1. Introduction
Climate changes challenges people’s life and sustainability [
1]. With the prominence of various intense environmental problems worldwide, ways to deal with these problems and improve anthropocentric and environmental sustainability has attracted recently ex-tensive attention [
2,
3]. Environmental problems seem to stem from human behavior or caused by it [
4]. Thus, the change of behavior is a necessary condition to improve the environmental situation [
5]. Scholars have conducted important work on the pro-environmental behavior of individuals, which include its conceptual connotation, formation mechanism, effect pathway, and educational needs for stakeholders [
5,
6]. Basically, there are reports on the influencing factors or results of pro-environmental behavior [
3,
7,
8]. Further, the relationship between pro-environmental behavior and other research topics are discussed, such as subjective well-being [
9] and social norms [
10]. Finally, the theoretical model of pro-environmental behavior has been constructed, named as the conceptual model for voluntary pro-environmental behavior of employees [
11].
Pro-environmental behavior, also known as green-, sustainable-, or environmentally friendly (eco-friendly) behavior, is defined as behaviors in which individuals take protective actions toward the environment [
12]. In the field of dentistry there are reports on sustainable behavior that face the issue of reducing the carbon footprint [
13]. According to the World Health Organization (WHO) [
14], there is an ethical obligation to protect public health in every state by developing an environmentally conscious behavior [
15]. In Europe, the European Green Deal is planning to transform the EU into a modern, re-source-efficient, and competitive economy, ensuring that there are no net emissions of greenhouse gases by 2050 [
16]. The World Federation of Dentists (FDI) also stated that dentists should incorporate sustainable objectives into everyday clinical practice and support the transition to green economy [
17]. By now, legislation all over the world makes it obvious that all oral health care providers have an ethical obligation to perform clinical activities in a sustainable manner [
18] and cultivate pro-environmental behavior [
6].
A dentist is said to have a pro-environmental behavior when he takes actions and in-itiatives to minimize the negative impact of his own behavior on the environment, reduce harm to the nature and the world [
5,
19] and even benefit it [
20]. This can be done with ac-tions that diminish greenhouse gas emissions and the waste of natural resources, forward disposal of wastes according to legislation, apply the philosophy of 4Rs (Rethink, Reuse, Reduce and Recycle) in the dental office and home [
6], volunteer in environmental social actions and improve overall environmental sustainability [
21]. Positive public's attitudes towards sustainability in dentistry has also been reported as well as their willingness to make compromises to reduce the impact of their dental treatments on the environment [
22]. On the other hand, dentists in different countries seem also to start being more sensitive on environmental issues and are somehow willing to incorporate green dentistry philosophy in their practices [
13]. Elsewhere is mentioned a poor response of dentists to environmentally friendly actions in the dental practice, refusal to participate in eco-friendly initiatives in dentistry, lack of knowledge of legislation, reduced participation in environmental initiatives and reduced willingness to participate in relevant continuing education seminars [
6].
So far studying the pro-environmental behavior of dentists is done by research studies based in the form of questionnaires selecting opinions and observing current attitudes. Although necessary, this approach does not further explain how certain factors affect pro-environmental behavior and how the phenomenon can be evolved in the future in different environments and settings.
System dynamics is then a research approach for supporting the study of a process or phenomenon with the use of clean questions and simulation procedures to better under-stand it and develop capability to use it in different environments and cases by designing study models [
23]. Systemic modelling further allows us to make a clear prediction with-out relying on someone else’s opinion, but only on some ratings and factors we attribute to the case in question, to make a clear prediction. Systemic models then offer a prediction of what will happen with the issue in the future based on what is happening with it right now [
24]. Addressing this challenge requires the use of proper methods. System dynamics provides us with a powerful toolset for a holistic approach to the theme in question revealing feedback loops, accumulation dynamics, system delays, and nonlinear effects. In addition, through group model-building techniques [
25,
26], systemic modelers can engage stakeholders in the modeling process, which is particularly effective in identifying key behaviors [
27] and enhancing modeling quality and implementation [
25,
28,
29,
30,
31].
With the knowledge of this prediction, stakeholders can design educational interventions and strategies for changing the status quo for serious issues such as the enhancement of pro-environmental behavior of dentists. So far, even though systemic instruments have had a strong impact on the management of public policy systems in fields such as health and innovation [
24], pro-environmental behavior of healthcare workers and especially dentists have not been widely discussed by applying this type of instrument. Thus, the design of a systemic model that could effectively help our effort studying the eco response of dentists is highly needed for further evaluation.
This study makes three contributions to literature. First, it discusses factors influencing pro-environmental behavior. Second, we present a systemic evaluation framework, the ECODENT model for the study of dentists pro-environmental status quo. Third, we test the model in data receive from a sample of Greek dentists to assess opportunities and challenges associated to the implementation of such a systemic framework for policymaking in dentistry.
4. Discussion
The systemic ECODENT model explains the evolution of the phenomenon of WOM spread of green dental pro-environmental behavior among Greek dentists. At this stage it has no historical data, so it cannot fully explain specific situations. However, by applying this model to a small sample of the Greek dental population, it is possible to create historical data. The model can then be used by dental associations as a predictive and strategic decision-making tool for the education and adoption of green dentistry from all Greek dental practices. The function of the model is a function of a series of parameters as described above. System Dynamics contributed to the modeling of the process of integrating principles of green dentistry into the population of Greek dentists. It showed the dynamics of the phenomenon of influencing dentists' behavior by their own population through WOM (e.g., colleagues or patients’ opinion and other social interactions) qualitatively and quantitatively. Specifically, the model developed can give a quantitative approximation of the number of dentists touched, each time one of the main or secondary variables of the model changes. If fed with appropriate quantitative data, it can be a predictive and decision-making tool for the dissemination and adoption of green dentistry by other dental groups worldwide, as is discussed with the use of other systemic tools in the analysis of certain phenomena in the business field [
49].
Systemic approaches involve understanding the impact and potential of people (e.g., dentists) within a system and its implication on us as individuals [
23]. This bigger (systemic) view can assist dental associations in embracing difference, managing from a higher-level understanding as well as everyday outcome perspective and spread information needed for behavior changes within the dental population as suggested elsewhere too [
49,
50]. It can further reduce personalized frustrations that we usually experience when we are asked to proceed to changes in our dental offices (especially if cost is involved) as we find ourselves interrupting behaviors from a personal/productivity perspective and not from an understanding perspective. When we equip ourselves with basic systemic oversight such as how does a non-eco behavior effect the “system” as well as how does the “system” affects the individual dentist, we can start to empower ourselves to see beyond the problem (low environmentalism in dentists) as reported elsewhere [
6]. We can further see beyond a person’s behavior and low performance into what is enabling this behavior, what is the wider context and what can we harness from this experience to become better professionals [
51].
In this model we incorporated certain factors considering basically the strong influence of WOM among professionals and among social relationships, the state economic support and the financial status of dental professionals and the degree of urbanization as already reported in other studies [
6]. We focused on social ties, perceived risk about the environment and sharing of the information among dental professionals. This approach is more direct and does not cause overload of information or other obligatory thus stressing educational activities. From the United Nations’ attempt to capture the attention of professionals with an overload of information inputs and sheer volume of ideas on sustainable development issues under the single grand vision of education for a sustainable future, we have learned that such attempts will only end up in a mass mental blurriness on environmental literacy [
52]. This action has impeded our ability to sustain concentration on serious environmental problems that touch the core of human existence and enhance our core mental skills to connect with the natural system and our place in it. Consequently, if dentists are forced to proceed to environmental changes in their practices with an overload of information, rules, and legislation, they may be forced to become unaware of what is really happening around them. The systemic ECODENT model though suggests minimum educational hours and more influence of all other parameters mentioned before, to interact with pressing environmental issues, confronting professionals of the field.