KAMPALA UNIVERSITY

ASSESSMENT OF KNOWLEDGE ATTITUTE AND PRACTICE OF MEDICAL WASTE

MANAGEMENT AMONG HEALTH CARE WORKERS AT GABILEY GENERAL HOSPITAL,
GABILEY, SOMALIALND.

BY

WaberiJamaWarsame.

HKMPH01915H

ARESEARCH THESIS SUBMITTED TO KAMPALA UNIVERSITY IN PARTIAL FULFILLMENT OF

THE REQUIREMENTS FOR THE AWARD OF DEGREE OF MASTER OF PUBLIC HEALTH

SUPERVISOR: NZANZU TWALIBU (PhD)

November 2019

I
Declaration

I declare that this research thesis is my original work and has not been presented for a Master’s
Degree in any other University and that all sources of material used for the research thesis have
been fully acknowledged.

Approval
II
This research thesis is submitted for review with my approval as an advisor of the candidate.

Signature

SUPERVISOR: NZANZU TWALIBU (PhD)

November 2019

ACKNOWLEDGEMENT

I am most thankful to the Almighty God, for enabling me to accomplish this work. May all

III
The glory, honor and blessing be unto Him. My special thanks go to my supervisors
NzanzuTwalibu (PhD) and Prof. Najeb, president of Hope University for introducing me to this
exciting field of science and for their dedicated help, advice, inspiration, encouragement and
continuous support, throughout my . I thank the staff of Gabiley General Hospital for their
support, cooperation and participation in the study.

Many people have freely given their time and expertise which assisted me during the process of
writing this thesis.

I also thank my classmates, MrHusein and Mr Mustafa for moral support and the valuable ideas we
exchanged during the course of our studies.

I am delighted to thank, Kampala University for the invaluable support and encouragement.
Finally, my sincere thanks also go to my mother for her encouragement, understanding and. My
earnest thanks go to my sister Hodan for her encouragement and financial support.

I owe my deepest gratitude towards my wife for her eternal support and understanding of my
goals and aspirations. Her infallible love and support has always been my strength. Here patience
and sacrifice will remain my inspiration throughout my life. Without her help, I would not have
been able to complete much of what I have done. It would be ungrateful on my part if I thank
Fihima in these few words. I am thankful to my two daughters Fatima and Ayan, My son
Abdurahman for giving me happiness during my resting time.

LIST OF ABBREVIATIONS

EPA Environmental Protection Agency

IV
 GGH Gabiley General Hospital

HBV Hepatitis B virus

HCW Health Care Waste

HCW Health Care Worker

HIV Human ImmunoDefiencey Virus

MoH Ministry of Health

MW Medical Waste

MWM Medical Waste Management

PHC Primary Health Care

PPE Personal Protective Equipments

SAQ Self-administered questionnaire

SPSS Statistical Package for Social Sciences

WHO World Health Organization.

Contents
Declaration..........................................................................................................................................................II

Approval............................................................................................................................................................III

ACKNOWLEDGEMENT................................................................................................................................III

LIST OF ABBREVIATIONS...........................................................................................................................IV

V
LIST OF FIGURES..........................................................................................................................................IX

LIST OF TABLES............................................................................................................................................XI

Abstract............................................................................................................................................................XII

CHAPTER ONE:................................................................................................................................................1

INTRODUCTION AND BACKGROUND........................................................................................................1

1.1: Background..............................................................................................................................................1

1.2: Background to the study area..................................................................................................................5

1.2.1: District Geographical Size................................................................................................................5

1.2.2: Health services......................................................................................................................................5

1.3: Statement of the Problem.........................................................................................................................5

1.4: OBJECTIVES..........................................................................................................................................6

1.4.1; General Objective..............................................................................................................................6

1.4.2: Specific Objectives............................................................................................................................6

1.4.3: Research questions............................................................................................................................6

1.5: Justification of the Study.........................................................................................................................6

1.6: Conceptual Framework............................................................................................................................8

1.7: Significance of the study..........................................................................................................................8

1.8: scope of the study.....................................................................................................................................9

1.8.1: Geographical Scope...........................................................................................................................9

1.8.2: Time Scope........................................................................................................................................9

CHAPTER TWO...............................................................................................................................................10

LITERATURE REVIEW..................................................................................................................................10

2.0. Introduction................................................................................................................................................10

2.1. Medical waste management (MWM) process. Types............................................................................13

2.1.1: Medical Waste Management Chain................................................................................................14

2.1.2: Medical Waste Segregation and Storage.........................................................................................14

2.1.3: Medical Waste Transportation........................................................................................................16

2.1.4: Medical Waste Treatment and Disposal..........................................................................................17

2.5 Techniques for Medical Waste Treatment and Disposal.........................................................................18

2.6 Knowledge of Health Workers about MWM..........................................................................................19

2.7 Attitude of Health Workers about MWM...............................................................................................25

2.8 Attitude and practice regarding waste management................................................................................27

2.9 Practices of Health Workers about MWM..............................................................................................28

CHAPTER THREE...........................................................................................................................................36

VI
METHODOLOGY............................................................................................................................................36

3.0 Introduction.................................................................................................................................................36

3.1: study Area:.............................................................................................................................................36

3.2: Source population..................................................................................................................................36

3.3: Study Population....................................................................................................................................36

3.4: Study design...........................................................................................................................................36

3.5: Study setting...........................................................................................................................................36

3.6: Sample Size Determination and Sampling technique............................................................................37

3.6.1. Sample size determination...............................................................................................................37

3.6.2. Sampling Techniques......................................................................................................................37

3.7.1: Inclusion criteria..............................................................................................................................37

3.7.2Exclusion criteria...............................................................................................................................37

3.8: Measures to ensure validity....................................................................................................................38

3.9: Variables.................................................................................................................................................38

3.9.1: Dependent variable..........................................................................................................................38

3.9.2: Independent variable.......................................................................................................................38

3.10: Data Collection.....................................................................................................................................38

3.10.1: Data Collection Method................................................................................................................38

3.11: Data management.................................................................................................................................38

3.11.1: Questionnaire................................................................................................................................38

3.13: Quality Assurance................................................................................................................................40

3.13.1: Pretested........................................................................................................................................40

3.13.2: Validity..........................................................................................................................................40

3.13.3: Reliability.....................................................................................................................................40

3.14: Data Processing and Analysis..............................................................................................................40

3.15: Ethical Consideration...........................................................................................................................40

3.16: Dissemination of the result...................................................................................................................41

CHAPTER FOUR.............................................................................................................................................42

DATA ANALYSIS AND PRESENTATION...................................................................................................42

4.0. Introduction................................................................................................................................................42

4.1: Socio-demographic characteristics.........................................................................................................42

Chapter five.......................................................................................................................................................76

5. DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS..............................................................76

5.2 Conclusion...............................................................................................................................................85

VII
 5.3 Recommendations...................................................................................................................................86

5.4: Limitation...............................................................................................................................................86

Reference...........................................................................................................................................................87

LIST OF FIGURES

Figure 1. Age of the health care workers ------------------------------------------------------------------------45

Figure 2. Sex characteristics of the HCW------------------------------------------------------------------------46

Figure: 3. marital status of the respondents----------------------------------------------------------------------47

Figure: 4 Educational levels……………………………………………………………………………47

VIII
Figure:5. Designation level ----------------------------------------------------------------------------------------48

Figure: 6. Presentation of sorting medical waste by HCW. -------------------------------------------------52

Figure: 7. Presentation on the need to sort MW ----------------------------------------------------------------53

Figure: 8: presentation of monitoring reason behind sorting ------------------------------------------------53

Figure:9 presentation of monitoring knowledge of packing medical waste by HCW. ------------------54

Figure; 10. Presentation of dealing the risk of medical waste ----------------------------------------------54

Figure; 11. Presentation showing monitoring of HCW to take training. --------------------------------55

Figure: 12. Presentation monitoring type of training. ---------------------------------------------------------55

Figure: 13. Illustration showing knowledge about color cording. -------------------------------------------56

Figure:14 presentation of hundelling liquid waste. -----------------------------------------------------------56

Figure;15. Illustration shows disposal procedures of expired blood units. --------------------------------57

Figure: 16. Presentation showing knowledge about dealing expired medicine ---------------------------57

Figure 17. segregation of medical waste takes place at the point of waste collection. ------------------60

Figure: 18. Presentation of containment of sharps in safe waste management----------------------------60

Figure: 19. Presentation showing Attitude towards Hepatitis B vaccine. ----------------------------------61

Figure: 20. presentation showing attitude about needle stick injury. ---------------------------------------61

Figure: 21. Presentation of attitude of throwing blood in to domestic waste. ------------------------------62

Figure: 22. Presentation showing practice about site of segregation. --------------------------------------67

Figure: 23. Presentation about practice about sorting medical waste. --------------------------------------67

Figure: 24. Illustration showing practice of separation sharp waste from blunt waste. ------------------68

Figure:25. Presentation showing type of waste segregated from the general waste. --------------------68

Figure: 26. Presentation showing type of containers used for MW. ----------------------------------------69

Figure:27. Illustration showing practice of protective clothing during handling MW. ------------------69

Figure:28. Illustration showing practice of protective clothing during handling MW-------------------70

Figure: 29. Presentation showing type of containers used during collection. ----------------------------70

Figure: 30. Disposal method for final segregation. ----------------------------------------------------------71

Figure:31. Illustration showing practice of use Trolleys for waste transportation. ----------------------71

Figure:32. Reporting needle stick injury to the control unit. -------------------------------------------------72

Figure: 33 There was adequate number of staffs in the hospital ---------------------------------------------72

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Figure: 34. Presentation showing practice of liquid waste in bags that prevent leakage. -----------------75

Figure:35. practice of HCW about collecting of blood waste with other waste in ordinary bags------- 75

Figure: 36. Practice of gathering expired medicine with other wastes. -------------------------------------74
Figure:37. Hospital depends on the city’s cleaning authority. ------------------------------------------------74

Figure:38. sing medical waste outside using hospitals own vehicles…………………………………75

Figure 39. Overall KAP of HCW. --------------------------------------------------------------------------------75

LIST OF TABLES
Table 1: Operational defining………………………………………………………………………….39

Table 2: Socio-demographic Characteristic …………………………………………………..….……42

Table 3: Period of time working at the hospital ……………………………………………………….48

Table 4: Health care worker’s knowledge about dealing with medical waste………..………………49

Table 5: Health care worker’s Attitude about dealing with medical waste ………………………….59

X
Table 6: Health care worker’s Practice about dealing with medical waste…………………………..64

Table 7: Overall KAP of HCW………………………………………………………………………75

Abstract

Background: The management of waste poses a major problem in most developing countries of
the world, especially hospital waste. Recently, medical waste disposal has posed even more
difficulties with the appearance of disposable needles, syringes, and other similar items. Since the
development of disposable medical products in the early 1960s, the issue of medical waste has
confronted hospitals and regulators.

XI
Aim and Objectives: The aim of this study was to assess the knowledge, attitudes and practices
of Medical Waste Management among health care workers at Gabiley General Hospital,Gabiley
Somaliland .

Setting: The setting for this study was Gabiley General Hospital, Gabiley province.

Methods: The study was done in July 2019 using hospital based Cross-sectional study design. A
total of 40 health care professionals including doctors, nurses, laboratory technician, Dentist and
cleaners were including the study. Both administered and self-administered questionnaire were
used to this study. Data were collected using a questionnaire and analyzed using excel and the
Statistical Package for the Social Sciences (SPSS).

Results: Knowledge of MWM was generally inadequate, with 90% of the participants scoring ‘poor’
overall. Just over half of the participants reported a good practice towards the appropriate disposal of
MWM 60%. In this study overall attitude of the respondents were good scored 80%.

Conclusion: Appropriate training and supervision in HCW management as well as relevant and
ongoing in-service training is needed to ensure appropriate knowledge, attitudes and safe practice
among all members of Health Care Workers.

XII
 CHAPTER ONE:
INTRODUCTION AND BACKGROUND
1.0: Introduction

This chapter presents the preliminary sections of the study and is arranged in seven sections;
background to the study, background to the study area, statement of the problem, objectives,
research questions, Justification of the study and the conceptual framework.

1.1: Background.
The management of waste poses a major problem in most developing countries of the world,
especially hospital waste. Recently, medical waste disposal has posed even more difficulties with
the appearance of disposable needles, syringes, and other similar items. Since the development of
disposable medical products in the early 1960s, the issue of medical waste has confronted
hospitals and regulators. Previously, reusable products included items such as linen, syringes,
and bandages; they were sterilized or disinfected prior to reuse, and principal waste product was
limited to human pathological tissue. Waste generated by hospitals/clinics includes a broad range
of materials, from used needles and syringes to soiled dressings, body parts, diagnostic samples,
blood, chemicals, pharmaceuticals, medical devices and radioactive materials.(Manyele, 2004a).

In Nigerian medical waste falls under the category of infectious waste (FEPA, 1991). Within this
category bare culture and stock infectious agents, pathological waste, waste from surgery or
autopsy that were in contact with infectious agents, sharps (hypodermic needles, syringes, scalpel
blades), waste from human blood and products of blood and laboratory waste (Basseyet al,
2006). This class of waste require a particular type of management rather than being lumped with
the rest of the lot.In recent times, medical waste because of their nature presents peculiar
environmental and health challenges especially in developing countries (Nigeria inclusive). The
health hazards due to improper medical waste management affect not only hospital occupants but
also spread into the vicinity of a hospital. The problem of occupational health hazards arising
from medical waste is not well publicized as there is a lack of information (Manyele, 2004a).

The general public’s health can also be adversely affected by medical waste. Improper practices,
such as dumping of medical waste in municipal dustbins, open spaces and water bodies, which is
often the case in most developing countries, can lead to the spread of diseases. In most urban
areas in Nigeria there are often no systematic approaches to medical waste disposal. Hospital
wastes are simply mixed with the municipal waste in collecting bins at roadsides and disposed
off similarly. Some wastes are simply buried without any appropriate measure. As a result,
syringes are often

reused, mixed in with everyday garbage, or even abandoned in public areas, exposing health
workers, patients, and communities to unnecessary risk and contributing to the estimated 23.5
million new HIV, hepatitis B, and hepatitis C infections transmitted every year through needle
reuse and accidental needle stick injuries. And as developing world health systems grow stronger
and better care reaches more people, castoff medical waste is increasing. Also, the emergence of

1
an army of human scavengers in recent times who make their living from refuse dumps have
added another dimension to the general concern on medical waste disposal. These youths who
comb refuse dumps are prone to exposure to toxic and dangerous chemicals (Ayuba, 2008).

The improper disposal of medical waste causes serious environmental problems in terms of air,
water and land pollution. Manyele (2004b) observed that environmental problems can arise from
the mere generation of medical waste and from the process of handling, treatment and disposal.
Poor management of medical waste potentially exposes health care workers, waste handlers,
patients and the community at large to infection, toxic effects and injuries, and risks polluting the
Medical waste disposal methods in Jalingo metropolis environment. It is essential that all
medical waste materials are segregated at the point of generation, appropriately treated and
disposed of safely to reduce its harmful impact on the environment. Various aspects of waste
management has been studied but not much has been done in relation to medical waste from
hospitals/clinics as an entity in Nigeria and Taraba State in particular compared to what is
obtainable in developed countries. Given the increasing number of clinics and hospitals
(private/public) in the Metropolis, it has become necessary to examine what happens to the
medical waste generated in the clinics and hospitals in the study area.

Worldwide, an estimated 16 billion injections are administered every year. Not all needles and
syringes are disposed of safely, creating a risk of injury and infection and opportunities for reuse.
(WHO, UNICEF et al 2015)

Injections with contaminated needles and syringes in low- and middle-income countries have
reduced substantially in recent years, partly due to efforts to reduce reuse of injection devices.
Despite this progress, in 2010, unsafe injections were still responsible for as many as 33 800 new
HIV infections, 1.7 million hepatitis B infections and 315 000 hepatitis C infections. (Pépin J,
Abou Chakra et al 2014).

A person who experiences one needle stick injury from a needle used on an infected source
patient has risks of 30%, 1.8%, and 0.3% respectively of becoming infected with HBV, HCV and
HIV. Additional hazards occur from scavenging at waste disposal sites and during the handling
and manual sorting of hazardous waste from health-care facilities. These practices are common
in many regions of the world, especially in low- and middle-income countries. The waste
handlers are at immediate risk of needle-stick injuries and exposure to toxic or infectious
materials. In 2015, a joint WHO/UNICEF assessment found that just over half (58%) of sampled
facilities from 24 countries had adequate systems in place for the safe disposal of health care
waste (WHO/UNICEF et al 2015).

Huge amounts of infectious and hazardous waste are generated in hospitals and clinics around
the world on daily basis The amount of waste generated depends on factors such as waste
management techniques, the type of health care institution, health care specializations, the
quantities of reusable

2
equipment available in the hospital/clinic and the number of patients treated daily Medical waste
is ‘special’ as compared to other types of wastes because of its high potential of causing infection
and injury. ( Alhumoud, J.M., Alhumoud, H.M. et al 2007)

Improper biomedical waste management has the potential to spread infections leading to
development of resistant organisms and bringing these resistant hospital organisms to the
doorstep of the community. But among all health problems, there is a particular concern with
HIV/ AIDS, Hepatitis B and C for which there is a strong evidence of transmission through
health care wastes (Paria B, Roy SK, Ganguly A et al . 2017).

Globally, WHO estimates that, in 2000, injections with contaminated syringes caused 21 million
hepatitis B virus (HBV) infections, two million hepatitis C virus infections and 260 000 HIV
infections worldwide. Many of these infections were avoidable if the syringes had been disposed
of safely. The re-use of disposable syringes and needles for injections is particularly common in
certain African, Asian and Central and Eastern European countries. In developing countries,
additional hazards occur from scavenging at waste disposal sites and the manual sorting of
hazardous waste from health-care establishments. These practices are common in many regions
of the world. The waste handlers are at immediate risk of needle-stick injuries and exposure to
toxic or infectious materials. Abd El-Salam, M.M., 2010.

There are various estimates regarding hazardous and nonhazardous constituents of healthcare
waste. According to World Health Organization (WHO) related reports and studies, around 85%
of hospital wastes are nonhazardous, 10% are infectious (biologically hazardous), and the
remaining 5% are toxic chemicals, pharmaceutical, and radioactive wastes (WHO et al 2004)

In 2002, the results of a WHO assessment conducted in 22 developing countries showed that the
proportion of healthcare facilities that did not use proper waste management was significant,
ranging from 18% to 64 % .(WHO October 2004).

In 2011, WHO stated that high developed countries produce an average up to 0.5 KG of
hazardous waste perhospital bed per day while the figure for developing countries was only 0.2
KG per hospital bed per day.Biomedical waste was often not properly segregated in to hazardous
or non hazardous wastes that made the actualamount of hazardous waste possibly much higher.
85% of generated waste from hospitals and other health carefacilities were in fact non-hazardous
while remaining 15% is considered to be hazardous materials that may beradioactive, toxic or
infectious.(World Health Organization 2011).

In developed countries, legislation and good practice guidelines define medical wastes and state
the various possible ways for collection, transport, storage and disposal of such wastes. Also, the
best available technologies are used for the development of alternatives for proper disposal of
medical wastes with minimal risks to human health and the environment. (Tudor et al 2005)

3
Generally there is no single disposal practice as a solution to the problems of managing hospital
waste, so in most cases, a number of practices include landfills, incineration, autoclaving, and
recycling are used in combination. Each practice has its own weaknesses and strengths . (Silva et
al 2005).

However, in developing countries, medical wastes have not received sufficient attention. In many
countries, hazardous and medical wastes are still handled and disposed off together with
domestic wastes, thus creating a great health risk to municipal workers, the public, and the
environment. For instance India approximately generates 2 kg/bed/ day 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 infection, and also cause disruptions in the
environment, and adverse impact on ecological balance.Patil et al (2001).

A National Health Policy of Somaliland plays a vital role in defining a country's vision, policy
directions and strategies for ensuring the health of its population. It responds to the growing calls
for strengthening of health systems and the renewal of Primary Health Care: universal coverage,
people-centered care, emphasis on public health and health in all policies; it also serves to guide
and steer the entire, pluralist health sector rather than being command-and-control plans for the
public sector; it also go beyond the boundaries of health systems, addressing the social
determinants of health and the interaction between the health sector and other sectors in society.
In the other hand a national health policy is a key in the management of every hospital work. All
activities carried out by medical personnel could be achieved with policy directions. Somaliland
has a national health policy in place. It focuses on “increased utilization of quality health services
especially by people in the underserved area, by improved access to quality and responsive
health services, strengthened governance and management in health sector, improved
institutional mechanisms for community participation and systems for accountability; and
strengthened financial management systems (WHO.et al 2011, November.

Recent study conducted at Hargeisa Public Hospital, in Hargeisa most workers who deal with the
medical wastes are able to identify the nature of medical waste. They know reasons behind
sorting medical wastes but could be lazy. The study was also looked at the collection,
segregation and handling of medical waste and the findings revealed that there is no effective and
active department responsible for waste available within hospital management. Budget for waste
management inadequate and thus, impossible to address waste disposal issues within hospital. In
addition to that the type of containers used for collection and internal transport of the waste were
bags and wheelbarrows and after wastes are segregated, the storage area while awaiting removal
from the hospital or disposal were allocated storage boxes and bags. Such methods still pause
the risk to health because they stink in places where they are scattered. Where wastes are
segregated and buried in hospital grounds, taken to municipal landfill or open burned, most of

4
the sharp or metallic substances remain harmful to physical health of all people that come or
work in the hospital as well as the patients. (AbdisalamHasan 2018).

1.2: Background to the study area.

1.2.1: District Geographical Size
Gabiley has a total land area of about 5 square km of this 37% is suitable for rain fed agriculture,
11% has potential for irrigated agriculture. Gabiley city is the administrative center of the new
region, and the region has 6 districts including Gabiley and they are: Gabiley, Wajaale, Arabsiyo,
Agabar, Geed-balaadh and Alay baday.The new region is bounded on the west by AwdalRegion
and on the north by the Gulf of Aden. On the east it is bordered by the nation‘s capital Hargeisa,
and on the south Gabiley region is bounded by the fifth-Somali –State in the Ethiopian
Federation.(Gabiley et al 2014-2016)

1.2.2: Health services.

Gabiley region consist of 6 districts; Gabiley, Arabsiyo, Wajaale, Allay baday, Agabar, Geed
balaadh. The population of the region is estimated 200,000 where population relies on
agro/pastor in the term of health the region have two hospitals; General hospital and TB hospital
with the total beds 200 patients. The other facilities that regional health have include two
standardized laboratories one for general hospital, one for TB hospital, theatre, pharmacy, wards
and other health services. Gabiley General Hospital has 45 staff with different titles.The region
has 6 MCHs and the total health staff number are 78 staff with different titles: 3 doctors, 10
nurses, 35, Auxiliaries and 30 subordinate staff. (Gabiley et al 2014-2016)

1.3: Statement of the Problem

Medical waste generated in our nation contains infectious and hazardous materials. It is
important on the part of the employees to be acquainted with the hazards of the biomedical waste
in the work environment and make its disposition effective and in a scientific manner. It is
important that the different professionals engaged in the healthcare sector have adequate
Knowledge, Attitudes and Practices (KAP) with respect to biomedical waste management.
Several injuries such as hand cut due to handling broken glass occurred due to exposure to
medical wastes inside and outside hospital premises. (United States Environmental Protection
Agency 2011).

Furthermore, Mismanagement of infectious waste results in environmental pollution and

unpleasant odours due to harmful pathogens that may develop many infections such as typhoid,
cholera, tuberculosis and other diseases namely; Hepatitis and HIV/ AIDS. (Zhang HJ, Zhang
YH, et al. 2013).

5
One of the strangest things of Gabiley General Hospital is that hospital has no incinerator or
medical waste disposal facility. There is no separate stream to ensure hazardous waste does not
end up in the hospital’s regular refuse. This could endanger the hospital’s custodial staff and the
general public. In addition, the hospital has no process to dispose of an amputated body parts
such as limbs they simply ask the patients family members to take it with them and bury it.

Significant assessment of medical waste management and disposal system has not been
conducted to the Gabiley General Hospital. The worsening Environmental situation of the
hospital is not only a threat to the health staff and patients but also indicates progressive
environmental contamination and a public at large.

1.4: OBJECTIVES
1.4.1; General Objective
The aim of the study was to assess the knowledge, attitude and practice of HCWs towards
Medical waste management at Gabiley General Hospital.

1.4.2: Specific Objectives

To assess the level of knowledge of medical waste management among Health care workers at
Gabiley General Hospital in Gabiley district.

1. To assess the level of attitude of Medical Waste Management among health care workers
at Gabiley General Hospital in Gabiley district.

2. To determine the level of Practice of Medical Waste Management among Health care
workers at Gabiley General Hospital in Gabiley district.

1.4.3: Research questions

1. What is the level of Knowledge of Medical Waste Management among health care
workers attending at Gabiley General Hospital?

2. What is the attitude of Medical Waste Management among health care workers attending
at Gabiley 4General Hospital?

3. What is the level of Practice of Medical Waste Management among health care workers
attending at Gabiley General Hospital?

1.5: Justification of the Study

Globally, WHO estimates that, in 2000, injections with contaminated syringes caused 21 million
hepatitis B virus (HBV) infections, two million hepatitis C virus infections and 260 000 HIV
infections worldwide. Many of these infections were avoidable if the syringes had been disposed

6
of safely. The re-use of disposable syringes and needles for injections is particularly common in
certain African, Asian and Central and Eastern European countries. In developing countries,
additional hazards occur from scavenging at waste disposal sites and the manual sorting of
hazardous waste from health-care establishments. These practices are common in many regions
of the world. The waste handlers are at immediate risk of needle-stick injuries and exposure to
toxic or infectious materials. (Abd El-Salam, M.M. 2010).
Recent study conducted at Hargeisa Public Hospital, in Hargeisa most workers who deal with
the medical wastes are able to identify the nature of medical waste. They know reasons
behind sorting medical wastes but could be lazy. The study were also looked at the collection,
segregation and handling of medical waste and the findings revealed that there is no effective
and active department responsible for waste available within hospital management. Budget for
waste management inadequate and thus, impossible to address waste disposal issues within
hospital. In addition to that the type of containers used for collection and internal
transport of the waste were bags and wheelbarrows and after wastes are segregated, the
storage area while awaiting removal from the hospital or disposal were allocated storage boxes
and bags. Such methods still pause the risk to health because they stink in places where they are
scattered. Where wastes are segregated and buried in hospital grounds, taken to municipal
landfill or open burned, most of the sharp or metallic substances remain harmful to physical
health of all people that come or work in the hospital as well as the patients.(AbdisalamHasan et
al December 2018).

7
 1.6: Conceptual Framework
In application of the understanding Adopted from (Prasad et al., 2016) in baseline of guardedness
and checked knowledge attitude and practice of MWM (dependent Variable) and
KAP(Independent variables). Like socioeconomic status, and environment. The following
variables was identified in this conceptual framework below

INDEPENDENT VARIABLE DEPENDANT VARIABLE

KAP of Medical Waste Management

Knowledge.

-Information on MWM

-Understanding on MWM

Attitude

-Behavior
Medical Waste
-Belief Management.

-Perception

Practice

-Habitual

-Application

Figure 1: Conceptual Framework Showing the relationship between Knowledge, Attitude and
Practices among health workers towards MWM.

In figure 1, MWM (dependent Variable) postulated to have an effect of KAP (independent

variables). Knowledge wasoperationalized as information, experience and skill. Attitude was
operationalized as behavior, believes and characteristics. Practice was also further
operationalized as application standards, operation and customary Performance. Therefore, the
independent variables of Knowledge Attitude Practice are expected to effect the MWM among
health workers in Gabiley General Hospital. Source: Prasad et al., 2016.

1.7: Significance of the study

The outcome of this study is useful in biomedical waste management, awareness raising/health
education and promotion strategy in Gabileycity in designing effective biohazard preventative
programs among GGH health workers.

Further, the study outcomes is also be utilized in health care policy development and support the
need for managing strategy to prevent the biological hazards from the Health Care workers and
community at large. The potential users of the survey results will include the ministry of health,
WHO, UNICEF and other non-government and international organizations which are engaged
infection prevention programs in the country.

8
This study contributes to the overall advancement of knowledge on medical waste in Gabiley.
Study provides evidence based information for the MoH to strengthen the national response by
ensuring the ‘duty of care’ and safeguarding the environment for current and future generations.

The results of the study will also serve as baseline information for further studies.

Lastly completion of this study aids future researchers to graduate as a master of public health
specialist.

1.8: scope of the study

1.8.1: Geographical Scope
The study was carried out in Gabiley General Hospital. Gabiley Region locates on the
Somaliland‘s western fertile regions and it is called the bread basket of Somaliland because of its
agricultural productivity level compared to the other Regions of the country. Gabiley city is the
administrative center of the new region, and the region has 6 districts including Gabiley and they
are: Gabiley, Wajaale, Arabsiyo, Agabar, Geed-balaadh and Alay baday. The new region is
bounded on the west by Awdal Region and on the north by the Gulf of Aden. On the east it is
bordered by the nation‘s capital Hargeisa, and on the south Gabiley region is bounded by the
fifthSomali –State in the Ethiopian Federation.(Gabiley et al 2014-2016).

1.8.2: Time Scope

This study was done from July 2019 to Nov 2019

CHAPTER TWO
LITERATURE REVIEW
2.0. Introduction
This chapter focuses on the review of literature on similar studies that have been carried out on
Medical Waste Management. It contains literature from online journals, websites and text books.
Literature on these studies will be very important while discussing results in chapter four.

9
Medical wastes:United States Environmental Protection Agency (USEPA) has defined medical
wastes (MW) as containing all waste materials generated by Health Care Facilities,(HCFs), such
as hospitals, clinics, physician’s offices, dental practices, blood banks, and veterinary
hospitals/clinics, as well as at medical research facilities and laboratories. This definition
contains, but is not limited to, blood-soaked bandages, culture dishes and other glassware,
discarded surgical gloves, discarded surgical instruments, discarded hypodermic needles (e.g.,
medical sharps), microbiological cultures, stocks, swabs used to inoculate cultures and
withdrawn body organs after a surgery. (United States Environmental Protection Agency et al
2011).

Medical waste is any kind of waste that contains infectious material (or material that’s potentially
infectious). This definition includes waste generated by healthcare facilities like physician’s
offices, hospitals, dental practices, laboratories, medical research facilities, and veterinary clinics.
( LLC, et al, 2019).

Ordinary medical wastes: It includes the following: Any laboratory reagents, or lab materials
noninfectious or acute and affect no on worker. Any waste includes no vital human blood or
human or animal blood products. Any human discharges of urine, feces, nasal secretions and
tears except if contain no human blood. Hazardous medical waste: Part of medical waste that can
cause health risks. ( LLC, et al, 2019).

Medical waste management:is specific software and procedures taken by each person concerns
in sorting, collecting, storing, transporting and processing medical waste generated in hospitals,
to reduce or eliminate the risks that can occur when handling or exposing to unprocessed medical
waste. Thus, it gives a guide for dealing correctly and safely with medical waste generated in
hospitals which should provide proper and valid protection for all who deal with medical waste,
as well as the local community and environment adjacent to hospitals to reduce environmental
pollution. (WHO 2014).

This waste is generated as a result of the following acts, such as diagnosis, processing,
vaccination of humans or animals and may result from various scientific medical research,
remnants of the tests such as vaccines, serums and antibodies. (Majdi Al-Habash and Ali Al-Zu'bi
et al 2012).

According to the World Health Organization (WHO), HCW is defined as the total waste streams
that include a wide range of materials, such as used needles and syringes, soiled dressings, body
parts, diagnostic samples, blood, chemicals, pharmaceuticals, medical devices and radioactive
materials In detail, it can be classified into eight main categories including general waste,
chemical waste, pathological waste, radioactive waste, infectious waste, sharps, pharmaceutical
waste and pressurized containers. ( Komilis D, Fouki A et al 2012 Jul).

10
Medical waste handlers (MWHs) play a key role in proper waste disposal as they are involved in
the entire waste management processes. Optimum practice and use of personal protective
measures depend on their level ofknowledge and attitude about medical waste and its
management. comprises interrelated key stages starting from segregation, collection, storage,
transportation, treatment, and end up to its final disposal. Appraisal of MWH’s knowledge and
their skill for proper waste management could be a fruitful exercise to quantify and minimize
occupational associated risks. ( Siddharudha S, Sowmyashree et al 2015)

Waste handlers are often at high risk than healthcare professionals. Healthcare professionals once
they produced the waste, they throw it in the garbage; however, waste handlers handle it
extensively throughout and mostly very little attention is given for their safety. They have often
observed washing medical devices and become at risk of cut with broken glassware and other
sharp medical supplies. (Ruth S.et al 201).

Adequate knowledge, proper techniques, and safety practice measures can go a long way toward
safe waste disposal and protection of the community from various adverse effects of hazardous
waste. (Padmaja K. et al 2017)

Medical waste handlers are working in a very poor and unsafe working environment and mostly
they are victims of occupationalhealth hazards from poor waste management practice.
Alemayehu T, Worku A et al 2016.

Adequate knowledge, favorable attitude, and adequate practices of waste handles are key factors
for having proper hazardous MWM and to protect them from exposure to potentially hazardous
substances. (Adogu P, et al 2014)

The aim of this study was to evaluate the level of knowledge, attitude, and practices
(KAP)towards Health Care Warkers, attending at GGH.

Functional Elements of Medical Waste Management:

• Sorting medical waste.

• Classification of medical waste.

• Collection of medical waste.

• Storing medical waste.

• Circulation of medical waste.

• Disinfection of medical waste. Processing of medical waste andFinal disposal

of medical waste.
Hazardous medical waste is classified in to the following types:

Infectious waste: Waste containing, or believed to be containing microbes or organisms causing

infectious diseases (bacteria), viruses and fungi. Anatomical waste (pathological): Wastes that
are competent and directly related to the human body or tissues as sick organs have been

11
eradicated, cut off limbs, dead embryos, or body fluids such as blood or such tissue that are sent
for laboratory testing. Sharp waste: these tools are used by medical staff and used for medical
purposes or analytical and may cause cut or puncture of human body and any sharp tool may be
used in surgical operations.

Chemical waste: Solid, liquid or gas waste resulting from diagnostics experimental, therapeutic,
disinfection and cleaning.

Pharmaceutical waste: Those expired or pharmaceutical products and non-complied with

specifications, or different pharmaceutical and industrial remnants whether liquid or solid. Mixed
medical waste: A group may be a mixture of normal and medical hazardous waste and mixed
waste should be classified as medical waste and can also be: Medical waste mixed with
hazardous and infectious waste must be classified as a dangerous and contagious.

Medical waste mixed with radioactive waste must be classified as radioactive waste and should
be subject to the instructions contained in this regard ((WHO, UNICEF et al 2015)

Health risks

Health-care waste contains potentially harmful microorganisms that can infect hospital patients,
health workers and the general public. Other potential hazards may include drug-resistant
microorganisms which spread from health facilities into the environment.

Adverse health outcomes associated with health care waste and by-products also include: sharps-
inflicted injuries; toxic exposure to pharmaceutical products, in particular, antibiotics and
cytotoxic drugs released into the surrounding environment, and to substances such as mercury or
dioxins, during the handling or incineration of health care wastes; chemical burns arising in the
context of disinfection, sterilization or waste treatment activities; air pollution arising as a result
of the release of particulate matter during medical waste incineration; thermal injuries occurring
in conjunction with open burning and the operation of medical waste incinerators; and radiation
burns.

2.1. Medical waste management (MWM)

process. Typesof Bio Medical Waste

• Infectious waste

• Pathological waste

• Sharps

• Pharmaceutical waste

12
 • Genotoxic waste

• Chemical Waste
• Waste with high content of heavy metals

• Pressurized containers: Gas cylinders; gas cartridges; aerosol cans Radioactive

waste.

Sources of Health Care Waste

• Government hospitals

• Private hospitals

• Nursing homes

• Physician's office/clinics

• Dentist's office/clinics

• Dispensaries

• Primary health centres

• Medical research and trainingestablishments

https://www.who.int/news-room/factsheets/detail/health-care-waste

• Mortuaries

• Blood banks and collectioncentres

• Animal houses

• Laboratories

• Research organizations

• Vaccinating centres

• Bio-technology institutions

Items and Equipment Required for BioMedical Waste Management

Protective aids like gloves, boots, over garment, etc.
Colored bins and bags

• Trolley

• Temporary central storage room

• Needle cutter

• Sodium hypochlorite solution

• Waste water treatment plant. (WHO et al 2018)

13
2.1.1: Medical Waste Management Chain
Key steps that have been identified in the management of medical waste include segregation of
waste from its source and storage in appropriate containers; transportation within and out of the
health facilities; treatment and final disposal. There are challenges at each of the steps along this
chain in South Africa.(Johannesse LM, Dijkman et al 2000)

2.1.2: Medical Waste Segregation and Storage

This first step in the waste management chain is the most important step because it determines
the eventual quantity of waste that is to be treated and disposed of. In order to avoid
accumulation of medical waste in the wards, theatres and other sites where they are generated,
there is a need for designated storage areas within each of the wards and a central storage site for
all the wards withinthe health facility where they can be temporarily stored before they are
transported offsite. (Vumase BS et al 2009.)

The World Health Organization (WHO) prescribed that medical waste should be sorted and
dumped into separate waste containers from the source, and afterwards stored in a safe place
inaccessible to rodents and unauthorized people for a maximum of 48 hours and then transported
to the treatment or disposal site. (WHO et al Geneva 2005).

If this guideline is strictly followed, the quantity of medical waste which is eventually passed to
treatment/disposal facilities will be small and manageable. South African health facilities
generate about 45,000 tons of medical waste annually, out of which only about 4,500 tons are
hazardous (Jewaskiewitz S. A et al 2017). But, while the waste is all mixed together, it becomes
necessary to treat it as hazardous and cannot be recycled and reused without pre-treatmen
(Jewaskiewitz S. A et al 2017). The Department of Environmental Affairs and Tourism (DEAT)
reported that health facilities in eight out of the nine provinces in South Africa do not classify or
segregate their medical waste from source; thus, it is difficult to identify the categories of the
waste being generated and make a proper budget on the materials needed for temporary storage
and transportation out of thehealth facilities (DEAT et al 2015). A poor knowledge of the
characteristics of medical waste may be responsible for the poor segregation practice (Gabela SD
et al 2007)

Survey results done by Walker (1991)in Britian, Hussein (1997)in Egypt, And Abdulla et al.
(2008)in Jordan reported that the problems encountered in hospital waste management were
inappropriate segregation of infectious wastes from non-infectious wastes into colour-coded bags
and deficiency in plastic bags supply and bag holders. A study in Bangladesh revealed that there
was no proper, systematic management of medical waste except in a few private heath-care
establishments that segregate their infectious wastes. Some cleaners were found to salvage used
sharps, saline bags, blood bags, and test tubes for resale or reuse.( Department of Health.
National Department of Health Annual Report 2014/15. Pretoria; South Africa 2015 ). The

14
hazards caused by such waste mismanagement been detected by the WHO (2003)which reported
that mycobacterium tuberculosis kills 2.7 million people each year in developing countries where
the patients remain as the main reservoir of infection. The most well-known transmission route
for infections from health-care waste is from needle stick injuries caused by sharps contaminated
with blood. This is why loose sharp items should not be placed in plastic bags that are easily
punctured. Also, to reduce the risk of airborne transmission avoids using open, uncovered waste
containers (30.) Pretoria et 2016.

the health facility where they can be temporarily stored before they are transported offsite.
(Vumase BS et al 2009.)

The World Health Organization (WHO) prescribed that medical waste should be sorted and
dumped into separate waste containers from the source, and afterwards stored in a safe place
inaccessible to rodents and unauthorized people for a maximum of 48 hours and then transported
to the treatment or disposal site. (WHO et al Geneva 2005). If this guideline is strictly followed,
the quantity of medical waste which is eventually passed to treatment/disposal facilities will be
small and manageable. South African health facilities generate about 45,000 tons of medical
waste annually, out of which only about 4,500 tons are hazardous (Jewaskiewitz S. A et al 2017).
But, while the waste is all mixed together, it becomes necessary to treat it as hazardous and
cannot be recycled and reused without pre-treatmen (Jewaskiewitz S. A et al 2017). The
Department of Environmental Affairs and Tourism (DEAT) reported that health facilities in eight
out of the nine provinces in South Africa do not classify or segregate their medical waste from
source; thus, it is difficult to identify the categories of the waste being generated and make a
proper budget on the materials needed for temporary storage and transportation out of thehealth
facilities (DEAT et al 2015). A poor knowledge of the characteristics of medical waste may be
responsible for the poor segregation practice (Gabela SD et al 2007)

Survey results done by Walker (1991)in Britian, Hussein (1997)in Egypt, And Abdulla et al.
(2008)in Jordan reported that the problems encountered in hospital waste management were
inappropriate segregation of infectious wastes from non-infectious wastes into colour-coded bags
and deficiency in plastic bags supply and bag holders. A study in Bangladesh revealed that there
was no proper, systematic management of medical waste except in a few private heath-care
establishments that segregate their infectious wastes. Some cleaners were found to salvage used
sharps, saline bags, blood bags, and test tubes for resale or reuse.( Department of Health.
National Department of Health Annual Report 2014/15. Pretoria; South Africa 2015 ). The
hazards caused by such waste mismanagement been detected by the WHO (2003)which reported
that mycobacterium tuberculosis kills 2.7 million people each year in developing countries where
the patients remain as the main reservoir of infection. The most well-known transmission route
for infections from health-care waste is from needle stick injuries caused by sharps contaminated
with blood. This is why loose sharp items should not be placed in plastic bags that are easily

15
punctured. Also, to reduce the risk of airborne transmission avoids using open, uncovered waste
containers (30.) Pretoria et 2016.

A study done in Tehran on Assessment of Medical Waste Management in Educational Hospitals

of Tehran University Medical Sciences revealed that some amount of hazardous waste is stored
in the same containers as the domestic wastes and no control measures exist for the management
of these wastes. (Fard, 2008).

The study also showed that in 58% of hospitals, paper and household wastes were segregated
from total medical wastes and in 96% of hospitals infectious wastes were segregated. All the
hospitals had provided plastic bags and strong plastic containers for infectious waste such as
empty containers of antiseptics used in the hospitals. In 58% of hospitals, infectious wastes were
segregated from other wastes. The 42% of hospitals used both plastic bags and containers, 28%
use only plastic bags, 17% used only plastic containers and 16% used only paper and textile bags
for storing their household wastes. (Fard, 2008)

2.1.3: Medical Waste Transportation

Transportation of medical waste within the health facility should be by means of trolleys and
carts which are not used for any other purpose, and out of the facilities by suitable vehicles
marked with biohazard symbol [36]. The frequency of collection of the waste from the wards to
the temporary storage area within the facilities and out of the temporary storage area to the final
treatment/disposal site will depend on the size of the hospital, a number of available equipment
and workers. The workers involved in the transportation of medical waste should be trained on
the different classification of the waste and their containers to help them in the handling of the
waste and prevent them from mixing together different categories of waste which were
previously segregated.(Vumase BS et al 2009).

According to WHO Central storage rooms are locations in special areas or in the grounds of a
hospital where larger containers, e.g., 1.1 m four wheeled bins (eurobins) should be used to store
waste until it goes for final disposal either on- or off-site. (Manyele SV et al 2004).

Intermingling of infectious wastes with general waste in the health-care establishments is a threat
to environmental health. In some health-care establishments in Bangladesh, all the infectious
wastes were found to be separated from the non-infectious waste stream at the site of generation,
but during disposal in the dustbins the wastes were then mixed together. (Pretoria; South Africa
2016).

2.1.4: Medical Waste Treatment and Disposal

The methods which have been adopted for medical waste treatment and disposal include the
traditional open dumping on lands or water bodies, deep burial, burning and the modern

16
incineration, autoclaving, shredding, superheated stream sterilization, microwave disinfection,
wet oxidation technology and electron beam gun technology Yawson P. et al 2014. Though the
World Bank permits open burning of toxic waste as the last resort on the condition that the site of
burning is in the rural area, far away from busy complexes to limit the number of people being
exposed to the adverse effects of the event.World Bank et al 2002. However, an indiscriminate
burning of waste where it affects any person violates the constitution of South Africa (Act 108 of
1996).

Modern methods which are more environmental-friendly were developed in order to minimize
the risks posed to people and the environment by the traditional methods. However, many of the
modern methods are very expensive and not available in many developing countries. (Maseko Q.
et al 2014).

Though some of the new methods are being employed in some parts of the country, especially in
the Gauteng Province, a larger part of South Africa still employ the traditional methods of open
dumping, burning and the lowest standard of incineration to dispose of their medical waste While
some facilities dispose their waste within the health facility compound, others outsource the
disposal to licensed treatment facilities (Vumase BS et al 2009).

However, there have been reports of sudden malfunctions, breakdown, planned and unplanned
maintenances of equipment which interfere with proper waste disposal by the treatment facilities.
(RSA et al 2008) . In Gauteng and Western Cape Provinces, all the facilities use reusable
materials while in Mpumalanga, all the facilities use incineration, but in the other provinces,
different practices were observed in different health facilities. Vumase BS et al 2009.

Also, medical waste has been discovered indiscriminately and illegally dumped into water
bodies, veld, the backyard of brick factories and even a beach parking lot in South Africa.(The
Sunday Times et al 2017)

2.5 Techniques for Medical Waste Treatment and Disposal

The World Health Organization recommended that the choice of the mode of treatment and
disposal of medical waste should be guided by cost-effectiveness, easy implementation and
environmental friendliness.(Hossain MS, Santhanam et al 2011). unique characteristics of the
constituent of medical waste make it imperative that it be treated effectively before final disposal
to make the end-product of the waste safe to the handlers and the public. Different modes of
treatment have been employed for specific constituents of medical waste. That is why
segregation at the point of generation is vital to make it easy for each group of waste to be passed
to their different treatment sections. Final disposal is usually in a landfill.

17
The techniques which have been documented for treatment and disposal of medical waste
include:

• Open dumping/burning: This method is widely employed in many

developing countries because it is cheap and easily available. However,
open dumping/burning constitute a great risk to the public because it
renders the dumped waste accessible to the public and scavengers. Burning
is usually used to reduce the volume of waste and prevent its spread.
However, toxic gasses can be released into the atmosphere during the
burning process. The waste dump is also usually a source of injury to the
community whether through direct contact or indirectly through land, water
and air pollution (Nemathaga F, et al 2008)

• Incineration: This is the choice of treatment for pathological wastes, sharps

and other clinical wastes that cannot be reused, recycled or disposed of in a
landfill. A standard incinerator uses high temperature to convert the waste
into a minimal residue in the form of residual gases and ashes.(Hossain
MS, Santhanam et al 2011). However, many incinerators being used in
developing countries are made locally, designed poorly to use coal as fuel
and are unable to achieve complete combustion of the waste; thus, resulting
in an enormous quantity of ash(Nemathaga F, et al 2008). The unburned
waste and ashes are eventually disposed of at a landfill.Autoclaving: A
cheaper alternative treatment method to incineration is autoclaving.
Autoclaving sharps and medical wastes contaminated with blood and other
human secretions at an optimum temperature of 160°C help to rid the waste
of bacteria. However, the autoclaved waste still need to be retreated using
another means before final disposal (Jang YC, Lee C, et al 2006). Besides,
there is a limit to the type of waste that can be autoclaved – large quantities
of waste, large body parts and waste from chemotherapy treatment cannot
be autoclaved because of the length of time required for the wastes to
achieve the required optimum temperature. (Hossain MS, Santhanam et al
2011).

• Microwave disinfection: This is a modification of waste autoclaving which

involves the use of microwaves to provide heat for disinfection of medical
waste. However, wastes containing metal objects cannot be microwaved to
prevent the generation of dangerous sparks (Windfeld ES, et al 2015).

• Landfilling: Standard landfilling requires more than a simple burial of

waste in a shallow pit, it must be located and constructed in an authorized
site approved by the government and not within the reach of unauthorized
persons (Yawson P. et al 2014). However, in many developing countries,

18
 landfills are operated like open dumping where all forms of waste are
dumped and later burned. (Hossain MS, Santhanam et al 2011). Where the
landfill is not properly constructed, erosion may cause the washing of the
waste into water bodies, thus contaminating the water.

2.6 Knowledge of Health Workers about MWM.

A study conducted at DebreMarkos Town Healthcare Facilities, Northwest Ethiopia in
2018 in this study, HCPs with adequate knowledge score were 168 (56.8%). One hundred
sixty-nine (57.1%) of the study participants identified the biohazard symbol. Regarding
knowledge on segregation of BMWs, 235 (79.4%), 217 (73.3%), and 253 (85.5%) of the
study participants were aware that general, infectious, and sharp wastes should be placed
in a black, yellow, and a safety box, respectively. In addition, 254 (85.8%) of them were
aware that a safety box should be filled only a maximum of 3/4th. Only twenty-nine
(9.8%) of the study participants knew the maximum storage time of infectious wastes
before treatment or disposal. Two hundred eighteen (73.6%) of them knew 72 hours as a
maximum time delay to start HIV postexposure prophylaxis. All doctors were concerned
about needlestick injury than other healthcare professionals. About 46% of health officers
did not consider all BMW as hazardous (AdekunleOlaifa et al 2018).

19
A study done in Iran on Assessment of Medical Waste Management in Educational Hospitals of
Tehran University Medical Sciences revealed that some of the hospitals had provided the
following essential equipment for the safety of employees, housekeeping employees, in-patients
and out patients:- Protective clothing for personnel who handled The hospital personnel were
trained about handling and managing medical waste, infection control and protection, hospital
personnel and protection against medical waste hazards, e.g. Hepatitis B and C, AIDS, and
Typhoid. 15% of managers, 45% of nurses and 40% of labors were trained about medical waste
disposal. The training methods consisted of lecturing (29%), workshop (32%), brochure (7%),
slides and clips (7%) and face-to-face training (25%). The training programs have been conducted
by environmental health specialists that work in hospitals or NGOs. (Fard, 2008)

A study conducted in Yemen on Assessment of Medical Waste Management in the Main

Hospitals showed that the waste-workers’ knowledge about dealing with medical waste 11.5%
and 45.9% of workers in government and private hospitals respectively were able to identify the
types of medical waste they were collecting. Few of the government hospitals workers (19.5%)
and more than half of the private hospitals workers (61.3%) considered it necessary to sort
medical waste. Only 11.5% of the workers in government hospitals and 44.4% of the workers in
private hospitals could understand the reasons behind sorting medical waste. Consequently none
of the government hospitals’ workers and only 25.0% of the private hospitals’ workers knew the
adequate quantities for packing medical waste. (NC., 2013)

A study carry out Buraimi Governorate, Sultanate of Oman (9, 2018) The percentage of Nurses
knowledge regarding the biomedical waste documents and legislation implemented inhospital
(61.8%) was significantly higher than other 3 category doctors (30.5%), laboratory technician
(28.5%) and housekeeping staff (20%) (P=0.000). Regarding the knowledge of health care
workers about different types of wastes, it was found that 98.2% of nurses, 92.2% of laboratory
technicians,

90% of housekeeping staff and 88.9% of doctor’s staff knew that infectious waste belong to the
biomedical waste, statistically it was insignificant among the respondent (P=0.333).
Health care workers who responded correctly about diseases which are transmitted through
mishandling of biomedical waste management, like Hepatitis B, Hepatitis C and CCHF
(CrimeanCongo hemorrhagic Fever) were found to be statistically significant with P-value (0.004,
0.000 and 0.025 respectively). About the color coding segregation of biomedical waste the
knowledge of housekeeping staff (100%) and nurses (94.5%) were significantly better than
doctors (58.3%) and laboratory technician (64.2%) (P=0.000).Furthermore, regarding the
knowledge of usage the personal protective precaution while dealing with patients known to be
positive with infectious diseases it was found to be “statistically insignificant” (P=0.124), but the
knowledge of laboratory technician (92.8%) was better than nurses (80%), doctors (75%) and
housekeeping staff (60%). Although all health care workers in 4 category nurses (100%),
laboratory technician (100%), housekeeping (100%) and doctors (97.2%) answered that the sharp
container is the correct place for the sharp objects to bedisposed but “statistically” it was found to
be “insignificant” (P=0.474).
20
The knowledge about the correct statement of Sealing the Hazardous waste containers (yellow
bin) was considered to be highly significant (P=0.000)with high percentage among nurses 90.9%.
It was observed that housekeeping staff (90%) significantly had better knowledge than doctors
(58.3%), nurses (58.1%), and laboratory technician (28.5%) regarding the post exposure
prophylaxis management protocol (P=0.011). By evaluating, overall participants “satisfactory”
knowledge score, it was found to be (81.6%) with higher knowledge score in nurses (90.9%)
followed by laboratory technicians(78.6%), housekeeping staff (75%) and doctors (72.2%) but
overall satisfactory knowledge scores of the participants was “statistically insignificant” (P=
0.100). Ahmed Yar Mohammed Dawood et al 2018.

Similar study conducted at DelhiAround 3/4th of health personnel were aware of BMWM Rules
whereas other study carried out by Nirupama et al, at Karimnagar, to assess KAP with reference to
BMWM rules, discloses that around half of HCWs knew correctly about BMWM rules.7 This
difference is might be due to HCWs in Delhi, capital of India, have more access to publicity of BMWM
rule. Other reasons behind this difference are there was more emphasis given on the awareness
regarding HIV transmission through mass electronic media, government involvement and political will
in awareness generation among public including HCWs. But those workers working at primary level in
rural areas may not have that much access to information.8 A total 70.6% HCWs were having equal idea
about segregation of bio-medical waste and majority (95.8%) of HCWs have knowledge about various
health problem caused by bio-medical waste. Overall knowledge of HCWs was high but nursing staff
was excellent.
This could be explained by the fact that most of study subject not only received superior trainings
frequently on BMWM but also nearly half of the HCWs have been received training within one
year. Knowledge of nursing staff regarding colour coding system of bags for bio-medical waste is
statistically significant (p=0.02; χ 2 =5.30; df=1). Similar results were found in another study
conducted by Shafee et al at Karimnagar.7 Nursing staff know very well in which bag infected
waste should be disposed than other workers. This was credited to nurses because they were more
involved in applied work and tasks given by higher authorities. (Yavatmal, Maharashtra, et
all).Knowledge of HCW management at a district hospital in KwaZuluwas generally inadequate,
with 42.7% of the participants scoring ‘poor’ overall.

In general, nurses demonstrated a better level of knowledge compared with the other
designations, with other professional healthcare workers having the lowest knowledge score. The
poor level of knowledge of other professional healthcare workers is surprising considering that
doctors, medical technologists and dentists have regular contact with hazardous healthcare
material and would be expected to be knowledgeable about HCW management. Just under half
(48%) of the respondents reported that they had never received any formal training in HCW
management and just over 50% reported receiving any in-service training. These results reflect
the lack of exposure to HCW management during undergraduate training as well as a lack of
exposure to in-service, ongoingtraining at the hospital regarding HCW management. The higher
knowledge level amongst nursing staff may be due to their undergraduate and more structured in-

21
service training. Of concern is the lack of knowledge among the non-professional healthcare
workers who collect and dispose of the waste. (AdekunleOlaifa et al 2018)
A Study conducted in Nigeria on Assessment Studies on Hospital Waste Management in Imo
State stated results which shows that the waste handlers in St. David and General hospital are not
aware of the WHO recommendation on hospital waste management; hence it is not implemented
while 33.3% of respondents from Federal Medical Centre were aware of the guideline. 100% of
respondents from St. David, 60.0% from General Hospital and 53.3% from Federal Medical
Centre were aware of health implication of hospital waste. The result on level of training shows
that training of staff are not often given in St Davids hospital , General hospital offered yearly
training while Federal Medical Centre offered training 2-3 times yearly. (NC, 2013)

A study done in Ghana on Assessment of Medical Waste Management in Bawku Presbyterian

Hospital of the Upper East Region indicated in concerning training of waste worker in dealing
with biomedical waste, 6 (54.55%) indicated that they are trained and only once in a year, while 5
(45.45%) stated otherwise. Despite most of them claiming that there was training for workers in
dealing with medical waste, the hospital had no formal training programmes. However, this is an
encouraging observation, since training is a very important aspect in the field of medical waste
management but the frequency could be improved to twice or more often. (Akum, 2014)

A study conducted in Buraimi Governorate, Sultanate of Oman (9, 2018 ) The majority of health care
workers 84.8% including laboratory technician (92.7%), nurses (87.3%), doctors (80.5%) and
housekeeping staff (80%) strongly disagreed that the safe management of biomedical waste is not an
issue at all but “statistically” was not found to be “significant” (P=0.639).
Regarding the statement that ‘waste management effort is a team work and no single class of
people is responsible for its safe management’, the attitude of nurses (92.7%) was significantly
greater as compared to doctors (83.2%), laboratory technician (64.3%) and housekeeping staff
(60%) (P=0.024). The study participants also disagreed regarding efforts on safe management of
biomedical waste which cause an increase in the financial burden on management (P=0.063,

“statically insignificant”). The percentage of laboratory technician (78.5%) who did not agree
about safe management of biomedical waste as an extra burden on work, was higher than nurses
(76.3%), doctors (63.8%) and housekeeping staff (60%) was found to be statistically not
significant (P=0.088).

Consequently it was found that the percentage of laboratory technician (100%) who agreed that
voluntary programs are important for upgrading the knowledge about the biomedical waste was
higher verses doctors (94.4%), nurses (92.8%) and housekeeping staff (80%) but statistically was
insignificant (p=0.455).

The attitude of staff regarding importance of washing their hands before and after contact with
each patient was found to be statistically highly significant(p=0.000) with high proportion among

22
nurses (100%) and laboratory technicians (100%). The health care workers who agreed that body
fluids, pathological material, radioactive materials and pressurized containers are hazardous
medical wastes were found to be statistically highly significant (p=0.000, p=0.000,p=0.000 and
p=0.002 respectively). Also, it was found that the attitude of laboratory technicians (100%)
towardsfurther strict implementation of biomedical waste was highly “significant” comparing to
doctors (86.1%), nurses(72.7%) and housekeeping staff (65%) (P= 0.040). Meanwhile, 80% of all
respondent i.e. housekeeping staff,doctors, nurses and laboratory technician stated that they will
inform waste collection team in case if they puttedthe waste in a wrong bin which was
statistically significant (P= 0.055).

It was noted that “significantly” morelaboratory technicians (100%) than nurses (96.4%), doctors
(94.4%) and housekeeping staff (40%) agreed thatneedle stick injury is a concern (P= 0.000). The
perception about the risk of infection and taking precautionsamong health care workers after
receiving the vaccination was statistically insignificant (P=0.371. The proportionof laboratory
technicians (100%) was more as compared to doctors (94.5%), nurses (91%) and housekeeping
staff(85%). Furthermore, among staff about 90.9 % of nurses considered that every patient should
be treated as if theyare carrying blood borne pathogen which was considered statistically highly
significant (p=0.000).

The overall“satisfactory” attitude scores was 91.2% with higher attitude score in nurses (94.5%)
compared to laboratorytechnicians (92.9%), doctors (91.7%) and housekeeping staff (80%), but
attitude of satisfactory score was found tobe “statistically insignificant” (32)
Another study conducted at a district hospital in KwaZulu-Natal, South Afirca in 2018,reported
that over half (54%) of the staff were considered to have a good attitude towards the appropriate
disposal of HCW based on their response to the questions. Most participants, however, expressed
a good attitude towards the proper handling of HCW but were unaware of the hazards associated
with its improper disposal.

Similar study conducted at Delhi, Attitude of BMWM among HCWs Attitude of all HCWs was
highly positive towards BMWM. Similar level of positive attitude was found in another study
conducted by Shafee et al at Karimnagar. 7 Proportion of HCWs having positive attitude towards
following BMWM rules, colour coding system of segregation of BMW, reducing spread of
infections and implementation of rules and regulations was close to the findings of a survey
carried out in Karimnagar (99.2%, Soyam GC et al. Int J Community Med Public Health. 2017
Sep;4(9):3332-3337 International Journal of Community Medicine and Public Health | September
2017 | Vol 4 | Issue 9 Page 3336 98.8% and 98.4% respectively). Also attitude of technicians and
housekeeping staff also match with findings at Karimnagar.7 While compare to technicians and
the housekeeping workers, nursing personnel have statistically significant attitude. (Yavatmal,
Maharashtra et al 2018).

Attitude of HCW management at a district hospital in KwaZulu Just over half (54%) of the staff
were considered to have a good attitude towards the appropriate disposal of HCW based on their
response to the questions. This is somewhat of a surprise and may have been influenced by the
23
wording of the questions and needs further investigation. Most participants, however, expressed a
good attitude towards the proper handling of HCW but were unaware of the hazards associated
with its improperdisposal. A good attitude towards safe HCW handling in the hospital is an
important finding with the World Health Organization stating that with regard to safe HCW
management the human element is more important than the technology. Almost any system of
treatment and disposal that is operated by well-trained, and well-motivated staff can provide more
protection for staff, patients and the community than an expensive or sophisticated system that is
managed by staff who do not understand the risks, and the importance of their contribution. In
general the responses of non-professional healthcare workers suggest a poorer attitude towards
HCW management.

However, a significant proportion of the nonprofessional staff did not answer the attitude
questions, which may suggest that they did not understand the questions or a knowledge gap
rather than a poor attitude towards HCW management. Other studies have shown that training
and ongoing monitoring is essential if policy is to be implemented. (AdekunleOlaifa, et 2018)
Resent study conducted at DebreMarkos Town Healthcare Facilities, Northwest Ethiopia in 2018
in this study one hundred ninety-six (66.2%) of the study participants had favorable attitude score
on BMWM. The mean attitude score of Likert items ranged from 3.80 to 4.45. In addition, 161
(45.9%) of the study participants strongly agreed to the statement “BMWs should be segregated
into different categories at the source” and 191 (58.1%) study participants agreed to the statement

“safe BMWM is an issue involving a teamwork. (TeshiwalDeress et al 218)

Over 66.2% of HCPs have information on color coding system (table 3).Only 16% of HCPs had
information on the amount of medical waste in relation to general waste in the hospital. About
40% knew how medical waste is managed in routine practice and over 28% knew who is
responsible for MWM. While 96% of participants were aware that needle prick injury endangers
health, only 73% had information on some specific consequences of needle prick injury. When
these knowledge questions were summed to obtain a total score, the total score ranged from 0 to 9
with a mean knowledge score of 4.7 (SD 1.8). Table 4 shows comparison of the mean score with
various characteristics of participants. The mean score for people with a college/institute degree
was 0.5 higher than the mean score of people with no degree and this difference was statistically
significant. Other factors which were significantly associated with higher knowledge of waste
management were male gender, being training and being in service for more than 5 years.

Regarding knowledge of waste management, high scores were recorded by most HCWs regarding
knowledge of the basics of MWM and handling aspects, such as the categorization of different
types of waste, policies on needle-stick injury, existence of infection control department within
the hospital, and the health risks associated with poor waste handling. However, previous
training, availability of training, and awareness of recycling of medical waste scored lowest.
About half, 49.8% (315/632) of participants stated that they received some training in MWM.
This was much higher than the findings of another study done in India, (Mane V, Nimbannavar et
al 2016)

24
Which reported that only 16.3% of participants had received any training in MWM. Further, an
intermediate score was observed regarding aspects of knowledge concerning waste differentiation
and training and disposal of waste after collection. Most nurses 96.2% (377/392) reported
knowledge of needle-stick injury reporting policies, which is consistent with the findings of an
Indian study where 88.6% of nurses were also aware of needle-stick injury reporting policies.
(Asadullah MD, Karthik et al 2013)

However, our findings are in contrast with those reported from a study done in South Africa,
which found that only 47.2% of HCWs had adequate knowledge of correct disposal of healthcare
waste and only 36.0% employed appropriate disposal practices of medical waste. (Makhura RR,
Matlala SF, et al 2016)

2.7 Attitude of Health Workers about MWM.

A study conducted in Buraimi Governorate, Sultanate of Oman (9, 2018 ) The majority of health
care workers 84.8% including laboratory technician (92.7%), nurses (87.3%), doctors (80.5%)
and housekeeping staff (80%) strongly disagreed that the safe management of biomedical waste is
not an issue at all but “statistically” was not found to be “significant” (P=0.639). Regarding the
statement that ‘waste management effort is a team work and no single class of people is
responsible for its safe management’, the attitude of nurses (92.7%) was significantly greater as
compared to doctors (83.2%), laboratory technician (64.3%) and housekeeping staff (60%)
(P=0.024).

The study participants also disagreed regarding efforts on safe management of biomedical waste
which cause an increase in the financial burden on management (P=0.063, “statically
insignificant”). The percentage of laboratory technician (78.5%) who did not agree about safe
management of biomedical waste as an extra burden on work, was higher than nurses (76.3%),
doctors (63.8%) and housekeeping staff (60%) was found to be statistically not significant
(P=0.088). Consequently it was found that the percentage of laboratory technician (100%) who
agreed that voluntary programs are important for upgrading the knowledge about the biomedical
waste was higher verses doctors (94.4%), nurses (92.8%) and housekeeping staff (80%) but
statistically was insignificant (p=0.455).

The attitude of staff regarding importance of washing their hands before and after contact with
each patient was found to be statistically highly significant(p=0.000) with high proportion among
nurses (100%) and laboratory technicians (100%). The health care workers who agreed that body
fluids, pathological material, radioactive materials and pressurizedcontainers are hazardous
medical wastes were found to be statistically highly significant (p=0.000, p=0.000,p=0.000 and
p=0.002 respectively). Also, it was found that the attitude of laboratory technicians (100%)
towardsfurther strict implementation of biomedical waste was highly “significant” comparing to
doctors (86.1%), nurses(72.7%) and housekeeping staff (65%) (P= 0.040). Meanwhile, 80% of all
respondent i.e. housekeeping staff,doctors, nurses and laboratory technician stated that they will
inform waste collection team in case if they puttedthe waste in a wrong bin which was
statistically significant (P= 0.055). It was noted that “significantly” morelaboratory technicians

25
(100%) than nurses (96.4%), doctors (94.4%) and housekeeping staff (40%) agreed thatneedle
stick injury is a concern (P= 0.000). The perception about the risk of infection and taking
precautions among health care workers after receiving the vaccination was statistically
insignificant (P=0.371.

The proportion of laboratory technicians (100%) was more as compared to doctors (94.5%),
nurses (91%) and housekeeping staff(85%). Furthermore, among staff about 90.9 % of nurses
considered that every patient should be treated as if theyare carrying blood borne pathogen which
was considered statistically highly significant (p=0.000). The overall “satisfactory” attitude scores
was 91.2% with higher attitude score in nurses (94.5%) compared to laboratory technicians
(92.9%), doctors (91.7%) and housekeeping staff (80%), but attitude of satisfactory score was
found tobe “statistically insignificant”

Another study conducted at a district hospital in KwaZulu-Natal, South Afirca in 2018,reported

that over half (54%) of the staff were considered to have a good attitude towards the appropriate
disposal of HCW based on their response to the questions. Most participants, however, expressed
a good attitude towards the proper handling of HCW but were unaware of the hazards associated
with its improper disposal. (25)Similar study conducted at Delhi, Attitude of BMWM among
HCWs Attitude of all HCWs was highly positive towards BMWM. Similar level of positive
attitude was found in another study conducted by Shafee et al at Karimnagar. 7 Proportion of
HCWs having positive attitude towards following BMWM rules, colour coding system of
segregation of BMW, reducing spread of infections and implementation of rules and regulations
was close to the findings of a survey carried out in Karimnagar (99.2%, Soyam GC et al. Int J
Community Med Public Health. 2017 Sep;4(9):3332-3337 International Journal of Community
Medicine and Public Health | September 2017 | Vol 4 | Issue 9 Page 3336 98.8% and 98.4%
respectively). Also attitude of technicians and housekeeping staff also match with findings at
Karimnagar.7 While compare to technicians and the housekeeping workers, nursing personnel
have statistically significant attitude. (Yavatmal, Maharashtra, et al 2018).

Attitude of HCW management at a district hospital in KwaZulu Just over half (54%) of the staff
were considered to have a good attitude towards the appropriate disposal of HCW based on their
response to the questions. This is somewhat of a surprise and may have been influenced by the
wording of the questions and needs further investigation. Most participants, however, expressed a
good attitude towards the proper handling of HCW but were unaware of the hazards associated
with its improperdisposal. A good attitude towards safe HCW handling in the hospital is an
important finding with the World Health Organization stating that with regard to safe HCW
management the human element is more important than the technology. Almost any system of
treatment and disposal that is operated by well-trained, and well-motivated staff can provide more
protection for staff, patients and the community than an expensive or sophisticated system that is
managed by staff who do not understand the risks, and the importance of their contribution. In
general the responses of non-professional healthcare workers suggest a poorer attitude towards

26
HCW management. However, a significant proportion of the nonprofessional staff did not answer
the attitude questions, which may suggest that they did not understand the questions or a
knowledge gap rather than a poor attitude towards HCW management. Other studies have shown
that training and ongoing monitoring is essential if policy is to be implemented.
( AdekunleOlaifa, Romona et al 2018).

Resent study conducted at DebreMarkos Town Healthcare Facilities, Northwest Ethiopia in 2018
in this study one hundred ninety-six (66.2%) of the study participants had favorable attitude score
on BMWM. The mean attitude score of Likert items ranged from 3.80 to 4.45. In addition, 161

(45.9%) of the study participants strongly agreed to the statement “BMWs should be segregated into
different categories at the source” and 191 (58.1%) study participants agreed to the statement

“safe BMWM is an issue involving a teamwork. (TeshiwalDeress ,1FatumaHassen et al 2018) The

results of participants’ opinions/attitudes on issues in relation to MWM revealed that over 96% of
participants agreed with the importance of medical waste management (MWM), but 66% believed that
MWM is done properly in their workplace and only 20% believed that the health facility has provided
necessary training for HCP. (Sarko Masood Mohammed, Nasih Othman, et al 2017)

2.8 Attitude and practice regarding waste management

Attitude toward waste management among respondents: Most respondents agreed that medical
waste should be segregated at the point where it is generated. This was consistent with the results
from a study in India, (Yavatmal, Maharashtra et al 2018) where 96.9% of respondents agreed
that waste should be segregated. Pertaining to the practice of waste management, the study
established presence of high level of agreement that there was a colour-coding system in the
hospital under study. Nonetheless segregation of medical waste was problematic with mixing of
the different types of waste. Segregation was found to be high in Indian studies conducted by
Chudasamaet al.[36] and Charania and Ingle,[37] who found that the correct response was as high
as 86.9% and 82.4% respectively. In addition, adherence to MWM policies in this study was
found to be poor, and HCWs were rarely included in the development of waste handling policies.

There was evidence that the different departments involved in medical practice do not synergise
with each other towards proper MWM. For example, waste was often found mixed up, although
the institution has a colour coding system, and placement of waste is not in proper receptacles all
the time or always.” This is similar to another study from South-Eastern Nigeria, where Anozie
and others reported that 98.1% of hospitals in this region practiced indiscriminate waste disposal,
with only 40% of healthcare managers reporting having received any training on MWM.
Respondents reported several challenges to proper practice of MWM. Half of the participants
reported inadequacy or inappropriate receptacles. The next most reported challenge was absence
of protective gear, such as heavy-duty gloves for the cleaners, followed by doctors’ failure to
dispose of waste after medical procedures. The most recognized obstacle to MWM in this study
was the “lack of knowledge of the dangers of improper waste management by the HCWs” with a

27
63.1% (399/632) “yes” response. Doctors contributed the highest response of 67.2% (425/632),
whereas the housekeeping personnel had the lowest at 53.8% (340/632). The least scoring
obstacle was “laboratory staff do not see waste separation as their concern” with 9.2% (58/632)
responding affirmatively. It should be noted that this might be explained by the low numbers of
HCWs in this category, as well as the fact that laboratory staff do not share workstations with
most respondents from the other categories of HCWs in this study.

2.9 Practices of Health Workers about MWM.

A study conducted in Buraimi Governorate, Sultanate of Oman (9, 2018 most of the participants

(89.6%) stated that they do practice all “universal precautions” while caring patients anddealing with
biomedical waste. In this regard, practices of nurses (98.2%) were significantly better thanhousekeeping
staff (95%), laboratory technician (85.7%) and doctors (75%) (P= 0.004). It was found that
thepercentage of housekeeping staff (100%) had better practices than nurses (92.7%), doctors (86.1%)
and laboratorytechnician (85.7%) about the following of color coding segregation of biomedical waste,
but statistically it wasfound as insignificant (P= 0.075). Also, it was observed that doctors (72.2%) had
“significantly” better practicesfor not putting the waste in the wrong bin as compared to housekeeping
staff (65%), laboratory technician (57.1%)and nurses (54.5%) (P= 0.000). Regarding the “re-capping” of
used needles, 81.1% of nurses confirmed that theydo not re-cap the used needles which was
“significantly” better in contrast to practices of laboratory technicians (64.3%), doctors (61.4%) and
housekeeping staff (30%) (P=0. 000). ( AhmedYar Mohammed Dawood et al 2018).

Similar study conducted at Delhi Around Regarding BMWM practices., it was found that the
nursing staff practiced BMW management better than the technical and housekeeping staff and
difference was statistically significant. Practices of gloves wearing while handling BMW by
nursing staff were (87.8%) and paramedical staff were (79.4%). This findings are in line with
results in study done at Bangalore in 2005, with the purpose of assessing KAP regarding
occupational safety among nursing professionals, where almost three fourth (72%) nursing staff
took precautions while handling waste. This difference is due to training status of nurses in Delhi.
Majority of nursing staff (80.5%) put non-infected hospital waste in black container but around
60% other staff doing same practices. Only 57.4% of nursing staff sort out hospital waste at
source. (Yavatmal, Maharashtra, et al 2018).

Another study conducted at a district hospital in KwaZulu-Natal, South Afirca in 2018

Considering the important safety and medico-legal implications for staff and patients, the HCW
management practices in the hospital were disappointing, with only one participant having
excellent practice and only just over 50% of participants demonstrating good practice. The large
number of staff with poor HCW management practice reported in this study is consistent with
reports in both private and public hospitals in Limpopo province, suggesting that HCW
management practices need improvements in both the public and private sectors.(23)
(Siddharudha S, et al 2015)

28
The poor practices demonstrated in this study could be partly attributable to inadequate
knowledge, as there was a significant but moderate association between the two. In addition, this
study has shown that there was inadequate effort made to ensure adequate knowledge of and
compliance with hospital policy, with just under half of the respondents reporting a lack of in-
service training on HCW management as well as inadequate supervision and monitoring of their
HCW management practices. (AdekunleOlaifa, Romona D et al (2018)

Another study conducted in Yemen on Assessment of Medical Waste Management in the Main
Hospitals; the interviews and observations showed that the waste-workers were collecting
medical and nonmedical wastes together manually in all hospitals without receiving adequate
training and without using proper protective equipment. There was poor awareness about medical
waste risks and safe handling procedures among hospital administrators, and most hospitals did
not differentiate between domestic and medical waste disposal. Budgets were not allocated for
waste management purposes, which led to shortages in waste handling equipment and an absence
of training programmes for staff. Poor knowledge and practices and a high rate of injuries among
waste-workers were noted, together with a risk of exposure of staff and visitors to hazardous
waste (Al-Emad, 2011).

Resent study conducted at DebreMarkos Town Healthcare Facilities, Northwest Ethiopia in 2018
in this study, 229 (77.4%) of the study participants had adequate practice score and 174 (58.8%)
used a visual aid in their department/section. Regarding the use of personal protective equipment,
277 (94%) and 288 (97%) of the study participants have always used gloves and gown,
respectively, while they were handling BMWs. Two hundred eighty-eight (79.1%) of the study
participants practiced labeling BMW containers. With respect to segregation of BMWs, 275
(92.9%) of the study participants segregated BMWs at the source of generation. However, only
261 (88.2%) of them followed color coding segregation. Among these, 228 (77%), 198 (66.9%),
and 247 (83.4%) of them put general, infectious, and sharp wastes into the black bin, yellow bin,
and safety box, respectively. More specifically, 26 (83.9%), 140 (85.9%), 27 (100%), 45 (91.8%),
and 23 (88.5%) doctors, nurses, midwives, laboratory professionals, and health officers,
respectively, followed color coding segregation. (TeshiwalDeress ,1FatumaHassen et al 2018)

A study conducted in Somalia city on Assessment of the Management and Disposal Practices of
Medical Waste in the Hospitals of Mogadishu city revealed that the administrators of the three
hospitals have agreed that there are mismanagement acts of medical waste management. They
justified this through a lack of disposal technologies and educated staff for medical waste
management and safe disposal. Also the administrators indicated that none of the hospitals
provide annual education or training on waste management for employees. In addition,
segregation of the waste in the hospitals didn’t exist and there was no existence of medical
committees. The study also indicated the most common disposal methods were burning (Adam,
2012)
The study showed that 68% of HCPs followed the color coding system for segregation of medical
waste. While 91% of HCPs always/frequently disposed of used sharps and syringes to safety
boxes, 9% of HCPs never or only sometimes did so. Recapping the used needles was a common
29
practice in 79% of HCPs who always or frequently did so while only 12% reported they never
recapped used needles. In this relation 49% of participants reported that they had experienced at
least one needle prick injury during their work but only 37% of them had reported the injury to a
supervisor and only 4% of those injured had filled an injury form. Study conducted at
Suleimani health facility in Kurdistan. The knowledge, attitude and practices of HCPs were
dissimilar among participants; many factors may lead to this difference like the level of education
of HCPs, working experience, participation in training courses and their practical involvement in
the hospital waste handling and MWM.

This study showed that gender, service years, qualification and participation in training were statistically
significant factors of better knowledge while duration of training course was not.

The current study showed that from a total of 406 HCPs participated in the study, 261(64.3%)
were females and 145(35.7%) were males with female to male ratio of 1:1.8. The present study
showed that 66% of HCPs have information on color coding system; this was similar to a study
done in Pondicherry- India reported that 50% of HCPs had the knowledge of color coding and
segregation of MWM, (M. Azage, G. Haimanot, et al 2013). this result was also comparable to a
study done in Pakistan reporting that 86% HCPs have information about waste color codes. (A.

Malini, B. Eshwar, et al 2015).

Another similar study from West Bengal revealed that 76% HCPs knew about various types of color-
coding bags for collection of MW [19]. (R. Kumar, A. Zulfiqar, et al 2013.).

In the present study 15.9% of HCPs have knowledge about the percentage of MW in whole
waste. This was similar to a study done in Delhi, India reporting that HCPs with knowledge of
approximate proportion of infectious waste generated in HCFs were found to be 36% (M. Basu,
P. Das, R. Pal, et al 2012).

Another study from India reported that HCPs knowledge about the proportion of infectious waste
generated from a hospital was found only in 39.3% of respondents. (S. Pradhan, S. Prasad, BR.

Chinmaya, S. Tandon, et al 2016).

This may be due to low level of HCPs knowledge and the absence of national guidelines in HCFs.
The current study showed that gender, participation in training, qualification, and service years
were significantly associated with better knowledge of waste management while training duration
was not. Regarding training course in relation to MWM (79.7%) of HCPs had not participated in
any training courses during their working periods and only (20.3%) HCPs have participated in
MWM training course. This result was similar to a study done in India revealed that around 16%
HCPs had received training on MWM. S. Pradhan, S. Prasad et al 2014

another study in Puducherry-India reported that (74%) of HCPs have not undergone training on
medical waste management.(M. Azage, G. Haimanot, et al 2013). This result was inconsistent
with a study done in Turkey that reported training of staff on medical waste was about 80% (R.
Sanjeev, S. Kuruvilla 2014). The low participation in training highlights the need for
strengthening training courses and involving all HCP in such trainings. This study also shows the

30
need for such training programs to be conducted regularly and make it compulsory for all the
HCPs to attend either annually or at the beginning of their service. In the present study 96% of
HCPs knows that needle prick injury is dangerous. It is similar to a study done in Bosnia and
Herzegovina reported that 70% of HCPs were aware that needle prick injury carries risk for blood
borne infection.

In the current study 96% of HCPs believe that proper management of MW is important, 82%
believes that MW management is a team work, it is similar to a study done in Lucknow -India
which revealed that majority of HCPs has seen MWM process as a team work and all were
responsible for safe disposal (M. Azage, G. Haimanot, et al 2013). This is not consistent with a
study done in India which revealed that 82% has seen that safe management of healthcare waste
was the responsibility of the institution and not the HCPs (S. Jankovic, J. Bojanic, et 2009).

This difference may be due to education level, knowledge, and attitude of participants. In the
present study 22% of HCPs believe that MWM is a burden on HCPs. This result was inconsistent
with a study done in India revealed that attitude and practices towards BMW management
majority 90% has seen that safe management of health care waste was an extra burden on work,
however, 85% felt that safe management of BMW was not an issue at all (S. Jankovic, J. Bojanic,
et 2009). In the current study 66% of HCPs believes that MWM is properly done in the
workplaces and 54% of HCPs were satisfied about MWM process in their workplace. This result
was similar to a study done in India reporting that 36% HCPs were satisfied about waste disposal
practiced in their hospital (M. Basu, P. Das, R. Pal, et al 2012).

In the present study 71% of HCPs were ready to participate in voluntary training courses
regarding MWM, and this rate is comparable to a study in India (96%) where HCPs would like to
attend a training program on BMW management A. Khanna et al 2014.
The present study showed that 96% of HCPs believes all health facilities must have a system for
cleaning sewerage, 95% of HCPs believes health authorities must be informed on breaches in
relation to MWM, 95% HCPs thought that it is important issue to report to DOH if their
workplace is not complying with standard MWM guidelines. This proportion is over what is
reported by a study from Delhi, India which reported that 52% HCPs expressed their willingness
on reporting to health authority of India about the institutions who is not complying the
guidelines for MW management (M. Azage, G. Haimanot, et al 2013).
Study conducted at Suleimani health facility in Kurdistan. The knowledge, attitude and
practices of HCPs were dissimilar among participants; many factors may lead to this difference
like the level of education of HCPs, working experience, participation in training courses and
their practical involvement in the hospital waste handling and MWM.

This study showed that gender, service years, qualification and participation in training were statistically
significant factors of better knowledge while duration of training course was not.

The current study showed that from a total of 406 HCPs participated in the study, 261(64.3%)
were females and 145(35.7%) were males with female to male ratio of 1:1.8. The present study
showed that 66% of HCPs have information on color coding system; this was similar to a study
done in Pondicherry- India reported that 50% of HCPs had the knowledge of color coding and

31
segregation of MWM, (M. Azage, G. Haimanot, et al 2013). this result was also comparable to a
study done in Pakistan reporting that 86% HCPs have information about waste color codes. (A.

Malini, B. Eshwar, et al 2015).

Another similar study from West Bengal revealed that 76% HCPs knew about various types of color-
coding bags for collection of MW [19]. (R. Kumar, A. Zulfiqar, et al 2013.).

In the present study 15.9% of HCPs have knowledge about the percentage of MW in whole
waste. This was similar to a study done in Delhi, India reporting that HCPs with knowledge of
approximate proportion of infectious waste generated in HCFs were found to be 36% (M. Basu,
P. Das, R. Pal, et al 2012).

Another study from India reported that HCPs knowledge about the proportion of infectious waste
generated from a hospital was found only in 39.3% of respondents. (S. Pradhan, S. Prasad, BR.

Chinmaya, S. Tandon, et al 2016).

This may be due to low level of HCPs knowledge and the absence of national guidelines in HCFs.
The current study showed that gender, participation in training, qualification, and service years
were significantly associated with better knowledge of waste management while training duration
was not. Regarding training course in relation to MWM (79.7%) of HCPs had not participated in
any training courses during their working periods and only (20.3%) HCPs have participated in
MWM training course. This result was similar to a study done in India revealed that around 16%

HCPs had received training on MWM. S. Pradhan, S. Prasad et al 2014

Another study in Puducherry-India reported that (74%) of HCPs have not undergone training on
medical waste management.(M. Azage, G. Haimanot, et al 2013). This result was inconsistent
with a study done in Turkey that reported training of staff on medical waste was about 80% (R.
Sanjeev, S. Kuruvilla 2014). The low participation in training highlights the need for
strengthening training courses and involving all HCP in such trainings. This study also shows the
need for such training programs to be conducted regularly and make it compulsory for all the
HCPs to attend either annually or at the beginning of their service. In the present study 96% of
HCPs knows that needle prick injury is dangerous. It is similar to a study done in Bosnia and
Herzegovina reported that 70% of HCPs were aware that needle prick injury carries risk for blood
borne infection [25]. In the current study 96% of HCPs believe that proper management of MW is
important, 82% believes that MW management is a team work, it is similar to a study done in
Lucknow -India which revealed that majority of HCPs has seen MWM process as a team work
and all were responsible for safe disposal (M. Azage, G. Haimanot, et al 2013).

This is not consistent with a study done in India which revealed that 82% has seen that safe
management of healthcare waste was the responsibility of the institution and not the HCPs (S.
Jankovic, J. Bojanic, et 2009). This difference may be due to education level, knowledge, and

32
attitude of participants. In the present study 22% of HCPs believe that MWM is a burden on
HCPs. This result was inconsistent with a study done in India revealed that attitude and practices
towards BMW management majority 90% has seen that safe management of health care waste
was an extra burden on work, however, 85% felt that safe management of BMW was not an issue
at all (S. Jankovic, J. Bojanic, et 2009). In the current study 66% of HCPs believes that MWM is
properly done in the workplaces and 54% of HCPs were satisfied about MWM process in their
workplace. This result was similar to a study done in India reporting that 36% HCPs were
satisfied about waste disposal practiced in their hospital (M. Basu, P. Das, R. Pal, et al 2012).

In the present study 71% of HCPs were ready to participate in voluntary training courses
regarding MWM, and this rate is comparable to a study in India (96%) where HCPs would like to
attend a training program on BMW management A. Khanna et al 2014.

The present study showed that 96% of HCPs believes all health facilities must have a system for
cleaning sewerage, 95% of HCPs believes health authorities must be informed on breaches in
relation to MWM, 95% HCPs thought that it is important issue to report to DOH if their
workplace is not complying with standard MWM guidelines. This proportion is over what is
reported by a study from Delhi, India which reported that 52% HCPs expressed their willingness
on reporting to health authority of India about the institutions who is not complying the
guidelines for MW management (M. Azage, G. Haimanot, et al 2013).
Regarding practices of HCPs, 91% disposes of needles and sharps to safety box
frequently/always. This result was better than 53% reported from Ethiopia. This may due to that
DOH have provided all HCFs with adequate number of safety boxes to ensure the safe disposal of
needles and sharps. The present study showed that 79% of HCPs recap needles after use either
frequently or always which is a risky practice exposing the person to needle prick injury. This is
similar to a study done in Puducherry, India reported that nearly 50% of HCPs recap the needle
(M. Azage, G. Haimanot, et al 2013).

The study carried out in a tertiary care hospital in Rohtak, Haryana to study about the knowledge,
attitude and practices regarding BMW management.The study concluded that the knowledge
regarding biomedical waste management waste was higher among doctors, nursing staff and
paramedical staff as compared to the cleaning staff. 96% doctors were aware about BMW
Handling and Management rules. All the doctors, nursing staff and paramedical staff were aware
of separate colour coding containers. However, the knowledge regarding the type of BMW waste
and the colour coding of bag was not upto the mark among the nursing staff, paramedical staff
and the class IV staff. These findings were consistent with the findings in the study conducted by
Maliniet al15 which showed the knowledge among doctors to be >95% regarding biomedical
waste management and segregation and lesser knowledge among nursing staff (50%) and
paramedical staff (80%). Similar findings were reported in the study done by Mathur et al in
Lucknow as knowledge of BMW management at 91%, 92%, 85% (Nitika Sharma1, Neelam
Kumar et al 2017).

33
A study conducted at a Tertiary Hospital in Botswana aimed to study the knowledge, attitude, and
practices of HCWs at a tertiary hospital in Gaborone, Botswana, regarding management of
medical waste. Findings revealed that there were differences in knowledge, attitudes, and practice
of waste management among the four categories of HCWs at the hospital under study. There were
deficiencies in the knowledge levels of waste management among all the categories of HCWs in
this study. The agreement observed with regard to possible remedial importance of educating
HCWs in waste management in this study was consistent with the 70% (n = 89) overall
agreement found in another study from the United Kingdom.

The results from our own studies did not reveal a statistically significant association between
postbasic training and performanceof members of each category of HCWs. However, there was a
strong relationship between the performance ofeach group of HCWs and the demographic
characteristics of the respondents. For example, there was a strong relationship between highest
level of education andlocation of basic training for doctors, when comparedwith nurses and
laboratory technicians, in favor of those that had obtained their postbasic training outside
Botswana (B Mugabi, S Hattingh1 et al 2018).

Results of study conducted in north India questionnaire analysis show that about 85% and 81% amongst
the consultant and resident respondents respectively, have relevant knowledge of BMW management.
Out of these there were 12 consultants of medical departments and rest 16 were of surgical side. Though
all the consultants were having the relevant knowledge but they were having varying attitude and
practices. There was a significant difference amongst them, as far as attitude and practices of BMW
were concerned. The details of these data have been shown in table no 2.

This shows that the people with higher education have more awareness about the environmental
issues, national and international activities in Biomedical waste management and the rules
prescribed there in; significantly the professional status and higher education were not having a
direct positive impact on their attitudes towards the facts and thus their practices were also not
corresponding. The nursing staff is the backbone of the patient management. Though the trauma
center has been a high-pressure area of patient care, there is a significant and acute shortage of
nursing staff in the trauma center. The other significant fact regarding nursing staff is concerned
that as there is no independent staff marked for trauma center, so whatever nurses in ward are
there, many of them are temporary with not much and appropriate training. There is a very
serious complaint that these nurses are being very frequently transferred from their place of work.
This fact is directly relevant and significant as this may directly affect the training of these nurses
about BMW management. Despite of these facts, there was very significant high knowledge and
attitude of BMW management amongst the nursing staff of the trauma center. There were
significantly low practices of biowaste management.

An appropriate BMW management system is essential or prevention of hospital-borne infection,

to safeguard the environment and public health at large. It is also an essential component of
hospital quality assurance. Recognizing the importance of this issue, the Government of India
notified the Biomedical waste (Management and handling) Rules, 1998, which were further

34
amended in 2003. Infection prevention practices and hospital waste management systems need to
be in place for assured quality of care in hospitals.

Proper handling, treatment, and disposal of BMW are important elements of healthcare infection
control program. Statutory public health guidelines of BMW management and close monitoring
of its compliance alone cannot achieve the ultimate goal if it is not accompanied with social
science approach of education, motivation, and change in mindset in all strata of healthcare
personnel. Any system of treatment and disposal that is operated by well-trained and
well-motivated staff can provide more protection for staff, patients, and the community than an
expensive or sophisticated system that is managed by staff who do not understand the risks and
the importance of their contribution. It can lead to an increased incidence of hospital-acquired
infections. In the operation room setting, these infections can sometimes be fatal. It is also
important to understand that all healthcare personnel are legally bound to follow appropriate
practices as prescribed by the Biomedical waste management rules, 1998. Anesthesiologists have
been among the pioneers of patient and hospital safety. Anesthesiologists in the present day are
not only responsible for administering anesthesia but also are assuming leadership role of
perioperative directors and managers of operating rooms.

They have the vantage point of working and coordinating with physicians and nurses of multiple
specialities in the operating room. Anesthesiologists have to take responsibility for initiating and
continuing waste management methods. By involving themselves in waste auditing, waste
planning, and training of personnel working in the operating room, anesthesiologists can
contribute not only to environmental benefit but also to economic benefit of the institution. They
should be an integral part of hospital waste management and infection control committees.

In conclusion, this study highlights the need to train and reorient all the operation room personnel
regarding BMW management. Correct waste management is not only a moral and ethical duty for
all healthcare personnel but also a legal binding. It may be appropriate to train the operation room
personnel through orientation program before induction to their job to bridge the gaps and
increase compliance. Continuous surveillance and monitoring may help maintain a favorable
behavior toward BMW management (Singh Ajai, Srivastava RajeshwarNath et al )

CHAPTER THREE
METHODOLOGY
3.0 Introduction
This chapter presents the methodology that was used in conducting this research and describes
how the study was conducted. It includes the study area, target population, study population, ,
study design, sample population, methods for selecting the sample, inclusion and exclusion
criteria, sample size and rationale, ethical consideration, tools for data collection, measure to
ensure validity and reliability, variables, data collection and possible limitations of the study.

35
3.1: study Area:
Gabiley city is the capital of both the district and Gabiley Region. The district has an estimated
current population of 104,000 with a land area of approximately 4,300 km2, Gabiley General
Hospital (GGH) is one of the Regional hospital in the Republic of Somaliland and also the
teaching hospital for medical universities in Tima-ade. It is the largest regional hospital in
Gabiley district where many patients visit to seek medical services. The hospital’s capacity to
deliver better medical services was significantly low due to the limited number of qualified
medical practitioners (Gabiley et al 2014-2016)

3.2: Source population

The source population of the study was all Health workers at Gabiley General Hospital during the
data collection period.

3.3: Study Population

The Study population was the all health care workers of the hospital to assess hospital waste
management practice. At Gabiley General Hospital, Gabiley Somaliland

3.4: Study design

The study was conducted in hospital based Cross-sectional study design at Gabiley General
Hospital, Gabiley, and Somaliland. The type of waste generated was identified through direct
observation and use of questionnaire. The knowledge and practice of waste handlers was assessed
through questionnaire and Interviewed.

3.5: Study setting.

Gabiley Region locates on the Somaliland‘s western fertile regions and it is called the bread
basket of Somaliland because of its agricultural productivity level compared to the other Regions
of the country. Gabiley city is the administrative center of the new region, and the region has 6
districts including Gabiley and they are: Gabiley, Wajaale, Arabsiyo, Agabar, Geed-balaadh and
Alay baday. The new region is bounded on the west by Awdal Region and on the north by the
Gulf of

Aden. On the east it is bordered by the nation‘s capital Hargeisa, and on the south Gabiley region is
bounded by the fifth-Somali –State in the Ethiopian Federation.

The population of the region is estimated 150000 where population relies on agro/pastor in the term of
health the region have two hospitals; General hospital and TB hospital with the total beds 200
patients. The other facilities that regional health have include two standardized laboratories one for
general hospital, one for TB hospital, theatre, pharmacy, wards and other health services. Gabiley
General hospital has 45 staff with different titles. The region has 6 MCHs and the total health staff
number are 78 staff with different titles: 3 doctors, 10 nurses, 35, Auxiliaries and 30 subordinate staff
(Gabiley et al 2014-2016)

36
3.6: Sample Size Determination and Sampling technique
3.6.1. Sample size determination
The sample of this study is 40 health care workers of the hospital in Gabiley and the flowing formula
was used.

Sample Size

Slovenes formula of sample size determination was used. It is stated here below;

Sample Size

N
n=
1+N (e 2 )
,

Where; n = the required sample size;

N = the known population size; and

e = the level of significance, which is = 0.05.

100
n= = 40
1+100(0.0025)❑

3.6.2. Sampling Techniques

To assess the medical waste management in Gabiley General Hospital, a total of 40 respondents
were sampled from the workers of the hospital who were attending the hospital during the time of
data collection.

Simple random sampling technique was applied, because this technique gives every Health worker
the chance of being selected.

3.7: Inclusion and Exclusion criteria.

3.7.1: Inclusion criteria
All Hospital staff within the sample size who were present on data collection time and able to
respond

3.7.2Exclusion criteria
The following was not be included in the study. All hospital staff who were absent on data
collection time and those patients who are in wards and out patients and visitors.

3.8: Measures to ensure validity

The measure to ensure validity was included;ensuring that data tools are capturing information
about the study objectives that the researcher wants to know.interaction time of respondents were
planned enough.
3.9: Variables.
3.9.1: Dependent variable
Medical waste Management

37
3.9.2: Independent variable
• Knowledge of MWM

• Attitude of MWM

• Practice of MWM

3.10: Data Collection

3.10.1: Data Collection Method
Data was collected at the selected Health Care at Gabiley General Hospital rooms. By the
principal investigator only. Interviews were explained to the participant on the purpose of
the interview to study participants within the broader context of the research study. The
interview were conducted face-to-face and involve one interviewer and one participant. In
these situations, however, care was taken not to intimidate the participant. Before asking
any interview questions, the interviewer was obtained informed consent from the
respondent in accordance with procedures specified for the study. For this study in-depth
interview, informed consent was both oral and written.

3.11: Data management

At the end of each day, filled questionnaires were reviewed for completeness and consistenc.
Data was entered into MS Excel, and SPSS version 20 applications. The collected data will
always be put in files and kept clean.

3.11.1: Questionnaire
A questionnaire is a series of written questions on a topic about which respondents opinions are
sought. The defining characteristic of a questionnaire is that the questions are constructed ahead
of time. A questionnaire can be administered by interview, or it can be self-administered, as when
people fill out the paper (UCDAVIS, 2011).

According to Saul McLeod a questionnaire is a research instrument consisting of a series of questions

for the purpose of gathering information from respondents. (McLeod, 2018)

According to WHO there are two forms of questionnaires. A self-administered questionnaire

(SAQ) and interviewer administered questionnaire. The self-administered questionnaire refers to
a questionnaire that has been designed specifically to be completed by a respondent without
intervention of the researchers collecting the data. Interviewer administered questionnaire is
when the researcher fills aself-administered questionnaire by asking questions from some of the
respondents(less educated or uneducated), while majority of respondents fill questionnaire
themselves, this method be called interviewer administered questionnaire. (WHO, Foodborne
disease outbreaks: Guidelines for investigation and control, 2005)

Both interviewers administered and self-administered questionnaire was used to this study. An
interviewer administered was used waste handlers while self-administered questionnaire filled out
by respondents who can read and understand the questions.

38
Questionnaire was pre-tested on a small number of respondents to identify the likely problems
and to eliminate them. Each and every dimension of the questionnaire was pre-tested. The sample
respondents should be similar to the target respondents of the study.

A 7-page questionnaire was administered to the hospital administrators, nurses, dentist, doctor,
laboratorytechnicians and sanitation staff/cleaners where they exist. Information regarding
quantities and waste types generated and profile of waste handlers were collected through
administered questionnaires. The discussion were organized to obtain additional information from
respondents and heads of units and wards as well as use the responses to validate some of the
results from the questionnaire and in-depth interview. The study was covered all the categories of
Gabiley General Hospital.

3.12: Operational definitions.

Knowledge state of knowing about a particular fact or situation

Good - those who respond 8-10 questions

fair - those who respond 4-7stions
poor - those who respond 0-3 questions

Attitude way of doing something that is common or habitual

Good - those who respond 4-5 questions

poor - those who respond 0-3 questions

Practice. way of doing something that is common or habitual

Good - those who respond 7-10 questions

poor - those who respond 0-6questions

3.13: Quality Assurance

3.13.1: Pretested.
The questionnaire was pre-tested at GGH in which the study was being carried out. Corrections
and readjustments were done by the research supervisor for any ambiguity question/s within the
questionnaire to improve the quality of the Instrument.

3.13.2: Validity
Validity is the extent to which research results can accurately be interpreted and generalized to
other population; it is the extent to which a questionnaire actually measures what it is intended to
measure, or how far, or to what extent the items listed in questionnaire actually address the
purpose, objectives, questions and hypotheses of the study. The validity of the questionnaire was

39
established through expert judgement; two experts were asked to assess the relevance of each
item in the questionnaire to the study objectives. (Sonpar et al., 2018)

3.13.3: Reliability
Reliability was measured by repeatedly checking, and also there was a questionnaire translation
to the respondents and pretest was done. The reliability of this study was controlled by test-retest
method. Test-retest reliability refers to the temporal stability of a test from one measurement
session to another. The procedure is to administer the test to a group of respondents and then
administer the same test to the same respondents at a later date.

3.14: Data Processing and Analysis.

Quantitative data was entered in SPSS (IBM v20); data were cleaned by running frequencies of
all the variables to check for incorrectly coded data. Incorrectly coded data was double checked
with the raw data in the questionnaire and corrected.

Statistical methods were used to analyses the data collected such as descriptive statistics, for
example numerical summations, graphs and tables. The analysis software performed using the
data were Statistical Package for Social Sciences (SPSS) and Microsoft Excel (v2013) statistical
software packages.

3.15: Ethical Consideration.

Ethical clearance was obtained from Kampala University. The researcher will be protected the
respondent’s identities and integrity of the data by reporting data as block instead of high lighting
individual cases: the researcher will not falsified the data to conform some determined opinion,
the researcher was also keeping the privacy of respondents; confidentiality and integrity of the
data informed consent is the sought and no information is submission. There was no any benefit
that the study participants got.

Study participants was informed that publications or reports will not mention any individual
names of the participants but was collective and that this survey is completely voluntary and that
participants have the rights to refuse to participate or withdraw at any time before the data has
begun being analyzed. The privacy of the participants was maintained at all times during the data
collection by conducting the consenting in private rooms and providing a designated collection
box dissertation consent forms and survey consent forms and survey questionnaire.

Informed Consent: The researcher was obtained consent from the participants in the research
from the waste workers and other staffs in the hospitals included in the sample. The participants
were informed of the purpose research and how it will be conducted.

Confidentiality: All information obtained in the course of this study was treated with utmost
confidentiality and were not used outside the scope of the study. This is done in compliance with

40
the requirement for confidentiality, which seek to protect the identity of research subject against
potential abuse/stigmatization

Voluntary participation: The participants were appropriately informed that their participation in
the research survey was purely voluntary. There were not any punitive measure taken against
those who declined to participate and neither was there any reward for participation.

3.16: Dissemination of the result

The result was disseminated to the Gabiley General Hospital and the respective University of Kampala

CHAPTER FOUR
DATA ANALYSIS AND PRESENTATION
4.0. Introduction
This chapter dealt with data presentation, analysis and interpretation which were obtained from a
total number of 45 participants attending Gabiley General Hospital. Every respondent’s
background information, knowledge, Attitude and practice of medical waste management was
present this chapter. In the age, marital status, period of working and educational level of both
waste workers and hospital staff were reconfigured after the data was collected. Statistical
Package for Social Sciences (SPSS) and Microsoft Excel was used to aggregate and analyze the

41
data presented in this chapter. The presentation of this data is in line with the aim of the study
which was assessed of medical waste management at Gabiley general hospital.

4.1: Socio-demographic characteristics.

Source: Primary.

Table 2. Background characteristics of the participants.

Variable Total of participants Percentage (%)

N=40
1.Age of the participants

20—29 years 18 45.0

30—39 years 16 40.0

40---59 years 5 12.5

Above 60 years. 1 2.5

2.Sex
Male 20 50
Female 20 50

3.Marital status.

Single 19 47.5

Married 17 42.5

Divorced 2 5.0

Widowed 2 5.0

4.Educational level

Illiterate 16 40.0

Primary 3 7.50

42
 Secondary 8 20.0

Tertiary 13 32.5

5.Designation level

medical doctor 5 12.5

Dentist 3 7.5

Nurse 8 20.0

laboratory worker 8 20.0

Cleaners 12 30.0

pharmacist. 4 10.0

6.Working period at hospital

5. Years 7 17.5

2-3 year 9 22.5

4 year 6 15.0

1 year 18 42.5

According to above table 40 waste workers were full responded the questionnaires and have the
following background information.

Socio demographic information of the waste workers were varied, of their age was 45%(N=18)
were between 20 up to 29 years while 40%(N=16) were between 30 up to 39 years and 12.5%
(N=5) were between the age of 40 up to 49 years, there is some ages that were above 50 years
which was 2.5% (N3=1) and their sex was the same that50 % (N=20) were females and 20
(N=20) were males.

In their marital status 47.5 (N=19) were single and 42.5% (N=17) were married while the others
were divorced and widowed each of them were2%. This indicates that the hospital workers are
mostly teenage and this will correlate their knowledge and experience of handling medical waste
management.
Participants have also different education backgrounds which have direct influence on how they
are dealing with the medical waste. Of their education level 40% (N=16) were illiterate workers
and majority of this respondents were sanitary health care workers in the hospital 55% ( N=22).
This will lead at risk on segregation or identifying the nature of medical waste. In addition to that
7.5% (N=3) of the respondents were primary level and 33% (N=13) were secondary level while
20% (N=8) were tertiary level of education.

The level of education of the waste workers is very important and helping them to identify the
nature of the waste, it also helps them to read the signs and hazard terms on different sections at
43
the hospital. This will have an adverse effect to over all hospital west management system and
fulnerability of the health workers to some infection.

This graph describes the the designation level of the hospital (30%) (N=12) cleaners , 20%(8)
was lab technicians, 20%(N=8) were nurse, while 10%(N=4),12.5%(N=5) and 8%(N=3), were
pharmacist,doctors and dentist respectively.

Working period and the experience of the waste worker is also another vital issue. Participants
have variety of working period; here is the number of years on each category. Most of workers
have been working the hospital less than a year 42.5% (N=18). There are some workers who have
been working the hospital for 2-3 years and (22.5%) (N=9) some others have been working 4
years (15% (N=6) have been working more than five years (17%) (N=7) have been working the
hospital (22.5%) (N=9). Experience of health care worker will directly contribute to the medical
waste management. Gabiley General Hospital was lack of professional and experienced staffs.
But fortunately the last three years there have been adequate staphs and the patrolled staphs were
increasing, but the problem is that do they have enough experience and knowledge about medical
waste management.

Figure: 1. Age

Age of the Health Care Workers. HCW

40-49 >50
12% 3%

20-29
45%

30-39
40%

Figure 1. Age of the health care workers.

44
age was 45%(N=18) were between 20 up to 29 years while 40%(N=16) were between 30 up to
39 years and 12.5%(N=5) were between the age of 40 up to 49 years, there is some ages that were
above 50 years which was 2.5% (N3=1).

Figure:1 age of the health care workers.

age was 45%(N=18) were between

20 up to 29 years while 40%(N=16)
were between 30 up to 39 years
and 12.5%(N=5) were between the
age of 40 up to 49 years, there is
some ages that were above 50 years
which was 2.5% (N3=1).

Figure: Sex characteristics

sex charecteristics of the respondents .

100

50

0
1 2

Male Female

Figure 2. Sex characteristics of the HCW.

The above figure states that the sex of the Health Care Workers was equal percentage and that 50%
(N=20) were male and 50%(N=20).

45
Figure 2. Sex characteristics of the HCW.

The above figure states that the sex of the Health Care Workers was equal percentage and that 50%
(N=20) were male and 50%(N=20).

Figure: 3. Marital status

marital status

single maried Divortced widowed

5% 5%

47.5%

42.5%

Figure: 3. Marital status of the respondents is that 47.5% (N=19) were single and 42.5%

(N=17) were married while the others were divorced and widowed each of them were 2% (N=5)

46
Figure: 4 Educational level

educational level

Tertiary
33% Illiterate
40%

Secondry Primery
20% 7.5%

Figure:4 Educational level

Participants have also different education backgrounds which have direct influence on how they
are dealing with the medical waste. Of their education level 40% (N=16) were illiterate workers
and majority of this respondents were sanitary health care workers in the hospital 55% ( N=22).
This will lead at risk on segregation or identifying the nature of medical waste. In addition to that
7.5% (N=3) of the respondents were primary level and 33% (N=13) were secondary level while
20% (N=8) were tertiary level of education.

Figure:5 Designation level

Designation level

10% 12% 8% medical doctor

Dentist
30%
20% Nurse
laboratory worker
20%
Cleaners
pharmacist.

Figure:5 Designation level

This grave describes the the designation level of the hospital (30%) (N=12) cleaners , 20%(8)
was lab technicians, 20%(N=8) were nurse, while 10%(N=4),12.5%(N=5) and 8%(N=3), were
pharmacist, doctors and dentist respectively. Table 3: period of time working at the hospital.

47
 Time frequency percentage

5. Years 7 17.5

2-3 year 9 22.5

4 year 6 15

1 year 18 42.5
Total 40 100%

This table describes the period of time working at the hospital 42.5% (N=18) have been working
the hospital for 1 years. There are some workers who have been working the hospital 4 years 15%
(N=6) and 23% % (N= 9) of them have been working 2-3while, 18% (N=4) have been working
>5 years.

Table 4: Health care worker’s knowledge about dealing with medical waste

Source: Primary

variable frequency Percentage%

Knows Identification to sort medical waste

Yes 14 35
No 26 65
Do you identify the need to sort medical waste during collection
Yes 12 41
No 28 59
knows the reason behind the sorting(seperation) medical waste?
Yes 19 47.5

48
 No 21 52.5

do you Know adequate knowledge for packing medical waste

Yes 15 37.5
No 25 62.5
Are you aware of risks in dealing with medical waste?

Yes 28 70

No 12 30

receive any form of training on the way you handle wastes

Yes 8 20
No 32 80

the form of training you received below

formal lecture 2 5
seminar 10 25
workshop 2 5
No 26 65
knows of the color coding of medical waste containers
yes 13 32.5
no 27 67.5
Do you know adequate disposal procedures for liquid waste
Yes 12 20
No 28 80
Have adequate knowledge about haw to dispose expired blood units.

Yes 28 71
No 12 29
Do you know adequate disposal procedures for expired medicine
yes 14 35
no 26 65

The above table presents categories of waste-workers’ knowledge and there is a variation on
their knowledge about dealing with medical waste and their views were considered important for
this study. 40 participants were fully responded the questionnaire and obtained as follows. 65%
(N=26) are unable to identify to sort the nature of medical waste while some of the respondents
53% (N=14) were able to classify the medical waste.

A similar study done in Tehran on Assessment of Medical Waste Management in Educational

Hospitals of Tehran University Medical Sciences revealed that some amount of hazardous waste
is stored in the same containers as the domestic wastes and no control measures exist for the
management of these wastes. (Fard, 2008)

49
The World Health Organization (WHO) prescribed that medical waste should be sorted and
dumped into separate waste containers from the source, and afterwards stored in a safe place
inaccessible to rodents and unauthorized people for a maximum of 48 hours and then transported
to the treatment or disposal site(WHO, et al 2005). If this guideline is strictly followed, the
quantity of medical waste which is eventually passed to treatment/disposal facilities will be small
and manageable. South African health facilities generate about 45,000 tons of medical waste
annually, out of which only about 4,500 tons are hazardous.But, while the waste is all mixed
together, it becomes necessary to treat it as hazardous and cannot be recycled and reused without
pre-treatment (Jewaskiewitz S. et al 2017).

In this study 59% (N=28) of waste workers have poor knowledge on identification need to sort
medical waste during collection while 41% (N=12) are able to identify need to sort medical
waste during collection in addition to that 53% (N=19) dealing with the medical did not know
reasons behind sorting medical wastes while 47% (N=21) knows well on the reasons behind
sorting medical wastes.

On the other hand most of Gabiley General Hospital workers (62.2%) (N=25) didn’t know
exactly the adequate quantities for packing medical waste. This may cause to pack the medical
waste extra and may result it risks that may affect patients, those who visit the patients and other
workers, while the remaining 37.5%(N=25) were able had knowledge of packaging medical
waste.

The most important issue is whether the workers are aware of risks in dealing with medical
wastes but this study indicated that the majority workers who deal with the medical wastes are
aware of risks in dealing with medical wastes (71%) (N=28) while the other percentage are not
aware of risks in dealing with medical wastes (29%) (N=12). Knowing haw to deal liquid waste
generated from hospital is very important to keep safe on both the environment and people.
Though health care workers have a knowledge about the risk of medical waste in this study 59%
(N=24) of workers in contrast do not know how to dispose of these liquid waste remains while
41% (N=16) knows how to dispose of these waste remains.

Recent similar study conducted at Hargeisa Public Hospital, in Hargeisa, Somaliland revealed that
most of the workers who deal with the medical wastes are able to identify the nature of
medical waste. They know reasons behind sorting medical wastes but could be lazy.(Abdisalam

Hasan et al 2018)
Another important point to take in to account is that whether Health Care Workers receive any
form of training on the way they handle wastes. Most of the respondents of Health Care Workers
do not get any form of supervision 45 %(N=32), only few them admit to get a supervision 20%
(N=20). That the type of training taken 5%(N=2),25%(N=10) and 5%(N=2), were formal lecture,
seminar and workshop respectively. This could be explained by the fact that the ministry of
environmental health The result on level of training shows that there is in adequate training and
of staff are not often given formal training at all.

50
A study done in Iran on Assessment of Medical Waste Management in Educational Hospitals of
Tehran University Medical Sciences, reveals that Protective clothing for personnel who handled
the hospital personnel were trained about handling and managing medical waste, infection control
and protection, hospital personnel and protection against medical waste hazards, e.g. Hepatitis B
and C, AIDS, and Typhoid. 15% of managers, 45% of nurses and 40% of labors were trained
about medical waste disposal. The training methods consisted of lecturing (29%), workshop
(32%), brochure (7%), slides and clips (7%) and face-to-face training (25%). The training
programs have been conducted by environmental health specialists that work in hospitals or
NGOs. (Fard, 2008)

In this study there is an insufficient training and supervision of hospital staffs. Increasing the
information level of health care personal has a crucial role of medical waste management.

Color coding system of medical waste containers was not satisfactory, and this indicates that
waste separation and sorting at the point of generation are mixed without storing in color coding
containers. % 67.5 (N=27) do not know color coding system of the containers and 30% (N=12)

Knowing how to deal liquid waste generated from hospital is very important to keep safe on both
the environment and people. In this 71% (N=32) of workers do not know how to dispose of these
liquid waste remains while 29% (N=8) do not have a knowledge on how to dispose of these waste
remains. Improper disposal of liquid west is directly correlate with the in adequate training and
supervision of health care workers.

The all category of medical waste management. Liquid wastes is among the most serious danger
to human health and the environment because they can directly enter the watersheds and this may
polute the ground water and consequently to the drinking water if they are not disposed.
Enormous infections results from this waste disposal system of the hospitals, diseases that can
emerge from this are include Choleriasis, bacillary dysentery and Hepatitis B. when such
improper disposal of liquid continuous, it will be public health risks and thus is a major problem
for healthcare services, their employees, and the community at a large. (WHO, UNICEF et al
2015)

One of the most bizarre things in Gabiley general hospital is that all health care workers have
failed adequate disposal procedures of expired blood units and by-products waste, and that
majority of them 70%(28) have no knowledge of this disposal procedure, while few of them have
sufficient knowledge 30%(N=12). In this 71% (N=28) of workers do not know how to dispose of
these liquid waste remains while 29% (N=12) do not have a knowledge on how to dispose of
these waste remains.
In this finding the waste workers were also dealt with the expired medicines and 65% (N=26)
does not know disposal procedures of expired medicines while 35 %(N=14) didn’t know disposal
procedures of expired medicines. This is related to knowledge attitude of the worker on how to
deal with these wastes so believing throwing expired medicines is considered important factor in
this study. In this 65% (N=26)) believes throwing expired medicines and 35% (N=14) didn’t
51
believe throwing expired medicines which means expired medicine should have their disposal
procedure.

Figure: 6. sorting medical waste

Able to identify sorting of medical

waste.

Yes
35%

NO
65%

Figure: 6. Presentation of sorting medical waste by HCW.

The above figure illustrates that 40 of the participants were fully responded the questionnaire and
obtained as follows. 65% (N=26) are unable to identify to sort the nature of medical waste 53%
(N=14) were unable to classify the medical waste.

Figure: 7. The need to sort MW

Monitor of need to sort medical MW.

Yes No
0%

41%
59%

52
Figure: 7. Presentation on the need to sort MW 59 % (N=28) of waste workers have poor
knowledge on identification need to sort medical waste during collection while 41% (N=12) are
able to identify need to sort medical waste during collection.

Figure: 8: presentation of monitoring reason behind sorting.

Monitor of reason behind sorting

yes
47%
no
53%

Figure: 8: presentation of monitoring reason behind sorting. 52.5% (N=19) dealing with the medical did
not know reasons behind sorting medical wastes while 47.5% (N=21) knows well on the reasons behind
sorting medical wastes. This facilitates risk that result from not sorting of the medical wastes.

Figure:9 knowledge of packing medical waste.

Monitor on knowledge of packing medical waste.

1 2

Yes
37.5%

NO
62.5%

Figure:9 presentation of monitoring knowledge of packing medical waste by HCW.

This figure show that most of workers (62.5%) (N=25) did not have exactly the adequate
quantities for packing medical waste. This may cause to pack the medical waste extra and may
result it risks that may affect patients, those who visit the patients and other workers, while the
remaining

37.5%(N=15) were able to knowledge of packaging medical waste.

53
Figure; 10. the risk of medical waste

Aware of dealinng risk of medical

waste.

1 2

30%

70%

Figure; 10. Presentation of dealing the risk of medical waste

This study indicated that the majority workers who deal with the medical wastes were aware of
risks in dealing with medical wastes71% (N=28) while the other percentage are not aware of risks
in dealing with medical wastes 29% (N=12).

Figure; 11. Monitoring of HCW to take training.

Monitor taking any training.

1 2

20%

80%

Figure; 11. Presentation showing monitoring of HCW to take training.

The above figure illustrates that the hospital staffs do not take adequate training 80%(N=32) and 20%
(N=8).

54
 type of training .

formal lecture seminar workshop no

5%

25%

65%

5%

Figure: 12. Presentation monitoring type of training.

Health Care Workers do not get any form of training 80 %(N=32), only few them admit to get a
supervision 20% (N=20). That the type of training taken 5%(N=2), 25%(N=10) and 5%(N=2),
were formal lecture, seminar and workshop respectively.

Figure: 13. Illustration showing knowledge about color cording.

HCW monitor of color cording

yes
32%

no
68%

Knowledge of HCW about color cording system of the waste containers were poor that
those respondents having no knowledge about color cording were scoring 68%(N=27) and
those having good knowledge were 32% (14).

Figure: 13. Illustration showing knowledge about color cording.

55
 monitor of hundelling liquid waste.

1 2

29%

71%

Knowing haw to deal liquid waste generated from hospital is very important to keep safe on both
the environment and people. In this 71% (N=32) of workers do not know how to dispose of these
liquid waste remains while 29% (N=8) do not have a knowledge on how to dispose of these waste
remains.

Figure;15. Illustration shows disposal procedures of expired blood units.

Monitor disposal procedures of expired blood units

.

yes no

0%

30%

70%

One of the most bizarre things in Gabiley General hospital is that all health care workers have
failed adequate disposal procedures of expired blood units and by-products waste, and that
majority of them 70%(28) have no knowledge of this disposal procedure, while few of them have
sufficient knowledge 30%(N=12).

56
 Figure: 16. Presentation showing knowledge about dealing expired medicine

knowledge about dealing with expired medicine.

yes
35%

no
65%

The waste workers were also dealt with the expired medicines and 65% (N=26) does not know
disposal procedures of expired medicines while 35 %(N=14) didn’t know disposal procedures of
expired medicines. This is related to attitude and practice of the worker on how to deal with these
wastes so believing throwing expired medicines is considered important factor in this study. In
this

65% (N=26)) believes throwing expired medicines and 35% (N=14) didn’t believe throwing expired
medicines which means expired medicine should have their disposal procedure.

Table 5: Health care worker’s Attitude about dealing with medical waste.

Variable frequency Percentage%

y

Segregation of waste at source increases the risk of injury to waste

handlers?

agree 12 30.0
strongly agree 17 42.5
disagree 4 10.0
strongly disagree 7 17.50
Containment of sharps does not help in safe management of hospital waste

Agree 7 17.5

57
 strongly agree 2 5.0
disagree 11 27.5
strongly dis agree 20 22.5

Hepatitis B immunization prevents transmission of hospital acquired

infections?

Agree 7 17.50
strongly agree 3 7.50
disagree 18 45.0
strongly disagree 12 30.0
Reporting of needle-stick injury is an extra burden on work?
agree 9 22.50
strongly agree 6 15
disagree 18 45
strongly disagree 7 17.5

The above table shows the attitude of medical health care workers at Gabiley General Hospital (GGH)
towards the hospital waste management.

This was considered important in this study for identifying their attitude of segregation,
immunization of Hepatitis B virus and reporting needle stick injury.

The responders has been asked whether segregation at the source of collection have an adverse effect to
the west handlers, and their response was agree, strongly agree, disagree and strongly disagree, 30%
(N=12),42.5%(N=17), 10% (N=4), 10(N=17.5). this indicates that majority of the respondents 72.5%
(N=29) have good attitude regarding segregation of waste.

Different types of infectious and toxigenic materials are processed for collection and separation however
this may cause infection or injury in waste handlers.

Similar study conducted in Gondar University Hospital, North West Ethiopia, 2013 stated that
regarding attitude towards health care waste segregation practice 283 (75.7%) of the respondents
had positive attitude i.e. who respond 35.3% of the respondents practiced correctly and 40.4%
practiced segregation incorrectly. Out of the total respondents, 175 (46.8%) used PPE (personal
protective equipment) when they are handling infectious health care wastes. AvierMesfin et.al
2013.

The attitude towards containment of sharps does not help safe management of waste.

In this study the majority of respondents have a good attitude of control of sharps scored 27.5% (N=11)
and 22.5%( N=20) and other respondents have poor attitude of practicing sharps

17.5%(N=7), 5% (N=2) .

58
Of the total participants 72.5% (N=29) believe hepatitis B vaccine can prevent some hospital infections
of this 37.5% (N=15) answered strongly agree and agree 35%(N=14).

The remaining percent of the respondents were 12.5% (N=5) and 10%(N=4) answered disagree and
strongly disagree respectively.

Health care workers are very vulnerable to have an infection acquired from hospital waste, this
include hepatitis B which more infectious than HIV and HCVs. Hepatitis B is a preventable
infection that is transmitted easily in many ways like needles contaminated with infected blood.
The only measure to prevent it is by using vaccination. Unless vaccination is given to the health
care workers they will be susceptible to an infections acquired from biomedical waste.

In this study almost all of the respondents had a good attitude about needle stick injury. Believing
Needle stick injury is an extra burden at work, all most all were disagree and strongly disagree
scored 70%(N=28) and 20%(N=8) total number of 90%(N=36) the other respondents were not
believing the needle stick injury can cause an infection.

Globally, WHO estimates that, in 2000, injections with contaminated syringes caused 21 million
hepatitis B virus (HBV) infections, two million hepatitis C virus infections and 260 000 HIV
infections worldwide.

An outbreak of hepatitis B in Gujarat, India, in 2009 is thought to have claimed the lives of 60
people and was blamed on the reuse of injection equipment. It led to the discovery of a black
market where used needles and syringes were repackaged and resold (Harhay et al., 2009;
Solberg, 2009)

Figure 17. Segregation of medical waste takes place at the point of waste collection.

Segregation at the point increases risk to the waste

hundlers.
Series1 Series2

42.5
30
17.5
12 17 10
4 7

agree strongly agree disagree strongly

disagree

Most of the respondents answered strongly agree 42%(N=17) Segregation at the point of
injury increases the risk of waste handlers, agree %30(N=12), disagree10%(N=4) and strongly
disagree 17.5%(N=7).

59
Figure: 18. Presentation of containment of sharps in safe waste management.

Containment of sharps does not help

in safe waste management.

50
40
30
20
10
0
Agree strongly disagree strongly dis
agree agree
17.5 5 27.5 22.5
7 2 11 20

Respondents differ from the attitude of containment of sharps. Majority of them 31 had had a good
attitude towards containments of sharps. Agree 17.5%(N=7), strongly agree 5%(N=2 ), disagree

27.5%(N=11), Strongly disagree 22.5% (20).

Figure: 19. Presentation showing Attitude towards Hepatitis B vaccine.

Hepatitis B does not prevent hospital aquired infections.

45
30
17.5
7.5 18 12
7 3
Agree strongly agree disagree stronglydisagree

Their respond were Agree 17.5 %(N=7), strongly agree 7.5%(N=3), disagree 45%(N=18) and strongly
disagree 30%(N=12).

60
This reveals that health care workers have a good attitude about prevention of hepatitis B vaccine,
scoring. 75%(N=30).

Figure: 20. presentation showing attitude about needle stick injury.

needle stick injury is an extra burden at work

70

20
28
7.5 8
3 2.5
1
agree stronlgy agree disagree strongly disagree

This figure illustrates the attitude of health care workers about needle stick injury total of 40
respondents were Agree 7.5 %(N=3), strongly agree 2.5%(N=1), disagree 70%N=28) and 20%
(N=8). They had a good attitude about needle stick injury 72.5%.

Figure: 21. Presentation of attitude of throwing blood in to domestic waste.

Throwing blood in to domostic waste is an adequate

disposal

67.2

25
27
5 2.5 10
2 1
Agree Disagree Strongly
Strongly agree disagree

This figure shows that most of the respondents had a good attitude about throwing blood in to
domestic waste is not an adequate disposal. Agree 5%(N=2),strongly agree 1%(N=5),disagree
25%(N=10) and strongly disagree 67.5%(N=27).
61
 Table 5:Health care worker’s Practice about dealing with medical waste. Source
primery

Variable frequency Percentage%

Segregation area
In the rooms 23 57.5

Outside the rooms 17 42.5

The type of waste (in any) that is segregated from general waste stream

Pathological waste 35 87.5

Infectious waste 5 12.5

Chemical waste 0 0

Pharmaceutical waste 0 0

Sharps. 0 0

The type of containers/bags (primary containment vessels) are used to segregate

waste

Cardboard Boxes 17 58.5

Plastic Containers 3 7.5

Metal Containers 20 34

Boxes 0 34

Type of labeling, color-coding (if any) is used for marking infectious waste in
segregated waste.

Yellow 12 30

Red 20 50

Black 8 20

Who handles (removes) the segregated waste (designation of the hospital staff
member)

Other staff 10 25

Cleaners 30 75

Waste handler using any protective clothing (gloves, etc.) during waste handling

Yes 35 67.5

No 5 12.5

Where is the segregated waste stored while awaiting removal from the hospital or
disposal

Bags 0 0

62
 Allocated storage boxes 1 2.5

Taken to Municipal Landfill 5 12.5

Buried on Hospital Grounds 30 75

Open Burier 1 2.5

Incinerated 0 0

Do you sort medical waste during collection? Sorting medical waste.

Yes 26 65.0

No 14 35.0

Do you separate sharp waste from blunt waste?

Yes 31 77.5

No 9 22.5

Do you move medical waste using trolleys?

Yes 0 0.0

No 40 100

ever reported a needle stick injury to control unit

yes 10 25

No 30 65

Number of people employed to handle waste in the hospital are adequate?

yes 24 60.0

No 16 40.0

Do you collect liquid waste in bags that prevent leakage?

yes 30 75.0

No 10 25.0
Do you collect blood waste together with other waste in ordinary bags?

yes 8 20.0

No 32 80

hospital visitors exposed to medical waste?

yes 22 55.0

No 13 32.5

gathering medical wastes in open areas

yes 29 72.5

No 10 27.5

Hospital have standard stores for temporary storage of medical waste

yes 15 37.5

No 25 62.5

63
Hospital depend on the city cleaning authority.

yes 33 82.5

No 7 17.5

Does the hospital dispose of medical waste outside using its own vehicles?

yes 37 92.50

No 3 7.50

The above table shows the categories of waste segregation, collection, storage, and handling.
These questions were asked on different hospital staffs in different sections the hospital.
According to their level of knowledge, experience and training, medical health care workers have
different response to different questioners.

Slightly half of the respondents are segregating the hospital waste in the rooms 57%(N=23) and
42.5% (N=17) are believing that segregation takes place outside. For effective waste management
health care workers should have enough knowledge on the management of medical waste
specially segregation of waste and the final disposal process.

Majority of respondents Health care workers able to sort medical waste were 65 %(N=26) and
those respondents that are un able to separate medical waste scored 35% (N=14). In addition to
that the number of health care workers that are able to classify medical waste are much more than
those that are unable to sort sharp waste from blunt waste, their number were % 77.5 (N=31) and
9%(N=22.5 ) respectively.

The most common type segregated from general waste is to separate sharp waste from the other
waste in order to prevent injury to the waster handlers. In this study the segregation is a major
problem facing workers. 87.5 %(N=35) they agreed that the most type of waste generated from
waste was pathological waste and infectious waste, 12.5%( N=5).Regarding the color coding
system of most of the respondents were red and black 80 %(N=28) and 20 &(N=12) were yellow
color-coding used for marking infectious wastes. Color coding makes it easier for workers to put
waste items into the acceptable container, and to maintain separation of the wastes during
transport, storage, treatment and disposal.

This color cording problems of the workers will lead that all waste generated from the hospital are
to be collected indiscriminately in a different container without segregating properly, which arise
from insufficient knowledge and practice to the color cording symbols. This type of practice
correlates with inadequate of knowledge and training given to the HCW and lack of supervision.
Containers should have well-fitting lids, either removable by hand or preferably operated by a
foot pedal. Both the container and the bag should be of the correct colour for the waste they are
intended to receive and labelled clearly. Mixing colours – such as having yellow bags in black
bins – should be avoided, because it will increase the potential for confusion and poor
segregation. WHO (2007).
64
In contrast to this study another similar study conducted in DebreMarkos Town Healthcare
Facilities, Northwest Ethiopia is totally differ from it stated that Health care workers were 168
(56.8%). One hundred sixty-nine (57.1%) of the study participants identified the biohazard
symbol. Regarding knowledge on segregation of BMWs, 235 (79.4%), 217 (73.3%), and 253
(85.5%) of the study participants were aware that general, infectious, and sharp wastes should be
placed in a black, yellow, and a safety box, respectively. In addition, 254 (85.8%) of them were
aware that a safety box should be filled only a maximum of 3/4th. Only twenty-nine (9.8%) of the
study participants knew the maximum storage time of infectious wastes before treatment or
disposal.(TeshiwalDeress et al. 201)

Personal protective clothing is very important in this study. Most of the waste handlers were used
protective clothing (gloves, etc.) during waste handling scored 87.5%(N= 35) while the remaining
percentage do not use protective clothing as 12.5%(N=5).

Type of containers is used for collection and internal transport of the waste were 65% (N=26) and
%30(N=12) Wheelbarrows and the remaining percentage were cardboard boxes % 5% (N=2).In
addition to that in this study the total number of health workers did not use totally 100%(N=40)
does not use Trolleys for transporting medical waste in the hospital. Type of transportation of
waste in side of hospitals are wheelbarrows and bardboard boxes.

The most disposal method of the final segregated wastes is buried on hospital grounds, taken to
municipal landfill and open burned and allocated storage boxes as 75% (N=30), 5% (N=12.5),
and 1% (N=2.5) and 1%(N=2.5) respectively.

A total number of staphs 40% out of 30% responded that they had never reported a needle stick injury to
the control unit and remaining 10 have responded yes. Workers at risk from infection and injury include
health-care providers, hospital cleaners, maintenance workers, operators of waste-treatment equipment,
and all personnel involved in waste handling and disposal within and outside health-care
facilities.Training in health and safety is intended to ensure that workers know of and understand the
potential risks associated with healthcare waste, and the rules and procedures they are required to
respect for its safe management. They should be informed on the importance of consistent use of
personal protective equipment (PPE) and should be aware of where to obtain post-exposure follow-up in
case of a needle-stick injury or other blood exposure. Health-care personnel should be trained for
emergency response if injured by a waste item, and the necessary equipment should be readily available
at all times. Written procedures for the different types of emergencies should be drawn up. Safe
management of wastes from health-care activities should be carried out by designated personnel
specially trained for the purpose.

There was adequate number of staphs in the hospital and 60%(N=24) of respondents has
responded that the hospital staphs in the hospital are adequate 40% ( N=16) agree that there is no
adequate number of staphs.

65
In this study almost all of the Health Care Workers 80%(N=32) are able sort the blood waste from
the other wastes in ordinary bags and the remaining percentage of the respondents are 8% (N=20)
practicing mixing blood in to the other wastes in ordinary bags and gathering expired medicine
with other wastes were practicing 72.5.5% (N=17) and those others 27.5% (N=13) were not
practicing. The interviewed participants majority ( HCW) has responded that the hospital waste
management system depends on the city’s cleaning authority while few of them answered no,
82.5% ( 33) and 17.5% (N=7). In addition to that majority of the respondents answered no about
question whether hospital dispose medical west outside by using its own vehicles others answered
yes 92% (N=37) and 7.5.5% (N=3) respectively. This reveals that the hospital does not have a
enough facility to handle medical waste during internal and external transportation.

Majority of the hospital workers 82.5% (N=33) responded that they collect liquid waste in a bags
that prevent leakage and 17.5% (N=7) of the respondents are not practicing collection of liquid
waste inn a bags that prevent leakage.

Almost all of the Health Care Workers 80%(N=32) are able sort the blood waste from the other
wastes in ordinary bags and the remaining percentage of the respondents are 8% (N=20)
practicing mixing blood in to the other wastes in ordinary bags.

Gathering expired medicine with other wastes respondents answered no 72.5.5% (N=17) were others
27.5% ( N=13) answered yes.

Figure: 22. Presentation showing practice about site of segregation.

segregation takes place in side rooms or outside the rooms.

In the rooms Outside the rooms

42.5

17 57.5

23

1 2

This figure illustrates that almost slightly half of the respondents answered that Segregation takes place
in the rooms 57% (N=23) Vs Segregation takes place out side42.5%(N=17).

Figure: 23. Presentation about practice about sorting medical waste.

66
 Able to sort medical waste.

70

60

50
Axis Title

40

30

20

10

0
Yes 26 65
No 14 35

Health care workers were able to sort medical waste west was 65% (N=26) and those unable to
sort were 35% ( N=14). There for health care workers had a good practice about sorting medical
waste.

Figure: 24. Illustration showing practice of separation sharp waste from blunt waste.

Able to seperate sharp waste from blunt waste.

100
90
80
70
Axis Title

60
50
40
30
20
10
0
1 2
No 9 22.5
Yes 31 77.5

The number of health care workers that are able to classify medical waste are much more than
those that are unable to sort sharp waste from blunt waste, their number was 31% (N=77.5) and
9%(N=22.5) respectively.

67
Figure:25. Presentation showing type of waste segregated from the general waste.

type of waste that is segregated from

the general waste.

Pathological waste Infectious waste

Chemical waste Pharmaceutical waste
Sharps.

35

The most common type segregated from general waste they agreed were pathological waste
87.5%(N=35) and infectious waste, 12.5%( N=5). This means that the total of the respondents
have no practice at all for practicing a segregation.

Figure:26. Presentation showing type containers used .

The most common type of used to segregate wastes is metal container as indicated the responses
(55.4%) (N=20) and the second common type is cardboard boxes (41.9%) (N=31).

68
Figure: 27. Presentation showing color coding practice of medical waste.

Practice of color cording system

Yellow Red Black

20%
30%

50%

The color coding system of infectious waste is yellow 20% (N=12), red 50% ( (N=20) and black 30%
(N=8). HCW had a poor practice of color-coding system scoring 80% of the respondents.

Figure:28. Illustration showing practice of protective clothing during handling MW.

Using protective clothing during hundling waste.

Series1 Series2

35

Yes No

Most of the waste handlers were used protective clothing (gloves, etc.) during waste handling scored

87.5%(N= 35) while the remaining percentage do not use protective clothing as 12.5% (N=5).

Figure: 29. Presentation showing type of containers used during collection.

69
 Type containers used
6

4
Axis Title

0
Category 1 Category 2 Category 3 Category 4
Series 1 4.3 2.5 3.5 4.5
Series 2 2.4 4.4 1.8 2.8
Series 3 2 2 3 5

Type of containers is used for collection and internal transport of the waste were 65% (N=26)
bags %30 (N=12) Wheelbarrows and the remaining percentage were cardboard boxes % 5%
(N=2). This shows that type of containers used for internal transportation are safe enough to
protect the waste handlers.

Figure: disposal method.

The most disposal method of the final segregated wastes is buried on hospital grounds, taken to
municipal landfill and open burned and allocated storage boxes as 75% (N=30), 5% (N=12.5),
and 1% (N=2.5) and 1%(N=2.5) respectively.

70
Figure:31. Illustration showing practice of use Trolleys for waste transportation.

Practise of using Trolleys for medical

waste.

100
80
60
40
20
0
1 2
No 40 100
Yes 0 0

The total number of the respondents 100% (N=40) does not use Trolleys for transporting medical waste
in the hospital.

Figure:32. Reporting needle stick injury to the control unit.

Ever report needle stick injury to the control unit.

100
80
Axis Title

60
40
20
0
1 2
Series2 30 75
Series1 10 25

A total number of staffs 40 out of 30 responded that they had never reported a needle stick injury
to the control unit and remaining 10 have responded yes. This is an indicator that practice of
reporting needle stick injury was poor among participants in the hospital.

71
Figure: 33 adequate number of staffs.

Number of the staff in the hospital are adequate.

100
80
Axis Title

60
40
20
0
1 2
Series2 16 40
Series1 24 60

There was adequate number of staffs in the hospital and 60%(N=24) responded that the hospital
staffs in the hospital are adequate 40% ( N=16) agree that there is no adequate number of staffs.

Figure: 34. Presentation showing practice of liquid waste in bags that prevent leakage.

Collecting liquid waste in a bags that prevent leakage.

100
80
60
40
20
0
1 2
Series2 10 25
Series1 30 75

Majority of the hospital workers 82.5% (N=33) responded that they collect liquid waste in a bags
that prevent leakage and 17.5% (N=7) of the respondents are not practicing collection of liquid
waste in a bags that prevent leakage. HCW had a good practice of collecting liquid waste.

Figure:35. Presentation showing the practice of HCW about collecting of blood waste with other waste
in ordinary bags.

72
 Collecting of blood waste with other
wastes in ordinary bags.

100

50

0
1 2
Series2 32 80
Series1 8 20

Almost all of the Health Care Workers 80%(N=32) are able sort the blood waste from the other
wastes in ordinary bags and the remaining percentage of the respondents are 8% (N=20)
practicing mixing blood in to the other wastes in ordinary bags.

Figure: 36. Practice of gathering expired medicine with other wastes

Gathering expired medicine with other wastes.

100
80
Axis Title

60
40
20
0
1 2
No 17 72.5
yes 13 27.5

Gathering expired medicine with other wastes respondents answered no were 72.5.5% (N=17) and
those others 27.5% ( N=13). They have a good practice about expired medicine.

Figure:37. Hospital depends on the city’s cleaning authority.

73
 Hospital depend on the city's cleaning authority.

100
90
80
70
60
50
40
30
20
10
0
1 2
Series2 7 17.5
Series1 33 82.5

The interviewed participants majority ( HCW) has responded that the hospital waste management
system depends on the city’s cleaning authority while few of them answered no,

82.5% ( 33) and 17.5% (N=7).

Figure: 38. disposing medical waste outside using hospitals own vehicles

Does the hospital dispose waste out side by using its

own vehicles.

100
80
Axis Title

60
40
20
0
1 2
No 3 7.5
yes 37 92.5

. .

Majority of the respondents answered no about question of whether hospital dispose medical west
outside by using its own vehicles others answered yes 92% (N=37) and 7.5.5% (N=3) respectively.

Table: 7. Over all KAP percentages of the study subjects

Figure: 37.
74
 Percentage Cut point percent
Knowledge 10% 66%
Attitude 80% 50%
Practice 60% 60%

Over all KAP percent of the HCWs.

Percentage Cut point percent

50 %
60 %

66 % 80 %
60 %

10 %

Knowledge Attitude Practice

Figure: 39. Over all KAP percent of the HCWs.

Knowledge of MWM was generally inadequate, with 90% of the participants scoring ‘poor
‘knowledge. Just over half of the participants reported a good practice towards the appropriate
disposal of MWM 60%. In this study overall attitude of the respondents were good scored.

Chapter five
5. DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS

This is the first study to be done in Gabiley General Hospital to study about the knowledge,
attitude and practices Medical Waste Management (MWM) among health care workers. The
medical waste is generated by various sources. The major sources are govt. hospitals and private
hospitals, primary health centers, medical colleges and veterinary colleges and animal research
centres.

(Mathur P, Patan S, et al 2012).

Inadequate biomedical waste management not only poses significant risk of infection due to
pathogens like HIV, Hepatitis B & C virus but also carries the risk of water, air & soil pollution
thereby adversely affecting the environment and community at large (Central Pollution Control
Board et al 2016)

A study done in Ghaza strip – Palestine reports that private and public healthcare facilities still
suffer from inappropriate management of medical waste; healthcare workers do not have
information on the place of medical waste storage and methods used for management, there is a
deficiency in providing training to improve their knowledge, attitude and practices and only half

75
of those interviewed had participated in training courses about how to deal with medical waste
management. (M. Marki, A. Dnane et al 2013).

A study done in King Abdulla hospital in Jordan reported that despite government plans and
efforts for implementation of medical waste management rules and legislations, it still does not
meet the safety standards for healthcare workers inside public hospitals and outside . The study
also reports that there are still many wrong practices that may lead to real problems regarding
public health and environment safety (Muhwezi, P. Kaweesa et al 2014).

The study assessed level of knowledge, attitude, and practices of Health Care Workers regarding
MWM. The knowledge, attitude and practices of Health Care Workers were not same among
participants; some factors may lead to this difference like the level of education of health care
workers, working experience, participation in training courses and their practical participation in
the hospital and haw they handle waste.

Socio demographic characteristics.

Age was 45%(N=18) were between 20 up to 29 years while 40%(N=16) were between 30 up to
39 years and 12.5%(N=5) were between the age of 40 up to 49 years, there is some ages that were
above 50 years which was 2.5% (N3=1) and their sex was the same that 50 % (N=20) were
females and 20 (N=20) were males. This indicates that the hospital workers were mostly teenage
and young age whom needs an knowledge and adequate experience to handle medical waste
properly.

Overall, 40 respondents participated in the study. Majority of these respondents were cleaners.
30%(N=12), followed by lab technicians 20%(8), nurse, 20%(N=8), while 10%(N=4),12.5%
(N=5) and 8%(N=3), were pharmacist, doctors and dentist respectively.Regarding the marital
status of the respondents majority of them were single 47.2 (N=19) and 42.2% (N=17) were
married while the others were divorced and widowed each of them were2%.Participants have also
different education backgrounds which have direct influence on how they were dealing with the
medical waste. Of their education level 40% (N=16) were illiterate workers and majority of this
respondents were sanitary health care workers in the hospital 55% (N=22). This will lead at risk
on segregation or identifying the nature of medical waste. In addition to that 7.5% (N=3) of the
respondents were primary level and 33% (N=13) were secondary level while 20% (N=8) were
tertiary level of education.

Working period and the experience of the waste worker is also another vital issue. Participants
have variety of working period; here is the number of years on each category. Most of workers
have been working the hospital less than a year 42.5% (N=18). There are some workers who have
been working the hospital for 2-3 years and (22.5%) (N=9) some others have been working 4
years (15% (N=6) have been working more than five years (17%) (N=7) have been working the
hospital (22.5%) (N=9). Experience of health care worker will directly contribute to the medical
waste management. Gabiley General Hospital was lack of professional and experienced staffs.
But fortunately, the last three years there have been adequate staphs and the patrolled staphs were

76
increasing, but the problem is that do they have enough experience and knowledge about medical
waste management.

In this study over all knowledge of MWM was generally inadequate, with 90% of the participants
scoring ‘poor’ overall. Just over half of the participants reported a good practice towards the
appropriate disposal of MWM 60%. In this study overall attitude of the respondents were good
scored 80%.

Health Care Worker’s Knowledge about Medical waste management.

However, in this study it is discovered that 68% (N=27) are unable to identify to sort the nature of
medical waste. In this study 33% (N=13) of waste workers have poor knowledge on identification
need to sort medical waste during collection while 41% (N=12) are able to identify need to sort
medical waste during collection in addition to that 53% (N=19) did not know reasons behind
sorting medical wastes while 47% (N=21) knows well the reasons behind sorting medical wastes.

Therefore, Health Care Workers have insufficient knowledge about sorting of medical waste.

A study done on Healthcare waste generation in government Health facilities of Dare-Salaam

(United Republic of Tanzania) in 1995/1996 showed that there was a lack of knowledge and
interest in safe waste disposal by most health workers. In addition, the absence of adequate
funding to implement waste management programs was a challenge. (Akter et al 2000).

The World Health Organization (WHO) prescribed that medical waste should be sorted and
dumped into separate waste containers from the source, and afterwards stored in a safe place
inaccessible to rodents and unauthorized people for a maximum of 48 hours and then transported
to the treatment or disposal site(WHO, et al 2005). If this guideline is strictly followed, the
quantity of medical waste which is eventually passed to treatment/disposal facilities will be small
and manageable. South African health facilities generate about 45,000 tons of medical waste
annually, out of which only about 4,500 tons are hazardous.But, while the waste is all mixed
together, it becomes necessary to treat it as hazardous and cannot be recycled and reused without
pre-treatment (Jewaskiewitz S. et al 2017).

A similar study done in Tehran on Assessment of Medical Waste Management in Educational

Hospitals of Tehran University Medical Sciencesrevealed that some amount of hazardous waste is
stored in the same containers as the domestic wastes and no control measures exist for the
management of these wastes. (Fard, 2008).

On the other hand most of Gabiley General Hospital workers (62.2%) (N=25) didn’t know
exactly the adequate quantities for packing medical waste. This may cause to pack the medical
waste extra and may result it risks that may affect patients, those who visit the patients and other
workers.

77
Present study showed that the workers have a knowledge of awaring of risks in dealing with
medical wastes (71%). Knowing how to deal liquid waste generated from hospital is very
important to keep safe on both the environment and people. Though health care workers have a
knowledge about the risk of medical waste in this study 59% (N=24) of workers in contrast do
not know how to dispose of these liquid waste remains while 41% (N=16) had a knowledge to
dispose of these waste remains.

Another important point to be noted is that whether Health Care Workers receive any form of
training and supervision on the way they handle wastes. Most of the respondents of Health Care
Workers did not get any form of training 80 %(N=32), only few them admit to get a training
20% (N=20). That the type of training taken 5% (N=2),25%(N=10) and 5%(N=2), were formal
lecture, seminar and workshop respectively.

A study conducted in DebreMarkos town healthcare facilities, northwest Ethiopia however, in

this study, only 30.9% of the study participants were trained which is not in compliance with the
national and international requirements (Imaad MI, Annarao GK et 2013). This result was better
than a finding from India in which none of the Medical Waste Handlers were trained at all
(Nwankwo C et al 2018). however, better finding (81%) was obtained from Nigeria (Healthcare
waste management directive et al 2005)

A study done in Sulaimani Polytechnic University in Iraq revealed that regarding training course
in relation to MWM (79.7%) of HCPs had not participated in any training courses during their
working periods and only (20.3%) HCPs have participated in MWM training course. This result
was similar to a study done in India revealed that around 16% HCPs had received training on
MWM. Another study in Puducherry-India reported that (74%) of HCPs have not undergone
training on medical waste management (M. Azage, G. Haimanot et al 2013). This result was
inconsistent with a study done in Turkey that reported training of staff on medical waste was
about 80% (R. Sanjeev, S. Kuruvilla et al 2014).

A study conducted in Morocco revealed that healthcare facilities are in need of continuous
training courses for old and new employees, continuing health education for management and
support staff members in order to apply safe methods of medical waste handling and management
(S. Rasheed, S. Iqbal, LA et, al 2015).

There for increasing the information level of health care personal has a crucial role of medical waste
management.

Color coding system of medical waste containers was not satisfactory, and this indicates that
waste separation and sorting at the point of generation are mixed without storing in color coding
containers. 70 % (N=27) do not know color coding system of the containers and only 30%
(N=13) knew.

78
 A study conducted in KwaZulu-Natal in south Africa reported that respondents had a poor
knowledge of the purpose of the different coloured bags used for sorting medical waste and Just
under half of the participants (48.3%) reported that they have never received any formal training
in HCW management.

Knowing how to deal liquid waste generated from hospital is very important to keep safe on both
the environment and people. In this 80% (N=32) of workers do not know how to dispose of these
liquid waste remains while 20% (N=7) do not have a knowledge on how to dispose of these waste
remains. Improper disposal of liquid west is directly correlate with the in adequate training and
supervision of health care workers.

One of the most bizarre things in Gabiley General hospital is that all health care workers have
failed adequate disposal procedures of expired blood units and by-products waste, and that
majority of them 70%(28) have no knowledge of this disposal procedure, while few of them have
sufficient knowledge 30%(N=12).

The waste workers were also dealt with the expired medicines and 71% (N=28) does not know
disposal procedures of expired medicines while 29 %( N=12) didn’t know disposal procedures of
expired medicines. This is related to attitude and practice of the worker on how to deal with these
wastes so believing throwing expired medicines is considered important factor in this study. In
this 71% (N=23)) believes throwing expired medicines and 29% (N=17) didn’t believe throwing
expired medicines which means expired medicine should have their disposal procedure.

A total of number of respondents were asked on different hospital staffs in different sections of
the hospital for identifying their attitude of segregation , immunization of Hepatitis B virus and
reporting needle stick injury.

The responders has been asked whether segregation at the source of collection have an adverse
effect to the west handlers, and their response was agree , strongly agree, disagree and strongly
disagree, 30% (N=12),42.5%(N=17), 10% (N=4), 10(N=17.5). this indicates that majority of the
respondents 72.5% (N=29) have good attitude regarding segregation of waste.

Different types of infectious and toxogenic materials are processed for collection and separation
however this may cause infection or injury in waste handlers.

Similar study conducted in Gondar University Hospital, North West Ethiopia, 2013 stated that
regarding attitude towards health care waste segregation practice 283 (75.7%) of the respondents
had positive attitude i.e. who respond 35.3% of the respondents practiced correctly and 40.4%
practiced segregation incorrectly. Out of the total respondents, 175 (46.8%) used PPE (personal
protective equipment) when they are handling infectious health care wastes AvierMesfin et. al
2013.

Haw ever this if different from a study conducted at Kapsabet County Referal Hospital, Nandi
County, Kenya, findings indicate that, 32% of respondents had no idea of what waste segregation
is, this is closely related to a study done by Abdullah & Al-Mukhtar, (2013) whose study had

79
29.8% of the respondents indicating that they had no idea about how the process of waste
segregation is done hence the need of informing the whole medical staff about the medical waste
management plan applied in the hospitals.

An average of 35% of the respondents said that waste segregation should not be done at the
generation point. This contradicts with a study done by WHO, (2011) which showed that it is
essential that all medical waste materials are segregated at the point of generation and Chartieret
al., (2012), who stated that segregation at source is recommended as it makes it easier to prevent
spread of infection, helps in making it easier to choose among the options of disposal, and can
reduce the load on the waste treatment system and prevent injuries. The study went further to
show whether the attitude towards containment of sharps does not help safe management of
waste.

In this study the majority of respondents have a good attitude of control of sharps scored 27.5%
(N=11) and 22.5%( N=20) and other respondents have poor attitude of practicing sharps 17.5%
(N=7), 5% (N=2) .

Of the total participants 72.5% (N=29) believe hepatitis B vaccine can prevent some hospital infections
of this 37.5% (N=15) answered strongly agree and agree 35%(N=14).

The remaining percent of the respondents were 12.5% (N=5) and 10%(N=4) answered disagree and
strongly disagree respectively.

Health care workers are very vulnerable to have an infections acquired from hospital waste, this
include hepatitis B which more infectious than HIV and HCVs. Hepatitis B is a preventable
infection that is transmitted easily in many ways like needles contaminated with infected blood.
The only measure to prevent it is by using vaccination. Unless vaccination is given to the health
care workers they will be susceptible to an infections acquired from biomedical waste.

In this study almost all of the respondents had a good attitude about needle stick injury. Asking
question of believing Needle stick injury is an extra burden at work, all most all were disagree
and strongly disagree scored 70%(N=28) and 20%(N=8) total number of 90%(N=36) the other
respondents were not believing the needle stick injury can cause an infection.

Globally, WHO estimates that, in 2000, injections with contaminated syringes caused 21 million
hepatitis B virus (HBV) infections, two million hepatitis C virus infections and 260 000 HIV
infections worldwide.

An outbreak of hepatitis B in Gujarat, India, in 2009 is thought to have claimed the lives of 60
people and was blamed on the reuse of injection equipment. It led to the discovery of a black
market where used needles and syringes were repackaged and resold (Harhay et al., 2009;
Solberg, 2009).

Attitude of HCWs about Medical waste management.

80
The responders has been asked whether segregation at the source of collection have an adverse
effect to the west handlers, and their response was agree , strongly agree, disagree and strongly
disagree, 30% (N=12),42.5%(N=17), 10% (N=4), 10(N=17.5). this indicates that majority of the
respondents 72.5% (N=29) have good attitude regarding segregation of waste.

Different types of infectious and toxogenic materials are processed for collection and separation
however this may cause infection or injury in waste handlers.

Similar study conducted in Gondar University Hospital, North West Ethiopia, 2013 stated that
regarding attitude towards health care waste segregation practice 283 (75.7%) of the respondents
had positive attitude i.e. who respond 35.3% of the respondents practiced correctly and 40.4%
practiced segregation incorrectly. Out of the total respondents, 175 (46.8%) used PPE (personal
protective equipment) when they are handling infectious health care wastes (AvierMesfin et.al
2013).

The attitude towards containment of sharps does not help safe management of waste.

In this study the majority of respondents have a good attitude of control of sharps scored 27.5%
(N=11) and 22.5%( N=20) and other respondents have poor attitude of practicing sharps 17.5%
(N=7), 5% (N=2) .

Of the total participants 72.5% (N=29) believe hepatitis B vaccine can prevent some hospital infections
of this 37.5% (N=15) answered strongly agree and agree 35%(N=14).

The remaining percent of the respondents were 12.5% (N=5) and10%(N=4) answered disagree and
strongly disagree respectively.

Health care workers are very vulnerable to have an infection acquired from hospital waste, this
include hepatitis B which more infectious than HIV and HCVs. Hepatitis B is a preventable
infection that is transmitted easily in many ways like needles contaminated with infected blood.
The only measure to prevent it is by using vaccination. Unless vaccination is given to the health
care workers, they will be susceptible to an infection acquired from biomedical waste.

In this study almost all of the respondents had a good attitude about needle stick injury. Believing
Needle stick injury is an extra burden at work, all most all were disagree and strongly disagree
scored 70%(N=28) and 20%(N=8) total number of 90%(N=36) the other respondents were not
believing the needle stick injury can cause an infection.

Globally, WHO estimates that, in 2000, injections with contaminated syringes caused 21 million
hepatitis B virus (HBV) infections, two million hepatitis C virus infections and 260 000 HIV
infections worldwide.

An outbreak of hepatitis B in Gujarat, India, in 2009 is thought to have claimed the lives of 60
people and was blamed on the reuse of injection equipment. It led to the discovery of a black

81
market where used needles and syringes were repackaged and resold (Harhay et al., 2009;
Solberg, 2009)

Practice of HCWs about Medical waste management.

The categories of waste segregation, collection, storage, and handling. These questions were
asked on different hospital staffs in different sections the hospital. According to their level of
knowledge, experience and training, medical health care workers have different response to
different questioners.

Slightly half of the respondents are segregating the hospital waste in the rooms 57 %(N=23) and
42.5% (N=17) are believing that segregation takes place outside. For effective waste management
health care workers should have enough knowledge on the management of medical waste
specially segregation of waste and the final disposal process.

This agrees with a study done by WHO, (2011) which showed that it is essential that all medical
waste materials are segregated at the point of generation and Chartieret al., (2012), who stated
that segregation at source is recommended as it makes it easier to prevent spread of infection,
helps in making it easier to choose among the options of disposal, and can reduce the load on the
waste treatment system and prevent injuries.

This current study shows that more than a half of the respondents had a adequate practice about the
segregation at the point of collection takes place inside the rooms.

Majority of respondents Health care workers able to sort medical waste were 65 %(N=26) and
those respondents that are un able to separate medical waste scored 14% (N=14). In addition to
that the number of health care workers that are able to classify medical waste are much more than
those that are unable to sort sharp waste from blunt waste, their number was % 77.5 (N=31) and
9% (N=22.5) respectively.
The most common type segregated from general waste is to separate sharp waste from the other
waste in order to prevent injury to the waster handlers. 87.5 %(N=35) they agreed that the most
type of waste generated from waste was pathological waste and infectious waste, 12.5%(N=5).
Regarding the color-coding system of most of the respondents had chosen red and black 80 %
(N=28) and 20 &(N=12) were yellow color-coding used for marking infectious wastes. Color
coding makes it easier for workers to put waste items into the acceptable container, and to
maintain separation of the wastes during transport, storage, treatment and disposal.

This color cording problems of the workers will lead that all waste generated from the hospital
are to be collected indiscriminately in a different container without segregating properly, which
arise from insufficient knowledge and practice to the color cording symbols. This type of practice
correlates with inadequate of knowledge and training given to the HCW and lack of supervision.
Containers should have well-fitting lids, either removable by hand or preferably operated by a
foot pedal. Both the container and the bag should be of the correct color for the waste they are

82
intended to receive and labelled clearly. Mixing colors – such as having yellow bags in black
bins – should be avoided, because it will increase the potential for confusion and poor
segregation. WHO (2007).

In contrast to this study another similar study conducted in DebreMarkos Town Healthcare
Facilities, Northwest Ethiopia is totally differed from it stated that Health care workers were 168
(56.8%). One hundred sixty-nine (57.1%) of the study participants identified the biohazard
symbol. Regarding knowledge on segregation of BMWs, 235 (79.4%), 217 (73.3%), and 253
(85.5%) of the study participants were aware that general, infectious, and sharp wastes should be
placed in a black, yellow, and a safety box, respectively. In addition, 254 (85.8%) of them were
aware that a safety box should be filled only a maximum of 3/4th. Only twenty-nine (9.8%) of the
study participants knew the maximum storage time of infectious wastes before treatment or
disposal. (TeshiwalDeress et al. 201)

Personal protective clothing is very important in this study. Most of the waste handlers were used
protective clothing (gloves, etc.) during waste handling scored 87.5%(N= 35) while the remaining
percentage do not use protective clothing as 12.5%(N=5).

Type of containers is used for collection and internal transport of the waste were 65% (N=26) and
%30(N=12) Wheelbarrows and the remaining percentage were cardboard boxes % 5% (N=2). In
addition to that in this study the total number of health workers did not use totally 100%(N=40)
does not use Trolleys for transporting medical waste in the hospital. Type of transportation of
waste in side of hospitals are wheelbarrows and cardboard boxes.

The most disposal method of the final segregated wastes is buried on hospital grounds, taken to
municipal landfill and open burned and allocated storage boxes as 75% (N=30), 5% (N=12.5),
and 1% (N=2.5) and 1%(N=2.5) respectively.

A total number of staffs 40% out of 30% responded that they had never reported a needle stick injury to
the control unit and remaining 10 have responded yes.
Workers at risk from infection and injury include health-care providers, hospital cleaners,
maintenance workers, operators of waste-treatment equipment, and all personnel involved in
waste handling and disposal within and outside health-care facilities. Training in health and safety
is intended to ensure that workers know of and understand the potential risks associated with
healthcare waste, and the rules and procedures they are required to respect for its safe
management. They should be informed on the importance of consistent use of personal protective
equipment (PPE) and should be aware of where to obtain post-exposure follow-up in case of a
needle-stick injury or other blood exposure. Health-care personnel should be trained for
emergency response if injured by a waste item, and the necessary equipment should be readily
available at all times. Written procedures for the different types of emergencies should be drawn
up. Safe management of wastes from health-care activities should be carried out by designated
personnel specially trained for the purpose.

83
There was adequate number of staffs in the hospital and 60% (N=24) of respondents has
responded that the hospital staphs in the hospital are adequate 40% ( N=16) agree that there is no
adequate number of staphs. 82.5% (N=33) hospital workers responded that they collect liquid
waste in a bags that prevent leakage and 17.5% (N=7) of the respondents are not practicing
collection of liquid waste in a bags that prevent leakage.

In this study almost all of the Health Care Workers 80%(N=32) are able sort the blood waste from
the other wastes in ordinary bags and the remaining percentage of the respondents are 8% (N=20)
practicing mixing blood in to the other wastes in ordinary bags and gathering expired medicine
with other wastes respondents answered no were 72.5.5% (N=17) and those others 27.5%
( N=13).

They have a good practice about expired medicine.

The interviewed participants majority ( HCW) has responded that the hospital waste management
system depends on the city’s cleaning authority while few of them answered no, 82.5% ( 33) and
17.5% (N=7). In addition to that majority of the respondents answered “no” about question
whether hospital dispose medical west outside by using its own vehicles others answered yes 92%
(N=37) and 7.5.5% (N=3) respectively. This reveals that the hospital does not have a enough
facility to handle medical waste during internal and external transportation.

The study also revealed that majority of the hospital workers had a good practice about collection
of liquid waste. 82.5% (N=33) responded that they collect liquid waste in a bags that prevent
leakage and 17.5% (N=7) of the respondents are not practicing collection of liquid waste inn a
bags that prevent leakage.

The most disposal method of the final segregated wastes is buried on hospital grounds, taken to
municipal landfill and open burned and allocated storage boxes as 75% (N=30), 5% (N=12.5),
and 1% (N=2.5) and 1%(N=2.5) respectively. Another similar study conducted in Nigeria on an
assessment of medical waste disposal methods in Jalingo Metropolis, Taraba State revealed that
the methods of waste disposal adopted in the hospitals/clinics include incinerator (50%), offsite
commercial disposal (16.7%) and onsite disinfection (11.6%).

5.2 Conclusion

This study was done at Gabiley General Hospital, Gabiley, Somaliland and was conducted among
doctors, nurses, laboratory technicians and cleaners. It was a descriptive and cross sectional study
using both Interviewer administered and self-administered questionnaire. The objective of the
study was to establish the level of Health Care Worker’s knowledge, attitudes, and practices
regarding Medical Waste Management. Results showed that there were gaps in knowledge and
practice of MWM by respondents across all categories of HCWs. This study demonstrated a good
attitude towards HCW management among the majority of staff members but inadequate
knowledge, and practices in respect of HCW management at this hospital.

84
Over all knowledge of MWM of HCW was generally inadequate, with 90% of the participants
scoring ‘poor’ overall. Just over half of the participants reported a good practice towards the
appropriate disposal of MWM 60%. In this study overall attitude of the respondents were good
scored 80%.

The most important problem in waste management was underscored as not having sufficient
training and supervision. Among the solution propositions, set alongside effective training and
supervision, is having the cleaning personnel subjected to a standard training program, and them
certificated for proficiency. Preparation of an effective waste management plan in hospitals,
application of a periodic training program at all levels, and supervision by institutions specialized
in that field would provide an important contribution to the waste management.

5.3 Recommendations.
Medical care is vital for human life and health, but the waste generated from medical activities
represents a real problem of living nature and human world. Improper management of waste
generated in health care facilities causes a direct health impact on the community, the health care
workers and on the environment every day; relatively large amount of potentially infectious and
hazardous waste are generated in the health care hospitals and facilities around the world. This
requires specific treatment and management prior to its final disposal.

Basing on the results the following recommendations are made to improve antenatal care:

1. The Ministry of Health should orient hospitals administrations to keep supervision of workers
during waste collection along with the raising workers awareness about knowing and dealing
with medical waste facilitates disposal and following up the procedures on each medical
waste.

2. Compulsory training of healthcare personnel from accredited training centres on a continuous

basis.

85
 3. It should be ensured that the injuries happening to the healthcare personnel are reported to the
person in-charge of biomedical waste management or to the biomedical waste management
committee, and they report it in the prescribed format to the pollution control board.

4. The entire waste management practices should be a part of total hygiene practice of the
society rather than confining to hospital and health facility.

5. The hospital administration should change the buried the waste on hospital grounds and use
the other advanced systems.
6. The hospital staffs should keep using protective clothing once dealing with the medical
wastes like sharps and dispose directly to their allocated boxes.

7. Community should participate waste management practice to prevent its health effects.

5.4: Limitation.

The study was conducted on a small number of study participants which may not represent other MWHs
elsewhere in different regions and locations of the country.

1. There was limited literature available on previous studies involving Health Care Workers in
similar developing countries.

2. A few of the respondents were medical students (sub-interns) with limited clinical experience.

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CONCENT SHEET

Study Title: Assessment of Knowledge attitude and practice of Medical Waste

Management among health care workers at Gabiley General Hospital (GGH). GabileySomaliland.

PI:WaberiJama.

Date: July 2019

We invite you to participate in a research study conducted by WaberiJamafrom the Kampala

University in Kampala.

We are asking you to take part in this study because we are trying to learn more about Medical
Waste Management in your hospital.

You were selected as a possible participant because you are a Health Care Worker at Gabiley
General hospital. We will ask you about 50 questions related to the hospital you are working such
as Medical waste disposal system and possible management. It will take about 20 minutes of your
time.

Your participation is voluntary. There are no anticipated risks or benefits to your participation. You
may decide to discuss your participation with your colleagues or friends. You will be given a copy
of this form.

93
Waberijamac@gmail.com.

ARESEARCH PROPOSAL SUBMITTED TO KAMPALA UNIVERSITY IN PARTIAL

FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF ADEGREE OF MASTER OF
PUBLIC HEALTH.

Section A: Demographic

1. Age (years)20—29 30—39 40---59 above 60

2. Sex: Male Female

3. Marital status:

Single Married Divorced Widowed

4. Educational Level:

(a.)Primary (b.) Secondary (c.) Tertiary (d.) Others

5. Designation level

(a.) Medical Doctor (b.) Dentist (c.) Nurse. (d) Laboratory Worker (e.)
Ward Attendant (f.) Porters (g.) Cleaners (h.) Paramedics

6. WORKING PERIOD AT HOSPITAL (years)

Less than 1 year 2 – 3 Years 4 Years. Above 5 Years

Section B. Knowledge of health workers about medical waste

yes No

6. . Are you able to identify the nature of medical waste?

7. If yes what criteria do you use to identify medical waste? Please state them

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below:

The most appropriate way of identifying the categories of health-care waste is

by sorting the waste into colour-coded plastic bags or containers.

8. Do you identify the need to sort medical waste during collection?

9. Do you know the reason behind sorting (separation of) medical waste?

10. If yes give reason why waste should be sorted at site?

11. Are you aware of risks in dealing with medical waste

13. Do you know adequate disposal procedures for liquid waste?

14. If yes, give a brief explanation of the procedure you use or know of
below:

15 Have you ever received any formal training on medical waste handling?

16. If yes, write down the type of training you received below:

Formal lecture B. seminar C. workshop D Case scenario E. Others

(please state below)

17. Do you know adequate disposal procedures for expired blood units and by-
product waste?

18. If yes briefly describe what you will do with it below:

19. Do you know adequate disposal procedures for human tissue remains?

20. If yes, briefly state the disposal approach you use:

21. Do you have appropriate knowledge of the colour coding of medical waste
disposal bags/containers?

22. If yes, state the categories of waste that goes into each of these colours:

i. RED

iv. BLACK

v. BLUE

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23. Do you know adequate disposal procedures for expired medicines

24 Do you believe that throwing blood waste into domestic waste is an

adequate disposal procedure?

25 Do you receive any form of supervision on the way you handle wastes?

26 Do you believe that throwing expired medicine into domestic waste is an

adequate disposal procedure?

Section C. Health workers’ practices in dealing with medical waste

Yes No

27. Do you sort medical waste during collection?

28. Do you separate sharp waste from blunt waste?

29. Do you move medical waste using trolleys?

30. Do you clean the waste trolley directly after each collection?

31 Do you use personal protection tools (e.g. gloves, safety goggles, face mask) ever or
when handling medical waste?

32. Do you think the number of people employed to handle waste in the hospitalis
adequate?

33. Do you collect liquid waste in bags that prevent leakage?

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34 Do you collect blood waste in bags that prevent leakage?

35 Do you collect human tissue remains in separate bags to prevent leakage?

36 Do you collect liquid waste together with other waste?

37 Do you collect blood waste together with other waste in ordinary bags?

38 Do you collect human tissue remains together with other wastes in ordinary bags?

39 Do you collect expired medicines together with other wastes?

40 Do you dispose of liquid waste into the sewage system after processing?

41 Are hospital visitors exposed to medical waste?

42 Do you gather medical wastes in open areas within the hospital for temporary storage
before being transferred outside the hospital?

43 Does the hospital have standard stores for temporary storage of medical

wastes?

44 Does the hospital depend on the city cleaning authority (e.g. DSW) in moving and
disposing of medical waste outside hospital?

45 Does the hospital dispose of medical waste outside using its own vehicles?

Section D. Attitude to waste management

Agree Strongly disagree Strongly

agree disagree

46. practices and knowledge of the consequences

ofinappropriate practices

47 Segregation of waste at source increases the risk of

injury to waste handlers

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48 Containment of sharps does not help in safe
management of hospital waste

49 Hepatitis B immunization prevents transmission of

hospital-acquired infections

50 Reporting of needle-stick injury is an extra burden on

work

98