bio medical waste management research paper

Biomedical Waste Management: A Study on Assessment of Knowledge, Attitude and Practices Among Health Care Professionals in a Tertiary Care Teaching Hospital

Divya Rao 1 , M. R. Dhakshaini 2 , Ameet Kurthukoti 3 and Vidya G. Doddawad 4

1 Department of Health System Management Studies, JSS University, Mysuru.

2 Department of Prosthodontics, Vice Principal, JSS Dental College, JSS University, Mysuru.

3 Dental Health Officer, Department of Health and Family Welfare, Government of Karnataka.

4 Department of Oral Pathology and Microbiology, JSS Dental College, JSS University, Mysuru.

Corresponding Author E-mail: [email protected]

DOI : https://dx.doi.org/10.13005/bpj/1543

Biomedical waste (BMW) generated in our nation on a day to day basis is immense and contains infectious and hazardous materials. It is crucial on the part of the employees to know the hazards of the biomedical waste in the work environment and make its disposition effective and in a scientific manner. It is critical that the different professionals engaged in the healthcare sector have adequate Knowledge, Attitudes and Practices (KAP) with respect to biomedical waste management. Many studies across the country have shown that there are still deficiencies in the KAP of the employees in the organizations and hence it is necessary to make the appraisal of the same. To ascertain the levels of and the expanse of gaps in knowledge, attitudes and practices among doctors, post graduates, staff nurses, laboratory technicians and house-keeping staffs in a tertiary care teaching hospital in Mysuru, Karnataka. A cross sectional study was carried out using questionnaire as the study tool among the health care professionals in a tertiary care teaching hospital. The study demonstrated gaps in the knowledge amongst all the cadres of the study respondents. The knowledge in relation to BMW Management including the hospital BMW protocols was more desirable among doctors, but practical facets were better in nurses and the lab technicians. Knowledge, Attitude and Practice amongst the different cadres of staff members were found to be significant statistically.

Attitude; Biomedical Waste; Healthcare personnel; Knowledge; Practice

Introduction

Health care waste is a unique category of waste by the quality of its composition, source of generation, its hazardous nature and the need for appropriate protection during handling, treatment and disposal. Mismanagement of the waste affects not only the generators, operators but also the common people too. 1

‘Bio-medical waste’ (BMW) means any solid and/or liquid waste including its container and any intermediate product, which is generated during the diagnosis, treatment or immunization of human beings or animals or in research pertaining thereto or in the production or testing thereof. 2

Due to the increase in the procedures that are carried out at the various health care setups, excessive amounts of waste have been generated at the centers of care.

India approximately generates 2 kg/bed/ day 3 and this biomedical waste encompasses wastes like anatomical waste, cytotoxic wastes, sharps, which when inadequately segregated could cause different kinds of deadly infectious diseases like Human immunodeficiency virus(HIV) hepatitis C and B infections, etc, 4 and also cause disruptions in the environment, and adverse impact on ecological balance. 5,6

Adequate knowledge amongst the health care employees about the biomedical waste management rules and regulations, and their understanding of segregation, will help in the competent disposal of the waste in their respective organizations. 7

Acceptable management of biomedical waste management begins from the initial stage of generation of waste, segregation at the source, storage at the site, disinfection, and transfer to the terminal disposal site plays a critical role in the disposal of waste. Hence adequate knowledge, attitudes and practices of the staff of the health care institutes play a very important role. 8,4,9

Teaching institutes play a critical role in the health care setup as it is from these places that the future health care professionals and all those persons involved in the care giving to the community are trained. 10

Studies documented from different parts of the country; still convey that there are gaps in the Knowledge, lacunae in the attitudinal component and inconsistency in the practice aspects which are matters of concern among the health care professionals. 8,11-15 With this background, the study was carried out to assess the current knowledge, attitude and practices of the health care workers like doctors, post graduates, interns, staff nurses, laboratory technicians and house-keeping staff in a tertiary care teaching hospital with regard to the management of BMW.

To assess the levels of knowledge, attitudes and practices among doctors, post graduates, interns, staff nurses, laboratory technicians and house-keeping staff in the different departments of a tertiary care teaching hospital.

To assess the gaps in knowledge, attitudes and practices among these health care workers in the different departments of a tertiary care teaching hospital.

Methodology

Study design

Cross-sectional study.

Study setting

Tertiary care teaching hospital

Study population

Staff working in the different departments of the hospital.

Eligibility Criteria

All consenting individuals amongst the different cadres of staff were included into the study. There were 2056 eligible participants, which was taken as the sampling frame.

Sample Size

Expecting that 50% of the study population had precise knowledge (considering the outcome variable) about the rules and legislation of biomedical waste management, 16 with an allowable error of 10%, at 95% confidence interval, and accounting for the finite population correction for 2,056 participants, a minimum sample size of 472 was calculated.

Sampling Strategy

The study population was classified according to the different strata based on their designation as doctors, postgraduates (junior residents), interns, staff nurses, laboratory technicians and house-keeping staff. Allocation of the population according to the strata.

Ethical Approval

The ethical clearance for the study was obtained from the Institutional Ethics Committee.

Materials and Methods

The tool used for the study was a pre-tested, semi-structured closed ended questionnaire which encompassed 42 questions on Knowledge, Attitudes and Practices.

The questions on knowledge appraised the participant’s knowledge on attributes related to the colour coding and their implications, identification of biomedical hazard symbol, waste categories, and hospital policies for biomedical waste management.

The questions on attitude were related to matters like, was biomedical waste hazardous, its management additional burden on their work or if their appropriate management burden on the finances of the hospital, and also on legislative measures for waste management.

The questions on practice appraised if the study respondents had received any training on biomedical waste management, if they were immunized against hepatitis B and if disinfection of sharps were carried out at the point of generation.

The literature review was done based on which the questionnaire was formulated according to the requirements of the study. The questionnaire was pretested and validated by a post-test and a pilot survey was conducted with a sample of 60 respondents, with representations from the various strata of the study respondents. The study tool consisted of 12 questions assessing the knowledge with yes/no/not sure responses, 10 questions assessing the attitude with agree/disagree/no comment as answers and 20 questions assessing the practices with yes/ no responses.

The participants filled up the self-administered questionnaires without scope for undue help.

The questionnaire was adapted from English to local language by an experienced professional who is involved in translating of health survey questionnaires to accommodate the housekeeping staff. The questionnaire was also back translated to English for checking of possible discrepancies and incorporating if any changes were required. The identity of the study respondents were maintained anonymous at various stages of the study.

The results were evaluated across 3 domains for all the cadres of the study population.

The results are Displayed as Under

Statistical Methods

Data was analysed using MS-Excel and R version 3.4.3. Percentages (with 95% confidence intervals) were calculated and the same are presented graphically. Chi-square test was performed to test the association between the different cadres related to their knowledge, attitude and practices towards BMW

Knowledge Score

The knowledge regarding general information about HCW was assessed, the mean score was highest in doctors (10) followed by nursing staff (9.3) and least in housekeeping staff (7.5). This is found to be statistically significant.

Table 1: The participant’s knowledge on biomedical waste management.

Overall, the study respondents showed satisfactory knowledge regarding biomedical waste management. The knowledge about BMW among doctors was the distinctively better, followed by that of nurses, technicians, post graduates, interns and housekeeping staff (in order). The gaps in knowledge were in the areas regarding the fate of the waste after it was segregated, and as well as who was the regulator for the safe transportation of biomedical waste from the hospital.

Table 2: The participant’s attitudes towards biomedical waste management.

The mean attitude score was 9.20 for the nurses and 9.18 out of 10 for the doctors. Favourable attitude was shown by most of the study respondents towards biomedical waste management. The best attitudes were displayed by the nurses showed, subsequently by doctors, interns, postgraduates, the laboratory technicians, and house keeping staff (in order). It was concerning that the lacuna in this domain was that biomedical waste management was considered as additional burden on work.

Table 3: The participant’s practices regarding biomedical waste management.

The mean practice score was 17.30 for the nurses and 16.50 for the housekeeping staff and 15.27out of 20 for the doctors, in the study. Though greater number of the study respondents displayed favourable biomedical waste management practices, it was noted that the nurses had the best practices, followed house keeping staff, doctors, technicians, interns and junior residents (in order). It was noted that the staff ware following the preventive measures of immunisation against Hepatitis B, and also routine health check-ups were conducted for the staff. Explicit training on BMW management was desired by most of the staff.

Chi-Square Test

The null hypothesis which was to be tested here was “The two attributes were independent”. Here three hypotheses were there to be tested:

Cadre and knowledge are independent.

(Chi-square = 160.8, Degrees of freedom=10, p-value < 0.0001)

Cadre and attitudes are independent.

(Chi-square = 95.6, Degrees of freedom=10, p-value < 0.0001)

Cadre and practices are independent.

(Chi-square = 538.45, Degrees of freedom=15, p-value < 0.0001)

The present cross-sectional study recognized certain inadequacies in the knowledge component amongst the different cadres of health care workers, though greater than 50% of the study respondents, across cadres, demonstrated satisfactory or good knowledge, attitudes and practices. The knowledge component of the doctors was more desirable compared to their practices whereas visa versa was true for nurses and lab technicians. The knowledge component was low amongst the housekeeping staff; which was identical to the results from other similar studies conducted previously. 10,13,16

The attitude towards BMW management of housekeeping staff was low. Low level of knowledge was mainly attributed to new staff coming on rotation to the hospital and also to comparably low educational levels of the housekeeping staff. Training of all cadres of staff will help in the analytical evaluations for suitable and applicable management of biomedical waste. 10,13,16

The practice of recapping the needles was very low across cadres. Recapping of needles is one of the important risk factor for needle stick injuries; the prevalence was very low in the organization. This may be associated to the awareness of the staff and also due to the adequate number of needle cutters in the various patient care areas of the hospital.

Higher practice scores found in the house keeping staff and nursing staff in the present study may be due to higher responsibilities assigned to them in handling of BMW which was similar to findings of previous studies. 1,17 Overall 8.1 % of the study respondents attended the external training programmes on BMW management on their own accord, but others too (~ 59%) of them communicated their willingness to do the same if opportunities arose in the future. 10,13,16

Conclusions

Overall, the knowledge, attitudes and practices towards biomedical waste management among the study respondents was satisfactory.

Knowledge, attitudes and practices toward biomedical waste management were better among the nurses and doctors than the other cadre of staff.

Knowledge, Attitudes and Practices of the study respondents are dependent on the cadre that they belong too.

This study was a modest attempt to evaluate the KAP of the health care workers towards BMW. We recommend further studies on a larger stratum across hospitals to evaluate the awareness of health care workers towards BMW.

Recommendations

Training programs need to focus on empowering the healthcare professionals on biomedical waste management with broad scope and practical knowledge in all aspects. The ethical requirements and the institutional level policies form the directional pathway for the practical components in the organization. The right practices and other activities of BMW management and its ramifications in the form of avoiding of injuries, importance of vaccinations and following of universal precautions can be achieved when adequately supported by IEC (information, education and communication) strategies like handouts, stickers, charts, celebrations of various days like hand hygiene day and other days etc can help in bettering the practices of the employees of the organizations. Training the staff with checklists and regular inspections can bring about accountability in the staff.

All health care professionals regardless of their designation, experience and qualification , designation must be included in these interventions, so that it can avoid cross infections among the professionals and patients in the health care sector.

Conflicts of Interest

There is no conflicts of interest.

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Biomedical waste management practices and associated factors among health care workers in the era of the covid-19 pandemic at metropolitan city private hospitals, Amhara region, Ethiopia, 2020

Getasew mitiku, amha admasie, amsalu birara, wubante yalew.

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Competing Interests: The authors have declared that no competing interests exist.

* E-mail: [email protected]

Received 2021 Aug 27; Accepted 2022 Mar 13; Collection date 2022.

This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Biomedical waste management is an important precondition to safeguard the healthcare workers and community members, as well as the environment, from being contaminated with infectious substances. However, biomedical waste management practices during the pandemic era of COVID-19 were unknown.

This study was aimed to assess biomedical waste management practices and associated factors among health care workers during the COVID-19 pandemic era at metropolitan city private hospitals, Amhara Region, Ethiopia.

An institutional-based cross-sectional study was conducted at metropolitan city private hospitals in Amhara Region. Simple random sampling was used to select 431 study participants. Data were collected through a self-administered questionnaire and observational checklists. The data were cleaned, coded, and entered into the Epi-data version 4.6, and then exported to SPSS version 20. for analysis. Variables with a p-value less than 0.05 were considered as significant factors in multivariable logistic regression analysis and AOR with a 95% confidence level was used to measure the strength of association.

The proportion of health care workers who had good practices in biomedical waste management was 49.4%. Participants who had MSc education level, [AOR = 4.20, 95% CI (1.01, 17.40)], Bachelor degree [AOR = 3.52, 95% CI (2.13, 5.82)], got training on biomedical waste management [AOR = 4.33, 95% CI (2.71, 6.93)], access to color-coded three bins in their working department [AOR = 6.24.95% CI (3.84, 10.13)] and those who had good attitude (AOR = 2.64, 95% CI (1.65, 4.22), were significantly associated with biomedical waste management practices in private hospitals.

The practice of biomedical waste management in the study area was low. Level of education, taking training on biomedical waste management, availability of color-coded three bins, and attitude of health care workers were significantly associated with biomedical waste management practices. Hence, in-service training is recommended to improve biomedical waste management practices.

Introduction

Biomedical waste (BMW) is any waste that is generated during the diagnosis, treatment, or immunization of human beings or animals or from research activities, and contains potentially harmful microorganisms which will infect hospital communities and the general public [ 1 , 2 ].

BMW includes sharps, non-sharps, blood, body parts, chemicals, pharmaceuticals, medical devices, and radioactive materials [ 3 ]. Common sources of biomedical waste include hospitals, nursing homes, clinics, laboratories, offices of physicians, dental, and veterinarians, home health care, and funeral homes [ 4 , 5 ]. BMWs are considered because they represent the second hazardous waste globally after radiation waste [ 6 ].

Biomedical waste is a relevant problem for several countries and poses serious public health threats worldwide [ 7 ]. Nearly 3.2 million tons of biomedical waste is generated by hospitals alone annually and the Environmental Protection Agency (EPA.2019) estimates that 10% to 15% of all biomedical waste is potentially hazardous [ 8 ].

According to the World Health Organization (WHO), nearly 85% of waste generated by the hospitals is general waste and about 15% of waste is biomedical waste, composed of 10% of infectious wastes and 5% of non-infectious wastes like radioactive and chemical wastes [ 9 ]. In developing countries, especially in Africa, BMW has not received the attention it deserves [ 10 ].

Biomedical waste management (BMWM) is the process of segregation, collection, storage, treatment, transport and disposal, and other safety measures of waste in health institutions [ 11 ]. Proper BMWM includes vital steps, such as segregation, collection, storage, transportation, treatment, and final disposal, of waste generated in health care settings [ 12 ]. Improper BMWM, which includes hazardous wastes (10–25%) mixed with the non-hazardous waste (75–90%) can result in the whole bulk waste becoming potentially hazardous [ 13 ]. There are international agreements and Conventions which are particularly pertinent in BMWM, environment protection, and its sustainable development and thus they should be kept in mind by preparing waste management policies [ 14 ]. Adequate knowledge, attitude, and practice (KAP) of health care workers (HCWs) are key factors for having a successful BMWM system, as they are important preconditions to safeguard the community [ 15 ], and the environment from being contaminated with infectious substances [ 16 ].

In Ethiopia, public hospitals provide training associated with infection prevention and healthcare waste management to waste handlers, environmental professionals, and heads of departments, but there was no published evidence indicating that private hospitals provide any training associated with healthcare waste management and infection prevention for health care workers [ 17 ].

In the Ethiopian context, there was no separate regulation specific for the HCFs to enforce them for the proper management of hazardous waste. However there are three BWM guidelines prepared by the Federal Ministry of Health (FMoH), Food, Medicine and Healthcare Administration and Control Authority (FMHACA), and Federal Environmental Protection Authority (FEPA) independently which are not, updated and lacked proper compliance on their implementation[ 18 – 21 ].

COVID-19 has been reported to first begin in December 2019 [ 22 ] while the WHO announced a Global Pandemic in March 2020. COVID-19 has been rapidly spreading all over the world, forcing countries and governments to adopt strict and specific measures to contain the pandemic. According to the Federal Ministry of Health of Ethiopia, the first COVID-19 case was reported in March 2020, and measures for tackling the pandemic have been taken ever since. In this regard, proper disposal of the waste is strongly relevant, as it may lead to the spread of communicable diseases [ 23 ]. Abundant use of medical technologies in hospitals and safety measures to stop the dissemination of the COVID-19 have led to a tremendous increase in BMW generation [ 24 ]. The generation rate was reported about 9200 tons/day of PW, with a total generation of more than 3.3 million tons per year in India [ 25 ], and The total mean weight of waste generation rate in the hospital was 492.5 kg/day in Ethiopia [ 26 ]. Moreover, the waste generated in health care facilities during the treatment and laboratory tests is highly contagious and hazardous [ 23 ].

According to the WHO 2018 report, the biomedical waste generation rate in low-income countries was 0.2kg of hazardous waste per hospital bed per day [ 27 ]. However, the Biomedical waste generation rates vary across different hospitals in Ethiopia where the generation rate ranges from (0.164–1.94) kg/bed/ day, and (0.396–0.866) kg/bed day (0.92kg/bed/day and/or 0.75kg/) patient/day hazardous waste [ 28 – 31 ]. Health facilities in Ethiopia have chosen incineration to treat BMW [ 32 , 33 ], but 80% of hospital incinerators used low-temperature technology that generates air pollutants [ 34 ].

The BMW is often the source of over 30 dangerous blood-borne pathogens [ 35 ]. Worldwide, about 5.2 million people (including 4 million children) die each year due to exposure to BMW [ 36 ], The hazards of exposure to hospital waste can range from developing gastroenteritis, respiratory and skin infections, as well as more deadly diseases like Human Immunodeficiency Virus Acquired Immunodeficiency Syndrome (HIV/AIDS), and Hepatitis B (HBV); moreover, injections with contaminated syringes caused 21 million hepatitis B infections (32% of all new infections), 2 million hepatitis C (HCV) infections (40% of all new infections) and 260,000 HIV infections (5% of all new infections) [ 37 , 38 ].

In developing countries, the management of BMW is becoming a growing concern in urban areas [ 39 ]. However, Pathogens and toxic chemicals in BMW can pose serious health risks for waste collectors, patients, and health care workers. Among these risks, HIV/AIDS, HBV, and HCV can be mentioned. HIV, HCV, and HBV have the risk of transmission 0.3%, 1.8%, and 30%, respectively from one sharp injury [ 40 ].

Few studies conducted in Ethiopia indicated that lack of training, awareness, staff resistance, managerial poor commitment, lack of adequate resources, negligence, and unfavorable attitude of the healthcare staff were the main identified challenges of BMWM [ 21 , 28 , 41 , 42 ]. Therefore, assessing the practice of BWM and its associated factors among health care workers is a pivotal element to halting this burden. Accordingly, this study is planned to assess the practice of biomedical waste management and associated factors among health care workers in private hospitals of the metropolitan city of the Amhara region.

Amhara Region is found in Northwestern Ethiopia and has an estimated acreage of about 170000 square kilometers. The region borders Tigray within the North, Afar within the East, Oromiya within the South, Benishangul-Gumz within the Southwest, and also the country of Sudan to the West. The region has three metropolitan cities (Bahir Dar, Gondar, and Dessie). In line with the population size estimation of 2016, the total population was 1,937,081. (797,794 in Bahir Dar 740,859, in Gondar, and 398,428 in Dessie). In these metropolitan cities, there are eight private hospitals namely Gamby, Adinas, Afelas, Dreamcare, Ethiogeneral, Batty, Selam, and Ibex with six hundred ninety healthcare workers.

Study design and period

An institutional-based cross-sectional study was carried out from November 25 to December 25/2020.

The source and study population of the study were all health care workers who were working in private hospitals in metropolitan cities of the Amhara region (Bahir Dar, Dessie, and Gondar). The study unit was, randomly selected health care workers.

Inclusion and exclusion criteria

Health care workers in private hospitals who were employed 6 months or longer were included in the study, However, health care workers who were unable to communicate due to illness were not eligible for the study.

Sample size determination and sampling procedure

The sample size was determined using Epi-info version 7 considering (78.9%) biomedical waste management practice in Debre Markos Town Healthcare Facilities, Amhara region [ 43 ]; at 4% of the marginal error, 95% of confidence level (CL), and a 10% response rate. Therefore, the sample size was 440. Amhara Region has three metropolitan cities. All private hospitals in the metropolitan cities in the region were identified by name and included in the study. The sample size was allocated proportionally to each private hospital. Then simple random sampling was employed to select healthcare workers from each private.

Study variables

Biomedical waste management practice was our dependent variable. On the other side, socio-demographic characteristics of respondents, Healthcare facility-related factors, Knowledge of HCWs, and Attitude of HCWs were the independent variables of the study.

Data collection method and instruments

The data were collected using a self-administered questionnaire and observational checklist. The questionnaire was comprised of socio-demographic characteristics, knowledge, attitude, and healthcare facility-related factors. The questionnaire and observational checklist were first developed in English and then translated into Amharic, by English and Amharic language professionals to check its consistency. Data were collected by 5 trained clinical nurses and supervised by 3 trained BSC Environmental Health Professionals.

Quality control

The training was given to data collectors, and supervisors regarding the objective of the study, a basic skill of communication, how to conduct the self-administered questionnaire for one day. Before the actual data collection, pre-testing was conducted on 5% of the sample size at Debre Tabor Referral Hospital and the necessary correction was made based on the pre-testing findings. The completeness of the questionnaire was checked every day by the supervisors and principal investigator. These supervisors were available throughout the data collection period.

Data processing and analysis

Data were entered into Epi-data software version 4.6 and then exported to the SPSS software version 20 for analysis. Descriptive statistics were carried out to illustrate the means, standard deviations, and frequencies of the demographic profile, knowledge, attitude, and BMWM practice. Binary logistic regression analysis was made to identify variables having an association with the dependent variable. Then all independent variables with a p-value < 0.25 in the bivariable analysis were entered into multivariable logistic regressions to control the effect of confounding. Model fitness was checked using the Hosmer Lemeshow test. Finally, variables with a p-value less than 0.05 were considered as significant factors, and AOR with a 95% confidence level was used to measure the strength of association.

Ethical statement

Ethical clearance was obtained from the ethical review board of the college of medicine and health science, Bahir Dar University. Communication with different official administrators was done through a formal letter obtained from Bahir Dar University and the metropolitan cities health bureau. Before starting data collection, the participants had read the objective, benefits, and risks of the study to get informed verbal consent of participants. The right of the respondent to withdraw from the interview or not to participate was respected. To keep the confidentiality of any information provided by study participants, the data collection procedure was anonymous.

Operational definition of terms

Biomedical waste, medical waste, healthcare waste, and hospital waste are terms that have been used interchangeably [ 41 ]. However, healthcare waste has been more frequently used by published articles so far [ 44 ].

Biomedical waste management practice

The response to questions related to biomedical waste management practice was summed up and calculated the mean. The mean and above indicated good practice and the below mean indicated poor practice towards biomedical waste management practice [ 39 ].

The response of knowledge questions was summed up and a total score was computed with value and taken mean score. The mean and above indicated good knowledge and the below mean indicated poor knowledge towards biomedical waste management practice [ 43 ].

Attitude is a judgment of individual behavior as good or poor and was measured based on the 5 points Likert scale by summing the Likert questions. The mean and above indicated a good attitude and the bellow mean indicated a poor attitude towards biomedical waste management practice [ 43 ].

Health care workers

HCWs are people who are involved in the promotion, protection, and enhancement of population health. In this study, the term health care worker was standing for clinical staff and cleaners [ 43 ].

Socio-demographic and healthcare-related characteristics

A total of 431 HCWs have participated in the study and the response rate was 98%. About, 245 (56.8%) were females. The mean age of the respondents was 29 years (with SD±4.68). Regarding educational status, 256 (59.4%) were first degree, and 12 (2.8%) were certificate and bellow. More than half, (52%) of the HCWs had more than 5 years of work experience. ( Table 1 ).

Table 1. Socio-demographic variables for BMWM among HCWs at metropolitan cities private hospitals of Amhara region, Ethiopia, December 2020.

Health care facility-related factors.

Regarding training access, 201 (46.6%) of health care workers had taken BMWM training. About 388 (90%) workers were working 8 hours a day in different work environments such as 155 (36%) in OPD, 132 (30.6%) in Ward, and the rest in the laboratory, emergency, pharmacy, and others. In the working environment, only 223 (51.7%) of them had three bins for waste segregation. ( Table 2 )

Table 2. HCF related factors for BMWM among HCWs at metropolitan cities private hospitals of Amhara region, Ethiopia, 2020.

**x-ray and OR.

As stated in Fig 1 below, among the studied participants, 178 (41.3%), 63 (14.6%)), and 58 (13.2%) were nurses, doctors, and cleaners respectively ( Fig 1 ).

Fig 1. Profession or job distribution of health care workers in metropolitan cities private hospitals of Amhara region 2020.

Knowledge of health care workers

From the total health care workers, 290 (67.3%) HCWs knew the benefit of BMWM. About 269(62.4%), and 283(65.7%) were aware that infectious and general wastes, should be placed in yellow, and black, respectively. Besides, 233(54.1%) were aware of a safety box should be filled a maximum of 3/4 th . 168 (39%) health care workers knew the maximum storage time (48 hours) limit of infectious wastes before treatment or disposal. Based on the summary of knowledge questions the mean score of HCW’s knowledge in biomedical waste management was 7.96 with SD±1.50 on a range of 1 to 13 questions. More than half, (62.4%) of Health care workers had good knowledge about biomedical waste management ( Table 3 ).

Table 3. Frequency of health care workers among each knowledge term question at metropolitan cities private hospitals of Amhara region, Ethiopia, 2020.

The attitude of health care workers.

Among all Health care workers, 174 (40.4%) strongly agreed with the statement proper biomedical waste disposal is important and 167 (34.7%) health care workers strongly agreed with the statement BMWs should be segregated into different categories. Based on the summary of Attitude questions, the mean score of HCWs’ Attitude in biomedical waste management was 53.68 with SD±8.753 on a range of 1to 14 questions. More than half (53.4%) of Health care workers had a good attitude about biomedical waste management ( Table 4 ).

Table 4. Frequency of health care workers among each attitude item question at metropolitan cities private hospitals of Amhara region, Ethiopia, 2020.

The practice of health care workers.

This study revealed that 98 (22.7%) health care workers encountered sharp injury at their health care service delivery. Regarding PPE, 337 (78.2%) and 332 (77.0%) of HCWs always used gloves and gowns while handling or working with BMWs respectively. Based on the summary of practice questions, the mean score of HCWs practice in this study was 6.77with SD ±1.42 on a range of 1 to 12 questions. Less than half (49.4%) of health care workers had a good practice of biomedical waste management with (95% CI: 44.6%, 54.2%) ( Table 5 ).

Table 5. Practice of health care workers among each practice item question at metropolitan cities private hospitals of Amhara region, Ethiopia, December 2020.

Among the studied participants, HCWs who had high scores of biomedical waste management practice 66% and 60.7% were medical doctors and nurses respectively. whereas HCWs who had list scores of BMWM practice 17.5% and 5.9% were cleaners and radiographers respectively ( Fig 2 ).

Fig 2. Frequency distribution of knowledge, attitude and practice of BMWM among HCWs in metropolitan cities private hospitals of Amhara region 2020.

Observation result

In the selected private hospital of each metropolitan city, observation was done at seven working departments such as OPDs, wards, laboratory, emergency, maternity, minor OR, pharmacy, and X-ray rooms of health care workers. Regarding the working department, more than half (62.5%) of departments had visual aid of biomedical waste containers. Gloves were available for each patient care cleaning device in all departments, except outpatient pharmacy departments. Three color-coding bins and leveled bins were available in Laboratory, Emergency, Maternity, and Minor OR departments, but not in other departments. The autoclave was available in some departments (maternity, Laboratory, and minor OR) but not in other departments rather it was available as a health care facility level in one fixed area. Personal protective equipment like heavy-duty gloves, aprons, and boots was available in maternity, emergency, laboratory, and minor OR rooms but not in others.

Regarding health care facilities, 37.5% of them had onsite storage rooms of biomedical wastes. The infection prevention and control committee was available only in two of them. All private hospitals had an incinerator, but it was not fenced (except one general hospital). Infection prevention and control guidelines were available in some hospitals’ infection prevention offices rather than in each working department. A placenta pit was available in all private hospitals.

Factors associated with biomedical waste management practice

In the bi-variable binary logistic regression analysis; age, attitude, knowledge of HCWs, level of education, training, availability of three bins, information about biomedical waste, information about biomedical waste management, and work experience were factors associated with biomedical waste management practice.

To start with the findings of socio-demographic factor, the odds of good biomedical waste management practice was found to increase by more than 4 times among health care workers who hold MSc and above the level of education when compared with a diploma and below [AOR = 4.20, 95% CI: (1.01, 17.40)].

Health care workers who took training on biomedical waste management had an association with biomedical waste management practice. Health care workers who took training [AOR = 4.33, 95% CI: (2.71, 6.93)] were 4.3 times more likely to practice good biomedical waste management than their counterparts.

The availability of three bins (black bin, yellow bin, and safety box) in the working department was associated with good biomedical waste management practice. Availability of three bins in the working department [AOR = 6.24. 95% CI (3.84, 10.13)] was 6.2 times more likely to practice good biomedical waste management than not the availability of three bins.

Health care workers who had a good attitude [(AOR = 2.64, 95% CI: (1.65, 4.22] were 2.6 times more likely to practice good biomedical waste management than those who had a poor attitude ( Table 6 ).

Table 6. Multivariable binary logistic regression analysis for factors associated with biomedical waste management practices among health care workers in metropolitan cities private hospitals of Amhara region, Ethiopia 2020.

* = p-value<0.05

***p-value<0.001, Hosmer and Lemshow goodness of fit test = 0.839.

In this study, 213 (49.4%) health care workers had a good practice of BMWM with (95% CI: 44.6%, 54.2%). This finding is in line with the finding of two previous studies done in South Africa and Biyem- Assi District Hospital in Yaoundé, which reported 53.9% and 50% respectively [ 45 , 46 ]. However, the finding of this study is found to be higher than the findings of three studies done in Rwanda, Jigjiga, and Gondar town, which reported 33.5%, 42.3%, and 31.5 of good practices respectively. [ 39 , 47 , 48 ]. This disagreement might be partly explained by a difference in health facility setup., since the above-mentioned studies (Jigjiga and Gondar) had a mixing of hospitals and health centers and the other study (in Rwanda) had only one district hospital. But the current study included only general hospitals. So, hospitals might have good practice of BMWM due to the presence of health care workers who had a high level of education than the health centers. But, the finding of this study is found to be lower than the finding of other previous studies done at Debre Markos Town in Ethiopia, in a tertiary hospital in Puducherry (Southern India) and Mahatma Gandhi Government Hospital of India, which reported 78.9%, 69.3%, and 54.7% were found respectively [ 43 , 49 , 50 ]. The low level of practice shown in this study might be due to the more availability of 3 bins in 81.4% of health care workers in their working department at Debre Markos Town than the current studied health care workers (51.7%) and cultural differences of Indian health care setup and this local area.

In the present study, there was a significant association between the level of education and biomedical waste management practices. Health care workers who held MSc and above education level were 4.20 times more likely to practice good biomedical waste management than those who were diploma and below and health care workers who were degree level of education also were 3.52 times more likely to practice good biomedical waste management than those who were diploma and below. This finding was similar to the finding of a study done in the Capital city of Uganda [ 51 ]. This indicates that educational status development helps to improve the practice of health care workers on biomedical waste management [ 52 ].

The other finding worth highlighting is related to training, a significant association between taking training and biomedical waste management practice was found. Health care workers who took training on BMWM had 4.33 times more likely to practice good biomedical waste management than those who didn’t take the training. This finding was in agreement with the previous studies conducted in Gondar town, Ethiopia, and the capital city of Uganda [ 48 , 51 ]. It is due to getting waste management training of all those who are responsible for handling wastes is important to improve BMWM [ 53 , 54 ].

Availability of color-coded three bins was significantly associated with biomedical waste management practice. Health care workers who had three bins in their working department were 6.24 times more likely to practice biomedical waste management than those who had no three bins. The finding was supported by the previous study done in Debre Markos town, Ethiopia [ 43 ]. This is due to the availability of three bins that make waste segregation being simple and safe to separate hazardous wastes from non-hazardous general wastes [ 55 ].

The attitude of health care workers was significantly associated with biomedical waste management practice. Health care workers who had a good attitude toward BMWM had 2.64 times more likely to practice good biomedical waste management than those who had a poor attitude toward BMWM. This finding was supported by the studies done in Biyem- Assi District Hospital in Yaoundé (Cameroon) and Agartala, Tripura (North-eastern India) [ 45 , 56 ]. The possible explanation might be due to a good attitude of health care workers helps to practice good biomedical waste management; because the level of attitude was one of the factors, which affect practice as seen in other studies. The study was conducted in all metropolitan cities’ private hospitals of the Amhara region, which covered all private hospitals in three cities. But there may be socially desirable bias for the practice of BMWM during data collection time. In this study, the quantification of the generation rate of biomedical wastes should have been measured.

Biomedical waste management practice was low among health care workers which is a risk of COVID 19 pandemic transmission. The level of education, taking training on BMWM, availability of three bins, and attitude of health care workers was found to have a significant association with biomedical waste management practice. Therefore, it was determined that it is better to provide in-service training programs on biomedical waste management and upgrade their educational level for health care professionals by regional health bureau and city administration health departments, as well as it is recommended to implement a three-bin system in the hospitals. Finally, all private hospitals should acknowledge the health care workers who practiced good biomedical waste management.

Although the study was conducted in private hospitals, the health tier system in Ethiopia both for private and public Hospitals is similar except for the ownership. Therefore, the finding can apply to other similar public hospitals within and across regions as well as in the least and middle-income countries.

Supporting information

Acknowledgments.

We acknowledge data collectors and supervisors for their contribution to the overall success of this study and all respondents for their cooperation, time, and genuine response. Our great thanks go to Dr.Mesafint Molla and Francesco Giulietti for their support in editing the language of the manuscript.

Abbreviations

Acquired Immunodeficiency Syndrome

Biomedical waste

Biomedical waste management

Hepatitis B Virus

Hepatitis C Virus

Health Care Workers

Human Immunodeficiency Virus

Infection Prevention and Control

Non-Governmental Organization

Personal Protective Equipment

Standard Operating Procedure

World Health Organization

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

Bahir Dar University, College of Medicine and Health Sciences funded this research, and Getasew Mitiku received the award. The funder has no role in study design, data collection, analysis, decision to publish, or preparation of the manuscript.

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