Academic Editor:Lucio Mango, "S.Camillo-Forlanini" General Hospital
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Knowledge and Practice for Bio-Medical Waste Management among Healthcare Personnel at Kabgayi District Hospital, Rwanda
Globally, about 10 to 25% of the volume of bio-medical waste from hospitals and healthcare institutions presents a serious health risks to patients, healthcare personnel, and anybody who comes in contact with it. The waste management practices in Rwanda healthcare facilities are poor and need improvement.
To assess the knowledge and practices regarding bio-medical waste management among healthcare personnel at Kabgayi district hospital in Southern Province of Rwanda.
A cross-sectional study design was conducted. A total of 200 healthcare personnel were selected randomly out of 400 target population including doctors, nurses, social workers, and cleaners. Structured questionnaire was used to collect data. Descriptive analysis using frequency and proportions were used. Chi-Square test was used to determine the association between the variables and level of significance was set at p ≤ 0.05.
The study found that about half (49.0%) of healthcare personnel had good knowledge about waste management. We found that the majority of healthcare personel 133(66.5%) had poor practices towards bio-medical waste management. The factors associated with good practice were better knowledge on bio-medical waste management (p=0.013) and older age group (p=0.001).
The level of in both knowledge and practice towards bio-medical waste management among healthcare personnel was low. Continuing education and training programmes and short courses on bio-medical waste management should be carried out to improve the knowledge and practices towards bio-medical waste management among healthcare personnel.
Bio-medical waste refers to material produced in the course of health protection, medical treatment and scientific research 1. Bio-medical wastes management is a current issue and inadequate management of bio-medical waste is a serious concern in many developing countries due to the risks posed to human health and the environment 2. In these countries, the quantity of bio-medical wastes has sharply risen in recent years as a result of rapid population growth and increasing demand for healthcare services. Despite large investment in expanding public and private healthcare facilities in most developing nations 3, bio-medical wastes are usually rampantly disposed in the environment without any treatment 4. Bio-medical waste management is the most neglected activity of most health service providers, resulting significant exposure to occupational risks among healthcare personnel, high incidence and prevalence of nosocomial infections and environmental contamination 5.
Recognizing the gaps in knowledge of the environmental impacts of healthcare waste and services underscored the need for increased understanding among health professionals of the integral link between human and environmental health 4. In East African countries, waste disposal has been reported to be problematic. Some of the waste is disposed off in open areas and some others into latrines and in rubbish pits. Various researchers found that wastes generated from healthcare activities are not well managed in East African countries 6, 7. Despite the fact that Ministry of Health and the government of Rwanda have empowered the healthcare services supporting waste management facilities, improper management of bio-medical waste management is still a public health concern.
Rwanda Ministry of Health and other health related sectors together with their different partners are working hard to improve healthcare services including environmental health. Compared to other healthcare programs, the management of waste generated from hospital activities is not strengthened. However, the types of these wastes, and their effects on healthcare personnel, patients and people around the health facilities have not been investigated. Generally, the report from National Institute of Statistics of Rwanda (NISR) showed that unhygienic sanitary facilities for excreta disposal, poor management of solid and liquid wastes and inadequate hygienic practices are responsible for a great portion of Rwanda’s disease burden 8. As there is no study conducted in this area about the present topic, determining the level of knowledge and practice about bio-medical waste management among the healthcare personnel was paramount as to plan for intervention.
The design was cross-sectional study. The study was conducted at Kabgayi District Hospital located in Southern Province of Rwanda. The latter is one of the five province that make Rwanda. It is in the South of Rwanda and has a common border with Kigali City to the North, Eastern Province to the East, Western Province to the West and Burundi to the South. It has an area of over 5701 km² and a population of 2,589,975. Kabgayi District Hospital was chosen because, it is only one District hospital in Southern Province which provide general medical, surgical, pediatric, maternity, laboratory, pharmacy and TB follow up unit. There are around 400 healthcare personnel including doctors, nurses, social workers, and cleaners working in selected health units of the Hospital.
The sample size was calculated using Yamane formula 9 (n=N/1+N*e2) as the target population was less than 2000. After considering ‘e’at 5% margin of error and ‘N’ target population of 400 healthcare personnel, the sample size calculated was 200 healthcare personnel. This study employed simple random sampling technique to select the respondents from each unit using the probability proportional to sample in each unit.
Data was collected using a structured questionnaire. It captured the following information: socio-demographic characteristics, knowledge about the bio-medical waste characterization and management and bio-medical waste management practice. The questionnaire used in this study was constructed based on the previous published studies and WHO protocol for bio-medical waste management in the healthcare settings 2, 10.
Data was checked for completeness and consistency, coded and entered in computer using SPSS (Statistical Package for Social Scientist) version 22 for data analysis. The data was analyzed and interpreted according to the objectives of the study. Frequency and proportion were used to describe the variables. Pearson’s chi-square test was used to establish the association between variables of demographic characteristics, knowledge and practice on bio-medical waste management. A p-value of less than 0.05 was considered statistically significant.
The level of knowledge and practice on bio-medical waste management was assessed using a score. The score for the overall knowledge ranged between 0 and 3 and was classified as good knowledge (9 -13 score), as average knowledge (6-9 score) and as poor knowledge (less than 6score). Similarly, the total score for practices was 16, and respondents with scores 8 and above were classified as having good practices while those who scored less than 8 were classified as having poor practices.
A research clearance certificate was sought and obtained from the Research and Ethical Clearance Board of Mount Kenya University. Approval and issuance of authorization letters from the District Hospital and Ministry of Health was obtained. Moreover, a written consent form was provided and all respondents signed before data collection.
The highest percentage(39.0%) of respondents were aged between 35 and 45 years. Female healthcare personnel were dominant (56.0%). About half (47.0%) of respondents were married and the highest number (43.0%)were nurses. According to work experience, 47% of the respondents worked for 11-15 years. Of the 200 participants, majority (78%) had received training about waste management and 52% of them had training twice in a year (Table 1).Table 1. Socio-demographic characteristics of respondents
|Age group in years|
|Worker experience (years)|
|Received training about waste management|
|Number of training (n=156)|
|Once a year||47||30.1|
|Twice a year||81||52.0|
|Thrice a year||28||17.9|
(Table 2) shows that more than half (52.0%) of respondents knew about bio-medical waste management process in the hospital. Of 200 participants 53.0%,61% and54.0% knew that HIV/AIDs, Hepatitis B and Hepatitis C can be transmitted through poor handling of bio-medical waste. Similarly, 37.0% knew that microwave can be used to handle bio-medical waste management, 51% knew that land can be used correctly to handle bio-medical waste. Most of the respondents 66.0% were aware that the universal precaution rule about bio-medical waste management. Majority (61.0%) also knew that the storage time for infectious waste can be 10 to11 minutes. The results show that nearly a half (49.0%) of respondents demonstrated a good knowledge about bio-medical waste management control.Table 2. Knowledge of healthcare personnel on bio-medical waste management
|Indicators of knowledge||Frequency||Percentage|
|Knowledge about bio-medical waste management process in the hospital|
|Knew about diseases which can be transmitted through poor handling of bio-medical waste|
|Hepatitis B (yes)||122||61.0|
|Hepatitis C (yes)||108||54.0|
|Knew universal precaution rule about bio-medical waste management|
|Knew the correct method used to handle bio-medical wastes based on their categories|
|Knew storage time for infectious waste|
|10 to 11 minutes||122||61.0|
|Level of knowledge|
Respondents were asked whether they use colour coding to dispose non-infectious wastes and only 22.0% use colour coding all the time. Out of 200 participants, more than half (53.0%) respondents use colour coding to dispose infectious waste, 55.5% segregate general waste from bio-medical waste, and 46.5% daily collect bio-medical waste and transport to the designated storage site. A total of 107(53.5%) temporary treat and dispose hospital waste for one day. Most(60.0%) were using weight handler and keep record of generated waste and 67.5%use wheeled for waste transport. The majority of respondents 66.5% use personal protective equipment(PPE) when handling bio-medical wastes. Regarding the compliance with safety precautions, the highest number (35.5%) always comply with safety precautions (Table 3).Table 3. The practices of healthcare personnel on bio-medical waste management
|Use of color coding to dispose the non-infectious waste||All the time||44||22.0|
|Not at all||18||9.0|
|Use of color coding to dispose infectious waste||Yes||106||53.0|
|Segregation of general waste from bio-medical waste||Yes||111||55.5|
|Daily bio- medical waste collection and transport to the designated storage site||Yes||93||46.5|
|Temporarily treatment and disposal of hospital waste||Yes (1 day)||101||50.5|
|Weight handler and keep record of generated waste||Yes||120||60.0|
|The use of waste transport||Wheeled trolleys||135||67.5|
|Use of personal protective equipment in handling bio- medical wastes||Yes||133||66.5|
|Compliance with safety precautions||Always||70||35.0|
|Use of safe disposal of sharps||Always||85||42.5|
|Wear overall safety protection while handling wastes||Always||73||36.5|
|Wear gloves while handling bio- medical waste||Always||78||39.0|
|Hand washing with bactericidal agent after handling wastes||Always||71||35.5|
|Overall practices towards waste management||Good practices||67||33.5|
Concerning the use of safe disposal of sharps, 42.5% always use safe disposal of sharps, 41.0% do it often while 16.5% do it sometimes. Respondents were also asked when they wear overall safety protection while handling wastes and about one third (36.5%) do it always. Regarding the types of PPE used by respondents, 39.0% always wear gloves, 43.0% always wear gowns, 69(34.5%) always wear caps, and 46.5% always wear masks when handling bio-medical waste. The highest percentage (35.5%) used to wash their hands always with bacterial acid agent after handling bio-medical waste. Regarding the overall practice score, only 33.5% demonstrated a good practice towards bio-medical waste management (Table 3).
The findings presented in Table 4 showed that age was the only demographic factor significantly associated withgood practices towards bio-medical waste management (p=0.007). Overall knowledge score about waste management was significantly associated with practices of bio-medical waste management (p=0.013) where most of respondents with good practices had good knowledge about bio-medical waste management (Table 4).Table 4. Factors associated with practices towards bio-medical waste management among healthcare personnel
|Variables||Practices towards bio-medical waste management||Chi-Square||P-value|
|Good, n(%)||Poor, n(%)|
|Age group in years||25.47||0.007|
|Worker experience in years||4.27||0.37|
|Received training about waste management||0.98||0.322|
|Knowledge about waste management||8.62||0.013|
The overall objective of this study was to assess the knowledge and practice regarding bio-medical waste management among healthcare personnel at a District Hospital. A total of 200 healthcare personnel participated in the study. The findings from this study showed that about a half of respondents (49.0%)had good knowledge about bio-medical waste management process. This is in agreement to a study conducted in India among 100 nurses where 47% had excellent knowledge about bio-medical waste management11. Similarly, a study in Tanzania revealed that the knowledge level in management of medical waste was low among healthcare personnel12. However, the figure (49.0%) was low compared to the recent study conducted in Nigeria which reported that respondents in the various facilities had adequate knowledge of medical waste collection and handling 13. These difference could be probably the sample size and source of the target population.
The study revealed that 53.0% healthcare personnel use color coding to dispose infectious waste, 55.5% segregate general waste from bio-medical waste, and 46.5% daily collect bio-medical waste. These findings are supported by a systematic review of six studies which reported that color coding of wastes was not done by 67% of the subjects 14. Another study found that almost one out of every three respondents (35.7%) did not know that a symbol had been assigned to indicate bio-hazardous wastes. Another study also found that only 57.7% respondents were aware of all four color codes (Blue/White-Black-Red-Yellow) used for the bags into which bio-medical wastes are segregated 15. This shows that there is a need of refresher trainings to ensure sustainability and further improvement.
The overall practice in this study was very low where only 33.5% had good practice on bio-medical waste management. This was similar to the study done in Ethiopia which reported 31.5% 16. However, the result is lower than the study done in Pakistan where 94.3% of the study participants had adequate practice 17. This difference could be explained due to low enforcement or monitoring by the regulatory body in the health facilities.
Bio-medical waste management knowledge and bio-medical waste management practices were significantly associated in the present study where adequate practice was higher among respondents with good knowledge. This is similar to a study carried out in India, which revealed lack of knowledge about waste management significantly affects the safe practices for management 11. This demonstrates that improved knowledge can lead to as accepted practice. It is captivating to imagine a knowledge threshold where theoretical knowledge transcends into practice.
Among the socio-demographic factors, only age group was significantly associated with good practice of bio-medical waste management. The age group of 35 to 45 years had significantly more likely to exercise good practice compared to those aged between 18 to 25 years. This could be indirectly related to the years of experience as it is believed that increased experience will increase safer practices.
Like other cross-sectional studies, the present study does not provide causal relationship between the variables and cannot be generalized nationwide because the study area is small and contains only one district hospital. Another limitation was self-report to assess the practice regarding bio-medical waste management among healthcare personnel. However, the respondents were explained the purpose of the study and the information was obtained by trained research assistants.
Our study found that the knowledge and practice about bio-medical waste management were low at 49.0% and 33.5% respectively. Age group and knowledge were significantly associated with good practice of bio-medical waste management among healthcare personnel.
Therefore, we recommend that the Ministry of health and District Hospitals should undertake vigorous and regular training programs on bio-medical waste management for healthcare personnel. Much improvements and efforts should be made in strengthening and enforcing sanitation policies and practices whereby availing bio-medical waste management regulations and guidelines and their accessibility at all levels. Moreover, proper waste segregation at the source must be implemented and color-coding must work hand-in-hand with segregation.
The authors would like to thank Ministry of Health, Mount Kenya University Rwanda and Kabgayi District Hospital for granting us authorization letter to conduct the study. In addition, the authors would like to extend their appreciation to all the study participants for their time.