Cleaner and Responsible Consumption 2 (2021) 100017

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Cleaner and Responsible Consumption

journal homepage: www.journals.elsevier.com/cleaner-and-responsible-consumption

Hierarchical analysis of factors influencing acceptance of remanufactured

medical devices
Damola Ikeoluwa Akano a, *, Winifred Ijomah a, James Windmill b
a
Department of Design, Manufacture and Engineering Management, University of Strathclyde, G1 1XJ, Glasgow, UK
b
Department of Electrical and Electronics Engineering, University of Strathclyde, G1 1XJ, Glasgow, UK

A R T I C L E I N F O A B S T R A C T

Keywords: The growth of remanufacturing has seen its application in different industrial sectors including automotive,
Consumer electronics and medical devices. In medical and healthcare sector, remanufacturing presents an opportunity to
Remanufacturing equip facilities with functional, safe, affordable and sustainable medical systems. However, there is a lack of
Medical devices
understanding of the key factors that influence customers' acceptance of remanufactured medical devices. This
Sustainability
AHP
study addresses this gap by analysing and ranking key factors that impact customers' decisions to purchase and
use remanufactured medical systems using pairwise comparisons obtained from the analytical hierarchical pro-
cess (AHP) model. The structural decision hierarchy was developed followed by a description of the adopted scale
of importance. Thereafter, pairwise comparisons were performed by the expert panel constituted by six medical
equipment experts with a total of 194 years’ experience between them. The responses were tested for rationality
and consistency, the analysis of the comparisons was performed, and factor weights obtained for each factor.
Results obtained ranked product quality as the most critical factor affecting acceptance of remanufactured devices
followed by price, warranty, brand equity, available information, added value services and environmental
friendliness. Findings from this study highlight the peculiarity of medical devices remanufacturing which gives
more attention to product quality in terms of performance and safety. Taken together, these results provide a basis
on which medical devices remanufacturers can improve customer acceptance. Before this study, discussions on
customer acceptance of remanufactured medical devices were purely anecdotal and this is the first comprehensive
investigation of customer factors in medical devices remanufacturing.

1. Introduction environmental, economic and social benefits (Butzer et al., 2016;

Golinska et al., 2015; Subramoniam et al., 2013) and it has been
Ongoing discussions about sustainability issues caused by resource described as good for business, environment and the consumers. Also,
depletion, population blowout and climate emergencies have resulted in “remanufacturing results in conservation of inherent product value,
direct and indirect actions of businesses to reduce material and energy protection of intellectual property and creation of new market opportu-
consumption, waste generation and landfill impacts (Lahrour and Bris- nities” (Subramoniam et al., 2009). Remanufacturing has been described
saud, 2018; Subramoniam et al., 2009). Concerns about the unsustain- as an industrial operation that returns a used device to “as new” condi-
able interactions of humans with non-renewable resources are tion in terms of performance and warranty (Ijomah et al., 2007a) through
championing a drive towards circularity and sustainable development. a series of activities which include core collection, disassembly, cleaning,
Sustainable development strategies ensure that the ability of future inspection, sorting, part recovery or replacement, reassembly and testing
generations to provide for themselves is not negatively impacted by ef- (Ijomah et al., 2007a; Lund, 1985; Nasr and Thurston, 2006) as shown in
forts to meet present needs (Gehin et al., 2008). Fig. 1. Table 1 shows the description of end-of-life product recovery
Different end of life recovery strategy such as reuse, repair, recon- options.
ditioning, refurbishment, remanufacturing and recycling have been dis- Remanufacturing achieves a significant reduction in environmental
cussed in literature (Ijomah et al., 2007a; Paterson et al., 2017; Yang footprint (Bras and Hammond, 1996) which favourably places it as a key
et al., 2015). Particularly, remanufacturing has been preferred due to its facilitator of sustainable development (Gehin et al., 2008; Nasr and

* Corresponding author.
E-mail address: damola.akano@strath.ac.uk (D.I. Akano).

https://doi.org/10.1016/j.clrc.2021.100017
Received 13 November 2020; Received in revised form 28 April 2021; Accepted 29 April 2021
2666-7843/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
D.I. Akano et al. Cleaner and Responsible Consumption 2 (2021) 100017

Fig. 1. Remanufacturing process.

Thurston, 2006). As a result, remanufacturing has received much atten- competitors in the industry (Hede et al., 2013). However, awareness and
tion across many industrial sectors such as automotive, aerospace, elec- acceptance of such sustainable practices is abysmal, especially in the U.K.
trical and electronic equipment, furniture marine and offshore, rail, with remanufacturing intensity in the medical devices industry being as
heavy duty and off road equipment and medical devices (ERN, 2015; low as 0.5% (Widera and Seliger, 2015). Eze et al. (2019) defined
Steinhilper and Weiland, 2015). However, there is need for greater medical devices remanufacturing (MDR) as a process that returns used
traction in the utilisation of remanufacturing in medical devices industry, medical devices to the initial specifications of the OEM in terms of per-
especially in the UK. In Europe, for instance, medical devices remanu- formance, safety, intended use, warranty and post-sales technical ser-
facturing (MDR) account for 3.4% of the overall market turnover and vices (Eze et al., 2019). Although this definition provides a basis to better
only 0.83% of total remanufacturing firms engage in MDR in 2015 (ERN, understand remanufacturing, other recovery options like refurbishment,
2015). servicing and recycling are more commonly used in the medical devices
Although discussions on the recovery of end of life medical devices industry (Centre for Remanufacturin, 2008; R et al., 2009).
have been going on for the past 2 decades, it is only recently that re- Despite the extensive benefits of remanufacturing medical devices
searchers began to suggest ways to reduce the complexity of medical (Kwakye et al., 2010), critics continue to misunderstand the process and
devices remanufacturing (Eze et al., 2019; Foley, 2006; Jensen et al., raise issues surrounding the safety of the patient. Some have argued that
2019; Leung, 2019). Widera and Seliger (2015) highlighted key barriers patient consent should be sought before reprocessed equipment can be
in core acquisition, steps in the remanufacturing process and selling of used on them (MacPherson, 2010). These, coupled with the biases of
remanufactured devices (Widera and Seliger, 2015). Jensen et al. (2019) OEMs, who fear reduced revenue and market share (Widera and Seliger,
assessed sustainable values created through the end of life recovery 2015; Sloan, 2007), continue to stifle the growth of reprocessing in the
programs of 3 manufacturers (Jensen et al., 2019). Although these medical field.
studies (Jensen et al., 2019; Widera and Seliger, 2015) offer solutions to Conversely, proponents of MDR have claimed that there are no
specific problems for OEMs, they do not assess the critical factors that known evidences associating the use of remanufactured medical devices
impact the acceptance of remanufactured medical devices (Akano et al., to increased risk to patients (Kwakye et al., 2010). Coincidentally, Amadi
2021). As original manufacturers consider end of life recovery option for et al. (2011) recorded a decline in neonatal mortality in healthcare
their products, there is a need to present a comprehensive assessment of centres where digitally recycled incubators were used (Amadiet al.,
factors that influence customer acceptance (Widera and Seliger, 2015). 2011). Remanufactured circular mapping catheters by Leung et al.
Thus, this study presents a brief review of MDR followed by a compre- (2019) had good mechanical performance when tested against the
hensive assessment and ranking of key consumer factors using numerical specifications of the OEM and its use did not put patient safety at risk
weights obtained from AHP. This study aims to rank the relative (Leunget al., 2019). Also, MacPherson (2010) emphasized that safety of
importance of factors considered by medical equipment experts in the UK patients is a mandatory consideration in procurement frameworks used
when deciding whether or not to use, recommend, repair or perform any by healthcare boards and that obtaining patient consent may not be
related activities on remanufactured medical devices. The remainder of necessary as equipment that put patient at risk would not be purchased in
this report is structured as follows. Brief review of medical devices the first place (MacPherson, 2010). However, the lack of data and
remanufacturing and consumer acceptance literature is presented in research on MDR continues to play part in its slow growth.
section 2 followed by description of the AHP method in section 3. The Although remanufacturing of hospital beds is routine in the US (Heese
results, discussions and conclusion are presented in section 4, 5 and 6 et al., 2005), consumer acceptance of remanufactured medical devices in
respectively. the UK is low (Leunget al., 2019). Kwakye et al. (2010) reported that
about 25% of healthcare centres in the United States use at least one type
2. Literature review of reprocessed single use medical devices in 2002 (Kwakye et al., 2010).
Leung et al. (2019) estimated an annual potential cost saving of £17
2.1. Medical devices remanufacturing million from reprocessing single use medical devices in the UK
(Leunget al., 2019). Kwakye et al. (2010) also forecasted the 2017 cost
The increasing waste generation in the healthcare sector (Leunget al., savings from remanufacturing single use devices in the US at $326
2019; Kwakye et al., 2010) coupled with reducing funding for healthcare million (Kwakye et al., 2010). Amadi et al. (2011) reported on the eco-
expenditure and growing pressure to keep down cost of healthcare nomic advantages of digitally recycled neonatal incubators in
equipment (Sloan, 2007) is driving the growth of sustainable practices in low-resourced settings (Amadiet al., 2011). Heese et al. (2005) discussed
the medical devices industry. Also, original manufacturers have realised significant cost savings associated with refurbished hospital beds in the
the leverage that reprocessing medical systems give them over US (Heese et al., 2005). Sloan, 2007 highlighted that up to 4.6 million

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D.I. Akano et al. Cleaner and Responsible Consumption 2 (2021) 100017

Table 1 of factors considered during the cost-failure decision trade-off. This is

Description of end-of-life product recovery strategies. achieved in this study by ranking the critical decision factors based on
Operation Description References their relative important to decision-makers.
Research effort on the decision-making of ‘whether or not’ to
Direct Reuse Reusing a product directly (Agrawal et al., 2016; Charter
means an end of use or and Gray, 2008; Ijomah, 2002; remanufacture a medical equipment is currently lacking. Taghipour et al.
returned product is put into the Paterson et al., 2017) (2011) developed a multi-criteria decision model (MCDM) to rank the
forward goods flow for the next criticality of medical devices and prioritize their maintenance or
customer without any reprocessing (Taghipour et al., 2011). Also, Hede et al. (2013) presented
mechanical work done. In
some cases, minor inspection
a multicriteria hierarchical model (MCHM) to incorporate the triple
and cleaning may be bottom line of sustainability (environment, economic, social) into the
performed but the overall aim development of medical devices (Hede et al., 2013). These models pro-
of reuse is to make the product vide an understanding of the nature of decision-making in medical de-
available for the next customer
vices industry, stating the key players, boundaries and considerations.
as quickly as possible.
Repairing Repair operations involve the (Brunoe et al., 2019; Camilleri, However, they fail to assess the considerations of medical experts when
fixing of specified faults or 2019; Gharfalkar et al., 2016; deciding to use remanufactured medical devices. Since remanufacturing
defects in a product with the Ijomah, 2002; Ijomah et al., decisions depend on customers accepting, purchasing and using rema-
aim of extending the useful life 2007a; King et al., 2006; nufactured medical systems, medical professionals and devices experts
of the product. The Parker and Butler, 2008)
consequence of this is that only
have massive impact on the decision process. Therefore, this study which
components specified as faulty aims to understand the relative importance of key factors that influence
would be corrected or in some acceptance and use of remanufactured medical systems lead the way in
cases replaced, which will this area of medical equipment remanufacturing research.
require spare parts. This is a
higher alternative to direct
reuse in terms of the 2.2. Customer acceptance of remanufactured products: identifying key
performance, but repaired decision factors
products have lower quality
and warranty when compared
Evaluating customer acceptance and market demand for remanufac-
to refurbished or
remanufactured products.
tured devices is a critical step when assessing the viability of remanu-
Refurbishment Refurbishing involves (Paterson et al., 2017; Brunoe facturing (Akano et al., 2021). Also, the success of remanufacturing
mechanical operations that fix et al., 2019; Ijomah et al., endeavour hinges on customers purchasing, using and/or recommending
or replace failed parts or €
2004; Ostlin et al., 2009; Ziout remanufactured products. However, customer acceptance of remanu-
components very nearly failed et al., 2014)
factured products is determined by the trade-off between their perceived
to take the product to a
physical and performance risks and perceived benefits (Milios and Matsumoto, 2019). Research
characteristic that is acceptable issues relating to customers purchase intentions of remanufactured items
to the customer. In most cases, has been discussed extensively in literature (Duan and Aloysius, 2019;
refurbished product quality is Shu et al., 2017; Singhal et al., 2019).
higher than repaired or
directly reused product, but it
Abbey et al. (2019) described risk as consumers’ judgement of the
is less than that of a probability of failure of remanufactured items and the relative impact of
remanufactured product. such defect on the user (Abbey et al., 2019), which would include both
Remanufacturing Remanufacturing is described (Paterson et al., 2017; Ijomah, the hospital and patient in the case of medical devices remanufacturing.
as the process of returning a 2002; King et al., 2006; Center
Consumer risk perceptions relates to the quality, performance, appear-
used (or preowned) product to for Remanufacturin, 2009)
a physical and performance ance and financing (Singhal et al., 2019), safety and disposal (Van
condition that is similar or Weelden et al., 2016; Baron, 2017), and serviceability (Milios and Mat-
better than that of an sumoto, 2019) of remanufactured devices. Perceived risks may also
equivalent new product. The include breakdown risks, technology/obsolescence risks, financial risks
quality and warranty of
remanufactured product is
and safety risks (especially in high-risk industries such as medical de-
highest of product recovery vices). These risks are associated with fear of frequent servicing,
operations. increased operating costs, higher safety concerns, and sudden breakdown
Recycling Recycling recovers the (Paterson et al., 2017; Nasr (Singhal et al., 2019). Benefits of remanufacturing have been extensively
inherent raw materials and Thurston, 2006;
discussed in literature (Ijomah et al., 2007a; Nasr and Thurston, 2006; Li
associated with a product at its Camilleri, 2019; Charter and
end of life. As such, the product Gray, 2008; Ijomah, 2002) et al., 2017; Hanson and Hitchcock, 2009). The financial benefit of
is broken down into the basic remanufactured medical devices as a cheaper alternative to new product
raw materials which can be without compromising its quality, safety and warranty is considered to be
used in other manufacturing the far-reaching motivation for customers.
activities.
Some customer decision factors that were identified in literature
include functional performance or product quality (Hosseini-Motlagh
medical devices were refurbished globally in 2004 (Sloan, 2007). et al., 2018; Vafadarnikjoo et al., 2018; Abbey et al., 2017), environ-
Perception, acceptance and use of remanufactured medical device is mental friendliness (Duan and Aloysius, 2019; Wang et al., 2018), brand
complex. For example, Sloan (2007) used examples of orthopaedic equity (Singhal et al., 2019; Li et al., 2017; Govindan et al., 2019),
blades, cardiac catheter, compression sleeves and trocar to validate a warranty (Alqahtani and Gupta, 2017, 2018; Gan and Chen, 2019),
model with which medical experts can compare the costs, probability of available product information (Milios and Matsumoto, 2019; Duan and
failure and cost of failure for new and reprocessed equipment and then Aloysius, 2019), services (Gaur et al., 2015; Van Weelden et al., 2016)
decide whether or not to use a remanufactured equipment in their facility and price (Govindan et al., 2019; Jim
enez-Parra et al., 2014; Bittar,
(Sloan, 2007). While this model gave useful insights into the key con- 2018), as shown in Fig. 2.
cerns of prospective users and help them decide whether or not to use a
remanufactured medical equipment, it failed to examine the importance 2.2.1. Quality of product (in terms of performance and safety) (F1)
As a product-related factor, quality is critical to customers and has

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D.I. Akano et al. Cleaner and Responsible Consumption 2 (2021) 100017

Fig. 2. Factors influencing the trade-off between risks and benefits (Van Weelden et al., 2016).

significant impact on the decision to procure and use a remanufactured to that of an equivalent new product, expressed as a percentage (Bittar,
device. It has been discussed in existing literature (Duan and Aloysius, 2018). Weelden et al. (2016) illustrated in his study that although lower
2019; Van Weelden et al., 2016; Hosseini-Motlagh et al., 2018; Vafa- pricing was a major motivation for customers' decision to purchase a
darnikjoo et al., 2018; Abbey et al., 2017; Gan and Chen, 2019). When remanufactured product, adjusting the price beyond a specific threshold
compared to other reprocessing strategies, remanufacturing offer devices will flip the balance between customers risk and benefit perceptions (Van
with higher functionality, safety, technology and appearance similar to Weelden et al., 2016). For example, customers may perceive remanu-
that of an equivalent new product (Paterson et al., 2017; Ijomah, 2009). factured item as having mediocre characteristic and performance if
The quality factor assessed in this study covers performance and accuracy priced significantly lower than new. On the other hand, a higher price of
of measurements (Qp ), physical appearance (Qpy ), safety (Qs ) and tech- remanufactured product does not imply superior product quality but may
nology (Qt ) of the remanufactured medical devices. The quality factor increase customers' perceived financial risks (Van Weelden et al., 2016).
also cover other issues (Qo ) such as the risk of infection, failure proba- This factor covers the cost of procuring remanufactured device (Pa ),
bility, limitations on use, decontamination and disposal procedure day-to-day operating cost (Po ), maintenance and repair costs (Pm ), and
(Leunget al., 2018). disposal costs (Pd ). The price factor may also include failure and training
8 costs.
>
>
Qp
8
>
< Qpy P
>
< a
F 1 ¼ Qs Po
>
> F3 ¼
>
: Qt >
: Pm
Qo Pd

2.2.2. Available information (e.g., previous use, expected life, quality 2.2.4. Warranty provided on the remanufactured device (F4)
certification) (F2) Alqahtani and Gupta (2018) defined warranty as a contract between
Information available to customers about a remanufactured product the seller (or the remanufacturer) and the buyer of the remanufactured
plays an influential role in helping customers form their opinions of the device regarding the liabilities and expectations from both parties in the
risks and benefits associated with using such product. Information pro- event that the purchased remanufactured device breaks down or does not
vision through product quality certification and eco-labelling plays an function as expected (Alqahtani and Gupta, 2018). For remanufactured
important role in consumers’ decision making (Milios and Matsumoto, medical devices, the warranty is expected to be similar to (or better than)
2019; Duan and Aloysius, 2019). Milios and Matsumoto (2019) reported that of new systems (Eze et al., 2019) The warranty factor assessed in this
that Swedish consumers targeted in their study were more likely to study covers the length of warranty (Wl ), the cost of warranty (Wc ),
accept remanufactured parts that are quality certified than uncertified trade-in value of remanufactured device (Wv ), and repair and other ser-
parts. Meanwhile, Eze et al. (2019) implied that disclosing information vices as a warranty (Wr ).
about the remanufacturing process, adjustments performed, parts 8
replaced and tests performed on remanufactured medical systems could > W
< l
Wc
have a beneficial impact on customer acceptance (Eze et al., 2019). This F4 ¼
factor covers information about the remanufactured product such as its >
: Wv
Wr
use history, reason for remanufacturing, number of remanufactured or
replaced components, age in lifecycle, results of tests performed as part of
2.2.5. Added value services (including post-sales technical services) (F5)
the remanufacturing process and quality certification (Van Weelden
To support its provision of warranty, remanufacturers may offer
et al., 2016), (Vafadarnikjoo et al., 2018).
value-added services such as scheduled preventive maintenance and re-
pairs to improve product performance and prevent unexpected failure of
2.2.3. Pricing (in terms of acquiring, operating and maintaining
components (Alqahtani and Gupta, 2017). This is a common practice in
remanufactured devices) (F3)
medical devices industry especially with new and remanufactured
Bittar (2018) discussed the concept of remanufactured product ‘price
medical systems by original manufacturers. These post-sales technical
ratio’ which is defined as the ratio of the price of remanufactured product
services may include provision of replacement parts, software updates,

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D.I. Akano et al. Cleaner and Responsible Consumption 2 (2021) 100017

servicing and maintenance, advice and help, and user training. This problem, 2) Understanding the scale of importance, 3) Pairwise com-
factor is important as a means of getting feedback from the users, col- parison, 4) Hierarchic analysis and rank, and 5) Testing for rationality
lecting diagnostic information about the remanufactured medical device and consistency.
and reliability assessment (Eze et al., 2019).
3.2. Developing structural hierarchy for decision problem
2.2.6. Brand equity (in terms of who performs the remanufacturing
operation) (F6) The model developed in this study (refer to Fig. 3) shows the decision
Bittar (2018) described brand equity as the extra value that a rema- hierarchy for assessing acceptance of remanufactured medical devices. At
nufactured device attracts based on who performed the remanufacturing the higher level, the goal of the study is to understand the relative
(Bittar, 2018). However, Weelden et al. (2016) argued that consumer's importance of different factors that influence consumer acceptance. At
perceived risks of using a remanufactured device depends on the seller's the criteria level, seven (7) consumer-related decision factors, identified
reputation rather than the identity of the remanufacturer (Van Weelden from the remanufacturing literature and from experience of the authors
et al., 2016). Thus, the term ‘brand’ in remanufacturing may refer to the as academic researchers, are adapted to medical devices. At the lower
seller, manufacturer or remanufacturer, what matters is the specific level, the alternatives are consumer decisions to or not to accept rema-
name(s) under which the remanufactured device is offered to buyers nufactured medical devices, which would inform the decision to
(Govindan et al., 2019). remanufacture medical device.

2.2.7. Environmental friendliness (in terms of waste generated, material and 3.3. Decision factors
energy consumption) (F7)
Environmental issues relating to the scarcity of finite resources, The seven (7) decision factors used in this study include product
population growth and climate breakdown has increased awareness of quality, available information, price, warranty, added value services,
sustainability and ensured a focus on waste generation, material and brand equity and environmental friendliness. Although each of these 7
energy consumption (Lahrour and Brissaud, 2018). Although there is lack factors have sub-factors described in section 2, they were not directly
of data to back this up, remanufacturing literature have emphasized the used in this study. That is, pairwise comparison of the sub-factors was not
significance of environmental friendliness of remanufactured products performed. However, these sub-factors were presented to the participant
(Ijomah et al., 2007a; Bras and Hammond, 1996). In contrast, Gutowski to improve their understanding of the seven (7) factors in the pairwise
et al. (2011) argued that although remanufactured devices have a history comparison matrix. By considering the seven (7) high-level decision
of saving energy, current product design and manufacturing trends factors, this study follows the suggestions in (Saaty and Vargas, 2012) to
ensure that new products are more energy efficient and that remanu- yield a better consistency, reduce confusion and make it easier for par-
facturing old devices with lesser energy efficiency is not environmentally ticipants to accurately complete the pairwise comparison (Vafadarnikjoo
friendly (Gutowski et al., 2011). The environmental friendliness factor et al., 2018).
assessed in this study covers waste generated (Ew ), material consumption
(Em ) and energy consumption savings (Ee ). 3.4. Scale of importance
(
Ew
This study adopted the fundamental scale recommended by Saaty
Fe ¼ Em
Ee (Saaty and Kearns, 1985; Saaty, 2002), shown in Table 2. Numerical
values (1–9) are used to represent linguistic terms that best describe the
3. Method relative importance of each factor with respect to others. For example,
when assessing the relative importance of the factor i over factor j, a
3.1. Analytical hierarchy process (AHP) in remanufacturing number xij is used. xij can be any number between 1 and 9 from Table 2.
Also, even numbers (2, 4, 6, 8) are intermediate values between the odd
The AHP technique, proposed by Saaty (Saaty and Kearns, 1985), is numbers and can also be used in the pairwise comparison. Consequently,
not new in remanufacturing research. Subramoniam et al. (2013) ranked the relative importance of j over i, xji is the reciprocal of xij as shown in
strategic decision factors in the automotive industry using AHP and the equation below. Further discussions on the AHP method and pairwise
proposed a remanufacturing decision-making framework (RDMF) based comparison can be found in literature (Saaty and Kearns, 1985; Saaty and
on the results of the AHP (Subramoniam et al., 2013). Also, using the Vargas, 2012; Korhonen and Voutilainen, 2006).
AHP technique, Gaur et al. (2017) proposed a pragmatic decision 1
framework based on the results obtained from a pair-wise comparison of xij ¼
xji
consumer-related factors that affect core acquisition and supply in the
remanufacturing industry (Gaur et al., 2017). While these two studies
3.5. Pairwise comparison
proposed decision frameworks based on the factor ranks, some other
studies have used factor weights obtained from AHP to develop models
3.5.1. Developing pairwise comparison questionnaire
and methods for remanufacturing decision-making. For example, Jiang
The number of pairwise comparisons performed in AHP depends on
et al. (2011) proposed a planning method for selecting remanufacturing
the number of factors (n). In this study, 7 factors were considered,
technology portfolio in the power plants and process industry (Jiang
therefore 21 pairwise comparisons are performed by each participant.
et al., 2011). Du et al. (2012) proposed a remanufacturability assessment
method for used machine tool to calculate technological feasibility,
3.5.2. Selection of participants
economic feasibility and environmental benefits of remanufacturing (Du
The medical equipment industry is classified as high risk, thus
et al., 2012). Both (Jiang et al., 2011; Du et al. (2012)) used factor
maintenance, repair and other activities in healthcare facilities are per-
weights from AHP. However, application of AHP in medical devices
formed by multi-skilled and highly experienced engineers. This category
remanufacturing is non-existent.
of experts, who have worked within the healthcare system for several
This study follows a five-step guideline set out by Saaty (Saaty and
years while maintaining and offering technical services on medical de-
Kearns, 1985; Saaty, 2002), in line with guidelines in existing remanu-
vices, were targeted in this study. Their experience puts them in a good
facturing literature (Subramoniam et al., 2013; Ahmed et al., 2016;
position to answer questions relating to the safety, functionality and
Chakraborty et al., 2017): 1) Developing structural hierarchy for decision
warranty requirements for remanufactured medical devices. Therefore, it

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D.I. Akano et al. Cleaner and Responsible Consumption 2 (2021) 100017

Fig. 3. Structural hierarchy of the decision problem.

Table 2 Table 3
Scale of relative importance (Saaty and Vargas, 2012). Title, Area of specialisation, location and years of experience of participants.
Level of Linguistic terms What this means Title Area of Location Number of years
importance specialisation of experience

1 Equal Importance The two factors contribute equally to the Head of Service, Medical Medical Equipment Scotland, 37
objectives Equipment Asset Management UK
3 Moderate Importance Your experience and judgement slightly Management
favour one factor over the other Acting Head of Medical Anaesthetics and Scotland, 28
5 Strong Importance Experience and judgement strongly Equipment ventilation UK
favour one factor over the other Management
7 Very strong or One factor is favoured very strongly Head of Electromedical Equipment Scotland, 30
demonstrated over the other factor and this has been Equipment Services management UK
importance demonstrated in practice Head of Medical Physics Diagnostic Imaging England, 30
9 Extreme importance The evidence that favours one factor & Clinical Engineering UK
over the other has the highest possible Chairman Asset management England, 30þ
level of affirmation and policy UK
Independent Medical Medical Equipment England, 39
Devices Professional Management UK
is imperative that this assessment be performed by a small group of
highly experienced professionals (Korhonen and Voutilainen, 2006).
Fifteen (15) potential participants were contacted by email (mostly based therefore a comprehensive explanation of the method was given and
on referral) and invited to participate in the study. The potential par- three (3) examples of the AHP pairwise comparison process were pre-
ticipants were followed up two weeks later by email, clearly highlighting sented to the participants. The pairwise comparison table was presented
the importance of their response and the impact of such serving as a basis as matrix and participants were asked to complete the upper diagonal
on which to improve medical devices remanufacturing. Six (6) completed half of the matrix in line with (Escobar and Moreno-Jim
enez, 2000;
pairwise comparison were obtained from six (6) medical equipment Shiraishi et al., 1998) and as shown in the examples provided to them.
professionals forming an expert panel with a total of 194 years of expe-
rience and an average of 32.33 years’ experience making decisions
3.6. Testing for rationality and consistency
related to medical devices as shown in Table 3.
Saaty recommended the use of the consistency ratio (CR) and the
3.5.3. Survey process
consistency index (CI) to measure the consistency of the pairwise com-
The survey was delivered to participants in the form of a question-
parison since the AHP methodology depends on a consistent and logical
naire. Beforehand, participants were not familiar with the AHP method,
response of the participant. Different thresholds of acceptable CR (τ) are

6
D.I. Akano et al. Cleaner and Responsible Consumption 2 (2021) 100017

recommended by Saaty (Saaty and Kearns, 1985; Saaty, 2002) depending Table 5
on the number of factors considered in the study. When three factors (n Estimated consistency ratio (CR).
¼ 3) are considered, CR must not exceed 5% (τ ¼ 0.05), a 9% (τ ¼ 0.09) Participants Estimated consistency ratio (CR)
threshold when the number of factors does not exceed four (n ¼ 4) and
First Attempt Second Attempt
10% (τ ¼ 0.1) when more than four factors (n > 4) are considered. When
these thresholds are exceeded (i.e. CR > τ), the comparison is considered Participant 1 0.08 0.08
Participant 2 0.08 0.08
inconsistent and unreliable, the pairwise comparison must be repeated, Participant 3 0.09 0.09
and CR recalculated until CR < τ (Saaty and Vargas, 2012). Participant 4 0.14 0.09
Participant 5 0.09 0.09
3.6.1. Estimating CR Participant 6 0.27 0.06
Aggregated Matrix 0.05
In this study, CR was computed for pairwise comparisons by each
participant in line with (Saaty and Vargas, 2012; Korhonen and Vouti-
lainen, 2006). The procedure for calculating the consistency ratio is 2018), is used. The geometric mean comparison matrix is presented in
outlined below. Once the pairwise comparison matrix X is completed, the Table 6. To calculate the relative weights of each factors, this matrix is
CI is calculated using the equation below: normalised to produce Table 7.
Table 8 shows the ranking of the factors based on the relative weights
λmax  n
CI ¼ (or factor scores) obtained from the AHP process and the cumulative
ðn  1Þ
factor weights represented in Fig. 4. The cumulative weights of the fac-
n is the number of factors considered in the study, λmax is the result of the tors show that the first 4 factors (quality, price, warranty and brand eq-
product of the row column sum and the eigenvector matrix, W. uity) account for 78.74% in line with the pareto principle (Backhaus,
2016; Sher, 2020). Also, the weight of product quality factor exceeds a
2 3
W1 third (1/3) of the total weights. This further shows the importance of
6 W2 7 quality of remanufactured devices especially in the medical devices in-
6 7
λmax ¼ ½C1s C2s C3s ::::::Cns  6 W3 7 dustry where safety of device is paramount.
4 ⋮ 5
Furthermore, analysis of the pairwise comparison of individual
Wn
participant shows some similarity. Five out of six (5/6) participants
C1s ; C2s ; C3s are the sum of column 1, 2, 3 up to the sum of the nth ranked quality as the most critical factor and environmental friendliness
column Cns as the least influential factor on their purchase or use decisions. A sum-
mary of this finding is presented in Table 9 and further discussions is
CI presented in the next section.
CR ¼
RI
5. Discussions
where RI is the random index which depends on the number of factors
considered in a study. The RI table given by Saaty (Saaty and Kearns, Results from the AHP ranked seven factors that influence acceptance
1985) is shown in Table 4. of remanufactured medical devices. These factors (listed in order) are
quality, price, warranty, brand equity, available information, added value
3.6.2. Dealing with inconsistencies (i.e., when CR > 0.10) service and environmental friendliness. Quality was ranked as the most
The results of the consistency ratio (CR) for each participant are critical factor that influences acceptance of remanufactured medical
shown in Table 5. Two (2) out of 6 responses had CR > 0.1, the partic- devices. The overall factor weight of product quality (32.38%) un-
ipants were contacted and asked to redo the pairwise comparison clearly derscores the underlying cause of a low acceptance of remanufactured
stating the importance of consistency in the AHP method. The revised medical devices because experts are wary of sudden failure, safety issues,
pairwise comparisons were consistent with CR < 0.10. Subsequently, the accuracy of measurements, contamination, and the impact of the rema-
consistency ratio of the aggregated matrix is estimated as 0.05 which is nufactured product on the patients. Four out of the six participants
less than the threshold 0.10. ranked quality first with factor weights more than 30% with the other
two participants sharing the significant weights between quality and
4. Results pricing. This is likely influenced by the perception of reprocessed devices
in other industries such as electronic devices (Van Weelden et al., 2016)
The participants in the majority (67%) agreed that the 7 factors used and the automotive industry (Vafadarnikjoo et al., 2018). This finding is
in this study cover their major considerations when deciding whether or backed up by existing research (Duan and Aloysius, 2019; Van Weelden
not to accept a remanufactured medical device. One of the participants et al., 2016; Hosseini-Motlagh et al., 2018; Vafadarnikjoo et al., 2018;
highlighted the importance of human factors such as ease of use or Abbey et al., 2017; Gan and Chen, 2019). A focus on ensuring that
likelihood of user making an error while operating the remanufactured medical systems are remanufactured to a quality standard that is as good
device. Another participant commented on the availability of replace- as new may increase customer acceptance.
ment parts to serve remanufactured devices. However, it can be argued Customers expect that the price of remanufactured items will be
that both human factors and availability of spare parts have been taken lower than that of new. Pricing and quality of remanufactured devices are
care of in the study using factor F5 (added value services) which include two cardinal factors that influence customer acceptance in medical de-
user training and supply of replacement parts as discussed in section 3.5. vices industry (Starret al., 2020). This is validated in our study with both
To aggregate the individual pairwise comparisons into one, the geo- factors accruing more than half of the overall factor weights (51.38%).
metric mean approach, which was proposed by (Saaty and Kearns, 1985; Also, analysis of each participants’ pairwise comparison showed the sum
Saaty, 1987) and generalised by (Dong et al., 2010; Krejcí and Stoklasa,

Table 4
RI for number of factors considered (Saaty and Kearns, 1985).
n 1 2 3 4 5 6 7 8 9 10

RI 0 0 0.58 0.90 1.12 1.24 1.32 1.41 1.45 1.49

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D.I. Akano et al. Cleaner and Responsible Consumption 2 (2021) 100017

Table 6
Geometric mean pairwise comparison matrix.
Factors Quality Available Price Warranty Added value Brand Environmental
information services equity friendliness

i. Quality of product in terms of performance and safety 1.00 4.74 2.22 2.29 3.89 2.57 5.97
j. Available information (e.g., previous use, expected life, 0.21 1.00 0.44 0.91 2.44 0.82 3.13
quality certification)
k. Price in terms of acquiring, operating and maintaining 0.45 2.28 1.00 1.05 2.99 2.14 5.38
medical devices
l. Warranty provided on the medical device 0.44 1.10 0.95 1.00 2.67 1.22 4.97
m. Added value services including post-sales technical services 0.26 0.41 0.33 0.37 1.00 0.53 2.80
n. Brand equity in terms of who performs the remanufacturing 0.39 1.22 0.47 0.82 1.87 1.00 4.82
operation.
o. Environmental friendliness in terms of waste generated, 0.32 0.32 0.19 0.20 0.36 0.21 1.00
material and energy consumption
SUM 3.06 11.07 5.60 6.64 15.21 8.49 28.07

Table 7
Normalised pairwise comparison matrix (X N ).
Factors Quality Available information Price Warranty Added value services Brand equity Environmental friendliness

i. Quality 0.3264 0.4283 0.3966 0.3446 0.2556 0.3026 0.2127

j. Available information 0.0689 0.0904 0.0784 0.1371 0.1602 0.0963 0.1116
k. Price 0.1470 0.2059 0.1786 0.1579 0.1968 0.2520 0.1916
l. Warranty 0.1426 0.0992 0.1702 0.1505 0.1753 0.1439 0.1769
m. Added value services 0.0839 0.0371 0.0596 0.0564 0.0657 0.0630 0.0997
n. Brand equity 0.1270 0.1104 0.0834 0.1231 0.1229 0.1178 0.1718
o. Environmental friendliness 0.1042 0.0288 0.0332 0.0303 0.0235 0.0244 0.0356

which also described warranty as a critical motivation to purchase a

Table 8
remanufactured device (Van Weelden et al., 2016; Vafadarnikjoo et al.,
Ranking of user-related factors using weights obtained from AHP.
2018). Provision of warranty may reduce customers' perceived risk
Rank Factor Relative Cumulative associated with using remanufactured devices, especially in high-risk
Weight Weight
industries such as the medical devices industry (Docters et al., 2010). A
1 Quality of product in terms of performance 0.3238 32.38% ‘like-new’ warranty may include scheduled preventive maintenance and
and safety
repairs to improve product performance and prevent unexpected failure
2 Price in terms of acquiring, operating and 0.1900 51.38%
maintaining medical devices of components (De Santana et al., 2018).
3 Warranty provided on the medical device 0.1512 66.50% Brand equity was ranked fourth with a relative weight of 12.24%. This
4 Brand equity in terms of who performs the 0.1224 78.74% finding is consistent with data obtained in a study by Vafadarnikjoo et al.
remanufacturing operation. (2018) which ranked remanufacturer and retailer's reputation as fifth
5 Available information (e.g. previous use, 0.1061 89.35%
and seventh respectively (Vafadarnikjoo et al., 2018), and Gan and Chen
expected life, quality certification)
6 Added value services including post-sales 0.0665 96.00% (2019) which ranked remanufacturer's and retailer's reputation as fourth
technical services and fifth, respectively (Gan and Chen, 2019). In healthcare, branding is
7 Environmental friendliness in terms of 0.0400 100.00% assumed to be an important consideration especially when the users have
waste generated, material and energy
little or no knowledge of, or experience with remanufactured medical
consumption
systems as is the case in the UK healthcare sector (Lee, 2010; Torney
et al., 2018). However, this research indicates a lower relative weight
of factor weights for quality and pricing as 49.99%, 64.98%, 43.98%, when compared to other factors i.e., quality, price, certification and
39.42%, 48.09% and 48.26%, which further reiterates the importance of warranty have a greater influence on the customers decision than
these two factors combined. Price is a key factor that drives customers branding of the remanufactured medical systems.
towards remanufactured systems (Jim
enez-Parra et al., 2014) and it was Available information about the remanufactured device is ranked as
ranked as the second most critical in this study, with an overall weight of the fifth most critical factor that influence acceptance of remanufactured
19.00%. A similar finding was reported by (Abbey et al., 2015) and the device with a factor weight of 10.61%. Knowledge of remanufacturing
importance of pricing as it relates to acceptance of remanufactured operation remains low in many industries, more so in medical equipment
products has been discussed by (Gaur et al., 2015; Vafadarnikjoo et al., industry (Basile and Quarngesser, 1997). Wang et al. (2019)'s result
2018; Phantratanamongkol et al., 2018). Developing an effective pricing reflect a low mean value of product knowledge of remanufactured
strategy is necessary for firms venturing into remanufacturing operation products whereas Milios and Matsumoto (2019) reported that up to
(Gaur et al., 2015). This study also supports evidence from (Callea et al., two-third (60%) of its participants were not aware of auto parts rema-
2017) which highlights the importance of pricing on the procurement nufacturing and a whooping 76.4% have not ever used remanufactured
and selection of medical devices. auto parts (Milios and Matsumoto, 2019; Wang et al., 2019). Customers'
In line with the definition of remanufacturing, customers expect negative perception about the quality level of remanufactured products
warranty similar to what is obtainable in a new device, or even better (Singhal et al., 2019) may be improved by issuing quality certification to
(Ijomah et al., 2007b). The extent to which customer acceptance of gain user confidence. Abbey et al. (2017) refers to this as ‘functional
remanufactured medical devices is influenced by warranty provision is quality labelling or certification’ (Abbey et al., 2017). Weelden et al.
reflected in the factor weight obtained in this study (15.12%) which (2016) concluded by suggesting that consumers are likely to accept
ranks warranty as the third most critical consideration. This result re- associated risks with refurbished products if comprehensive and acces-
flects those of Vafadarnikjoo et al. (2018) and Weelden et al. (2016) sible information is provided (Van Weelden et al., 2016).

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D.I. Akano et al. Cleaner and Responsible Consumption 2 (2021) 100017

Fig. 4. Cumulative sum of factor weights obtained from AHP.

Table 9
Factor weights and ranking by each participant.
Factors Factor Weight (Ranking)

Participant Participant Participant Participant Participant Participant

1 2 3 4 5 6

i. Quality of product in terms of performance and safety 30.15% (1) 38.10% (1) 21.78% (2) 30.56% (1) 33.37% (1) 27.21% (1)
j. Available information (e.g., previous use, expected life, quality certification) 3.82% (6) 12.02% (4) 8.69% (5) 19.66% (2) 7.19% (5) 19.17% (3)
k. Price in terms of acquiring, operating and maintaining medical devices 19.84% (3) 26.88% (2) 22.20% (1) 8.86% (6) 14.72% (3) 21.05% (2)
l. Warranty provided on the medical device 15.33% (4) 12.82% (3) 13.10% (4) 16.65% (3) 21.07% (2) 12.22% (5)
m. Added value services including post-sales technical services 8.03% (5) 3.24% (7) 7.74% (6) 10.92% (4) 6.82% (6) 4.99% (6)
n. Brand equity in terms of who performs the remanufacturing operation. 20.72% (2) 3.36% (6) 21.62% (3) 10.38% (5) 13.32% (4) 12.80% (4)
o. Environmental friendliness in terms of waste generated, material and energy 2.11% (7) 3.57% (5) 4.86% (7) 2.97% (7) 3.51% (7) 2.56% (7)
consumption

Customers consider warranty policy and added value services such as remanufactured devices. This finding supports previous arguments on
the availability of spare parts, repair and maintenance services only after the impact of environmental benefits on customer acceptance in the
assessing the price, quality and warranty of the remanufactured product. medical devices industry (Compton, 2018; Kadamus, 2008; Cheong et al.,
In most cases, service agreements are embedded with the warranty policy 2020).
at least for the duration of the warranty. This is reflected in the relatively
low ranking of added value services as sixth with a weight of 6.65% only 6. Conclusion
ahead of environmental friendliness. Added value services such as user
training and replacement part availability were suggested by participants Increasing awareness of the need to reduce waste equipment going to
in this study. This shows the slight importance attached to the provision landfills has provided a unique market opportunity. As manufacturers
of technical services in the medical devices industry. Weelden et al. jostle to make impact in the remanufacturing business, there is a lack of
(2016) described warranty and service as a major ‘risk reliever’, ‘builder understanding of consumer requirements from the perspectives of the
of consumer trust’ and a source of added value to the consumers (Van OEM. Also, a clear knowledge gap was identified on understanding the
Weelden et al., 2016). importance of factors that influence consumer acceptance of remanu-
Environmental friendliness is the least ranked factor with a weight of factured medical devices. Thus, this present study was designed to pre-
4.00% despite increasing discussions on sustainability in the medical and sent a background of medical devices remanufacturing followed by the
healthcare sector. This is another factor with the same ranking (7th) by ranking of the relative importance of consumer factors. To achieve this,
five of six participants. Duan and Aloysius (2019) suggested that in- pairwise comparison of seven factors identified in literature was per-
dustries with high environmental consciousness perceive remanufac- formed using the AHP method. Six highly experienced medical equip-
tured products to be of good and acceptable quality and vice versa (Duan ment experts form the expert panel. Results show that the responses from
and Aloysius, 2019). The low relative environmental consciousness in the the participants were consistent and rational with consistency ratio less
medical and healthcare sector partly explains the low acceptance of than 0.1 for all completed pairwise comparisons. This study ranked

9
D.I. Akano et al. Cleaner and Responsible Consumption 2 (2021) 100017

product quality in terms of performance, appearance and safety as the Akano, D.I., Ijomah, W., Windmill, J., 2021. Stakeholder considerations in
remanufacturability decision-making: findings from a systematic literature review.
single most critical factor that influence customer acceptance of rema-
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formation, brand equity, added value services and environmental remanufactured products. J. Remanufacturing 7 (1), 19–47. https://doi.org/
friendliness. This finding echoes the importance of quality factors in 10.1007/s13243-017-0032-8.
Alqahtani, A.Y., Gupta, S.M., 2018. Money-back guarantee warranty policy with
medical devices industry, where reliability and safety of devices are preventive maintenance strategy for sensor-embedded remanufactured products.
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Declaration of competing interest Dong, Y., Zhang, G., Hong, W.C., Xu, Y., 2010. Consensus models for AHP group decision
making under row geometric mean prioritization method. Decis. Support Syst. 49 (3)
The authors declare that they have no known competing financial https://doi.org/10.1016/j.dss.2010.03.003.
Du, Y., Cao, H., Liu, F., Li, C., Chen, X., 2012. An integrated method for evaluating the
interests or personal relationships that could have appeared to influence remanufacturability of used machine tool. J. Clean. Prod. 20 (1), 82–91. https://
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