think that’s also a topic we are sick and tired of >laughs< it’s just the way it is. Int_21, Pos.78

It was often stated that big companies should start with being more sustainable because they would have a bigger impact on climate change than a small medical practice. Some participants said that sustainability is an individual decision everyone must make for themselves and their practice. Others said the entire health sector needed to reduce their carbon footprint, not just individual practices. Some believed sustainable change could happen on two levels. One was working on sustainable patient care and the other was being an example for society as a medical profession.

The big problem of climate change will not be solved by single actions but overall concepts, political concepts, political enforcement of concepts, possibly will solve it. FG_1, Pos.85

Costs of sustainable measures were frequently discussed. While owners of medical practices were thinking about the costs of implementing new sustainable measures, employees felt management was unwilling to invest.

Discussion

Main findings

This qualitative study explored the perceptions of primary care experts in Germany regarding actions for climate change mitigation in German primary care as well as determinants for their implementation. Various mitigation strategies were named, including the use of water and energy, recycling and waste management, supply chains and procurement, digitisation, mobility of staff and patients, as well as strategies concerning patient care, behavioural changes and on system level. Barriers and facilitators for implementation were identified, such as lack of financial incentives, staff shortages and sustainable materials. Participants asked for practical and clear guidance on the practise level and suggested sharing experiences and best practices through networks, politics, podcasts or websites. Hygienic regulations were considered to limit the capabilities of sustainable actions.

Comparison with existing literature

Only a few more sustainable measures were considered applicable in primary care, namely avoiding overprovision and limiting medicines’ disposal. Digitalisation was discussed to create a paper-free medical practice and use video consultation as a contribution to reducing carbon emissions. These statements are supported by a systematic review [15] that suggested that telemedicine can reduce the carbon footprint of healthcare as it contributes to lowering travel emissions [15].

However, only a few participants mentioned the renunciation of environmentally harmful drugs. This might suggest that sustainable measures in primary care as mitigation of climate change are not yet fully considered as part of a responsible health care provision.

Literature shows that primary care practices have opportunities to reduce their environmental impact, create a more sustainable workplace and change can be promoted on a small and big scale. Pendrey et al. [16] describe that primary care physicians can show leadership on a personal level by individually reducing their carbon footprint via reducing air travel, switching to a green electricity provider and using active or public transport [16]. Also, primary care practices can serve as role models by leading campaigns on waste reduction, recycling, or active transportation [17]. Individuals could also act indirectly through political actions such as voting or protesting [18]. Participants in this study saw a leadership role for employers, stating they needed to be enthusiastic about sustainability and see it as a management task since employees alone might not feel responsible or powerful enough. The lack of connection between knowledge and awareness of climate change and actual implementation of sustainable measures might indicate a need for practice management training on implementing sustainable measures and educating medical staff on how to start with small changes and go bigger over time. Financial incentives were seen as crucial in helping with switching to more sustainable measures, as such changes were often perceived as expensive investments. Consideration of such incentives needs to be discussed on a political level.

AnAker described that nurses did not see sustainability as a task at work [19], because saving lives, hygiene and safety measures to prevent infections and antibiotic resistance are top priorities. Climate change and sustainability were less important [19]. This mindset was also observed in this present study. Many participants said that hygiene standards must be met when talking about sustainable measures while others argued that they went too far and unnecessary precautions had been taken, e.g. individual packing. This might indicate that some participants felt constricted by hygiene standards set by the health department. It could also indicate that hygiene of sustainable alternatives is questioned and that hygiene and safety for one patient, staff or practice stands above the global population’s health. This suggests that more education is needed about the big picture of climate change and the consequences of daily actions, both personally and in the health sector.

Findings of this qualitative study showed that the participants are aware of climate change issues but contextual factors influencing the implementation of sustainable measures to reduce the carbon-footprint play a big role. Guidance, support and rules to implement sustainable measures should be introduced prominently by politics, the Department of Health or the German network of physicians as encouragement. Easy access to feasible guidelines and practical information, a website that disseminates general information on sustainability as well as sustainable ways to shape a medical practise could be an approach. Furthermore, management and employees need training in implementing sustainable strategies into their work. Physicians’ networks might be a promising setting for such activities.

Strengths and limitations

This study is a sub-study embedded in a qualitative study on building resilience in German primary care practices within the RESILARE project, which aims to improve their crisis resilience. To avoid selection bias, the interviews were not primarily advertised from a climate change perspective. Some participants knew in advance that climate change would be a topic due to their more detailed knowledge of the project objectives. Nonetheless, participants showed a vast spectrum of attitudes, awareness and approaches to climate change and sustainability. The intended interview duration of 45 min was reached or even exceeded, indicating a great willingness for discussion. A particular focus was placed on preventing socially desired answers using a sensible interviewing technique.

Conclusion

Findings of this study can inform development of future environmental impact-reducing strategies in primary care. Guidance and support for their implementation should be considered to facilitate sustainability.

Appendix: Interview guide

Main topics:

1. Own experiences in practice

   • – What was seen as a crisis? What turned it into e crisis?

2. Strategies

   • – What worked? What did not?

   • – Role of Recommendations

   • – What changed?

3. Crises resilience in medical practices

   • – Necessary training, competences for staff?

   • – Organisation

   • – Patient information and counselling

4. Anticipated future crises

5. Climate change as a threat

   • – Perceived impact for primary care and patients

6. Heat waves

   • – Impact so far on practice

   • – Recommendations for patients

   • – Medical guidelines

7. Mitigating ecological footprint

   • – Materials in primary care

   • – Medication

   • – Use resources

   • – Suggestions for improvements

   • – Challenges

   • – Discourse in medical practices

8. Quality indicators

   • – coverage

Funding Statement

The project RESILARE is fully funded by the Innovation Fund of the Federal Joint Committee (G-BA), grant number: 01VSF20029.

Disclosure statement

No potential conflict of interest was reported by the authors. The authors alone are responsible for the content and writing of the paper.