The EU policy and the 9R framework

The large volumes of single-use plastics consumed significantly contribute to the public sector’s environmental impact. However, as public procurement accounts for 14% of the European Union’s (EU’s) GDP (European Court of Auditors, 2023), it wields a substantial influence on public spending toward more sustainable and circular alternatives (European Commission, 2008b; Witjes and Lozano, Reference Witjes and Lozano2016). The EU action plan for a circular economy specifically mentions plastics as a main target area (European Commission, 2015). The strategy’s primary focus is on recycled content, biodegradable materials and waste reduction measures, while decreasing consumption is not a mentioned strategy (The European Parliament and the Council, 2019). The policy context thus lacks clear incentives to reduce single-use plastic consumption.

Different strategies have been introduced to support the reduction of resource and material consumption throughout the value chain. Since its introduction by Potting et al. (Reference Potting, Hekkert, Worrell and Hanemaaijer2017), the circular strategies framework has been highly impactful, refined (Blomsma et al., Reference Blomsma, Pieroni, Kravchenko, Pigosso, Hildenbrand, Kristinsdottir, Kristoffersen, Shahbazi, Nielsen, Jönbrink, Li, Wiik and McAloone2019; Kurilova-Palisaitiene et al., Reference Kurilova-Palisaitiene, Sundin and Sakao2023) and applied to a wide variety of products (Alamerew et al., Reference Alamerew, Kambanou, Sakao and Brissaud2020; Kambanou et al., Reference Kambanou, Matschewsky and Carlson2024). Circular strategies range from end-of-pipe focused efforts, such as energy recovery and recycling, to entirely rethinking value creation through new ways of satisfying customers or avoiding the production and use of a product altogether. Altogether, the circular strategies framework suggested by Potting et al. (Reference Potting, Hekkert, Worrell and Hanemaaijer2017) covers nine strategies. In policy, the 4R framework has been deployed by the EU since the adoption of the European Commission’s Community Strategy for Waste Management (European Commission, 1989) as the so-called waste hierarchy and the adoption of the waste framework directive in 2008 (European Commission, 2008a). According to Potting et al. (Reference Potting, Hekkert, Worrell and Hanemaaijer2017), the nine strategies can be grouped into three main categories:

• • 0R Refuse, 1R Rethink and R2 Reduce are associated with smarter product use and manufacturing.

• • R3 Reuse, R4 Repair, R5 Refurbish, R6 Remanufacture and R7 Repurpose are associated with the durability and lifespan of products and their parts.

• • R8 Recycling and R9 Recover are associated with traditional waste management practices focusing on the application of waste materials.

The R-framework is generally regarded in academic literature as a practical way of operationalizing the circular economy into applicable strategies (Diaz et al., Reference Diaz, Schöggl, Reyes and Baumgartner2021). Circular solutions require customer acceptance, and several behavioral aspects provide barriers, such as customer understanding and knowledge of the product, impact on everyday life, quality, risks and benefits derived from solutions (Camacho-Otero et al., Reference Camacho-Otero, Boks and Pettersen2018; Muranko et al., Reference Muranko, Andrews, Newton, Chaer and Proudman2018). However, studies often focus on customer behavior in the initial purchasing stage (Hazen et al., Reference Hazen, Mollenkopf and Wang2017), not the product’s use phase.

Single-use plastic gloves in the healthcare sector

Previous studies on single-use plastics have primarily focused on the potential for recycling (e.g., see Joseph et al., Reference Joseph, James, Kalarikkal and Thomas2021; RISE Research Institutes of Sweden, 2019) and plastic waste management (Ramos et al., Reference Ramos, Christensen, Oturai and Syberg2023). There are also studies on particular product types, such as formula bottles for infants (Leissner and Ryan-Fogarty, Reference Leissner and Ryan-Fogarty2019), single-use medical sensors (Leppälä et al., Reference Leppälä, Vornanen and Savinen2023) and other medical devices (Guzzo et al., Reference Guzzo, Carvalho, Balkenende and Mascarenhas2020; Lingegård et al., Reference Lingegård, Martin and Gheitasi2025). However, single-use nonsterile examination gloves, with a low end-of-life value, are unexplored. This type of glove (single-use, nonsterile examination glove) is by far the most commonly used single-use product in the healthcare system, and is used in various practices and situations across the healthcare sector.

In the past 10 years, the major trend for many items in the healthcare sector has been moving from multiple-use items to single-use items due to a combination of price reductions, convenience and the perception that they sustain and enhance hygiene (Bhutta, Reference Bhutta2021). There are indications that the extensive use of single-use plastic gloves, in some situations, has replaced traditional washing and sanitizing practices (Lindberg et al., Reference Lindberg, Skytt and Lindberg2020; Haenen et al., Reference Haenen, de Greeff, Voss, Liefers, Hulscher and Huis2022).

From a user perspective, some studies have examined the utilization of gloves by healthcare personnel, all focusing on clinical or healthcare viewpoints, focusing on the associated contamination risks. Research conducted in the Netherlands (Haenen et al., Reference Haenen, de Greeff, Voss, Liefers, Hulscher and Huis2022) and Sweden (Lindberg et al., Reference Lindberg, Skytt and Lindberg2020) indicate a low adherence to the World Health Organization’s hand sanitization requirements (WHO, 2009) in hospitals and care institutions, including reduced hand hygiene compliance caused by glove use in a UK case (Fuller et al., Reference Fuller, Savage, Besser, Hayward, Cookson, Cooper and Stone2011) (Flores and Pevalin, Reference Flores and Pevalin2006; Haenen et al., Reference Haenen, de Greeff, Voss, Liefers, Hulscher and Huis2022). Furthermore, large-scale reduction interventions for glove use, such as the 2018 “The Gloves are Off” campaign in the United Kingdom (NHS, 2018);, underline a suggested widespread overuse of gloves (glove wearing with no hygiene indication) since the glove volumes decreased by 18% with no implication for healthcare-associated infections ( Lalakea et al. Reference Lalakea, Noel and Meiklejohn2025; Peters et al., Reference Peters, Močenić, Spitilli, Bloomfield and Bhutta2025). Overall, the usage of gloves depends on several aspects related to individual risk perception, beliefs and experience, as well as organizational culture and social norms (Flores and Pevalin, Reference Flores and Pevalin2006; Haenen et al., Reference Haenen, de Greeff, Voss, Liefers, Hulscher and Huis2022). Several studies indicate overconfidence in correct glove usage; however, Kristiansen et al. (Reference Kristiansen, Bastien, Debesay and F2024) found that observations did not confirm this, leading to the conclusion that determining optimal glove wearing causes problems in practice (Bate Reference Bate2024).

Furthermore, using a double layer of gloves as an alternative to hand hygiene to save time contributes to excess consumption. Haenen et al. (Reference Haenen, de Greeff, Voss, Liefers, Hulscher and Huis2022) stressed the need for managers to facilitate hand hygiene practice and ensure adherence to hand hygiene guidelines (WHO, 2025). Additionally, one study examined the dispensing of gloves and how the design of dispensing boxes could reduce contamination of unused gloves (Assadian et al., Reference Assadian, Leaper, Kramer and Ousey2016). Moreover, Singh et al. (Reference Singh, Ogunseitan and Tang2022) point to a lack of training in waste separation among medical staff, while Hu et al. (Reference Hu, Davies, Morrissey, Smith, Fleming, Sharmina, Clair and Hopkinson2022) identified the Covid-19 pandemic and associated rise in consumption of single-use plastic may be a catalyst for the development of more circular approaches in healthcare. Overall, Rizan et al. (Reference Rizan, Mortimer, Stancliffe and Bhutta2020, p. 51) conclude that while the excessive use of single-use plastic products is driven by infection concerns, “in many cases, the risk of infection is hypothetical or infinitesimal and poorly evidenced.”

Status quo in procurement and regulations

This section reports and analyzes the study’s results, starting with a cross-country analysis of the purchasing data for examination gloves. Second, challenges related to the use phase of gloves are presented and analyzed, and solutions are suggested.

Figure 1 shows the volumes of examination gloves purchased in the Danish Capital Region and used in hospitals. The data span from 2019 to 2023 and clearly shows an expected increase during the COVID-19 pandemic from already large volumes prior. From ca. 63 million gloves in 2019, a peak of 101 million was reached in 2021. Still, the purchasing levels in 2023 were 19% higher than pre-pandemic levels, at 75 million gloves. Data acquired from the Stockholm Region indicates a similar development, with pre-pandemic levels in 2019 reported to be ~100 million gloves.

Identified challenges and solutions for circular strategies of single-use gloves

In this section, the workshop data are presented and analyzed. Table 3 and 4 present the Swedish and Danish data results, providing insight into the similarities and differences between the two datasets. The results are analyzed based on the four categories in the analysis: overuse, misuse, discarding and waste options.

Table 4.

Challenges identified for efficient and effective use of single-use gloves from a life cycle perspective, as well as proposed solutions in relation to circular strategies in the Danish context

Overuse, misuse and the underlying reasons

Both workshops included discussions on overuse and improper use/misuse. Below, overuse is conceptualized as the extensive use of gloves when the purpose of using gloves, as defined by the guidelines (NIR in the Danish case), does not apply. Misuse is characterized as the incorrect use of gloves according to guidelines (NIR in the Danish case), for example, wearing a double set of gloves instead of a single pair or failing to use gloves when required. However, an important takeaway from the discussions in both workshops is that correct glove use depends on a professional interpretation of the guidelines in a specific situation.

Participants in both workshops identified widespread glove overuse, confirming trends seen in the quantitative data (Figure 1). Overuse was evident even before the COVID-19 pandemic, with usage increasing during the pandemic and not returning to pre-pandemic levels due to changed practices, shifting norms and a heightened focus on hygiene procedures. However, workshop participants indicated that practices surrounding glove use are associated with multiple trends in the healthcare system and society at large. For example, younger staff tend to use gloves more frequently than their older colleagues, and gloves are often seen as part of the uniform rather than solely for hygiene purposes. Usage also varies by context; staff are less likely to wear gloves when treating children than when caring for elderly patients.

Most nurses will receive the basic hygiene routines within their education, but most of the time, they learn when they start practicing and thus adopt the praxis for that department. The results show that departmental praxis in the everyday procedures overrules the regulations, and the praxis differs depending on the department’s culture. Culture, norms and routines shape glove use practices, and the relatively loose guidelines are interpreted to fit existing routines locally at department levels in the hospitals.

Discussions and reflections occur for departments requiring gloves, and plans are in place. However, respondents reported that no reflections are carried out for low-risk departments and that gloves are widely overused. In Denmark, guidelines for gloves are established at national, regional and local levels, leading to ambiguities and room for individual interpretation, which often results in overuse. However, according to the national guidelines, staff must carry out a risk assessment before using gloves, which can be challenging and lead to gloves being used just in case. Such practices can be further triggered by placing gloves in the rooms right by the doors and nudging staff toward excessive glove use. Local culture, practices and norms at the departments also influence glove usage, leading to overuse of gloves and use of gloves in situations that do not provide improved hygiene protection. The workshop data obtained from the participating hygiene nurses suggested that current practices might not result in high protection when correct hand sanitation is replaced with extensive glove usage. Similar insights have been found in Sweden, for example, gloves are used when there is a known infection, even though it is not transmitted through hand contact. This is among the many myths circulating about glove use in the healthcare sector. Group pressure is added to the list of reasons for overuse, as well as the taboo of correcting someone with more authority. A hygiene nurse explained that if the first person entering a room takes a pair of gloves, then the others will as well, and that the same is true for washing and sanitizing hands. Respondents suggested changing the location of the gloves to move further away from the door to encourage the washing and sanitizing of the hands instead. This should always be done before glove use, but this is not the case for all users in both countries investigated. Sanitizing hands is more crucial than using gloves because the traditional single-use examination gloves are unsterilized. Staff mistakenly believe gloves offer more protection than they do, leading to a false sense of security.

Discarding

Hand sanitation is required to avoid contamination when dispensing gloves from a box. Nevertheless, respondents reported that not everyone follows this practice, leading to frequent contamination of the glove container. A Swedish hygiene nurse describes that when a patient is discharged, the room is cleaned and the glove container is discarded. This is more common in single-patient rooms than in rooms with multiple occupancy. A nurse carries out a risk assessment, but most of the time, the just-in-case approach is used, resulting in large volumes of discarded unused gloves. In the Swedish workshop, the discussion centered on reducing glove contamination by using smaller packets, even if this would result in higher purchasing costs. However, the follow-up interview with the hygiene nurse stated that a smaller glove container costs the same as a large one. Hence, in this situation, there appears to be no economic incentive to buy a smaller box to reduce the number of discarded gloves. Again, proper washing and sanitation of hands before touching the glove container would facilitate a lower contamination risk and, thus, alter the outcome of the risk assessment.

Additionally, respondents mention the box design and a suboptimal manufacturing process as contributors to discarded gloves. Multiple gloves can fall out when personnel tries to remove one, a problem mentioned in Swedish and Danish contexts. This is further related to the incorrect or sloppy layering of the gloves in the container, which causes them to become tangled.

A further aspect is the volume of discarded gloves due to extensive stockpiling, resulting in gloves passing their expiration date before use and needing to be discarded. This results from the convenience of having products close to patients (unit stockpiling) and the increased uncertainty in supply, which skyrocketed during the COVID-19 pandemic.

Limited waste management options

Challenges in waste management persist for used gloves, as they are designed for single use. Currently, there is no technology available to decontaminate and recycle the material. Besides the recycling process, waste sorting and logistics would be a challenge. Internal waste logistics and a lack of space for disposal boxes were also pointed out as hindering factors, as the gloves would require a separate material flow. In recent years, Swedish and Danish healthcare underwent a substantial efficiency push, for example, to optimize the limited space available and shorten the time healthcare professionals spend performing their tasks. According to the respondents, this has created new path dependency, as the organization of, for example, patient rooms is designed for the products and technology available when the change is made. Furthermore, even the short time spent deciding which recycling bin to use adds up on the typically highly intensive workdays, with respondents assuming that glove users will likely place all gloves into incineration just in case, rather than checking for contamination and selecting the recycling option.

The Swedish workshop explored the option of sanitizing gloves with hydrogen peroxide as a potential future method for reusing gloves. However, this would require an appropriate space and quality check for contamination. In Denmark, a pilot project has been conducted for reusable gloves (Re:GLOVE, 2024), focusing on designing and testing reusable and washable nitrile gloves. However, a commercial reusable examination glove is still not available.