The Adoption of Green Dentistry among Dentists in ...

The Adoption of Green Dentistry among Dentists in Thailand

A dissertation submitted to The University of Manchester for the degree of Master of Science in Healthcare Management in the Faculty of Humanities

2013

Voramon Agrasuta

MANCHESTER BUSINESS SCHOOL

Table of Contents List of Figures

5

List of Tables

5

Declaration

6

Copyright Statement

7

Acknowledgements

8

Abstract

9

Chapter 1: Introduction

10

1.1 Background of the Study

10

1.2 Statement of the Problem

11

1.3 Theoretical Framework

12

1.4 Purpose of the Study

13

1.5 Research Questions

13

Chapter 2: Literature Review

15

2.1 Green Dentistry

15

2.1.1 Amalgam Management

16

2.1.2 Radiographic Management

16

2.1.3 Waste Management

17

2.1.4 Infection Control Management

18

2.1.5 Energy Management

19

2.1.6 Water Management

19

2.2 Green Innovation Characteristics

20

2.2.1 Relative Advantage

20

2.2.2 Compatibility

21

2.2.3 Simplicity

21

2.2.4 Trialability

22

2.2.5 Observability

22

Chapter 3: Research Methodology

23

3.1 Research Approach

24

3.2 Research Strategy

24

3.3 Time Horizon

24

2

3.4 Sampling Procedures

24

3.5 Questionnaire Instrument Design

25

3.6 Data Collection

27

3.7 Data Analysis

28

Chapter 4: Findings and Analysis

29

4.1 The Demographic Profile of Respondents

29

4.1.1 Gender

29

4.1.2 Age and Working Experience

30

4.1.3 Education

31

4.1.4 Workplace

32

4.1.5 Work Role

32

4.2 The Perception of Green Dentistry

33

4.3 Knowledge of Green Dentistry

35

4.4 Attitudes to Green Dentistry

38

4.5 Practices Relating to Green Dentistry

41


41


41


41


42


42


42

4.6 The Adoption of Green Dentistry

45

4.6.1 The Adoption of Green Practices in the Future

45

4.6.2 The Innovation Characteristics

45

4.7 Additional Suggestions about Green Dentistry Chapter 5: Discussion

48

49

5.1 Knowledge Attitudes and Practice of Green Dentistry

49


50


51


51


51


52 3


52

5.2 The Persuasive Effect of Green Innovation Characteristics Chapter 6: Conclusion and Recommendations

52

55

6.1 Conclusion

55

6.2 Limitations

55

6.3 Recommendations

56

References

58

Appendix A

ผิดพลาด! ไม่ ได้กาหนดที่คนั่ หน้ า

Appendix B

ผิดพลาด! ไม่ ได้กาหนดที่คนั่ หน้ า

Word count: 10,217 words

4

List of Figures Figure 1: Theoretical framework

13

Figure 2: Radiographic waste from used film packet

17

Figure 3: Types of healthcare waste

18

Figure 4: The research 'onion'

23

Figure 5: A simplified formula to calculate sample size

25

Figure 6: A calculation of sample size in this survey

25

Figure 7: Gender of respondents

29

Figure 8: Age of respondents

30

Figure 9: Respondents' working experience

30

Figure 10: Respondents' workplace

32

Figure 11: Respondents' work role

32

Figure 12: Total score of knowledge questions

36

Figure 13: Practices regarding green dentistry

43

Figure 14: The adoption of green dentistry in future practices

45

Figure 15: The influential effect of innovation characteristics on the adoption of green practices among Thai dentists

47

List of Tables Table 1: Education of respondents

31

Table 2: Cross-tabulation between respondents' demographic profiles and their experiences of hearing the term 'green dentistry' Table 3: Questions assessing knowledge of green dentistry

34 35

Table 4: The Mann-Whitney test between gender and total knowledge score 36 Table 5: The Kruskal-Wallis test between workplace and knowledge score

37

Table 6: Attitudes towards green dentistry among Thai dentists

40

Table 7: The current practices among Thai dentists

44

5

Declaration No portion of the work referred to in the dissertation has been submitted in support of an application for another degree or qualification of this or any other university or other institute of learning

6

Copyright Statement Copyright in text of this dissertation rests with the author. Copies (by any process) either in full, or of extracts, may be made only in accordance with instructions given by the author. Details may be obtained from your Programme Administrator. This page must form part of any such copies made. Further copies (by any process) of copies made in accordance with such instructions may not be made without the permission (in writing) of the author. The ownership of any intellectual property rights which may be described in this dissertation is vested in the University of Manchester, subject to any prior agreement to the contrary, and may not be made available for use by third parties without the written permission of the University, which will prescribe the terms and conditions of any such agreement. Further information on the conditions under which disclosures and exploitation may take place is available from the Academic Dean of Manchester Business School.

7

Acknowledgements Apart from the efforts of myself, the success of my dissertation depends largely on the encouragement of many people. I would like to take this opportunity to express my gratitude to the people who have been instrumental in the successful completion of this dissertation. I would like to show my deepest appreciation to my supervisor, Dr. Adrian Nelson. I cannot say thank you enough for his tremendous useful comments, patient guidance, enthusiastic encouragement and persistent help. This work would not have been possible without his help and support. I would also like to extend my thanks to teachers and classmates in MSc Healthcare management, the University of Manchester for my valuable experiences. I would like to thank Mr.Kittithach Mongkolsiwa as well for the good advices. I would like to thank the following organisations for their supports in my survey: Srinakharinwirot University Dental Alumni Society, Thai Dentists’ facebook group and Thai Rural Dentists. Special thanks should be given to all dentists who participated in my survey. Furthermore, I would like to thank my colleagues in Sanamchaikhet Hospital, and my friends in Thailand, Manchester and elsewhere for their support and encouragement throughout. Finally, I would like to thank my parents and sister for their endless love, encouragement and unequivocal support throughout, as always, for which my mere expression of thanks likewise does not suffice.

8

Abstract Objective: To examine the diffusion of green dentistry by Thai dentists. This study focuses mainly on the current knowledge, attitudes and practice of green dentistry among dentists in Thailand in order to identify gaps in these three respects. Furthermore, it aims to determine which characteristics of green dentistry are the most influential in encouraging the adoption behaviour of green dentistry. Methodology: Data was collected using online questionnaires. The Thai dentists were contacted by various methods, including sending the URL address via email or social networks. Findings: The total number of respondents for this survey was 472. Most of them had never heard of the term ‘green dentistry’ before. Additionally, their current practices are not eco-friendly despite their high levels of knowledge and quite positive attitudes towards green dentistry. Specifically, most practices that are related to products or infrastructures have a low implementation score, especially amongst public sectors. This study reveals that the ‘simplicity’ characteristic is the most influential in persuading Thai dentists to adopt green innovations. Conclusion:

Due to green dentistry is a new topic, most Thai dental

practices are not environmentally friendly. In order to encourage the green strategies among Thai dentist, the green dentistry process should simple, easy, and do not require additional costs and resources over the basic requirements. Key words: Thailand, green dentistry, innovation characteristics

9

Chapter 1: Introduction 1.1 Background of the Study At the present time, global warming is one of the most serious issues facing people around the globe (World Health Organization [WHO], 2011; Garla, 2012). A wealth of evidence reports an increase in global average air and ocean temperatures, the widespread melting of snow and ice, and rising global average sea levels. Moreover, these effects seem to be larger during the

21st

century

than

those

observed

during

the

20th

century

(Intergovernmental Panel on Climate Change, 2007). One of the most significant negative effects of climate change is its potentially devastating impact on human health (WHO, 2011); there is a correlation between environmental abuse and human diseases (Bresnitz et al., 2004). A change in the global climate results in a rise of air pollutant levels, an increase in disease transmission through contaminated food and water, and a higher level of extreme weather hazards. Moreover, the spread of infectious diseases will be encouraged by the temperature shifts (WHO, 2008). An awareness of the environment is rapidly moving to the forefront of humanity’s consciousness (Dunlap et al., 1993). Many organisations are incorporating the environmentally responsible into their practices, or are ‘going green’ (Farahani and Suchak, 2007). The term ‘green’ is defined as ‘actions that reduce the impact on the environmental, such as ecopurchasing or recycling’ (Wolfe and Shanklin, 2001, p.209). Green innovations are therefore being considered across all businesses (Iqbal, 2012) and the healthcare sector is no exception; this is especially due the fact that it is the leading producer of waste and also the largest consumer of energy, water, and other resources (Levin, 2006; Iqbal, 2012). The benefits that the healthcare sector receives from green practice are not only health co-benefits, but also economic and social co-benefits. The economic cobenefit is the key advantage and consists of lower hospital expenses (Hitchcock and Willard, 2006; WHO, 2011). Dentists generate a variety of wastes in their practices that could challenge the global environment and human health such as amalgam 10

restorative materials, radiographic wastes, plastic/paper

wastes and

disinfectant chemicals (Muhamedagic et al., 2009; Al Shatrat et al., 2013; Garla, 2012). Although individual dentists produce only small amounts of environmentally ‘unfriendly waste’, the accumulated wastes produced by the profession may have a significant effect on the environment (Farmer et al., 1997). Every dentist has an environmental responsibility to conserve natural resources and to reduce toxic waste products. Therefore, a ‘green dentistry’ approach was introduced to improve human well-being through the minimization of waste, a decrease in pollution and the conservation of energy and water (Ruxandra et al., 2010). Thailand has the same attitude as other countries, which are also concerned about the development of sustainability in the future (United Nations Environment Programme, 2010). There were several projects related to environmental concerns in Thailand, for example, the Thai Ministry of Public Health launched the ‘Green and Clean Hospital Project’ to increase awareness about climate change amongst the healthcare sector. This project focused on garbage, restrooms, energy, the environment and nutrition (Punpeng, 2010). However, this project

still did not cover every

environmental issue within Thai dental practices and was not generally diffused throughout practices because its overall details were more geared towards the hospital context than the dental. Although there are some similarities between issues in green dentistry and those in other environmental concern strategies, the green dentistry approach is more specific to dental practices and is not only concerned with environmental issues, but also human health. 1.2 Statement of the Problem Although green dentistry has been adopted by dentists in many countries for several years, the practice is very new for dentists in Thailand. In order to diffuse the practice of green dentistry to Thai dentists, it is necessary to explore their current knowledge, attitudes and practice of green dentistry. Such findings are necessary for practical policy-making, in order to identify what could be improved and which specific characteristics of green 11

dentistry could persuade Thai dentists to adopt this practice. Currently, there are no studies on green practice in Thailand that have measured dentists’ knowledge, attitudes and practice. Additionally, no research has been conducted measuring which characteristics of green dentistry have the most influence on the adoption of green practice among Thai dentists. 1.3 Theoretical Framework Based on Rogers’ diffusion of innovation theory (1995), the term ‘innovation’ was defined as ‘an idea, practice, or object that is perceived as new by an individual or other unit of adoption’ (p.11). This study is going to label ‘green dentistry’ as an innovation because it is a new practice for Thai dentists. Innovation passes through individuals’ decisions by ‘a model of the innovation-decision process’ which consists of five stages; knowledge, persuasion (attitude formation), decision, implementation (use of the innovation) and confirmation. This study will focus on the knowledge and persuasion stages, to find out the ways in which Thai dentists make the decision to adopt green dentistry in their practice. The first two stages are necessary in understanding adoption behaviour as they entail the formation of an attitude about the innovation. The attitude formation in the second stage has been found to be highly based on individuals’ perceptions of the characteristics of the innovation. The innovation characteristics that influence an individual’s decision to adopt or reject innovation are relative advantages, compatibility, complexity, trialability and observability (Rogers, 1995).

12

Perceived characteristics of green dentistry 1. 2. 3. 4. 5.

Relative advantage Compatibility Complexity Trialability Observability

Figure 1 Theoretical framework Adapt from ‘a model of the innovation-decision process’ (Rogers, 1995)

1.4 Purpose of the Study The purpose of this study is to examine the diffusion of green dentistry by Thai dentists. This study focuses mainly on the current knowledge, attitudes and practice of green dentistry among dentists in Thailand in order to identify gaps in these three respects. Furthermore, it aims to determine which characteristics of green dentistry- relative advantages, compatibility, complexity, traialability and observability- are the most influential in encouraging the adoption behaviour of green dentistry. In achieving this, it is envisaged that the study will contribute to managerial understanding and guide the future diffusion of green dentistry. 1.5 Research Questions The research will seek to address the following questions: 1. What is the knowledge held by Thai dentists toward green dentistry? 2. What are the Thai dentists’ attitudes toward green dentistry? 3. Have Thai dentists adopted green dentistry in their current practices? 4. How do the innovation characteristics- relative advantage, compatibility, simplicity, trialability and observability- affect the adoption of green dentistry in dental practice? 13

In order to answer the questions above, quantitative data was collected using a survey method. This study will use online surveys sent to Thai dentists. The questionnaire consists of several questions that will be used to identify the respondents’ knowledge, attitudes, and practice of green dentistry. It will be further used to specify the influential level of innovation characteristics in the adoption of green dentistry practice. To conduct a good and thorough research, this study is structured into 5 main parts; literature review, research methodology, findings and analysis, discussion, and conclusion and recommendations.

14

Chapter 2: Literature Review This chapter begins with a background of green dentistry, including the definition of green dentistry, its details and practices. This is followed by an explanation of the concept of innovation characteristics that could influence the adoption of innovation. Further details will then be presented about the innovation characteristics that relate to green practices. 2.1 Green Dentistry In 2007, Farahani and Suchak published their study about eco-friendly dentistry. This study defined eco-friendly dentistry as ‘an approach to dentistry that implements sustainable practices by keeping resource consumption in line with nature's economy, by safeguarding the external environment through the elimination or reduction of outgoing wastes and by promoting the well-being of all those in the clinical environment by consciously keeping chemicals out of the air we breathe’ (Adams, 2007, p.581). In 2008, the Eco-Dentistry Association was established in the United States in order to educate and provide a members association for green dental

professionals

(Pockrass,

2009).

‘Eco-friendly

dentistry’

and

'environmentally friendly dentistry' are frequently used synonymously with the term ‘green dentistry’ (Higgins, 2009; Passi and Bhalla, 2012). In order to be more ecological, there are many approaches implemented by dentists that help them to make an easier transition to a more eco-friendly practice, for example, the Four R’s: rethink, reduce, reuse and recycle (Pockrass and Pockrass, 2008). The implementation of green practices for dentists in this study will be divided into the following areas: amalgam management, radiographic management, waste management, infection control, energy management and water conservation (Al Shatrat et al., 2013; American Dental Association [ADA], 2009).

15

2.1.1 Amalgam1 Management Amalgam contains mercury which is a serious concern in relation to both the environment and human health (Jokstad and Fan, 2006). Dental clinics produce approximately 3.7 tons of mercury waste per year (Pockrass, 2009); it is therefore important to have proper practices for the management of amalgam use. The American Dental Association (2009) recommended using pre-capsulated amalgam which can reduce the amount of disposed mercury. The installation of an amalgam separator2 is the most important environmental initiative for any dental clinic (Eco-Dentistry Association, 2013). Moreover, there are many alternative restorative materials such as tooth coloured restorations which do not contain mercury (Mercola and Klinghardt, 2001). 2.1.2 Radiographic Management Conventional radiographies produce large amount of wastes including paper, plastic and lead foil from used film packets (Figure 2), and the disposal of toxic chemical wastes such as developer and fixer 3 solutions (Elliott-Smith, 2008; Al Shatrat et al., 2013). Green dentistry suggests many proper methods for the management of radiographic waste, for example not putting used fixer down the drain (Vermont Department of Environmental Conservation, 2002; Muhamedagic et al., 2009). Furthermore, according to the Eco-Dentistry Association (2013), using digital x-rays instead of conventional types could reduce waste by 28 million litres of toxic fixer solution and 4.8 million lead foils.

1

‘Dental amalgam’ means a dental filing material consisting of an amalgam of mercury, silver and other materials such as copper, tin, or zinc (Vermont Department of Environmental Conservation, 2002, p.2) 2 ‘Amalgam separator’ means a wastewater treatment device involving sedimentation, filtration or centrifugation, or a combination of these technologies designed to separate amalgam particles from dental wastewater (Vermont Department of Environmental Conservation, 2002, p.2). 3 A solution normally used in the processing of dental radiographs (Muhamedagic et al., 2009)

16

Figure 2 Radiographic waste from used film packet (Source: http://upload.wikimedia.org/wikipedia/commons/8/89/Dental_x-ray_film_05.JPG)

2.1.3 Waste Management Healthcare sectors produce several types of healthcare wastes as shown by Figure 3 (Schroeder et al., 2013, p.193). However, currently there is no international standard for waste management in the healthcare sector, it varies in each country and many dentists have not practiced proper methods to manage healthcare waste. They still need to be educated regarding healthcare waste management methods to improve their knowledge and understanding of the problem (Muhamedagic et al., 2009). One significant waste within dental clinics is paper. Dentists could be more environmentally friendly by changing from a paper-based records system to a computer-based records system (Al Shatrat et al., 2013). Moreover, recycling is another green practice. There are several benefits of recycling such as a reduction of demand for new materials, a decrease in transportation and production costs, and the utilisation of used materials (Edwards and Harrison, 1999). However, only a few hospitals co-operate with recycling as part of their waste management (Lam, 1988).

17

Stationery

Used needles and syringes

Soiled dressings

IT waste

Food

Body parts

Healthcare Waste

Radioactive materials

Diagnostic samples

Chemicals Pharmaceuticals

Medical devices

Figure 3 Types of healthcare waste (Schroeder et al., 2013, p.193)

2.1.4 Infection Control Management Infection control methods from dental clinics produce one of the ‘big four’ of wastes and pollutants, and some chemical cleaners could be dangerous for staff and patients (Eco-Dentistry Association, 2013; Pockrass, 2009). Williamson (2010) coined the term ‘green cleaning’ to describe the process of reducing the carbon footprint and making sure that facilities are healthy for patients, staff, and the environment. The green dentistry approach suggests that dentists should use biodegradable disinfectants and steam sterilisation methods which do not release a toxic chemical or hazardous waste into the environment. Moreover, substituting single-use instruments with reusable ones which can be sterilised is another way to go green (Eco-Dentistry Association, 2013; Pockrass and Pockrass, 2008; Elliott-Smith, 2008).

18

2.1.5 Energy Management One of the first and most important concerns of green practice is energy management (Gul et al., 2008). Generally electricity is generated from the burning of fossil fuels such as coals, oil and natural gasses. During the burning processes, pollutants are released to the atmosphere and thus are the single largest contributor to greenhouse gases (United States Environmental Protection Agency, 2011). Reducing electricity use is therefore an important eco-friendly strategy, and could be achieved by practices in a variety of ways. Practices could, for example, switch to compact fluorescent light bulbs, which is not only energy saving but also have a longer life than incandescent lights (Chameides, 2007). Installing lighting motion detectors and unplugging electronics when they are not in use can also reduce electricity (Dalin, 2009; Henry, 2009). 2.1.6 Water Management Healthcare sectors consume huge quantities of water. In order to control water consumption, there are several things a practice can do such as monitoring water usage, ensuring that leaks are repaired, planting drought-resistant plants, and using efficient water technologies (Gleick and Cushing, 2009). Effective technologies for the conservation of water include the installation of motion sensors for water faucets and switching from a standard toilet to a dual-flush toilet (Henry, 2009; Dalin, 2009). McMillan (2008) said that by adopting water conservation strategies, his dental clinic is able to save 200,000 gallons of water per year. All of the above green dentistry approaches are new strategies that produce a less negative impact on the environment than conventional practices; these green approaches are therefore often referred as ‘ecoinnovations’ (Albino et al., 2009; Pujari, 2006). According to Beise and Rennings (2005), eco-innovations ‘consist of new or modified processes, techniques, practices, system and products to avoid or reduce environmental harms’ (p.6). In order to increase the adoption of this eco-innovation,

19

policymakers or business strategists have to understand the determinants driving and hindering the adoption decision making process (Jansson, 2011). The following section will present factors that could persuade the adoption of eco-innovation among Thai dentists. 2.2 Green Innovation Characteristics It has been demonstrated that green innovation is a new issue for Thai dentists; there has been no study on green dentistry among Thai dentists prior to this one, so it aims not only to discover their current knowledge, attitudes and practices but also to investigate the factors that could persuade Thai dentists to adopt the green innovation. As shown by research framework, factors that could affect the ‘persuasion stage’ are innovation characteristics: relative advantage, compatibility, complexity, trialability and observability. This section is going to review studies which relate specifically to green innovation characteristics. 2.2.1 Relative Advantage Relative advantage has been defined as ‘the degree to which an innovation is perceived as better than the idea it supersedes’ (Rogers, 1995, p.212). It has been found that the perception of relative advantage has a positive influence to the rate of adoption of several innovations (Agarwal and Prasad, 1997; Venkatraman, 1991) including eco-innovation (Guagnano et al., 1986; Labay and Kinnear, 1981; Völlink et al., 2002).

20

Relative advantage regularly relates to financial profitability (Esty and Winston, 2009; Feiertag, 1994; Rogers, 1995). Examples of eco-innovation relative advantage characteristics are improved efficiency, lower energy expenditures, reduction of waste, and renewable energy (Hitchcock and Willard, 2006; WHO, 2011). Several studies have focused on the processes in which hospitals have involved eco-innovations. A survey by Bush (2008) reports that the lowering of energy costs is the main reason that healthcare sectors have decided to be green. 2.2.2 Compatibility Rogers (1995) has explained compatibility as ‘the degree to which an innovation is perceived as consistent with the existing values, past experiences, and needs of potential adopters’ (p. 224). An innovation that is compatible with the organisational structure, value and norms of social system will be adopted more rapidly than an incompatible one (Higa et al., 1997). Studies reveal that the compatibility of innovation has a positive relationship with several innovations, including eco-innovation (Ndubisi and Sinti, 2006; Curran and Meuter, 2005; Labay and Kinnear, 1981). One of the biggest concerns for any healthcare professional is service quality; healthcare sectors are thus highly encouraged to be more ecological without compromising the quality of service that they provide to their patients (Bush, 2008). 2.2.3 Simplicity In order to keep a consistent positive-oriented direction, the term ‘simplicity’ was chosen instead of ‘complexity’. According to Rogers (1995), complexity, the inverse of simplicity, is ‘the degree to which an innovation is perceived as relatively difficult to understand and use’ (p. 242). Some innovations are easy to understand while others are more complex; the more complicated the innovation, the slower the innovation’s adoption rate. Research has shown that the complexity of an innovation has a negative influence on its adoption (Dickerson and Gentry, 1983; Hobday, 1998), including in relation to eco-innovations (Labay and Kinnear, 1981). 21

2.2.4 Trialability Trialability was defined as ‘the degree to which an innovation may be experimented with on a limited basis’ (Rogers, 1995, p. 243). Generally people tend to adopt new practices or ideas that can be tried beforehand easier than innovations that have not tried out (Rogers, 1995). The ability to test an innovation for a trial period has a positive influence with the adoption of innovation (Molesworth and Suortfi, 2002). However, some studies have found that the trialability characteristic has no influence on the adoption of eco-innovations (Labay and Kinnear, 1981; Völlink et al., 2002). 2.2.5 Observability The fifth innovation characteristic is observability, which is also regularly referred as visibility. Roger (1995) defined this characteristic as ‘the degree to which the innovation, or the results of adopting the innovation, is visible to others’ (p.244). The ease with which different ideas and practices are observed and communicated will vary (Agarwal and Prasad, 1998) and people are more likely to adopt innovations whose results are easier to see (Roger, 1995). The observability characteristic also has a positive relation with the adoption of eco-innovations (Labay and Kinnear, 1981; Guagnano et al., 1986).

22

Chapter 3: Research Methodology Research methodology refers to the ‘systematic, focused and orderly collection of data for the purpose of obtaining information from them, to solve/answer a particular research problem or question’ (Ghauri and Gronhaug, 2005, p.109). The previous chapter described the research questions and conceptual framework that were developed from a review of the available literature. This chapter will present the way in which this study collected data to answer its research questions, by drawing reference to the research ‘onion’ as outlined in Figure 4, (Saunders et al., 2012, p.128) The chapter has been divided into seven sections: research approach, research strategy, time horizon, sampling procedures, questionnaire instrument design, data collection, and data analysis.

Philosophy Approach

Methodological choice

Strategy (ies) Time horizon

Techniques and procedures

Figure 4 The research 'onion' (Saunder et al., 2012)

23

3.1 Research Approach An

important

stage

in

any research

project

is

gaining an

understanding of the available research approaches, which can be either inductive, abductive or deductive (Saunders et al., 2012). This study applied the deductive approach to attain its research objectives. The deductive approach establishes a theory and hypothesis, and then designs tests for that hypothesis (Saunders et al, 2012). 3.2 Research Strategy Research strategies provides guidance for data collection and data analysis (Bryman and Bell, 2007), enabling researchers to find answers to the questions set for any research. This study employed a quantitative approach which allowed for more generalised information through the analyses of the survey results. 3.3 Time Horizon In the research design stage the time frame needs to be taken into consideration, either through cross-sectional or longitudinal studies. A crosssectional design was judged more appropriate for this study, because the time scales of the programme allowed only a short period to process this research. Further, it is appropriate given that the data was collected at a specific point in time in order to investigate the current knowledge, attitudes, practices and the adoption of green innovation among Thai dentists. 3.4 Sampling Procedures The target population of this research was Thai dentists. Regarding sample size, Bryman and Bell (2007) recommend that the larger the sample size, the more the accuracy of the results. There are several methods to determining sample size. Given the total population number was known, Yamane’s (1967) formula was used to calculate a sample size which could accurately represent the total 11,876 dentists currently practicing in Thailand (The Royal College of Dental Surgeons of Thailand, 2012). The formula in 24

Figure 5 was used to calculate the sample size in Figure 6. A 95 per cent confidence level and p = .05 are assumed for this equation.

Figure 5 A simplified formula to calculate sample size (Yamane, 1967) (where ‘n’ is the sample size, ‘N’ is the population size, and ‘e’ is the level of precision) N

=

11,876 = 1+(11,876)(0.05)(0.05)

11,876 30.69

= 386.97

Figure 6 A calculation of sample size in this survey From the formula, the sample size for this study is 387 dentists. This survey used a non-probability sampling, consists of convenience sampling and snowball sampling. The respondents were chosen based on their availability to respond to the survey. These approaches are used because, even though a convenience sampling could cause an error sampling, but snowball sampling helps to better define the target population (Hair et al., 2007). Finally, the total number of respondents for this survey was 472. 3.5 Questionnaire Instrument Design An effective questionnaire should be developed to meet the purposes of study and customised to the research method (Aaker et al., 2004). A selfdesigned survey questionnaire was developed and administered in order to relevant to each of the research questions, as derived from the review of the related literature (Smerecnik and Andersen, 2011; Al Shatrat et al., 2013). The survey also included a statement and online form for informed consent, which described the nature of the survey and its anonymity. If the participant agreed with the terms of consent, they would then progress to the survey. A definition was provided, framing the concept of green dentistry in order to help respondents to interpret the questionnaire. The survey included questions on knowledge, attitudes and practices of green dentistry and some regarding the green innovation characteristics that influence dentists to adopt 25

green practice. A final page thanked the participant and provided a space for their feedback. The questionnaire consisted of five sections (Appendix A). The first had eight questions relating to demographic information. The second part contained seven about knowledge information. The first question of this part asked whether they had ever heard of the term ‘green dentistry’. Other questions were multiple choices such as ‘What is a proper method to manage amalgam disposal?’. Respondents chose only one option that they thought was the correct answer to each question. The best score for knowledge was 6, followed by: 4 to 5=high, 3=moderate, 1 to 2=low and 0=very low. The third section contained eleven questions regarding attitudes about green dentistry practices. For instance ‘Green practice has many long-term benefits, such as lower energy and water bills’. Single-item five-point semantic differential and Likert-type scales were used to identify dentists’ attitude towards green dentistry. A measure was employed to determine their level of agreement (strongly disagree to strongly agree) towards a statement concerning green dentistry. The next part included fifteen questions about their current practices. A variety of questions were used to evaluate whether each dentist had implemented green dentistry into their current practices; these indicated either that it was fully implemented, in process, not implemented, or that the respondent was not sure. The last section included nine questions about the persuasive effects of innovation characteristics on the adoption of green innovation; five constructs were developed based on the literature review (Smerecnik and Andersen, 2011). The degrees of influence were measured using a five-point scale ranging from 1 (not at all influential) to 5 (extremely influential). The five constructs were measured using 5 items relating to relative advantage, compatibility, simplicity (the inverse of complexity), trialability and observability. The 50-item questionnaire was developed using Qualtrics™ survey software and a pilot survey was conducted on a small sample of Thai dentists to ensure clarity and ease of completion. The questionnaire was developed in two versions; a Thai language and an English language 26

version. The Thai version was used to distribute and collect the data because the targeted samples were Thai dentists who may not have been fluent in English. The English version was used as an illustration of the Thai version. An example questionnaire (in both English and Thai) is shown at Appendix A. 3.6 Data Collection Data was collected using Qualtrics™ online data collection system. The participants were contacted by various methods, including sending the URL address via email or social networks. The Facebook group of Thai Dentists was used as one questionnaire distribution channel because it specifically targeted Thai dentists. The questionnaire approach was selected for this research because of several reasons. First, a large amount of data can be collected, standardised, and used for comparison (Saunders et al., 2012). Moreover, it is also suitable for research that is taking place within a limited time frame and budget (Bryman and Bell, 2007). However, there is some disadvantages should be considered. In particular, it should not contain a lot of questions in the questionnaire because the respondent might fatigue, resulting in a higher risk of missing data (Bryman and Bell, 2007). Comparing with paper-based questionnaires, online questionnaires are perceived as more interesting and enjoyable, and have lower costs and faster responses (Pan et al., 2003). Moreover, online questionnaires can be an effective instrument to measure the respondents’ attitudes (Grossnikle and Raskin, 2001). Based on the discussion above, online questionnaires were considered to be an appropriate method for collecting the primary data in this study. Participating dentists accessed the survey online through Qualtrics™ survey software between 13rd June and 7th July 2013. An introductory message was sent via email and posted in the Facebook group, introducing the purpose of the study and emphasizing the importance of the results. After the initial contact, a formal letter was sent requesting participation; this provided the unique URL and an explanation of the study. Respondents were not required to identify themselves or their institutions in the questionnaire, 27

and a secure server was used to restrict access and protect the privacy of each participant. Finally, a third letter was sent two weeks after the second letter to serve as a reminder and again encourage participation. 3.7 Data Analysis The data was coded and analysed by SPSS. A descriptive statistical method was used, including means, frequencies, and standard deviations. The data was tested for normality of distribution before analysis, and the results show that the data deviates from a normal distribution. As a result, non-parametric statistics, such as the Chi-square test, the Mann-Whitney test and the Kruskal-Wallis test were used in this study. The independent variables included the demographic profile, while the dependent variables were the knowledge, attitudes and practices of green dentistry. In order to address the first research question, reporting of means and standard deviations were used to obtain a general view of dentists’ knowledge towards green practices. Next, the attitudes of Thai dentists toward green dentistry were measured to address the second research question. Following this, the implementation of green practices (research question 3) was measured by determining means and standard deviations for items designed to measure green practices. Finally, persuasion to adopt green practices through green innovation characteristics (research question 4) was measured.

28

Chapter 4: Findings and Analysis This chapter presents an analysis of the results of the survey. Firstly, the demographic profile of respondents will be presented. The second part will show the results concerning the knowledge of respondents, which is linked to the first research question. This will be followed by the results surrounding their attitudes towards green dentistry, which is related to the second research question. Next, the findings related to the respondents' current practices are presented; this is linked to the third research question. Fourthly, the findings that relate to the fourth research question are analysed, these being the characteristics which influence respondents to adopt a green practice. Finally, the qualitative suggestions of the respondents are presented. More details about the questionnaire and results are given in Appendix A and B. 4.1 The Demographic Profile of Respondents The online questionnaires were completed by 472 respondents. Their demographic profile is summarised in this section. 4.1.1 Gender It can be seen in Figure 7 that the majority of the total number of respondents are female, accounting for 72.2 per cent (or 340 respondents), while 27.8 per cent (or 131 respondents) of the total are male.

Figure 7 Gender of respondents

29

4.1.2 Age and Working Experience The ages of the respondents ranged from 24 to 63 years, and the average age was 32.4 years (SD=6.342). Figure 8 illustrates the age groups, ranging from the group of respondents who were aged below 31 to the group of those over 50 years old. The group of respondents aged below 31 was found to be the largest group of respondents in this research (44.7%), followed by the group aged between 31 and 40 (43.0%). Results concerning working experience (Figure 9) are, to a certain extent, similar to those for the age groups, which means that there are more of the younger respondents represented in the less experienced groups than of the experienced respondents. Almost half of the respondents (45.7%) had been working between 6 and 10 years. This is followed by the group that has an experience of less than 6 years (28.1%). For the online survey, the respondents were generally young, due to the fact that the online survey may have been more accessible to the new generation of professionals.

41-50 9.5%

Above 50 2.8%

Below 31 Below 31 44.7% 31-40 43.0%

31-40 41-50 Above 50

Figure 8 Age of respondents (years)

Figure 9 Respondents' working experience (years) 30

4.1.3 Education Table 1 shows the highest level of education of the respondents in this research. The majority of people who participated in this survey have achieved a Bachelor's degree (45.7%), which is a Doctor of Dental Surgery (DDS) from Thailand. This was followed by those who graduated with a Master’s degree (19.4%) or a post-graduate certification (18.5%). Finally, people who held a Doctoral degree were in the minority (2.8%). Only 4.3 per cent of the respondents graduated in their highest degree at an institution abroad. Table 1 Education of respondents; country of qualification by education level Thailand

The United Kingdom

The United States

Japan

Australia

Total

Bachelor’s degree

212

0

0

0

0

212 (45.7%)

Postgraduate certification

83

0

3

0

0

86 (18.5%)

Master’s degree

81

3

5

0

1

90 (19.4%)

Residency training programme

62

0

1

0

0

63 (13.6%)

Doctorate degree

6

2

1

2

2

13 (2.8%)

Total

444 (95.7%)

5 (1.1%)

10 (2.2%)

2 (0.4%)

3 (0.6%)

464 (100%)

31

4.1.4 Workplace Most of the respondents worked in public sectors, which can be divided between the Ministry of Public Health (62.1%) and other Ministries (6.2%). Approximately one-fifth worked in the private sector (20.8%), and only 10.9 per cent worked in the faculties of dentistry (Figure 10). Faculty of dentistry 10.9% Private clinic 17.2% Public hospital in MoPH 62.1%

Private hospital 3.6%

Public hospital in Ministry of Public Health Public hospital in other Ministries Private hospital Private clinic Faculty of dentistry

Public hospital in other Ministries 6.2%

Figure 10 Respondents' workplace

4.1.5 Work Role Figure 11 illustrates that, of the respondents who completed the survey, the majority had a role as a dentist (68.4%), while those who are a chief of a dental department represent 17.8 per cent, teachers 10.2 per cent and dental clinic owners 3.6 per cent.

Figure 11 Respondents' work role

32

Research Question 1: What is the knowledge held by Thai dentists toward green dentistry? 4.2 The Perception of Green Dentistry This issue was examined through the following question: ‘Before completing this questionnaire, had you ever heard of green/ eco-friendly/ environmentally friendly/ ecological dentistry?’ The green innovation was not something generally perceived by Thai dentists. Eighty-three per cent (83.5%) of respondents indicated that they had never heard the term ‘green dentistry’, whereas there were only 78 respondents (16.5%) Who had some idea of what it meant. A Chi-square (Table 2) was used to examine whether the proportion of respondents who had heard about green dentistry varied according to their demographic profile. There were no statistically significant associations found for gender, education levels, country of graduation, speciality or work role. The only exceptions were age, working experience and workplace. The proportion of respondents who had heard about green dentistry increased from 10.0 per cent in respondents aged below 31 to 38.5 per cent for respondents aged above 50. There is a significant difference between the proportion of each age group with regard to their experience in hearing about green dentistry (p