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COMPARATIVE ASSESSMENT OF HEALTHCARE WASTE

MANAGEMENT IN PUBLIC AND PRIVATE SPECIALIST HEALTHCARE

FACILITIES IN PORT HARCOURT, RIVERS STATE, NIGERIA.

A DISSERTATION SUBMITTED

DR OFFORMA, IKECHUKWU MADUKA

DEPARTMENT OF COMMUNITY MEDICINE

UNIVERSITY OF PORT HARCOURT

PORTHARCOURT

RIVERS STATE

FACULTY OF PUBLIC HEALTH

NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR AWARD OF

FELLOWSHIP OF NATIONAL POSTGRADUATE MEDICAL COLLEGE

OF NIGERIA IN COMMUNITY HEALTH

NOVEMBER, 2017

DECLARATION

I hereby declare that this dissertation or part of it has not been and will not be submitted for

any diploma, fellowship or any other examination.

-----------------------------------------------

DR OFFORMA, IKECHUKWU MADUKA

CERTIFICATION

This is to certify that this dissertation titled COMPARATIVE ASSESSMENT OF

HEALTHCARE WASTE MANAGEMENT IN PUBLIC AND PRIVATE SPECIALIST

HEALTHCARE FACILITIES IN PORT HARCOURT, RIVERS STATE, NIGERIA was

carried out by DR OFFORMA, MADUKA IKECHUKWU, a Senior Registrar in

Department of Community Medicine, University of Port Harcourt Teaching Hospital, Port

Harcourt, Rivers State under my supervision.

--------------------------------- ------------------------------------

DR KINGSLEY DOUGLAS Prof. BEST ORDINIOHA

Head of Department (SUPERVISOR)

Community Medicine Department of Community Medicine

University of Port Harcourt Teaching Hospital University of Port Harcourt Teaching

Port Harcourt Port Harcourt

DEDICATION

This work is dedicated to my elder brother, Nze Moses Chibueze Offorma for his unwavering

support and guidance.

ACKNOWLEDGEMENT

My utmost gratitude goes to God Almighty for the enablement to complete this work. To

Him alone be all the glory. I wish to appreciate my supervisor, Professor Best Ordinioha, for

making this work what it is today. His contributions and corrections were instrumental

towards successful completion of this dissertation. My gratitude goes to my head of

department, Dr Kingsley Douglas for his encouragement and mentorship throughout the

period of my residency programme. His contribution to this work is deeply appreciated. I owe

all my consultants and senior colleagues heart-felt gratitude for taking time to go through this

dissertation.

I wish to thank Dr Okey Ibeabuchi, whose ingenuity, benevolence and unimaginable fatherly

status in my life made this work and my journey in residency programme to be a completed

project. I also extend my profound gratitude to Dr Okafor Iby ( Eagles Watch ) and Blessing

Bassey for their wonderful contributions to this work.

Finally, I want to thank my dear wife, Obidiya and my wonderful children for their patience

and dedication while this work lasted. I love you all.

TABLE OF CONTENTS PAGES

Title i

Declaration ii

Certification iii

Dedication iv

Acknowledgements v

Table of contents vi

List of tables x

List of acronyms xi

Operational definition of key terms xii

Abstract xiii

CHAPTER ONE: Introduction

1.1 Background 1

1.2 Problem statement 4

1.3 Justification 5

1.4 Research question 6

1.5 Objectives 7

1.6 Research hypothesis 7

CHAPTER TWO: Literature Review

2.1 Overview 8

2.2 Healthcare generation and quantification 9

2.3 The knowledge of HCWM by health workers 12

2.4 Attitude of health workers to HCWM 14

2.5 HCWM practice by the health workers 15

2.5.1 HCWM practice in healthcare facilities in Nigeria 15

2.5.2 HCWM practice in healthcare facilities in Rivers State 16

2.5.3 The reality of improper HCWM practices 16

2.5.4 HCWM plan/guideline

2.5.5 The practice of sharp waste management by health workers 19

2.5.6 Making medical injections safe project in Nigeria 20

2.5.7 The burden of diseases due to poor sharp waste management practices 22

2.5.8 The place of standard precautions 23

CHAPTER THREE: Materials and Methods

3.1 Study area 24

3.2 Study design 24

3.3 Study population 25

3.4 Sample size determination 26

3.5 Sampling technique 28

3.6 Data collection tool 31

3.7 Data collection methods 33

3.8 Data analysis 33

3.9 Ethical approval 34

3.10 Limitations of the study 34

CHAPTER FOUR : Results 35

Section 1: Socio-demographic characteristics of health workers 37

Section 2: Comparison quantities of waste generated 42

Section 3A: Knowledge, attitude and practice of HCWM 44

Section 3B: comparison of sharp waste management practices 60

Section 3C: Assessment of Implementation of HCWMP 64

Section 3D: Comparison of HCWM practice among waste handlers 69

CHAPTER FIVE : Discussion 70

CHAPTER SIX : Conclusion and recommendation 79

6.1 Conclusion 79

6.2 Recommendation 80

References 81

Appendix I Informed consent and information form 92

Appendix II Questionnaire for health workers 94

Appendix III Interview guide for key informant interview 100

Appendix VI Observation checklist 102

Appendix V Questionnaire for HCW handlers 105

Appendix VI Work plan 108

Ethical approval letter 109

LIST OF TABLES PAGES

Table 3.5.1 Selection of respondents in public specialist HCFs 30

Table 3.5.2 Selection of respondents in private specialist HCFs 30

Table 4.1.1 Categories of health workers 37

Table4.1.2 Years of experience of health workers 38

Table 4.1.3 Comparison of mean years of experience among health workers 39

Table 4.1.4 Socio-demographic characteristics of waste handlers 40

Table 4.1.5 Comparison of mean years of experience among waste handlers 41

Table 4.2.1 Comparison of waste generated 42

Table 4.3.1 Comparison of correct knowledge of HCWM 44

Table 4.3.2 Comparison of aggregate knowledge of HCWM 47

Table 4.3.3 Comparison of mean score knowledge of HCWM 48

Table 4.3.4 Comparison of health workers trained in HCWM 50

Table 4.3.5 Comparison of correct attitude to HCWM among health workers 52

Table 4.3.6 Comparison of level of attitude to HCWM 54

Table 4.3.7 Comparison of mean score of attitude of health workers to HCWM 55

Table 4.3.8 Comparison of correct practice of HCWM by health workers 56

Table 4.3.9 Comparison of level of HCWM practice by health workers 57

Table 4.3.10 Comparison of mean score of practice of HCWM by health workers 59

Table 4.4.1 Comparison of SWM practice by health workers 60

Table 4.4.2 Comparison of level of SWM practice by health workers 62

Table 4.4.3 Comparison of mean score of SWM practice by health workers 63

Table 4.5.1 Comparison of level of implementation of HCWMP in the HCFs 65

Table 4.5.2 Result of key informants interview on HCWM training 66

LIST OF ACRONYMS

AGPMPN Association of General and Private Medical Practitioners of Nigeria

CDC Centre for Disease Control

ESM Environmentally Sound Management

FMOH Federal Ministry of Health

GHGs Green House Gases

HBV Hepatitis B Virus

HCF Healthcare Facility

HCFs Healthcare Facilities

HCV Hepatitis C Virus

HIV Human Immunodeficiency Virus

HCW Healthcare Waste

HCWMP Healthcare Waste Management Plan

MMIS Making Medical Injections Safe

LIC Low Income Countries

PEPFAR Presidents’ Emergency Plan for AIDS Relief

SIGN Safe Injection Global Network

SWM Sharp Waste Management

SPSS Statistical Package for Social Sciences

UNCED United Nations Conference on Environmental Development

UNEP United Nations Environmental Programme

WHO World Health Organization

OPERATIONAL DEFINITION OF KEY TERMS

Healthcare waste : Healthcare waste is described as waste generated by health care

establishments, research facilities and laboratories. It also includes waste generated in the

course of healthcare activities undertaken at home.

Healthcare waste management : Healthcare waste management involves all activities from

healthcare waste generation, segregation, quantification, storage, handling, collection,

transportation, and disposal in accordance with healthcare waste management plan or

guidelines to avoid injury or infection and environmental pollution.

Healthcare waste management plan: Healthcare waste management plan is a guideline that

provides an approach to the management of healthcare waste that is safe for healthcare

facilities, waste handlers, the public and the environment.

Waste segregation: Waste segregation consists of characterisation at the source generation

and clearly identifying the various types of healthcare waste and how they can be collected

separately using different colour coded containers.

Waste quantification: Weighing, measurement or estimation of waste to determine the

quantity generated.

Waste Disposal: This is intentional burial, deposit, discharge, dumping, placing or release of

any waste material into or on any air, land or water.

ABSTRACT

Background - Healthcare waste is described as waste generated by health care

establishments, research facilities and laboratories. This study compared the quantities of

healthcare waste generated in each of the healthcare facilities, the knowledge, attitude and

practice of healthcare waste management including sharp waste management among health

workers and also the level of implementation of healthcare waste management plan in the

public and private specialist healthcare facilities.

Methodology : This study utilized a comparative cross-sectional design. The selection of

health workers was done using simple random sampling. Data collection was by quantitative

and qualitative methods. The quantitative method was carried out using structured

interviewer-administered questionnaire. Qualitative method was done by conducting key

informant interview, field observation and use of checklist. Data was analyzed using

Statistical Package for Social Sciences (SPSS) version 20.0 computer software.

Results : A total of 260 health workers participated in this study; 149 participants were from

the public and 111 participants were from the private healthcare facilities. The mean

quantities of waste generated by public and private health care facilities (HCFs) were 2.67±

0.14kg/bed/day and 1.21± 0.17kg/bed/day respectively. The difference in mean quantity

generated in both HCFs was statistically significant (p = 0.001).

More of the health workers in private (90.1%) had an aggregate knowledge score of ≥70%

compared with those in public (83.2%) HCFs. The difference was not statistically significant

(p = 0.287). Majority of health workers in both public (96.0%) and private HCFs (99.1%) had

positive attitude toward HCWM. The difference in proportion was not statistically

significant( p = 0.244 ). More health workers in private HCFs (75.7%) had better practice of

HCWM as compared to those in public HCFs (54.4%). The difference in proportion was

statistically significant (p = 0.001).

Good practice (score of 70% and above) of sharp waste management (SWM) was low in both

HCFs. Only 46.3% of health workers in public and 40.5% of private HCFs scored above 70%

on SWM score rating. There was poor implementation of HCWMP in both public and private

HCFs. In public and private HCFs, there were 26.2% and 11.3% scores for good

implementation of HCWMP respectively. The difference in proportion was statistically

significant ( p = 0.0021).

Conclusion: This study has revealed that there is difference in the HCWM in the public and

private specialist HCFs in Port Harcourt and that the current HCWM practices in both HCFs

cannot be relied upon to protect the environment and the health of the health workers and

their patients.

CHAPTER ONE

INTRODUCTION

1.1 Background

Healthcare waste (HCW) includes all the waste generated by health care establishments,

research facilities and laboratories.1 Healthcare waste management (HCWM) involves

activities from generation of waste to final disposal. It includes those measures taken in the

generation, characterization, quantification, storage, handling, collection, transportation, and

disposal of wastes.1 It has become a major public health concern globally due to the potential

of poorly managed healthcare waste to cause disease and injury.1 The sustainable

management of healthcare waste has continued to generate increasing public health interest

due to the health problems associated with exposure of human beings to potentially

hazardous wastes arising from healthcare .1,2,3 In Nigeria, healthcare waste falls under the

category of infectious and non-infectious waste.4 Within the category of infectious wastes are

culture and stock of 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. 4 The category of non-

infectious wastes are general health care wastes generated in the course of administrative and

housekeeping functions of healthcare establishments; and hence are comparable to the usual

domestic waste.4

Presently, considerable gap exist with regard to the assessment of healthcare waste

management practices in line with the healthcare waste management plan (HCWMP)

particularly in Nigeria and in several other countries in sub – Saharan Africa. The need to

imbibe the processes prescribed in the HCWMP becomes a necessity in view of the

indiscriminate dumping of HCWs in the metropolitan city of Port Harcourt, Rivers State,

Nigeria.5 The nature and quantity of healthcare waste generated as well as institutional

practices with regards to sustainable methods of healthcare waste management (HCWM),

including waste segregation and waste recycling are often poorly examined and documented.

This is seen in several countries of the world including Nigeria, despite the health risks posed

by the improper handling of HCW 5,6. However, about 10-25% of healthcare wastes is

hazardous, and can create variety of health risks if not properly managed 5.

WHO estimates that over 20 million infections of hepatitis B, hepatitis C and HIV occur

yearly due to unsafe sharp disposal following the re-use of syringes and needles, in the

absence of sterilization 7, while the indiscriminate dumping of other healthcare wastes can

lead to ground and surface water contamination,8 and even cancer9. Other health problems

associated with improper collection, treatment and disposal of health care wastes include

typhoid fever, cholera, skin diseases, malaria and gastroenteritis 10,11. Indiscriminate burning

and incineration of healthcare waste have been linked to serious public health threat and

pollution resulting in the release of toxic dioxin, mercury and many other toxic substances.

These substances produce remarkable variety of adverse effects in humans even at extremely

low doses 12. Putrefaction occurs in portions of open refuse dumps, which have not been fully

burnt and add to air pollution through foul smells and release of green house gases. Sanitary

landfill of HCW can lead to pollution of ground water if not properly managed. These make

the safe waste disposal of healthcare wastes very important, a fact that has been emphasized

in various international conventions including Agenda 21, adopted in 1992 at United Nations

Conference on the Environment and Development (UNCED). Agenda 21 recommends the

prevention and minimization of waste production, the reuse or recycling of waste to the

extent possible, and the treatment of waste by safe and environmentally sound methods 13. It

is also of serious concern that the level of awareness and practice, particularly of health

workers regarding healthcare waste management plan (HCWMP) has not been adequately

documented.

WHO Programme activities include developing technical guidance materials for assessing the

quantities and types of waste produced in different facilities, creating national action plans,

developing national healthcare waste management (HCWM) guidelines and building capacity

at national level to enhance the way HCW is dealt with in low-income countries

(LICs).Classification of Health Care wastes shows that of the total amount of waste generated

by health-care activities, about 80% is general waste. The remaining 20% is considered

hazardous material that may be infectious, toxic or radioactive. Every year an estimated 16

000 million injections are administered worldwide 7, but not all of the needles and syringes

are properly disposed of afterwards. Healthcare waste contains potentially harmful micro

organisms which can infect hospital patients, healthcare workers and the general public.

Healthcare activities protect and restore health and save lives and reverse should not be

allowed to be the case in the various healthcare facilities (HCFs) across the country. The

objective of this study is to assess and compare healthcare waste management in public and

private specialist HCFs, and based on the findings, suggest recommendations that will

improve HCW management.

1.2 Problem Statement

The process of HCWM involves measures taken in the generation, characterization,

quantification, storage, handling, collection, transportation, and final disposal of healthcare

wastes.1 Improper HCWM has resulted in transmission of various preventable diseases. The

World Health Organization estimates that each year there are about 8 to 16 million new cases

of Hepatitis B virus (HBV), 2.3 to 4.7 million cases of Hepatitis C virus (HCV) and 80,000 to

160,000 cases of human immune deficiency virus (HIV) due to poor knowledge and practice

of safe sharp waste and other healthcare waste management 14,15 . In developing countries like

Nigeria, where many health care facilities are competing for limited resources, it is not

surprising that the management of healthcare wastes has received less attention and the

priority it deserves. Some healthcare facilities dispose their healthcare wastes to municipal

dumpsites without pre-treatment, leading to an unhealthy and hazardous environment. Other

healthcare facilities dump HCWs openly around the healthcare institutions, which becomes

source of infections to the patients, staff and the host community1-3,16-18. This trend is

currently being experienced in Port Harcourt, Nigeria even when every disposal site is

required by law to have environmental pollution prevention and control measures19.

Hundreds of tonnes of HCWs are deposited in open dumpsites at the healthcare facilities and

on the roadsides of Port Harcourt metropolis untreated alongside non hazardous solid wastes,

which now pose health risks to health workers, cleaning staff, patients, visitors, waste

collectors, disposal site staff, waste pickers, drug addicts that use contaminated syringes and

needles 20.

The availability of records on the quantity and nature of HCWs is still a problem in many

HCFs. The HCW management techniques in these HCFs, with respect to proper disposal of

these wastes have remained a challenge in many developing countries of the world including

Nigeria 20.

1.3 Justification

This study was undertaken to identify and compare the lapses or gaps associated with the

handling of HCWs in public and private specialist HCFs in Port Harcourt Rivers State,

Nigeria in line with the healthcare waste management plan (HCWMP). Healthcare waste

management has received very little attention in waste management process in Nigeria 21.

Neither the government nor hospital authorities pay proper attention to its management.21

Unwholesome waste disposal by many public and private specialist healthcare facilities in

Port Harcourt Rivers State, pose serious health hazard to the residents in this city. 21. This

has led to the rising incidence of nosocomial diseases in both the public and private specialist

health care facilities in Port Harcourt, Rivers State 21. There is possibility of epidemic of

nosocomial diseases in the future if this ugly trend is not checked. This would affect hospital

workers, patients and the general public 21.

The climate typical of Niger Delta is humid, semi-hot and equatorial 22 and the relative

humidity of over 80% throughout the year and a temperature that varies from 24-27 oC 22

enhances the multiplication of many pathogenic organisms 23. Nosocomial infections (health

care acquired infections) affect approximately 10% of all hospital admissions and create a

significant burden both clinically and economically 24. Some of these diseases include gastro-

enteric infections, anthrax, genital infections, respiratory infections, skin infections,

meningitis, acquired immune deficiency syndrome (AIDS), fever, hepatitis, septicaemia and

bacteriaemia 25-27.

Microorganisms can be transmitted through injuries and needles contaminated by human

blood. This can result if sharp waste including hypodermic needles are not properly disposed

of 28 . HCW are a special category of waste because they often contain materials that may be

harmful and can cause ill health to those exposed to it. A number of studies have indicated

that the inappropriate handling and disposal of healthcare waste poses health risks to health

workers who may be directly exposed. Also people near health facilities, particularly children

and scavengers who may become exposed to infectious wastes with higher risk of diseases

like hepatitis and HIV/AIDS13,29-32.

Literature search revealed that most assessment of healthcare waste management was done at

public HCFs. Most of those studies were carried out in Primary Health Centers without

considering the different types of HCW that are generated in multi-specialist HCFs. This has

introduced a gap in knowledge of what is being done in the private HCFs in terms of proper

HCW management. No study in Port Harcourt had compared HCWM in government and

private HCFs. It will be therefore, worthwhile to investigate how HCW is being managed by

both government and private specialist HCFs in Port Harcourt where best practices are

expected. It is important also to assess how HCWM is carried out in these HCFs. This will

show whether the public or the private specialist HCFs have better approach to HCWM in

compliance to HCWMP.

The assessment of HCWM practices by the health workers will contribute to information

essential for accurate planning and implementation of intervention programs to reduce

mortality and morbidity associated with poor HCWM.

1.4 Research Questions

1. Is there any difference in healthcare waste management in public and private specialist

healthcare facilities in Port Harcourt?

2. Is healthcare waste management carried out in compliance with national healthcare

waste management plan/guideline in the selected public and private specialist

healthcare facilities in Port Harcourt?

1.5 Objectives

General :

To assess and compare the healthcare waste management practices in the selected public and

private specialist healthcare facilities in Port Harcourt, Rivers state.

Specific :

1. To quantify and compare the amount of healthcare waste generated in the selected

public and private specialist HCFs in Port Harcourt.

2. To assess and compare the knowledge of HCWM by the healthcare workers in the

selected HCFs.

3. To assess and compare attitude of healthcare workers to HCWM in the selected HCFs

4. To determine and compare HCWM practice by the healthcare workers in the selected

HCFs

1.6 Research Hypothesis

1. Null hypothesis (H0 ) : There is no difference in the healthcare waste management in

public and private specialist healthcare facilities in Port Harcourt.

2. Alternative hypothesis ( H1 ) : There is difference in the healthcare waste management

in public and private specialist healthcare facilities in Port Harcourt.

CHAPTER TWO

LITERATURE REVIEW

2.1 Overview

Healthcare waste (HCW) is described as waste generated by health care establishments,

research facilities and laboratories. It also includes waste generated in the course of

healthcare activities rendered at homes 33 or general health care wastes generated in the

course of administrative and housekeeping functions of healthcare establishments 33.

Healthcare waste management (HCWM) involves activities from generation of waste to final

disposal. It includes those measures taken in the generation, characterization, quantification,

storage, handling, collection, transportation, and disposal of wastes. It also covers

managerial, technological and control measures involved in the HCWM practices as well as

the continuous plan towards ensuring sustainable waste management within a locality like

Port Harcourt 34, 35.

Healthcare wastes are categorized into non-risk (which are general HCWs) and hazardous

wastes. Non risk HCWs include all wastes that have not been contaminated with infectious

materials or other hazardous materials. United Nations Environmental Programme (UNEP)

recommends that wastes such as gloves, gauze and dressings materials that have not been

contaminated be considered as general HCWs. This HCW category is considered as domestic

waste and can be managed as general wastes by municipal waste services33.Hazardous

healthcare waste is of primary concern in Nigeria and the world, due to its potential to cause

infections and diseases. Precise definitions of types of HCW takes into account the associated

hazards of such wastes 36. The hazardous nature of HCW may be due to the fact that it

contains infectious agents, sharps, toxic or hazardous chemicals or pharmaceuticals and

radioactive materials.

Healthcare waste consists of diverse materials which are categorized as infectious waste,

pathological waste, pharmaceutical waste, genotoxic waste, radioactive waste and sharps.33, 36

WHO estimated that, in 2000, injections with contaminated syringes caused 21 million

hepatitis B virus (HBV) infections, 2 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 syringe 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 37.

The HCW handling stages include waste minimization at source of generation and recycling,

sorting receptacles (colour coded ) and collection, storage, treatment, transportation and final

disposal 38-40.

2.2 Healthcare waste generation and quantification

The basic step in healthcare waste management is quantifying and qualifying the different

types of HCW being generated. This involves measurement and characterization of HCW.

This process was followed by studies carried out in Port Harcourt41 and Jos42, Nigeria. It is

important to have a system that is developed for the collection and analysis of basic

information about HCW 43. The data needed are the quantities of HCW generated, their

composition and characteristics. This information gives the basis for the development of

appropriate HCWM plan. Data collection and management should be a continuous exercise

to enable monitoring and evaluation for future and long term planning and decision making in

matters related to healthcare waste management 44.

Quantification of the HCW generated in healthcare centres depends on type of HCF and

availability of instruments for measurement. The economic, social and cultural orientation of

the patients might change the amount of HCW generation. The higher number of day-care

and in-patients in public HCFs, may lead to generation of larger amount of HCW in them

than private healthcare facilities 44. As a result of higher number of patients care, public

HCFs may produce more healthcare waste than private hospitals. This may not be the case for

specialist public and private HCFs since the sub-specialties and number of patients are almost

the same. However, total waste and the proportion of clinical waste per bed may be similar in

both public and private HCFs 44. The healthcare waste generation rate depends on the size

and the type of the medical institution, but also it differs from country to country based on the

level of economic development. The developed countries generate higher amounts of

healthcare waste than that of the developing countries. Data from World Health Organization

also reveal that North America produces 7–10kg of healthcare waste per bed/day, whereas

South America produces 3 kg of waste per bed/day. This difference was also found in Europe

and Asia. Western Europe produces 3–6 kg, whereas Eastern Europe 1.4–2 kg of waste per

bed/day. In Asia, richer countries produce 2.5 kg per bed/daily, and poorer countries 1.8–2 kg

per bed/daily 45. From the available data it is evident that amount of healthcare waste

generation rate depends on the level of economic development of the region. It has also been

noticed that, due to higher level of economic development, the North America produces

larger amount of healthcare waste when compared with the other parts of the world. This may

be due to the developed nation’s lifestyle demands, consumption of a high amount of goods

and services which tend to generate a higher amount of waste. Furthermore, the use of

disposable instruments and packaging materials rather than the use of reusable items in HCFs

in developed countries has increased the amount of healthcare waste generation. In contrast,

the proportion of healthcare waste generation rate among total waste in healthcare facilities

depends on several factors such as waste management plan, segregation activities at waste

generation source. Waste generation source, quantity and quality of waste generation are the

key issues to decide an effective healthcare waste management practice. It is important to

minimize waste generation rate at each generation source. On this basis, appropriate

segregation and sorting of healthcare waste at generation source can be an effective solution

45.

Recent study in Nigeria has estimated an average waste generation of between 0.562 to 0.670

kg/bed/day and as high as 1.68 kg/bed/day 16. A study in a public HCF in Abuja, Nigeria,

showed an average waste generation rate per bed/day was determined and found to be 2.78kg

of solid waste. Measurement at the central storage site showed that 26.5% of the total waste

was hazardous in nature 38. A report showed comparable values, for Denmark (25 %) and for

New York City (28 %)46,47. This variation may be due to differing living habits and standards,

availability of different treatment facilities, geographical location and perhaps the ways in

which solid wastes are segregated and categorized in the different countries 46.

In another study in a specialist private HCF in Abuja, the average healthcare waste generation

rates were in the range of 1.053kg/bed/day to 2.290kg/bed/day. Similar ranges have been

reported for Dhaka City (0.8kg/bed/day to 1.67 kg/bed/day), Amsterdam (2.7kg/bed/day) and

Paris [2.5kg/bed/day 48. However higher ranges 1.0kg/bed/day to 4.5kg/bed/day were

documented for New York City, Chile, Brazil, Argentina, and Venezuela 49 and in Ibadan,

Nigeria (1.0kg/bed/day to 1.50kg/bed/day) 50. When the rates of HCW generation in Abuja

and Ibadan are compared, It shows that the rate is higher in Abuja50. This could be attributed

to level of economic activities and development in Abuja, being the capital city of Nigeria.

This confirms the fact that level of economic activities and development contribute a lot to

quantity and quality of HCW generation 45.

In a survey conducted in Abuja, the average generation rates per bed per day was lowest at

the ENT unit (0.08kg/bed/day) and highest at the labour ward (57.7kg/bed/day) 51. The

considerable smaller quantities of solid wastes generated at the ENT clinic is not surprising

given the fact that the kind of therapy usually prescribed here does not lead to generation of

much wastes. The variation in the waste generation rate from one ward or unit to another

within each health institution obtained is as expected, since this depended on the nature of

activities in a specific ward or unit 49. Majority of the patients attended to at the injection

rooms were out patients, generating typically light weight wastes such as needles, syringes;

whereas relatively heavy and moisturized wastes such as soaked swabs, gauze, pads,

disposable napkins were generated by the largely in-patients at the labour ward. Similar

reason accounts for the high value of waste generation rate at the neonatal and postnatal

wards of other HCFs surveyed in Ibadan 50. From the above findings, quantities of different

HCW depend of the medical services rendered by the sub-specialties in the HCFs. This is

why this study is undertaken in specialist public and private HCFs to ensure that HCW

generation and quantification in major sub-specialties are covered.

2.3 The knowledge of HCWM by health workers

The knowledge of HCWM by the health workers is very important as this enhances the

overall aim of HCW management. In health institutions, the business of HCW management is

usually left in the hand of cleaners and waste disposal contractors. Other health workers do

not know much about HCWM. In a study carried out in Abuja, it was found that waste

handlers and health workers had poor knowledge of HCWM in many hospitals surveyed 38. A

study in Abuja reported a similarity in poor knowledge of HCW data and management in two

general hospitals. This was characterized by poor waste segregation practices and lack of

instructive posters on waste segregation and disposal of HCW with general waste 42. The

mismanagement of healthcare waste poses health risks to people and the environment by

contaminating the air, soil and water resources. Hospitals and healthcare units are supposed

to safeguard the health of the community. However, healthcare waste if not properly

managed can pose an even greater threat than the original diseases themselves 31. A study of

HCW management in Jos Metropolis, Nigeria has demonstrated that the knowledge of health

workers in waste management options in the hospitals did not meet the standard 42. The

findings in these studies showed poor knowledge of HCWM among the health workers. Lack

of knowledge of HCWM implies that the attitude and practice of the health workers will also

be poor. One needs to be aware of the principles of HCWM before developing good attitude

and belief towards it. The practice of HCWM cannot be possible without being aware of the

guidelines, principles and procedures. In a study carried out in Pakistan, data analysis

showed that doctors and nurses had better knowledge of HCWM than sanitary workers and

paramedics. This may be attributed to higher training of the doctors and nurses. It implies that

the more educated health worker (HW) is more li2kely to be knowledgeable. The HW will be

more willing to read HCWM instructions and wall posters and become more equipped for

proper HCWM. Mostly doctors (68%) were aware of segregation of infectious HCW at

source as per WHO guidelines, while there was poor knowledge among sanitary workers and

paramedics 52,53 . In a study in South Africa, it was observed that training was essential to

acquiring knowledge of HCWM 54.The need for HW training on HCWM before HCW

handling was highly emphasised in another study 55. This shows that with training on

HCWM, great knowledge could be imparted to health workers to improve their practice

irrespective of their professional disciplines.

In another study carried out in a general hospital in Onitsha, Anambra State, Nigeria, 90% of

doctors, 90% of nurses, 87% of pharmacists, 83% of laboratory staff and 58% of healthcare

attendants knew about waste segregation 56. HCW segregation at source of generation was

known by 80%, 70%, 50%, 90% and 5% of doctors, Nurses, pharmacists, laboratory staff and

healthcare attendants respectively. All the doctor respondents knew about injury from poor

HCWM. Only 35% of healthcare attendants possessed the same knowledge. This is contrary

to another study carried out in HCFs in Southeast Nigeria where there was no significant

difference in knowledge of risks of improper HCWM among the health workers due to lack

of training 57.

In the same study, 57% of doctors, 53% of nurses and 50% of healthcare attendants knew

that sharps should be separated from other HCW. Seventy five percent (75%) of pharmacists,

90% of laboratory staff and 69%of healthcare attendants knew about colour coded bins 56.

Furthermore, 80%, 60%, 40%, 60%, and 30% of doctors, nurses, pharmacists, laboratory staff

and healthcare attendants respectively knew about the type of HCW disposed in the landfill,

while 85%, 50%, 20%, 50% and 20% of doctors, nurses, pharmacists, laboratory staff and

healthcare attendants knew about the HCW disposed using incinerator 56. Concerning

segregation of HCW at source as the best method, only 80% of doctors, 70% of nurses, 50%

of pharmacists, 90% of laboratory staff and 5% of healthcare attendants had that knowledge

56.

In assessment of good knowledge for HCWM, it was reported in studies in India58 and

Bangladesh59 that 34% and 4% of HWs respectively had good knowledge of HCWM. Good

knowledge of HCWM is a pre-requisite to curbing the high risk and burden of transmission

of infectious diseases and other health issues which are associated with poor HCW handling

60. The findings above reveal that those in higher education cadre have better knowledge of

HCWM. The translation of this knowledge into good attitude and practice will be justified at

the end of the study.

2.4 Attitude of healthcare workers to HCWM

The attitude of different cadres of healthcare workers towards the recommended HCWM is

very important in ensuring health and safety of the HCW handlers. The willingness of health

workers to practice HCWM is needed to safeguard the health of patients, health workers

themselves and also protect the hospital environment and host community. The willingness to

practice HCWM may not be enough but the ability to recommend to others colleagues to do

the same.

In a study in a teaching hospital in south east Nigeria, 94% of the respondents believed that

proper HCWM is beneficial to health workers. This is also similar with perception of benefit

to the patients and community 52. It was also ascertained that no difference was observed on

whether respondents thought that unsafe HCWM had no harm on the waste handlers or posed

any danger to the community or whether it was environmentally friendly 52. About 80% of

the total respondents believed that it was proper to use colour coded bins and liners for safe

HCWM 52.

In a study in Pakistan, majority of doctors (65%) and nurses (60%) had good attitude

regarding the HCW throw in the proper colour coded waste bin, compared to the paramedics

(20%) and sanitary workers (10%) 53.

A study in Anambra State, Nigeria, the proportion of doctors, nurses, pharmacists, laboratory

staff and healthcare attendants that displayed positive attitude to containment of sharps were

40%, 30%, 50%, 33% and 40% respectively 54. This was contrary to a report in a study in

Bayelsa, Nigeria where HCW disposal behaviour of some HCFs showed lack of adoption of

standard HCWM guidelines 61.

2.5 HCWM practice by the health workers in HCFs

2.5.1 HCWM practice in HCFs in Nigeria

In developing countries like Nigeria, where many health concerns are competing for limited

resources, it is not surprising that the management of healthcare wastes has received less

attention and the priority it deserves 20. Unfortunately, practical information on this important

aspect of HCWM is poor and research on the public health implications of improper HCWM

are few 20. Although reliable records of the quantity and nature of healthcare wastes and the

management techniques to adequately dispose of these wastes have remained a challenge in

many developing countries of the world, it is believed that several hundreds of tonnes of

healthcare waste are deposited openly in waste dumps and surrounding environments, often

alongside with non hazardous solid waste 19,20. A near total absence of institutional

arrangements for HCW disposal in Nigeria has been reported by other studies 30.

In a study in a general hospital in Anambra state on the respondents’ general practice of

HCWM, 80% of them always dispose HCW into appropriate receptacles, while 87% of the

respondents cover the bin after disposal 54. Also, 17% of the respondents said that they wear

personal protective equipment (PPE) when handling HCW, 45% of them said they do so

occasionally while 38% rarely wear PPE. Other studies showed that the use of PPE was

associated with low level of occupational hazards 52.

Healthcare waste which is particularly dangerous is best disposed of by incineration.

Incineration is practiced in several of the industrialised countries, particularly in large cities

due to lack of suitable land 45. A recent study in Abuja, assessed the management of solid

medical wastes. Results indicated that 18% of healthcare institutions incinerate their solid

wastes in locally built brick incinerators without adequate protection to the environment;

36.3% of the institutions simply disposed off their wastes into the Abuja municipal dumpsite,

these wastes were found not to be treated before dumping.38 In another study in Abuja 18.3%

of the hospitals incinerated waste in a locally built brick incinerator; 9.1% bury; 36.3% burn

waste in open pits while 36.3% dispose of a waste into municipal dumpsites 38.

In a recent study in Ebonyi State, Nigeria, it was reported that 1.8% of HCFs complied to

HCWM plan 83. This report was not different from the previous reports as seen above.

2.5.2 HCWM practice in HCFs in Rivers state

In a study carried out in Port Harcourt, 57.6% of healthcare facilities have healthcare waste

dumpsites. About 83.1% of the respondents in the study acknowledged cases of reported

nosocomial diseases in their healthcare facilities while 23% admitted that their HCF have

waste management units 41. The study revealed that majority of the HCF in Port Harcourt

lacked functional waste management units, incinerators and dumpsites.41

In 2013, Rivers State Waste Management Authority (RIWAMA) was established by the

Rivers State House of Assembly to take over from Rivers State Environmental Sanitation

Authority (RSESA) in the management of municipal wastes in the state. Presently, the Rivers

State government has come up with a framework for establishment of incinerators at

designated areas in the state to take care of hazardous wastes being generated from various

HCFs. There is an established legislation by the Rivers State government to ensure strict

compliance to proper HCW disposal by HCFs.

2.5.3 The reality of improper HCWM practices

Healthcare waste should be properly handled and disposed, to avoid risks to the healthcare

staff patient, the public and the environment. Consequently, many developed countries have

devised codes of practices and guidelines for handling and disposal such waste. Although

significant progress has been made, yet it still requires further modification in all aspect of

health waste management practices. The management of clinical solid waste is considered as

problematic due to its enormous volume of generation, serious threat for the human health as

well as disposal cost 41.

HCW is defined as any waste that is generated in the diagnosis, treatment, or immunization

of human beings or animal, in research pertaining thereto, or testing of biological, including

but not limited to: soiled or blood-soaked bandages, culture dishes and other glassware. It

also includes discarded surgical gloves and instruments, needles, lancets, culture, stocks and

swabs used to inoculate cultures and remove body organs. Healthcare waste may contain

potential pathogenic microorganisms’ .Therefore, HCW is perceived by many as hazardous

or infectious. Besides, there is a possibility of the contamination of non-healthcare waste with

infectious agents during unsafe handling, collection, storage and transportation. Hence,

effective attention must be placed during treating healthcare waste so that clinical waste

cannot mix with non-clinical waste during waste management. Consequently, clinical solid

waste should be properly handled, stored, transported and disposed of in order to safeguard

public health and to prevent environmental pollution 41.

Infectious pathogenic micro-organisms may infect the human body during unsafe handling

via direct contact (puncture, abrasion or cut in the skin) or indirect contact (mucous

membranes, inhalation or ingestion). Caution should be applied while handling sharp items

because they represent the most acute potential hazards to our health. In developing

countries, hazardous HCW has been handled and disposed together with the non-hazardous

HCW, which has created inevitable risks to the healthcare workers, the community and the

environment. WHO in 2002 conducted an investigation survey on management of healthcare

waste in 22 developed countries. Results showed that the proportion of HCFs that do not use

proper waste disposal methods ranges from 18% to 64% 49.

Studies reported that healthcare workers are not educated enough and most of them have not

had any special training on the segregation of HCW 68. This contrary to another report where

most HWs agreed that segregation of HCW should be at the point of generation 64. Most of

the healthcare institutions do not have appropriate colour coded bags or containers for sorting

the different types of waste. 65,66. Some of the HCFs in Nigeria and Mongolia used plastic

bags, paper bags or card board boxes to collect the clinical solid waste. Besides, HCW are not

sorted because of the high fee of their disposal cost, therefore, both clinical and non-clinical

waste are mixed together and dump illegally. Even most of the hospitals have no special

place for the storage of the HCW prior to disposal. Wastes are placed in an unsecured area

until collected and is fully accessible to the animals and scavengers 67-68.

2.5.4 Healthcare waste management plan/guideline

The objective healthcare waste management plan (HCWMP) is to provide an approach to the

management of HCW that is safe for HCFs, waste handlers, the public and the environment

as well as being cost effective and practical 68.

The process of HCWM involves the collection of different kinds of waste (from waste

storage bags/containers) inside the HCF, transportation of HCW within the HCF,

intermediate storage of segregated waste inside the premises of the HCF, transportation of the

waste outside the HCF (to the treatment/disposal facility) 68.

HCWMP involves the following procedures which include : storage of HCW at the point of

generation, recommended labelling and colour coding, certification and labelling of

biohazards, collection of waste inside the HCF, transportation of segregated HCW within the

HCF and transportation of HCW outside the HCFs for final disposal 68,69.

Various methods of HCW disposal are used which include open dumping and open burning

of the HCW, incineration, land fill, autoclaving, microwave and chemical disinfection 69.

Open dumping has been criticized because it has been recognized as potential source of

infections to the public and environmental pollution 69. Incineration is accepted world wide

as better means of treating and disposing HCW. It is also a good HCW disposal option for

wastes that cannot be recycled, reused or disposed by land fill 69. Landfill method of HCW

disposal should be properly managed to avoid health risk, infections and environmental

pollution 69 .

The disposal of HCW must be in accordance with the stipulations of Basel conference which

emphasizes the need to abide by the principle of duty of care, polluter pays principle and

precautionary principle 69.

Duty of care principle stipulates that any organisation that generates waste has a duty of care

to dispose of the waste safely. Therefore it is the HCF that has ultimate responsibility for how

waste is containerized, handled on-site and off-site and finally disposed of 69. Polluter pays

principle states that all waste producers are legally and financially responsible for the safe

handling and environmentally sound disposal of the waste they produce. In case of an

accidental pollution, the organisation is liable for the costs of cleaning it up. Therefore if

pollution results from poor management of health-care waste then the HCF is responsible 69.

Precautionary principle ensures that one must always assume that waste is hazardous until

shown to be safe. This means that where it is unknown what the hazard may be, it is

important to take all the necessary precautions 69.

2.5.5 The practice of sharp waste management by the health workers

Sharps are defined as comprising of needles, syringes, scalpels, blades and glasses. Sharps

are objects that may cause puncture and cuts. From their designs in the 1800s by Pravaz and

Woods, the syringe and needle have evolved from being an essential drug delivery

technology to a risk of transmitting infectious diseases and of illicit drugs use 69. Safe

injection practice is defined as injection that does not harm the recipient, does not expose the

healthcare provider to any avoidable risk, and does not result in waste which is dangerous to

other people 70. According to estimates produced for the 2003 Global Burden of Disease

Study, unsafe injections are responsible every year worldwide for 21 million new hepatitis B

cases (HBV), 2 million hepatitis C infections (HCV), and 260,000 HIV infections 71

. Review of HBV and HBC outbreaks that occurred in a variety of

healthcare settings in the United States (US) showed that, from 1998 to 2009, there were 51

outbreaks involving the notification of more than 75,000 potentially exposed patients and

identification of 620 who became infected with HBV or HBC 72. The majority of these

outbreaks resulted from unsafe injection practices and lapses in adherence to universal

precaution in sharp waste management 73. This portend that, even in wealthy countries such

as the US, the challenge of consistently providing safe care is not always met, as evidenced

by increasing reports of outbreaks associated with unsafe 2injection practices and related

breakdown in basic infection control 72.

The Federal Ministry of Health (FMOH) in Nigeria has introduced the National policy on

injection safety and healthcare waste management 74. Injection safety practices among health

workers are still poor. Studies from China showed 16% unsafe injections 75. Furthermore,

poor injection safety practices have been reported in both therapeutic and immunization

service delivery 67,75,76. Tertiary hospitals not only provide these services but are also centers

for training of healthcare cadres who would in turn practice at other levels of healthcare

provision including private healthcare facilities. Most assessment of injection safety practice

and sharp waste management were done at public HCFs with little or no effort to assess the

practice in private HCFs.

2.5.6 Making medical injection safer (MMIS) project in Nigeria

Safety boxes are inexpensive, puncture-proof cardboard containers used for the safe disposal

of sharps waste, including used needles and syringes. Ensuring the availability of supplies of

safety boxes is essential to the prevention of HIV and other blood-borne disease transmission

through safe disposal of sharps. A 2004 national injection safety assessment conducted by the

Making Medical Injections Safer project (funded by the U.S. President’s Emergency Plan for

AIDS Relief (PEPFAR) through the U.S. Agency for International Development) and in

collaboration with the Federal Ministry of Health, found that nearly two-thirds of health

facilities did not have a safety box available. In response, the project introduced safety boxes

into curative health services and trained facility staff on how to use them77.

The Federal Ministry of Health in collaboration with John Snow Incorporated is

implementing the Making Medical Injection Safer (MMIS ) project in Nigeria 77.The

initiative under the PEPFAR is to significantly reduce infections especially HIV, Hepatitis B

and C infections from medical injections. A three pronged approach as specified by WHO

Safe Injection Global Network (SIGN) is adopted as strategy to achieve the MMIS

objectives. This approach includes changing the behaviour of healthcare workers and patients

to ensure safe sharp disposal practices, ensuring availability of equipment and supplies, and

managing HCW safely and effectively 77.

In a study carried out in Lagos, there was noticeably poor and incorrect disposal of sharps in

all the HCFs visited for the study 77. Needles and syringes were disposed immediately after

use by recapping the needles or bending before disposing it. Sometimes, after treatment, the

nurses hand over used syringe and needle to patients to discard. Majority of healthcare

workers were unaware of the hazard or health implication of poor HCW disposal and

management 77. The dangers associated with poor sharp disposal include children playing and

hurting themselves with it. It could pierce the shoes of adults and prick them. There could be

left over injections fluids in the syringes which could have expired and become poisonous.

Infections like HIV, HBV and HCV can be contracted as a result of blood trapped in the

needles and syringes 77.

According to national cross-sectional survey conducted in 2004 among 80 HCFs, about

62.5% of the HCFs were observed not to have sharp/safety boxes in use and 23.5% had no

injection rooms. The syringes and needles used for injections were simply discarded into

general HCW bin 77. A study carried out by FMOH and John Snow Incorporated showed that

65% of HCFs surveyed in Lagos had sharp objects disposed on their premises and other

unsupervised areas, there by exposing the community to needle stick injuries and infections

77.

2.5.7 The burden of diseases due to poor sharp waste management practices

The use of injections in low-income country health settings is common-place. The estimated

number of injections per person per year amongst a sample of 13 low-income countries

ranged between 1.2million (in Tanzania and India) and 8.5million with a median of

1.5million 78. For eight of these countries, 25-96% of outpatient visits resulted in at least one

injection, and for five of these countries, 70-99% of the injections given were judged

unnecessary. The most common parenteral medications are vitamins, antibiotics, analgesics

and quinine, which are sometimes given inappropriately for upper respiratory diseases,

diarrhoa, fever or general fatigue 78.

Acknowledgement of the contribution made by unsafe sharp disposal practices to the blood

borne viruses in low-income countries has been slow to emerge. Most infections caused by

unsafe disposal of injection materials are likely to go unnoticed because they are rarely

associated with symptoms at the time of infection, or symptoms are rather non-specific. The

long incubation period between the time of infection and the development of the sequelae

such as HIV/AIDS means that the connection between the disease and the exposure to the

infected sharp months or years earlier is unlikely to be made.

The number of HBV, HCV and HIV infections attributable to poor sharp waste management

practice in low-income countries has been calculated as 8-16 million HBV, 2.3 – 4.7 million

HCV and 80,000 – 160,000 HIV infections globally every year 79 .The World Health Report

(2002) reports that poor sharp waste management practices account for 305 of HBV

infections, 31% of HCV infections, 28% liver cancer, 24% of cirrhosis cases, 5% of HIV

infections and 0.9% deaths worldwide 80.

Patients, Healthcare workers, healthcare waste management personnel, communities,

intravenous drug users are at higher risk of being infected than the general population. It has

been reported that one of the factors that predispose the healthcare workers, patients and

communities is inadequate supply of appropriate sharp containers 80.

2.5.8 The place of standard precaution

In 1985, largely because of the emergence of HIV/AIDS, guidelines for protecting healthcare

workers from becoming infected with HIV and other blood borne infection like HBV were

developed and became known as Universal Precautions (UP) 66.The new guidelines issued by

CDC in 1996 involve a two-level approach: Standard Precautions, which apply to all patients

attending HCFs and Transmission-Based Precautions, which apply only to hospitalized

patients 81. Most people with blood borne viral infections such as HIV and HBV do not have

symptoms, and therefore, cannot be visibly recognized as being infected. Standard

Precautions are designed for the care of all persons including the patient and care giver,

regardless of whether or not they are infected. Standard Precautions apply to blood and other

body fluids, non-intact skin and mucous membrane 77. The implementation of standard

precautions is meant to reduce the risk of transmitting microorganisms from known to or

unknown sources of infection, example; patients, contaminated objects not properly disposed

and needles and syringes that are not disposed in puncture-proof sharp containers within the

healthcare system. Applying standard precautions has become the primary strategy to

preventing nosocomial infections in hospitalized patients.

CHAPTER THREE

MATERIALS AND METHODS

3.1 Study Area

This study was conducted in Port Harcourt. The research work was embarked on to compare

the variations and similarities in the activities of HCW management within public and private

specialist healthcare facilities (HCFs) located in Port Harcourt. The specialist HCFs were

chosen for the study because of patient load and the sophistication of the procedures carried

out in these HCFs which were more likely to generate more hazardous wastes. These

specialist HCFs rendered medical services like paediatric care, obstetrics and gynaecological,

surgical and radiological services that generated HCWs that were specific to such facilities.

Port Harcourt is the capital of Rivers State, which is one of the thirty six states in Nigeria and

lie within the south-south geopolitical zone. It is among the states that constitute the oil

producing Niger-Delta. Rivers State has a total of 23 Local Government Areas (LGAs)

occupying an area of over 470km2 in Niger Delta with a total population of 5,198,716 82. It is

bounded in the south by the Atlantic Oceans, the north by Imo, Abia and Anambra states, the

east by Akwa-Ibom state and the west by Bayelsa and Delta states. Port Harcourt being the

capital of Rivers State is cosmopolitan in nature and harbours people of different ethnic and

racial backgrounds.

3.2 Study Design

The study was a comparative cross sectional study. Data collection was done using

quantitative and qualitative methods. The quantitative method was carried out using

structured interviewer-administered questionnaire. The questionnaires were administered to

the health workers of the HCFs in the category of doctors, nurses, pharmacists and staff of

laboratory departments, and waste handlers. Field observation of HCW generation rate and

quantification in both public and private specialist HCFs was also carried out.

Qualitative method was done by conducting key informant interview, field observation and

use of checklist. The key informant interview was conducted for the hospital administrators

and heads of each unit in both the public and private specialist HCFs. The interview was on

the HCWM policy, budgeting and training of staff on HCWM. Field observations on

implementation of healthcare waste management plan (HCWMP) based on six thematic areas

of HCWM criteria was carried out using check list.

3.3 Study Population

The study population included health workers of the HCFs in the category of doctors, nurses,

pharmacists, staff of laboratory departments, HCF administrators, heads of units and waste

handlers. The study population also included the specialist public and private healthcare

facilities. The specialist public HCFs are owned by the federal and state governments while

the specialist private HCFs are owned by individuals

Inclusion criteria (Staff )

1. The health workers of the HCFs (doctors, nurses, pharmacists and staff of laboratory

departments) who have actively been involved in providing clinical services for up to

one year.

2. Staff involved in waste management in the HCFs

3. Top management staff of the HCFs

Exclusion criterion (Staff )

1. Health workers that are no longer actively involved in providing clinical services in

the HCFs.

Inclusion criteria ( facility )

1. The public specialist HCFs located in Port Harcourt that render specialist medical

services in obstetrics and gynaecology, surgery, paediatrics, internal medicine with

laboratory/pharmacy and should have in-patients services and facilities.

2. The private specialist HCFs located in Port Harcourt that provide specialist medical

services in obstetrics and gynaecology, paediatrics, internal medicine, surgery with

laboratory/pharmacy and should have in-patients facilities.

Exclusion criteria (facility)

1. Specialist HCFs that do not provide services in all the four clinical specialties

2. Specialist HCFs that lack in-patient, laboratory, or pharmacy facilities.

3.4 Sample size determination

The formula for calculating sample size for comparison of two proportions was used to

determine minimum number of staff to be interviewed.83,84

n = [Z1-α √ 2p (1-p) + Z1- β √ p1 (1-p1) + p2 (1-p2) ] 2

(p1-p2) 2

Where

n = Minimum sample size for each group

Z1-α = Standard normal deviate corresponding to the probability of making type I error (α)

at 5% = 1.96

Z1- β = Standard normal deviate corresponding to the probability of making type II error (β)

of 20%. Power at 80% = 0.84

p1 = Proportions of healthcare workers with knowledge of HCWM from the public

specialist HCF was 90% from a similar study in Anambra State, Nigeria

p2 = Proportions of healthcare workers with knowledge of HCWM from the private

specialist HCF, assuming a difference of 10% between public and private specialist

HCF

p = Mean of the two proportions- (p1+p2)/ 2

In a study done in Anambra State Nigeria, it was reported that the knowledge of HCWM

among health workers was 90%74. With a difference in HCWM knowledge of 10% between

public and private specialist HCFs; p1 = 90%, p2 = 80%

p = (90+80)/2 = 170/2 = 85%

n = [1.96 √ 2(85) (100-85) + 0.84 √ 90 (100-90) + 80 (100-80)]2

(90-80)2

n = 99.35 per group, approximated to 100 per group

Therefore minimum sample size for each group will be, n = 100

Adjustment for population <10,000 using finite population correction formula84

The total number of health care workers in public and private specialists HCF in Port

Harcourt is approximately 3600 from the record obtained at AGPMPN and Rivers State

hospital board.

Adjusted sample size for population <10,000 = n0 N

n0 + (N-1)

where n0 is minimum sample size (100); N=total population (3600)

N= (100) (3600) = 97.3

100+ (3600-1)

Allowance for non-response rate; assuming a 10% non-response rate from the staff. The

sample size thus becomes; 97.3/0.9= 108

This is the sample size for one comparison group. Therefore, the total sample size = 108 x 2

= 216

3.5 Sampling technique

Stage I: Facility selection

3.5.1 Public specialist healthcare facilities

The only two public multi-specialist healthcare facilities in Port Harcourt which met the

inclusion criteria for public specialist HCFs were therefore selected for the study. They

included University of Port Harcourt Teaching Hospital (owned and managed by the Federal

Government of Nigeria) and Braithwaite Memorial Specialist Hospital Port Harcourt (owned

and managed by the Rivers State Government).

3.5.2 Private specialist healthcare facilities

The list of private specialist healthcare facilities in Port Harcourt was collected from the

office of the Association of General and Private Medical Practitioners of Nigeria

(AGPMPN), Rivers State chapter. Seventeen out of a total of twenty five private specialist

HCFs in Port Harcourt met the inclusion criteria; from which a total of ten facilities were

selected using table of random numbers. Ten multi-specialists private HCFs were selected

based on the fact that the patient load of five multi-specialist private HCFs was equivalent to

one public tertiary HCF. This was because from the record at Hospital Board of Rivers State,

an average number of out-patients and in-patients seen and admitted on daily basis in public

specialist HCFs in Port Harcourt were about 330 and 120 patients respectively. In each

specialist private HCFs in Port Harcourt, an average number of out-patients and in-patients

seen daily were about 60 and 25 respectively.

3.5.3 Stage II: Selection of participants

The respondents for the study were selected using stratified and simple random sampling

methods. The health workers were stratified according to their professional groups: doctors,

nurses, pharmacists and laboratory staff, which amounted to four categories of health

workers. Then selection of health workers was done using simple random sampling via a

computer generated table of random numbers. There was a list of staff in each stratum in all

of the facilities. Then serial numbers were assigned to each staff in keeping with the order of

the list. Using the computer generated table of random numbers, participants were selected

daily from each stratum in proportion to sample size until the total sample size was reached

for both public and private HCFs.

The formula below was used to select the participants in proportion to sample size:

n = x/∑x X N/1

Where;

n =number of participants required to be selected from each group

x = number of participants in each group

N = Sample size

The number of heath workers from the public and private specialist health facilities was

collected from their labour unions and hospital authorities.

For the purpose of clarity, the tables below illustrated how the respondents were chosen in

proportion to sample size.

Table 3.5.1 : Selection of respondents in public specialist HCFs

Health workers

∑x

Sample size

N = x/∑x X N

Number of

respondents

selected

Doctors 600 1725 108 600/1725X108 37.6

Nurses 800 1725 108 800/1725X108 50.1

Lab. Scientists 170 1725 108 170/1725X108 10.6

Pharmacists 110 1725 108 110/1725X108 6.9

Waste handlers 45 1725 108 45/1725X108 2.8

Total 1725 108

Table 3.5.2 : Selection of respondents in private specialist HCFs

Health workers

∑x

Sample size

N = x/∑x X N

Number of

respondents

selected

Doctors 120 384 108 120/384X108 33.8

Nurses 170 384 108 170/384X108 47.8

Lab Scientists 40 384 108 40/384X108 11,3

Pharmacists 30 384 108 30/384 X108 8.4

Waste handlers 24 384 108 24/384X108 6.8

TOTAL 384 108

Sampling with the table of random numbers started from a randomly chosen number, after

which selection was from left to right of the computer generated table of random numbers.

Numbers encountered in the table of random numbers that were greater or less than the

assigned numbers were not be used. Participants whose numbers matched with those in the

computer generated list of numbers constituted the randomly selected samples for the study.

3.6 Data collection tools

The data collection tools and methods used in this study include

3.6.1 Quantitative

The data collection tool was adapted from the rapid assessment tool developed for sub-

Saharan African countries by the World Health Organization and the secretariat of the Basel

Convention of the United Nations Environmental Programme (UNEP) 85. This tool was a

healthcare waste management inventory questionnaire that was used in assessment of

HCWM.

The various methodologies which have been used all over the world to assess HCWM were

employed. They included the use of field observation, questionnaire administration 17, 51, 72

and use of public and private HCF records on healthcare waste management where

available18. The questionnaire tested the knowledge, attitude and practice of HCWM by the

health workers and waste handlers. The questionnaire for each section has a total score of

100%. Each correct answer attracted one mark. At the end of the interview, the percentage of

the total score was calculated. A score below 50% was taken as poor, below 70% as fair and

above 70% as good knowledge, attitude and practice respectively. The researcher quantified

HCW generated at the central dump site of each HCF. The quantity of wastes generated was

calculated by the researcher using filling rate of the big waste storage bins at the central waste

storage depot. The volumes of bins were noted. The weight of the waste was determined by

using a volumetric mass ratio of 0.30kg/L 47. The average of weekly HCW generation gave

the estimate for daily waste generation. HCW generation per bed was estimated by dividing

the daily HCW generation by the number of beds in the HCF 47.

3.6.2 Qualitative

Key informant interview was conducted for the hospital administrators and heads of each

unit in both the public and private HCFs. The interview took place in their various offices

upon notification and it focused on the HCWM policy, budgeting and training of staff on

HCWM. The key informant interview was documented using a recorder where permission

was granted or free-hand documentation where recording was declined. The checklist was

instrumental in the field observations on compliance to HCWMP. Each correct practice

attracted one mark and the percentage of total score was calculated. The level of

compliance/practice was scored and graded as poor(below 50%), fair(above 50%) and good

compliance/practice (above 70%).

3.6.3 Pre-test of data collection instrument

Pre-testing of the interviewer administered questionnaire was carried out among the health

workers of Federal Medical Center, Owerri and appropriate amendments were made

thereafter.

3.6.4 Training of research assistants:

Four resident doctors from University of Port Harcourt Teaching Hospital were my research

assistants. They were involved in the field work and data collection. They were trained for

one week on the concept of the study. Each question in the questionnaire was explained in

details before the commencement of the study. They were also trained on the checklist for the

field observation on compliance to HCWMP by the HCFs.

3.6.5 Duration of study

This study was carried out over three months period. The activities that were covered during

this period included data collection, analysis and dissertation write-up.

3.7 Data collection methods

3.7.1 Quantitative data

Quantitative data was collected by using interviewer-administered questionnaires. Quantities

of HCW generated by each HCF was estimated by using volumetric – mass ratio of

0.3kg/Liter.

3.7.2 Qualitative data

Qualitative data was collected by conducting key informant interviews for HCF

administrative staff and heads of units. Check list was used for field observations.

3.8 Data analysis

3.8.1 Quantitative data

Data was analyzed using Statistical Package for Social Sciences (SPSS) version 20.0

computer software. Tables and charts were used for data presentation. Categorical variables

were expressed as frequencies and proportions while numerical variables were summarized

using means ± standard deviations, medians and ranges. The differences in proportions were

compared using Chi Square test or a Fisher’s exact test when the expected cell value was less

than five in 20% or more of the cells. The differences in means were compared using

independent t-test. Statistical level was set at a p-value of 0.05.2

3.8.2 Qualitative data

The key informant interview was transcribed and coded. The transcript contained every

question asked. Pre - determined themes were used to code the transcripts, corresponding to

the main categories of interest. Manual content analysis was used to compare participants’

responses on the healthcare waste management. These themes answered some of the

questions raised by the research question 85. The unit of analysis were the themes that were

relevant to the research question. An inductive approach was assumed to make the data set to

be related to the themes generated; meaning that there was no pre-existing frame. After this,

common issues in these themes were highlighted; comparisons of the various accounts of the

interviewees were made and various patterns of HCWM in HCFs revealed 86.

3.9 Ethical approval

Ethical approval was sought from the Ethics Committee of the University of Port Harcourt

Teaching Hospital before the study commenced. Permission was sought and received from

the management of the specialist HCFs that were used in the study. All participants were

given a consent form, containing relevant information on the research and the study to be

done and those consenting were required to sign the document after they have been assured

of strict confidentiality. The participants were free to opt out of the study without being

penalised or victimised. No staff was penalised for refusal to participate in the study.

3.10 Limitations of the study

The daily evacuation of bins as prescribed in HCWMP was not practised by some HCFs

thereby, making it difficult to determine daily HCW generation in such HCFs on daily basis.

Measurement of the HCW generation was taken every three days in such HCFs. The daily

mean HCW generation was divided by the number of beds in such wards.

The incessant industrial actions by various trade unions during this study in public specialist

HCFs affected patients’ attendance, thereby influencing the HCW generation. This limitation

was circumvented by extending the period of data collection to the time the industrial action

was called off. Volumetric method of weighing the HCW was used instead of directly

weighing the waste. Five private specialist hospitals were selected for each of the two public

specialist HCFs used for the study. Standards in the private HCFs might be different, but had

to be pooled together because of small number of in-patient beds.

CHAPTER FOUR

RESULTS

A total of 265 questionnaires were administered, out of which 260 were sufficiently

completed for analysis, giving overall response rate of 98%. The health workers in public

HCF received 153 questionnaires and 149 were completed giving a response rate of 97.4%.

The health workers in the private HCF received 112 questionnaires and 111 were completed,

giving a response rate of 99.1%. Therefore, 57.3% of the respondents were from public HCFs

and 42.7% were from private HCFs.

The results were presented in the following sections:

Section 1: Socio-demographic characteristics of health workers

Section 2: Comparison of quantities of waste generated from public and private HCFs

Section 3A: Knowledge, attitude and practice of HCWM among health workers in public and

private HCFs

Section 3B: Comparison of sharp waste management practices among health workers in

public and

private HCFs

Section 3C: Assessment of implementation of HCWMP among public and private HCFs

Section 3D: Comparison of HCWM practice among waste handlers in public and private

HCFs

SECTION 1: SOCIO-DEMOGRAPHIC CHARACTERISTICS

Table 4.1.1 Categories of health workers ( HW)

Types of HCFs

Discipline

Public (n=149)

n (%)

Private

(n=111)

n (%)

Total

(n=260)

n(%)

Doctors 52 (34.9) 38 (34.2) 90 (34.6)

Nurses 62 (41.6) 59 (53.2) 121 (46.5)

Pharmacist 10 (6.7) 2 (1.8) 12 (4.6)

Laboratory scientist 25 (16.8) 12 (10.8) 37 (14.2)

Chi square = 6.743; p value = 0.081

A total of 149 and 111 healthcare workers in public and private HCF respectively responded to

the questionnaire. The healthcare workers in public HCFs consisted of 34.9% of doctors, 41.6%

of nurses, 6.7% of pharmacists and 16.8% of laboratory scientists. The healthcare workers in

private HCFs consisted of 34.2% of doctors, 53.2% of nurses, 1.8% of pharmacists and 10.8%

of laboratory scientists. There was no significant difference in the categories of health workers

in the study HCFs.(p = 0.081).

Table 4.1.2 Years of experience of health workers

Years of experience Public n (%) Private n

(%)

Total n

(%)

1 – 5 years 55 (36.9) 44 (39.6) 99 (38.1)

6 – 10 years 35 (23.5) 37 (33.3) 72 (27.7)

11 – 15 years 9 (6.0) 17 (15.3) 26 (10.0)

16 – 20 years 4 (2.7) 5 (4.5) 9 (3.5)

Above 20 years 46 (30.9) 8 (7.2) 54 (20.8)

Chi square = 25.584; p value = 0.0001*

*Statistically significant

Higher proportion of health workers in public 55(36.9%) and private 44(39.6%) HCFs had

worked in their chosen profession from 1-5 years. This was followed by 6-10 years work

experience in public 35(23.5%) and private 37(33.3%). However, those with work experience

of 20 years and above were more in public 46(30.9%) as compared with private 8(7.2%)

HCFs. The difference in proportion of work experience was statistically significant (p =

0.0001).

Table 4.1.3 Comparison of mean years of experience among health workers

Discipline

Public

Mean±S.D

Private

Mean±S.D

Independent

t-test

P value

Doctor 6.59±4.62 8.47±6.44 -1.568 0.121

Nurses 17.58±11.43 7.89±5.48 5.727 0.0001*

Pharmacist 8.78±12.56 12.50±3.54 -0.400 0.698

Laboratory scientist 4.81±6.04 6.25±6.47 -0.643 0.525

*Statistically significant S.D – Standard deviation

The mean years of experience among doctors in public and private HCFs were 6.59 ± 4.62

and 8.47± 6.44 respectively. The difference in mean years of experience among the doctors

was not significant (p = 0.121). The mean years of experience among nurses in public and

private HCFs were 17.58 ± 11.45 and 7.89 ± 5.48 respectively. The difference in mean years

of experience among nurses in public and private HCFs was statistically significant (p =

0.0001). The mean years of experience among the pharmacists in public and private HCFs

were 8.78 ± 12.56. And 12.50 ± 3.54 respectively. The difference in mean years of

experience among the pharmacists in public and private HCFs was not statistically significant

(p = 0.698). The mean years of experience among laboratory scientists in public and private

HCFs were 4.81 ± 6.04 and 6.25± 6.47 respectively. The difference in mean years of

experience among laboratory scientists in public and private HCFs was not statistically

significant (p = 0.525).

Table 4.1.4 Socio-demographic characteristics of waste handlers

Educational level

Types of HCFs

Public

n (%)

Private

n (%)

Total

n (%)

Primary 1 (33.3) 2 (66.7) 3 (50.0)

Secondary 2 (66.7) 1 (33.3) 3 (50.0)

Fishers exact p value = 1.000

Type of employment

Hospital staff 0 (0.0) 2 (66.7) 2 (33.3)

Contract staff 3 (100.0) 1 (33.3) 4 (66.7)

Fishers exact p value = 0.200

Among the waste handlers interviewed in public HCFs, 33.3% attained primary school

education and 66.7% attained secondary education. In private HCFs, 66.7% attained primary

school education and 33.3 attained secondary education. The difference in level of education

was not statistically significant (p < 1.000). In public HCFs, all the waste handlers were

employed as contract staff and in private HCFs, 66.7% were employed as hospital staff and

33.3% were employed on contract basis. The difference in their employment status was not

statistically significant (p = 0.200).

Table 4.1.5 Comparison of mean years of experience among waste handlers

Public HCF

n = 3

Private HCF

n = 3

t-test p-value

Mean ± SD 5.67±1.53 5.00±1.00 0.632 0.561

S.D – Standard deviation

The mean years of experience among the waste handlers in public HCFs were 5.67±1.53 and

5.00±1.00 in private HCFs. The difference in the mean years of experience was not

statistically significant (p = 0.561).

SECTION 2: QUANTITY OF WASTE GENERATED

Table 4.2.1 Comparison of quantity of HCW generated by public and private HCFs

Public HCF

Kg/bed/day

Private HCF

Kg/bed/day

t-test p-value

Mean ± 2.67±0.14 1.21±0.17 11.53 0.0001*

*statistically significant S.D – Standard deviation

The above table shows comparison of mean quantity of waste generated by public and private

health facility in Kg/bed/day.

The mean quantity of waste generated by public and private were 2.67± 0.14 and 1.21± 0.17.

The difference in mean quantity generated in both HCFs was statistically significant (p =

0.0001).

Fig 4.1 Box and Whiskers plot showing distribution of quantity of daily waste generated

per bed in public and private health facilities.

The minimum value of HCW generated by public health HCF was 2.0kg/bed/day while the

maximum was 3.4kg/bed/day. The first inter quartile and third inter quartile ranges were

2.5kg/bed/day and 2.8kg/bed/day respectively. The median HCW generated was

2.7kg/bed/day.

In the private HCF, the maximum value of waste generated was 1.9kg/bed/day while the

minimum value was 0.6kg/bed/day. The first inter quartile and third inter quartile ranges

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Public Private

Q u

a n

ti ty

o f

d a

il y

w a

st e

g e

n e

ra te

d p

e r

b e

d (

k g

)

Type of health facility

were 1.1kg/bed/day and 1.4kg/bed/day respectively. The median of waste generated was

1.2kg/bed/day.

SECTION 3A: KNOWLEDGE, ATTITUDE AND PRACTICE OF HCWM

Table 4.3.1 Comparison of correct knowledge of HCWM among health workers in

HCF

Variables

Types of

HCF

Public

n (%)

Private

n (%)

Total

n (%)

χ2 p-value

Correct knowledge of

segregation of HCW

133 (89.3) 101 (91.0) 234 (90.0) 0.211 0.646

Correct knowledge of use black

container for general HCW

103 (69.1) 91 (82.0) 194 (74.6) 5.549 0.018

Correct knowledge of container

for highly infectious HCW

130 (87.2) 107 (96.4) 237 (91.2) 6.602 0.010*

Correct knowledge of use lead

box / radioactive waste

84 (56.4) 99 (89.2) 183 (70.4) 32.858 0.0001*

Correct knowledge of needle

disposal

97 (65.1) 77 (69.4) 174 (66.9) 0.524 0.469

Correct knowledge disposing

sharps/ general waste

138 (92.6) 101 (91.0) 239 (91.9) 0.227 0.634

Correct knowledge that HCW

should be treated before disposal

88 (59.1) 84 (75.7) 172 (66.2) 7.843 0.005*

Correct knowledge of having

specific storage area in HCF

138 (92.6) 109 (98.2) 247 (95.0) 4.171 0.041*

Correct knowledge that storage

area of HCW should be secured

142 (95.3) 108 (97.3) 250 (96.2) Fishers 0.524

Correct knowledge of treating

HCW by chemical disinfection

and incinerator

127 (85.2) 104 (93.7) 231 (88.8) 4.593 0.032*

Correct knowledge of HCW

disposal by incinerator and land-

fill technique

119 (79.9) 100 (90.1) 219 (84.2) 5.006 0.025*

*Statistically significant

Higher proportion of healthcare workers in both public 133(89.3%) and private 101(91.0%)

had correct knowledge of HCW segregation. The difference in proportion was not

statistically significant with p-value of 0.646. The private group 91(82.0%) had good

knowledge in the use of black container for general waste compared to the public group

103(69.1%). The difference in proportion was statistically significant, (P = 0.018).

Health workers in private HCFs 107(96.4%) had better had knowledge of the use of red

containers for highly infectious waste as compared to the public 130(87.2%). The difference

in proportion was statistically significant, (p = 0.010).The private group of health workers

99(88.2%) had good knowledge of use of lead box for radioactive waste compared to public

group 84(56.4%). The difference in proportions was statistically significant, (P=0.0001).

Both health workers in public 97(65.1%) and private 77(69.4%) HCFs had fair knowledge of

disposing used injection needle without being recapped. The difference in proportion was not

statistically significant with p value of 0.469. The public 138(92.6%) and private 101(91.0%)

groups had good knowledge of not disposing sharp wastes with general wastes. The

difference in proportion was not statistically significant ( p = 0.634).

Health workers in private 84(75.7%) HCFs had better knowledge that HCW should be treated

before disposal as compared with their private 88(59.1%) counterparts. The difference in

proportion was statistically significant ( p = 0.005). Both health workers in public

138(92.6%) and private 109(98.2%) HCFs had good knowledge that HCW should have

specific storage area. The difference in proportion was statistically significant (p= 0.041).

Also, both health workers in public 142(95.3%) and private 108(97.3%) HCFs had good

knowledge that HCW storage area should be secured.

However, healthcare workers in private 104(93.7%) had better knowledge of treating HCW

by chemical disinfection and incinerator than those in public 127(85.2%) HCFs. The

difference in proportion was statistically significant with the p value of 0.032. Also, health

workers in private 100(90.1%) had better knowledge of disposing HCW by land fill and

incinerator than those in public 119(79.9%) HCFs. The difference was statistically significant

( p = 0.025).

Table 4.3.2 Comparison of overall knowledge score of HCWM among

health workers in HCFs

Aggregate knowledge

Score

Type of HCF

Public

n (%)

Private

n (%)

Total

n (%)

Poor (score of less than 50) 5 (3.4) 3 (2.7) 8 (3.1)

Fair (score of 50 – 69) 20 (13.4) 8 (7.2) 28 (10.8)

Good (score of 70 and above) 124 (83.2) 100 (90.1) 224 (86.2)

Fishers exact test = 2.698; p value = 0.287

More of the health workers in private 100(90.1%) had good knowledge score of ≥70%

compared with those in public 124(83.2%) HCFs. The difference was not statistically

significant (p = 0.287).

Table 4.3.3 Comparison of mean scores of knowledge on HCWM among health workers

public and private health facilities.

Discipline

Public

Mean±S.D

Private

Mean±S.D

Independent

t-test

P value

Doctor 77.45±20.49 88.28±14.63 -2.780 0.007

Nurses 80.06±12.63 90.14±14.45 -4.091 0.0001*

Pharmacist 73.64±13.85 81.82±12.86 -0.768 0.460

Laboratory scientist 83.27±13.30 82.58±11.92 0.154 0.878

*Statistically significant S.D – Standard deviation

The mean scores of knowledge on HCWM among health workers according to their

professional disciplines showed that doctors in public and private HCFs had the mean scores

of 77.45 ±20.49 and 88.28 ± 14.63 respectively. The difference in the mean score was

statistically significant (p = 0.007). The mean scores among nurses in public and private

HCFs were 80.06 ± 12.63 and 90.14 ± 14.45 respectively. The difference was statistically

significant (p = 0.0001).The pharmacists in public and private HCFs had mean scores of

73.64 ± 13.85 and 81.82 ± 12.86 respectively and this was not statistically significant (p =

0.460). Among the laboratory scientists in public and private HCFs, mean scores of 83.27 ±

13.30 and 82.58 ± 11.92 were obtained respectively. The difference was not statistically

significant (p = 0.878).

The respondents’ source of knowledge on HCWM is illustrated in the figure 2 below:

15.7

58.6

25.7

12.8

78.0

9.2 0

Mass media Self study Conference/Seminars

F r e q

u e n

c y

( %

)

Fig 2 : Sources of knowledge on HCWM

Public

Private

In figure 2 above, 15.7% and 12.8% of public and private healthcare workers respectively

had their knowledge of HCWM through the mass media. Majority of the healthcare workers

both in public (58.6%) and private (78.0%) HCFs had their knowledge of HCWM from self

study. However, 25.7% and 9.2% of public and private healthcare workers respectively had

their knowledge from conferences and seminars.

Table 4.3.4. Comparison of Health workers trained on HCWM

Health workers

Types of HCF

Public

n (%)

Private

n (%)

Total

n (%)

Doctors

Trained on HCWM 22 (42.3) 29 (76.3) 51 (56.7)

Not trained on HCWM 30 (57.7) 9 (23.7) 39 (43.3)

Chi square = 10.341; p value = 0.001*

Nurses

Trained on HCWM 51 (82.3) 49 (83.1) 100 (82.6)

Not trained on HCWM 11 (17.7) 10 (16.9) 21 (17.4)

Chi square = 0.013; p value = 0.908

Pharmacist

Trained on HCWM 7 (70.0) 2 (100.0) 9 (75.0)

Not trained on HCWM 3 (30.0) 0 (0.0) 3 (25.0)

Fishers exact p value = 1.000

Laboratory Scientist

Trained on HCWM 22 (88.0) 11 (91.7) 33 (89.2)

Not trained on HCWM 3 (12.0) 1 (8.3) 4 (10.8)

Fishers exact, p value = 1.000

Among the doctors that responded to the questionnaire, 42.3% and 76.3% of them in public

and private HCFs respectively, were trained on HCWM. The difference was statistically

significant. (p = 0.001). The percentage of nurses trained on HCWM in public and private

HCFs were82.3% and 83.1% respectively. The difference was not statistically significant (p=

0.908). Among the pharmacists in public and private HCFs that responded, 70% and 100%

respectively were trained on HCWM (p= 1.000). The difference was not statistically

significant.

The percentage of laboratory scientists trained on HCWM in public and private HCFs were

88.0% and 91.7 respectively. The difference was not statistically significant ( p = 1.000).

ATTITUDE TO HCWM : Correct attitude of health workers to HCWM is presented in the

table below for comparison.

Table 4.3.5 Comparison of Correct Attitude of Health Workers to HCWM

Variables Types of HCF Total

n (%)

χ2 p-

value Public

n (%)

Private

n (%)

Correct attitude to HCW segregation 143 (96.0) 109 (98.2) 252 (96.9) Fishers 0.473

Correct attitude to benefit of proper

HCWM to health workers

147 (98.7) 111 (100.0) 258 (99.2) Fishers 0.509

Correct attitude to use of colour-coded

containers

142 (95.3) 108 (97.3) 250 (96.2) Fishers 0.524

Correct attitude to treatment of HCW

before disposal

121 (81.2) 105 (94.6) 226 (86.9) 10.028 0.002*

Correct attitude that HCW should not be

disposal by open dumping method

139 (93.3) 101 (91.0) 240 (92.3) 0.473 0.492

Correct attitude to use closed vehicle for

HCW disposal

128 (85.9) 98 (88.3) 226 (86.9) 0.318 0.573

Correct attitude to carry out HCW

segregation

128 (85.9) 101 (91.0) 229 (88.1) 1.566 0.211

Correct attitude to recommend waste

segregation to colleagues

134 (89.9) 107 (96.4) 241 (92.7) 3.923 0.048*

Correct attitude to disposal injection needle

without capping.

84 (56.4) 75 (67.6) 159 (61.2) 3.354 0.067

* Statistically significant

The health workers in public 143(96.0%) believed that HCW segregation is important as

compared with those in private 109(98.2%) HCFs. The difference was not statistically

significant with the p value of 0.473. All the respondents among the private health workers

111(100%) believed that proper HCWM was beneficial to health as compared to the public

group 147(98.7%). The difference was not statistically significant (p = 0.509). Majority of

health workers in public 142(95.3%) and private 108(97.3%) HCFs agreed that colour coded

container was the best practice for the HCW disposal. The difference in proportion was not

statistically significant (p = 0.524).

More health workers in private 105(94.6%) as compared with those in public 121(81.2%)

HCFs agreed that HCW should be treated before disposal. The difference was statistically

significant with the p value of 0.002. Majority of public 139(93.3%) and private 101(91.0%)

groups did not believe that HCW should be disposed by open dumping. The difference was

not statistically significant with the p value of 0.492. The public 128(85.9%) and private

98(88.3%) health workers preferred closed vehicle to open vehicle for HCW disposal. the

difference in proportion was not statistically significant (p = 0.573).

More health workers in private 101(91.0%) HCFs were willing to carry out HCW segregation

as compared with those in public 128(85.9%). The difference was not statistically significant

with p value of 0.211. Also, more of private health workers 107(96.4%) were ready to

recommend waste segregation to their colleagues as compared with those in public

134(89.9%). The difference was statistically significant with the p value of 0.048. However,

the health workers in public 84(56.4%) and private 75(67.7%) believed that it was important

to dispose injection needle without capping. The difference was not statistically significant (p

= 0.067).

Table 4.3.6 Comparison of overall attitude of health workers to HCWM

Level of attitude to HCWM

Type of HCF

Public

n (%)

Private

n (%)

Total

n (%)

Negative 6 (4.0) 1 (0.9) 7 (2.7)

Positive 143 (96.0) 110 (99.1) 253 (97.3)

Fishers exact test p value = 0.244

Majority of health workers in both public 143(96.0%) and private HCFs 110(99.1%) had

positive attitude toward HCWM. The difference in proportion was not statistically significant

( p = 0.244 ).

Table 4.3.7 Comparison of mean scores of attitude to HCWM by health workers

Discipline

Public

Mean±S.D

Private

Mean±S.D

P value

Doctor 90.17±17.42 91.81±12.30 -0.497 0.620

Nurses 86.56±14.80 92.47±11.57 -2.438 0.016

Pharmacist 84.44±14.99 88.89±0.00 -0.403 0.695

Laboratory scientist 82.22±17.27 87.04±4.32 -0.945 0.351

S.D – Standard deviation

The mean scores of attitude on HCWM among health workers with respect to their

professional disciplines showed that doctors in public and private HCFs had the mean scores

of 90.17 ±17.42 and 91.81 ± 12.30 respectively. The difference in the mean score was not

statistically significant (p = 0.620).

The mean scores among nurses in public and private HCFs were 86.56 ± 14.80 and 92.47 ±

11.57 respectively. The difference was statistically significant (p <0.016).The pharmacists in

public and private HCFs had mean scores of 84.44 ± 14.99 and 88.89 ± 0.00 respectively and

this was not statistically significant (p < 0.695). Among the laboratory scientists in public and

private HCFs, mean scores of 82.22 ± 17.27 and 87.04 ± 4.42 were obtained respectively.

The difference was not statistically significant (p = 0.351).

PRACTICE OF HCWM : The correct practice of HCWM among health workers in public

and private HCFs is presented in the table below for comparison

Tables 4.3.8 Comparison of correct practice of HCWM by health workers

Variables Types of HCF χ2 p-value

Public n

(%)

Private n

(%)

Total n

(%)

Correct practice HCW

segregation

116 (77.9) 102 (91.9) 218 (83.8) 9.257 0.002*

Correct practice of disposing

HCW into appropriate colour

coded receptacles

94 (63.1) 89 (80.2) 183 (70.4) 8.916 0.013*

Correct practice of wearing

PPEs when handling HCWs

119 (79.9) 103 (92.8) 222 (85.4) 8.518 0.004*

Correct practice of covering

waste bin after HCW disposal

119 (79.9) 103 (92.8) 222 (85.4) 8.518 0.004*

Correct practice of disposing

sharp wastes into sharp

container

130 (87.2) 109 (98.2) 239 (91.9) 10.27

0.001*

Correct practice of disposing

expired drugs into brown

container

107 (71.8) 70 (63.1) 177 (68.1) 2.241 0.134

*Statistically significant

Majority of health workers in private HCFs 102(91.9%) practiced HCW segregation as

compared with those in public HCFs 116(77.9%). The difference in proportion was

statistically significant (p=0.002). More of private health workers 89(80.2%) disposed HCW

into appropriate colour coded receptacles than those of the public 94(63.1%). The difference

was statistically significant (p = 0.003). Also, majority of private health workers 103(92.8%)

wore PPEs when handling HCW as compared with those in public 119(79.9%) HCFs. The

difference was statistically significant (p = 0.004).

There was better practice of covering the waste bin after disposal by the private health

workers 103(92.8%) as compared with those in public HCFs 119(79.9%).The difference was

statistically significant ( p = 0.004). The private health workers 109(98.2%) had better

practice of disposing sharp waste into sharp container as compared to public group

130(87.2%). The difference was statistically significant ( p= 0.001). However, there was poor

practice of not disposing expired drugs into brown containers among private health workers

70(63.1%) as compared with those in public HCFs 107(71.8%). The difference was not

statistically significant (p = 0.134).

Table 4.3.9 Comparison of Overall Practice Score of HCWM by health workers

Scores on practice of HCWM

Type of HCF

Public

n (%)

Private

n (%)

Total

n (%)

Poor (score of less than 50) 26 (17.4) 4 (3.6) 30 (11.5)

Fair (score of 50 – 69) 42 (28.2) 23 (20.7) 65 (25.0)

Good (score of 70 and above) 81 (54.4) 84 (75.7) 165 (63.5)

Chi square = 16.541; p value = 0.001**Statistically significant

It was observed that more health workers in private HCFs 84(75.7%) had better practice of

HCWM as compared to those in public HCFs 81(54.4%). The difference in proportion was

statistically significant (p = 0.001).

Table 4.3.10 Comparison of mean scores of HCWM practice by health workers

Discipline

Public

Mean±S.D

Private

Mean±S.D

Independent

t-test

P value

Doctor 68.59±26.74 74.56±21.83 -1.128 0.262

Nurses 67.74±25.58 85.31±18.33 -4.323 0.0001*

Pharmacist 66.67±34.25 83.33±0.00 -0.662 0.523

Laboratory scientist 76.00±27.67 90.28±8.58 -1.736 0.091

*Statistically significant S.D – Standard deviation

The mean scores of HCWM practice among health workers with respect to their professional

disciplines showed that doctors in public and private HCFs had the mean scores of 68.59

±26.74 and 74.56 ± 21.83 respectively. The difference in the mean score was not statistically

significant (p = 0.262).

The mean scores among nurses in public and private HCFs were 67.74 ± 25.58 and 85.31 ±

18.33 respectively. The difference was statistically significant (p = 0.001).The pharmacists in

public and private HCFs had mean scores of 66.67 ± 34.25 and 83.33 ± 0.00 respectively and

this was not statistically significant (p = 0.523). Among the laboratory scientists in public and

private HCFs, mean scores of 76.00± 27.67 and 90.28 ± 8.58 were obtained respectively. The

difference was not statistically significant (p = 0.091 ).

SECTION 3B: SHARP WASTE MANAGEMENT (SWM)

Sharp waste management practice among the health workers in the public and private HCFs

is shown in the table below for comparison.

Tables 4.4.1 Comparison of SWM practice by the health workers

Variables Types of HCF χ2 p-value

Public n

(%)

Private n

(%)

Total n

(%)

Use of sharp waste container in

HCF

124 (83.2) 106 (95.5) 230 (88.5) 9.389 0.002*

Disposal of sharp containers at

appropriate filling level (3/4

filled)

91 (61.1) 84 (75.7) 175 (67.3) 6.164 0.013

Use of correct PPEs when

handling sharps

119 (79.9) 104 (93.7) 223 (85.8) 9.965 0.002*

NOT disposing sharp waste into

general HCW container

110 (73.8) 85 (76.6) 195 (75.0) 0.257 0.612

NOT recapping needles after use 83 (55.7) 40 (36.0) 123 (47.3) 9.872 0.002*

NOT dropping sharp waste into

open dump

71 (47.7) 44 (39.6) 115 (44.2) 1.655 0.198

*Statistically significant

Majority of health workers in private HCFs 106(95.5%) used sharp containers when compared

with the public group 124(83.2%). The difference was statistically significant (p = 0.002). The

private health workers 84(75.7%) disposed sharp containers at appropriate three-quarter filling

level as compared to public group 91(61.1%). The difference was statistically significant (p =

0.013). Among health workers in private HCFs, 104(93.7%) wore PPEs while handling sharp

waste as compared to the public group 119(79.9%). The difference in proportion was statistically

significant (p = 0.002). Health workers in private HCFs 85(76.6%) did not dispose sharps in

general waste container as compare with those in the public HCFs 110(73.8). The difference was

not statistically significant with p value of 0.612. Among the health workers in public HCFs

83(55.7%) did not recap needles after use as compared with the private group 40(36.0%) which

was poor practice. The difference was statistically significant with the p value of 0.002. There

was poor practice of dropping sharps in open dumps generally as only 71(47.7%) of health

workers in public HCFs and 44(39.6%) of private group had never dropped sharps in open

dumps. The difference was not statistically significant (p = 0.198).

Table 4.4.2 Comparison of overall practice score of SWM by health workers

Practice level of SWM

Type of HCF

Public

n (%)

Private

n (%)

Total

n (%)

Poor (score of less than 50) 32 (21.5) 6 (5.4) 38 (14.6)

Fair (score of 50 – 69) 48 (32.2) 60 (54.1) 108 (41.5)

Good (score of 70 and above) 69 (46.3) 45 (40.5) 114 (43.8)

Chi square = 19.028; p value = 0.0001

The level of good practice (score of 70% and above) of sharp waste management was low

among health workers in both public (46.3%) and private (40.5%) HCFs . In the public and

private HCFs, 32.2% and 54.1% of the health workers respectively, had fair practice of

SWM by scoring between 50-69%.The health workers in both public (21.5%) and private

(5.4%) HCFs had poor practice of SWM by scoring below 50% on the level of SWM score

rating. The difference in the proportion was statistically significant (p = 0.0001).

This showed that poor practice of SWM was more among the health workers in public HCFs

though 46.3% of health workers in public HCFS had good practice of SWM when compared

with the private group who had 40.5%. The scores were not as wide apart as that of poor

practice.

Table 4.4.3 Comparison of mean scores of SWM practice by health workers

Discipline

Public

Mean±S.D

Private

Mean±S.D

t-test

P value

Doctor 63.78±28.91 72.81±19.15 -1.674 0.098

Nurses 68.01±30.97 65.82±22.19 0.445 0.657

Pharmacist 48.33±34.65 75.00±11.79 -1.041 0.323

Laboratory scientist 78.00±24.40 76.39±13.22 0.213 0.832

S.D – Standard deviation

The mean scores of sharp waste management among health workers with respect to their

professional disciplines showed that doctors in public and private HCFs had the mean scores

of 63.78 ± 28.91 and 72.81 ± 19.15 respectively. The difference in the mean score was not

statistically significant (p = 0.098).

The mean scores among nurses in public and private HCFs were 68.01 ± 30.97 and 65.82 ±

22.19 respectively. The difference was not statistically significant (p = 0.657).The

pharmacists in public and private HCFs had mean scores of 48.33 ± 34.65 and 75.00 ± 11.79

respectively and this was not statistically significant (p = 0.323). Among the laboratory

scientists in public and private HCFs, mean scores of 78.00± 24.40 and 76.39± 13.22 were

obtained respectively. The difference was not

statistically significant (p = 0.832)

SECTION 3C: ASSESSMENT OF IMPLEMENTATION OF HCWMP IN THE HCFS

The implementation of HCWMP by the public and private HCFs was assessed using check

list and key informant interview. A total of 27 key informant interviews with the HCF

administrators and unit heads were carried out, 14 in public and 13 in private HCFs. The age

range of the administrators and unit heads was between 40 to 56 years. The males were 21,

while females were 6 in number. They all had tertiary education with 22 having university

degree and 5 having post midwifery certification. Each of the administrators and unit heads

had worked in that capacity from 2 years upwards. Table 4.5.1 below showed the various

level of implementation of HCWMP by the HCFs.

Table 4.5.1 Level of implementation of HCWMP in HCFs

HCWMP implementation level

score

Types of

HCFs

Public

n (%)

Private

n (%)

Total

n (%)

Poor score ( < 50% 50(33.5%) 58 (52.3%) 108 (41.4%)

Average score (51-70%) 60(40.2%) 40 (36.0%) 100(38.5%)

Good score (>71%) 39(26.2%) 13 (11.3%) 52(20.0%)

Chi –square = 12.3; P –value = 0.0021

From Table 4.5.1 above, it was observed that the level of implementation of HCWMP was

higher in the public specialist HCFs than in the private specialist clinic. The difference was

statistically significant (p = 0.0021).

Table 4.5.2 Result of key informants interview on percentage of health workers trained

on HCWMP

Question Code Public HCF

Private HCF

What percentage of health

workers in your HCF are trained

in HCWM?

<30%

>30%

Ten and eight key informants from the public and private HCFs respectively stated that less

than 30% of the health workers were trained in HCWM. It was noted that four and three key

informants from the public and private HCFs respectively agreed that more than 30% of the

health workers have been trained on HCWM. One the head of unit in private HCF explained

that:

“Such training is not organised often in this hospital. In fact whatever we have learnt and

practiced here is due to private efforts” – Head of Unit

Another key informant in the public HCF stated that;

“Most of the medical staff learnt about HCWM when they were in school. They have not had

any additional training in the past 3years in this hospital, unless they attended training

programs on HCWM outside the hospital”.

HCWM Training Coverage

Other aspect explored in the key informant interview was the areas of HCWM that the health

workers were trained on, a key informant in public HCF stated;

“Our health workers are trained on HCW minimization, segregation and proper disposal.

However, our problem here is compliance to safety measures when handling HCW. We have

reports of needle stick injuries often especially among the nurses and cleaners” – Unit Head

Public HCF

HCWM training organised in a private HCF was for the nurses alone. The reason for

choosing only the nurses was explained by one of the head of the units;

“The nurses come in contact with HCW more often than other medical staff. They need the

training more so as to learn how to handle those HCWs. Other staff such as ward maids and

cleaners can be taught by the nurses after wards” – Head of Nursing Unit

Transportation of HCW from HCF

Key informants in both public and private HCFs stated that the HCWs were transported by

the waste contractors. One of the Administrators in public HCF explained;

“We have waste contractors that dispose our HCW. We have retained them for over 5 years

now and they are doing it well”

On how many times in a week the HCW are disposed by the contractors, the Administrator

has this to say;

“The young men come twice every week to dispose the waste from our hospital to municipal

site”

Code of conduct regarding HCW handling

There was no regulation or code of conduct regarding HCW handling in all HCFs as elicited

from the key informants in both public and private HCFs. Though, a key informant in the

public HCF said;

“We are working towards establishing the regulations in line with HCWMP”

Use of colour codes

No colour coded waste bins were used for HCW segregation in the public HCFs. A Unit

Head in public HCF stated that;

“Our big waste bins are not colour coded. They serve as collection bins at each of the

disposal points”- Unit Head

However, only administrators in four private HCFs said that they had colour coded waste

bins for HCW segregation. The utilization of these colour coded waste bins could not be

confirmed by the administrators.

Sharp waste handling

All key informants in public and private HCFs stated that they used sharp containers to

collect injection needles and other sharp wastes. There was no incinerator in all the private

HCFs as stated by the key informants. The administrators attributed the inability to have

functional incinerators in their HCFs to lack of fund and high interest rate on bank loans. This

was what one of the key informants said:

“There is paucity of fund to build an incinerator and what we generate as income in this

hospital goes into salaries and overhead costs. We buy a litre of diesel at N190.00 and use

more than two drums a week. How do we then get money to build an incinerator” -

Administrator

However, a key informant in one of public HCF pointed out that their incinerator was almost

completed for use. In his words;

“With the help of government, we are able to complete an incinerator plant which will be

commissioned soon and it will be ready for use” - Hospital Administrator

All the key informants in both HCFs could not specifically state how much was being

budgeted annually for the purpose of HCWM. Rather, they submitted that an estimate that

ranged from 0.3% to 0.8% of the annual budget was expended for HCWM. This percentage

was extrapolated from the monthly bill of the waste contractors in public and private HCFs.

100

Handgloves Safety boots

Safety

goggle Overalls Dump HCW

in open

places

Use closed

trucks for

HCW

diposal

100 100

33.3

100

66.7

100 100

66.7

100

33.3

F r e q

u e n

c y (

% )

Public

Private

SECTION 3D: COMPARISON OF PRACTICE OF HCWM AMONG WASTE

HANDLERS

Fig .3: HCWM practice components for waste handlers

From figure 3 above, all the waste handlers in public and private HCFs that responded wore

hand gloves and safety boots while handling HCW. Among those that wore safety goggle

were 33.3% in public and 0% in private HCFs. All waste handlers in public HCFs (100%) as

compared with those in private HCFs (66.7%) wore overalls while handling HCW. All waste

handlers in private HCFs (100%) that responded and 66.7% of those in public HCFs dumped

HCW in open places (indiscriminate dumping). No closed truck was used for HCW disposal

in public HCFs by the waste handlers that responded. The waste handlers in the private HCFs

that responded, 33.3% used closed trucks for HCW disposal.

CHAPTER FIVE

DSICUSSION

This comparative cross-sectional study was carried out among health workers (HW) in public

and private specialist health care facilities (HCFs) in Port Harcourt. The purpose of this study

was to assess and compare the daily quantity of health care waste (HCW) generated in public

and private HCFs per patient; knowledge, attitude and practice of HCWM and specifically

the practice of sharp waste management (SWM) by health workers in public and private

HCFs in Port Harcourt and finally the level of implementation of health care waste

management plan (HCWMP) by the HCFs with a view of recommending areas that need

improvement in HCWM to maintain cleaner hospital environment and safeguard the health of

health workers in particular and that of patients in general.

Findings in this study revealed significant difference in the mean quantities of HCW

generated in public specialist HCFs of 2.67kg/bed/day compared to 1.2kg/bed/day generated

in private specialist HCFs. This was more than double the quantity and significantly higher

than the quantity generated in private HCFs. The amount of HCW generated was similar to

previous studies conducted by researchers in Abuja, Nigeria 30 with an average HCW

generation rate of 2.78kg/bed/day in a public HCF. It is also similar to another study in Abuja

where the average HCW generation rate was in the range of 1.053kg/bed/day to

2.29kg/bed/day. 48 This was also similar to studies reported in Dhaka City (0.8kg/bed/day to

1.67kg/bed/day, Amsterdam (2.7kg/bed/day) and Paris ( 2.5kg/bed/day). 48 In this study, the

difference in quantities of HCW generated by public and private specialist HCFs might be

attributed to discount on cost of health services that was operational in both Federal and State

owned public HCFs in Port Harcourt which usually attracted more patients than the private

specialist HCFs despite similarities in health care services both provided. This significant

difference in quantities of HCW generated in both HCFs could also be due to greater patient

inflow and higher generation of general HCW from the higher bureaucracy in public HCFs.

In this study, the comparison of aggregate knowledge score showed that 83.2% of health

workers in public and 90.1% of health workers in private HCFs had good knowledge of

HCWM. The difference was not statistically significant. The high aggregate knowledge

scores among health workers in public HCFs could be explained by the higher mean years of

experience of the nurses (17.58 ± 11.3) in public HCFs .This difference in mean years of

experience among the nurses in public and private was statistically significant and could have

given leverage to the public HCFs to increase their aggregate knowledge score. The private

HCFs expectedly had a high aggregate knowledge score probably because they were

adequately trained on HCWM.

The comparison of mean scores of knowledge among health workers in public and private

HCFs revealed that doctors in private HCFs had significantly higher scores than their

colleagues in public HCFs. This significant difference was also revealed among the nurses in

public and private HCFs. The nurses in private HCFs had higher mean score than their

colleagues in public HCFs. In this study, it was also discovered that nurses in both public and

private HCFs had higher mean scores than the doctors. This finding was contrary to the

findings reported in Anambra State. 56 In terms of higher educational qualification, doctors

were expected to have higher mean scores than the nurses. The difference in the mean scores

could be explained by the level of training of health workers in HCWM. In this study, the

percentage of doctors trained in HCWM in public and private HCFs were 42.3% and 76.3%

respectively. This showed that higher proportion of doctors in the private HCFs were trained

on HCWM than their colleagues in public HCFs. The positive effect of this training was

reflected in higher mean knowledge scores among doctors in private HCFs. It was expected

that training on HCWM should be more frequent in public HCFs because of the attribute of

being training centers but this was not the case in this study.

It was also revealed in this study that the nurses in private HCFs had higher mean scores of

knowledge than the nurses in public HCFs. This was expected since knowledge could only

come by training. The nurses in the private HCFs were more exposed to training

opportunities on HCWM and that was why their mean score of knowledge on HCWM was

higher than that of their colleagues in public HCFs. It might be that training opportunities on

HCWM were created in public HCFs, but there could be poor participation among the health

workers probably due to work load or lack of disciplinary measures to ensure compulsory

attendance and participation.

In comparison of mean scores of knowledge among the doctors and nurses in both public and

private HCFs, it was discovered in this study that nurses in both public and private HCFs had

higher mean scores of knowledge on HCWM than the doctors of both HCFs. This

emphasized the fact that training opens the door to knowledge. There was higher proportion

of nurses trained on HCWM than the doctors as revealed in this study. Among the nurses

trained in HCWM in public and private HCFs were 82.3% and 83.1% respectively. This has

shown why nurses had higher mean knowledge scores than the doctors because they had

more training in area of HCWM than the doctors both in the public and private HCFs.

In comparison of correct knowledge of HCWM among health workers in public and private

HCFs, the study revealed that higher proportion of the health workers in private HCFs had

knowledge of HCWM than their colleagues in public HCFs. However, there was significant

difference in the correct knowledge of use of black container for general HCW, red coloured

container for highly infectious HCW, lead box for radioactive waste and treatment of HCW

before disposal. Higher proportion of health workers in private HCFs had knowledge of the

above variables more than those of public HCFs. This difference could be attributed to the

higher percentage of health workers in private HCFs that were trained on HCWM. In this

study, the percentage of health workers trained on HCWM in ratio of public to private HCFs

showed the following – doctors ( 42.3% : 76.3% ); nurses(82.3% : 83.1%); pharmacists (

70% : 100% ); Laboratory scientists ( 88.0% : 91.7% ). The finding in this study could be

compared with a report in a study in Jos which demonstrated that knowledge of health

workers in HCWM did not meet the standard because of lack of training of health workers in

HCWM. 42 The finding also compliments the report of another study where the need for

training on HCWM could not be over emphasized 54,55. This study also revealed that health

workers in both HCFs still recapped needles before disposal. This is not acceptable

considering the rising incidence of diseases associated with needle prick injuries. In a study

in south east Nigeria, it was shown that health workers had no significant difference in

knowledge about the risks posed by HCW especially in handling sharps due to lack of

training57. The present study revealed that health workers despite being made up of doctors,

nurses, pharmacists and laboratory scientists had insufficient knowledge of HCWM in the

selected HCFs. This finding was in line with reports of other studies carried out in India 58,

Bangladesh 59 and Nigeria 60. Part of the objective of this study was to discover these gaps

in HCWM practice and proffer solutions to implement standard precautions in handling

HCW.

In comparison of level of attitude of health workers to HCWM, this study revealed that health

workers in private HCFs had higher level of (positive) attitude to HCWM than those in public

HCFs. However, there was no significant difference in the level of their attitude to HCWM.

This difference could be attributed to regular training sessions on HCWM that was organised

for health workers in private HCFs and this had affected their orientation and attitude on

HCWM positively.

This finding was similar to the report of a study in Pakistan where majority of responders had

positive attitude of proper HCW segregation and disposal for safe HCWM. 53 This

overwhelming positive attitude of health workers could be attributed to self study of the

effects of poor HCWM and also the training obtained in the course of their career in various

disciplines as health workers.

In this study, there were higher mean scores of attitude on HCWM among health workers in

public than private HCFs. Though, the difference was not significant. However, there was

significant difference in the mean score of attitude on HCWM among nurses in public and

private HCFs. More nurses in private HCFs had higher mean score of attitude on HCWM.

The nurses in private HCFs were better trained on HCWM. This has reflected on their higher

mean scores of attitude on HCWM when compared with their colleagues in the public HCFs.

The observation in this study has further exposed the lapses capacity building and technical

development being experienced in public institutions. Most private institutions like the

private HCFs in Port Harcourt are not resting on their oars in areas of human capital

development in HCWM. This finding was similar to the report of a study conducted in south

east Nigeria where majority of the health workers in public HCF believed in proper

HCWM.52

Higher percentage of health workers in private HCFs exhibited correct attitude to HCWM as

compared to those of public HCFs. However, this study discovered that both health workers

in public and private HCFs had poor attitude to disposal of injection needle without capping.

This finding was similar to the report of a study carried out in Lagos where there was

noticeably poor attitude to sharps disposal in all HCFs. 78 The finding was also in line with

report of a study in Anambra where health workers that displayed positive attitude to

containment of sharps were below 50% on the average 56 . The report from a study in Bayelsa

state, Nigeria stated that there was poor HCW disposal behaviour in the HCFs surveyed 61.

This was also similar to finding of the present study .

Healthcare waste management was better practiced in private HCF when compared with the

public HCF. The level of good practice of HCWM was significantly higher among health

workers in private HCFs than their public counterparts. This showed that the more training

received by majority of healthcare workers in private HCFs on HCWM has translated into

good practice of HCWM when compared with their colleagues in public HCFs that were less

trained on HCWM.

The poor practice of HCWM was recorded more in the public than the private HCFs. It was

noted that 54.4% and 75.7% of public and private health workers respectively, scored above

the bench mark of 70% for good practice of HCWM. This was in line with report of a study

in Port Harcourt, Rivers State, where 57.7% of HCFs had HCW storage dump sites and 23%

admitted that they had HCWM units.41 Another study in Abuja had similar findings of poor

HCWM where 18% of the HCFs incinerate HCW in locally built incinerators and 36.3% of

the HCFs disposed HCW into municipal dumpsites showing high level of poor HCWM

practice. 51 This was not different from a report of a study carried out in Ebonyi state where

only 1.98% of HCFs surveyed complied to standard procedures in HCWM 63. In comparison

of mean scores of HCWM practice, it was revealed that health workers in the private HCFs

had higher scores than those in public HCFs. This was consistent with the findings of this

study in knowledge and attitude of health workers on HCWM. The good knowledge and

attitude of health workers in private HCFs actually translated in higher mean scores they

obtained in HCWM practice.

In comparison of mean scores of HCWM practice among the nurses, there was significant

difference in mean scores of nurses in public and private HCFs. The nurses in the private

HCFs had higher scores. This could be explained by the training on HCWM which was more

regular among the private HCFs nurses. Studies reported that health workers are not educated

enough on HCWM and the most of them have not had any special training on management of

HCW. 57 It was generally observed that mean scores of HCWM practice of all the cadres of

health workers in the private HCFs were more than that of the public HCFs. This showed that

the private specialist HCFs being owned by individuals had better training of their health

workers on HCWM than the public HCFs which were owned by the government.

In comparison of correct practice of HCWM, there was significant difference between the

public and private HCFs. Higher proportion of health workers in the private HCFs had

correct practice of HCWM when compared with those of the public. Majority of health

workers in the private HCFs had good practice of HCWM in areas of healthcare waste

segregation, use of appropriate colour coded receptacles, use of personal protective

equipments, covering of bin after disposal and disposing sharps into sharp containers.

However, health workers in public HCFs had better practice of disposing expired drugs into

brown container than their colleagues in the private HCFs. This could be explained by the

fact that pharmacy departments in public HCFs were better equipped and managed by

professionals. This had ensured the use of appropriate receptacles for expired drugs.

Segregation and disposal of HCW into appropriate colour coded receptacles had continued to

be a setback in HCWM especially in the public HCFs. This was similar to the findings of a

study carried out in Eneka, Nigeria 20,; Istanbul, Turkey 19 and Ibadan 30 and Zaria 65 in

Nigeria where most of the health workers did not segregate HCW, rather disposed into

general waste bins and in open dumps.

Higher proportion of health workers in private HCFs segregated their HCW at point of

generation and disposed in appropriate colour coded receptacles. This was similar to the

findings in a study in Anambra State where up to 80% of health workers disposed HCW into

appropriate receptacles and 87% of them covered the bins after disposal. 59 This is also

consistent with a report which indicated that 90.4% of respondents segregated HCW at the

point of generation 64.

Most health workers used the PPEs when handling HCWs. This was contrary to the findings

in same study in Anambra State where only 17% wear PPEs regularly and correctly. 56 Also

contrary to this finding was a report of a study where less than 30% of health care workers

used personal protective equipment 62.

Only 46.3% of health workers in the public and 40.5% in private HCFs had good level of

practice of SWM. This finding was below average for both HCFs. It was similar to the report

of Federal Ministry of health and John Snow incorporated where syringes and needles used

for injections were discarded in general HCW bin in most of the HCF visited for the study. 77

The same study found out that 65% of HCFs surveyed in Lagos, Nigeria had sharps disposed

on their premises and other unsupervised areas. 77 According to national cross-sectional

survey conducted in 2004 among 80 HCFs, about 62.5% of the HCFs were observed not to

have sharp safety boxes in use and 23.5% had no injection rooms. 77

In this study, the comparison of mean scores of sharp waste management (SWM ) showed

that there was no significant difference between the cadres of health workers in the public

and private HCFs.

In comparison of SWM practice, majority of health workers in both public and private HCFs

recapped needles after use, though this practice was observed more among the private health

workers and the difference was significant. This finding was similar to a report of a study in

China where SWM among health workers was very poor showing 16% of unsafe SWM.75 A

study carried out in Nigeria 67 also supported this finding of poor SWM practice among

health workers. This finding was also similar to another report in a study carried out in Lagos

where there was poor and incorrect disposal of sharps in all HCFs visited for the study. 77

In summary, the study revealed that health workers in the private HCFs had better practice of

sharp waste management (SWM) when compared with their public counterparts. The

difference was significant in use of sharp containers and correct use of PPEs. However,

majority of health workers in the public HCFs did not recap needles before disposal when

compared with the health workers in private HCFs. The difference was significant and could

be attributed to more years of experience of health workers in the public HCFs.

Majority of waste handlers in this study used safety boot, overalls, and hand gloves while

handling HCW in both public and private HCFs. This was contrary to a study carried in

Anambra where only 17% of waste handlers used PPEs. 56

The finding in this study on the level of implementation of HCWMP showed that the level of

implementation was poor and below average in both public and private HCFs. They were

scored based on pre-determined thematic areas which included general HCW management

strategy, HCW collection and segregation and HCW treatment and disposal. It was only

26.2% of the public and 11.3% of private HCFs that had good implementation of HCWMP

by scoring above 70% on these thematic areas. This showed that majority of the HCFs had

poor implementation of HCWMP and implications were so glaring. It was observed that

33.5% of public and 52.3% of private HCFs in this study had poor implementation of

HCWMP by scoring below 50% on the thematic areas. This finding was similar to the report

of previous study where majority of HCFs disposed their none segregated HCW in open

dumps and no functional incinerator was seen.69 Also similar to this finding was the report of

investigative survey conducted by WHO on HCWM in 22 countries. Results showed that

proportion of HCFs that did no use proper waste disposal methods ranged from 18% to 64%.

In this study, it was revealed during key informant interviews that in both public and private

HCFs, the average percentage of health workers trained in HCWM was below 30%.This was

similar to the report of a study conducted in Mumbai, India where health workers were not

educated enough and most of them have not had any special training on HCWM. 68 All the

public and private HCFs used waste contractors to transport their HCW. There was no

regulation or code of conduct regarding HCW handling in all HCFs as elicited from the

administrators and unit heads. Though, some HCF administrators were working towards

establishing the regulations in line with HCWMP. In this study, no colour coded waste bins

were used for HCW segregation in the public HCFs. However, only administrators in four

private HCFs said that they had colour coded waste bins for HCW segregation. The

utilization of these colour coded waste bins could not be confirmed by the administrators.

This finding was similar to the report of a survey conducted in Nigeria and Mongolia where

most HCFs did not have appropriate colour coded bags or containers for sorting different

types of HCW. 68

This interview also revealed that there was no incinerator in all the private HCFs. The

administrators attributed the inability to have functional incinerators in their HCFs to lack of

fund and high interest rate on bank loans. However, an administrator in public HCF pointed

out that an incinerator was almost completed for use. This finding was similar to the a report

in study in Nigeria where there was a near total absence of institutional arrangements for

HCWM .30

CHAPTER SIX

CONCLUSION AND RECOMMENDATION

6.1 Conclusion

This study compared the HCWM among health care workers of private and public specialist

hospitals in Port Harcourt. The results showed that there is difference in HCWM in the HCFs

that participated in this study. The difference in the mean quantities of HCW generated in the

public and private HCFs might be acceptable as this is similar to the report of other studies.

Public HCFs generated more HCW than the private HCFs. This could be that many patients

pay out of pocket to access healthcare; therefore, they prefer public to private HCFs because

they are less expensive. Universal health insurance coverage could address this disparity.

This study also has revealed that the current HCWM practices in the public and private HCFs

in Port Harcourt cannot be relied upon to protect the health of the health workers and their

patients including the environment. The study showed that majority of health workers in

public and private specialist HCFs had good knowledge and attitude towards HCWM but this

did not translate into good practices. The health workers in private HCFs had better level of

practice than their public counterparts. This has emphasized the need for training of health

workers on HCWM especially in the public HCFs to improve their knowledge and practice.

More health workers were trained in the private HCFs in this study, but there is always room

for improvement to achieve the standard HCWM. Lack of training has impacted negatively

on the practices of appropriate HCWM.

100

Both categories of HCFs had poor practice of sharp waste management. This poor practice

was seen more among the private HCFs in terms of recapping injection needles and dropping

of sharp wastes in open dumps indiscriminately.

There is no existing policy or plan in place in all the public and private HCFs for proper

HCWM. There is no specific budget set aside for HCW handling in both HCFs surveyed.

This is a pointer to the gross apathy being exhibited by the administrators of HCFs to the

concept of proper HCWM by health workers.

6.2 Recommendations

The following recommendations were made based on study findings :

1. Implementation of HCWM guidelines should be enforced by the management of all

HCFs in Port Harcourt.

2. Capacity building and training of health workers on HCWM should be organised

regularly by the management of the HCFs for knowledge update to ensure good

HCWM practices.

3. Appropriate resources should be allocated to HCWM by the administrators in all

HCFs. The current level of HCWM in the HCFs surveyed needed to be given more

attention through improved funding and research to protect the health of the public

and the environment.

4. There should be information dissemination by the administrators on HCWMP at

designated places of all the HCFs. This will create necessary awareness of best

practices of HCWM to all health workers and the patients.

101

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APPENDIX I : Informed Consent Form/Information sheet

Study title: Comparative assessment of healthcare waste management in public and private

specialist healthcare facilities in Port Harcourt, Rivers State, Nigeria.

Investigator: Dr Offorma, Maduka Ikechukwu. Department of Community Medicine,

University of Port Harcourt Teaching Hospital (UPTH)

114

Purpose of the research

The purpose of this project proposal is to provide information on how healthcare waste is presently

being managed by the public and private specialist healthcare facilities in Port Harcourt and give

recommendations from the Healthcare Waste Management Plan.

Your part in this research

You are requested to voluntarily participate in this study by answering the questions in the

questionnaire and providing any other information as pertains to the study.

Possible benefits

You will be educated on the ideal healthcare waste management.

Possible Risks

There are no foreseen risks associated with the study.

Compensation

Your participation is voluntary and therefore, you will not receive any form of compensation.

Your Right as a participant:

You have the right to withdraw at any time during the research and to clarify any part of the

research that is not understood. This study is also protected by Ethics committee of the

University of Port Harcourt Teaching Hospital (UPTH)

Volunteer Agreement

I have read the consent form describing benefits, risks and procedures for this study on;

COMPARATIVE ASSESSMENT OF HEALTHCARE WASTE MANAGEMENT IN

PUBLIC AND PRIVATE SPECIALIST HEALTHCARE FACILITIES IN PORT

HARCOURT, RIVERS STATE, NIGERIA.

115

Name_____________________________ Signature _______________

Date_____________

For Researcher only

I certify that the nature and purpose, the potential benefits and possible risks associated with

participating in this study have been explained to the above individual

Date………………………………………

Signature……………...........

APPENDIX II : Questionnaire for health workers

Date ………………………………………..

Healthcare facility ( Private or Public )…………………………………………

Questionnaire Code No………………………………………………………………..

116

Introduction: Good day Sir/Ma. My name is_______________________________I am

working with a research team to compare healthcare waste management (HCWM) in public

and private specialist healthcare facilities (HCFs) in Port Harcourt, Rivers State. Your candid

responses will be helpful in improving HCWM in this healthcare facility (HCF). Please note

that it is not compulsory for you to participate in this study. Should you accept to participate,

your answers will be treated with utmost confidentiality. Kindly acknowledge your

willingness to respond to the following questions by affixing your signature here:

___________________________Thank you.

SECTION 1: DEMOGRAPHIC FACTORS

1. Discipline..... Doctor / Nurse / Pharmacist / Lab. Scientist

2. Position........................................................

3. Length of experience in years…………………......

4. Public HCF worker ( ) OR Private HCF worker ( ). Tick as appropriate.

SECTION 2 : KNOWLEDGE OF HCWM

Here are statements about HCWM, some are true statements and some are false. Please read

each statement and then indicate whether you think it is true or false by putting a circle round

either TRUE or FALSE. If you do not know the answer please put a circle around DON’T

KNOW.

S/N QUESTION UNDERLINE TRUE OR FALSE OR DON’T

KNOW

1 Segregation of HCW can be done by putting

all the HCW into one container.

TRUE /FALSE/ DON’T KNOW

2 TRUE /FALSE/ DON’T KNOW

117

General HCW should be put in black

containers

Red coloured waste container is for highly

infectious HCW

TRUE /FALSE/ DON’T KNOW

4 Lead box is used for collecting radioactive

waste

TRUE /FALSE/ DON’T KNOW

5 Sharp wastes (needles) should be recapped

before disposal

TRUE /FALSE/ DON’T KNOW

6 Sharp wastes are better disposed with general

HCW

TRUE /FALSE/ DON’T KNOW

7 HCW should be treated before disposal ?:

TRUE /FALSE/ DON’T KNOW

8 There should be specific storage area for

HCW in HCFs

TRUE /FALSE/ DON’T KNOW

Storage areas should be secured

TRUE /FALSE/ DON’T KNOW

10 HCW is treated by chemical disinfection and

incinerator

TRUE /FALSE/ DON’T KNOW

Incinerator and land fill are HCW disposal

techniques

TRUE /FALSE/ DON’T KNOW

118

12 What is the source of your knowledge Mass media / Self studying / Others specify

_______________________

13 Have you received any training on HCWM

since you graduated.

YES/NO

14 If YES, what is the main source of your

training

In-service / CME / Conferences / Others

specify__________________________

SECTION 5 : ATTITUDE TO HCWM

15 Do think it is important to segregate

HCW.

YES / NO

16 Do you believe that proper HCWM is

beneficial to health workers.

YES / NO

17 Do you think that use of colour coded

containers for HCW is the best

practice.

YES / NO

18 Do you agree that HCW should be

treated before final disposal.

YES / NO

19 Should HCW be disposed using open

dumping method.

YES / NO

20 Would you prefer open vehicle to close

compaction vehicle to dispose HCW.

YES / NO

21 Are you willing to carry out waste

segregation ?

YES / NO

119

22 Can you recommend waste segregation

to your colleagues ?

YES / NO

23 Do you think it is important to dispose

injection needle without capping it ?

YES / NO

24 If your answer is YES in No 23 above,

why do you think it is important to

dispose injection needle without

capping it?

....................................................................

..................................................................

....................................................................

SECTION 6 : HCWM PRACTICE

25 Do you practice HCW segregation. YES / NO

26 If YES, how often do you practice HCW

segregation

RARELY / SOMETIMES / ALWAYS

27 Do you dispose HCW into appropriate

receptacles according to colour coding ?

YES / NO

28 If YES, how often do you dispose HCW

into appropriate receptacles.

RARELY / SOMETIMES / ALWAYS

29 Do wear PPEs (hand gloves, safety

booth, etc) when handling HCWs?

YES / NO

30 If YES, how often do you wear PPEs ?. RARELY / SOMETIMES / ALWAYS

31 Do you cover the waste bin after disposal

of HCW ?

YES / NO

32 If YES, how often do you cover the bin ? RARELY / SOMETIMES / ALWAYS

120

33 Where do you dispose sharps ? A). GENERAL WASTE BIN

B). SHARP WASTE CONTAINER

C). Others specify................................

34 Where do you dispose expired drugs ? A). GENERAL WASTE BIN

B). BROWN WASTE CONTAINER

C). Others specify................................

SECTION 7 : SHARP WASTE MANAGEMENT PRACTICE

35 Do you make use of sharp container in

this HCF.

YES / NO

36 If the answer in 34 is YES, how often do

use the sharp container.

RARELY / SOMETIMES / ALWAYS

37 At what filling-level do you normally

dispose the sharp containers ?

FULLY- FILLE D / HALF-FILLED /

QUARTER-FILLED

38 Do you dispose sharps into general HCW

container?.

YES / NO

39 Do you re-cap needles after use? YES / NO

40 If YES, how often do you recap the

needles ?

RARELY / SOMETIMES / ALWAYS

41 Have you or your colleague had needle-

stick injury in the past one year

Yes / NO

42 Do wear PPEs when handling sharp YES / NO

121

wastes

43 If YES, how often do you wear the

PPES?

RARELY / SOMETIMES / ALWAYS

44 Have you ever thrown sharps into open

dump ?

YES / NO

45 If YES, how often ? RARELY / SOMETIMES / ALWAYS

122

APPENDIX III : INTERVIEW GUIDE FOR KEY INFORMANT INTERVIEW ( HCF

ADMINISTRATORS)

1. What percentage of health workers in your HCF are trained in HCWM ?

_________________

2. In what areas of HCWM was the training given ?

_____________________________________________________________________

3. Who transports the HCW from your HCF ?

_____________________________________

4. Do you have any regulations or code of conduct regarding HCW handling ?

___________

_____________________________________________________________________

_____

5. Are these regulations in

operation?__________________________________________

6. Can you throw more light on how these regulations are

implemented?______________

123

7. Are colour coded bins in use in your HCF ?

___________________________________

8. How do you handle sharp wastes in your

HCF___________________________________

9. How much of your HCF annual budget is allocated to HCWM ?

_____________________

10. How much of it is actually used for HCWM ?

___________________________________

APPENDIX IV : OBSERVATION CHECK LIST FOR HCWM

CODE NUMBER ……………………………………………………….

DATE ……....................................................................

NAME OF FACILITY ……………………………………………......

FACILITY SCORE ……………………………………………………….

124

S/N HCWM CRITERIA INDICATORS YES NO SCORE

1 GENERAL

MANAGEMENT

STRATEGY

A). Any policy or strategy on

HCWM

B). Any special budget for

HCWM

C). Training of health wokers

on HCWM

D).PPE worn by waste

handlers :

Hand gloves

Safety booth

Cover-alls

Helmet

Safety goggle

E). Receptacles/Storage

containers available

F). Presence of instructive

posters on HCWM on the

walls

G). Presence of HCF records

on HCWM

2 HCW A). Number and adequacy of

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COLLECTION

AND

SEGREGATION

waste receptacles

B). Sharps and infectious

HCW collected separately

C). Is segregation regulated

or controlled

D). Presence of color coded

HCW containers

3. WASTE

RECYCLING

A). Any form of recycling

4 WASTE

STORAGE

A). Presence of purpose built

HCW handling facility

B). HCW dumped outside

HCF building

C). Open HCW disposal

5. WASTE

TREATMENT

A). Autoclaving of lab.

wastes

B). Sharp encapsulation

C). Waste burial within

facility

D). Crude Incineration

6 OFF SITE

DISPOSAL

A). Waste disposal

contracted out

B) HCW transported in open

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vehicle

C). HCW transported in close

compact vehicle

KEY TO SCORES :

CORRECT PRACTICE = 1

INCORRECT PRACTICE = 0

PERCENTAGE OF FACILITY SCORE WILL BE DEDUCED FROM NUMBER

OF SCORES FOR CORRECT PRACTICE DIVIDED BY TOTAL SCORE.

GRADING

<50% = Poor practice

50% = Average practice

<70% = Good practice

>70% = Best practice

APPENDIX V : QUESTIONNAIRE FOR WASTE HANDLERS

Healthcare facility ( Private or Public )…………………………………………

Questionnaire Code No………………………………………………………………..

Introduction: Good day Sir/Ma. My name is_______________________________I am

working with a research team to compare healthcare waste management (HCWM) in public

and private specialist healthcare facilities (HCFs) in Port Harcourt, Rivers State.

SECTION 1: SOCIO-DEMOGRAPHIC FACTORS

1. Level of education.............................

2. Length of experience in years …………………......

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3. Are you a hospital staff. YES / NO

4. Are you a contractor . YES / NO

Now answer the following questions. Tick the appropriate answers to the following

questions:

S/N QUESTIONS ANSWER

1. Do you think it is good to put all types of

hospital waste into one container?

YES / NO

2. Needles are supposed to be put into

general hospital waste containers.

YES / NO

3. Do you believe that personal protective

equipments ( PPES ) like gloves can be

useful in handling hospital wastes.

YES / NO

4. Do you wear PPEs ?

Hang gloves

Safety booth

Cover-alls

Safety goggle

YES / NO

5 If YES , how often do you wear PPEs ? RARELY/ALWAYS/OCCASIONALLY

6. Do you take precaution in handling

hospital wastes according to the colours

of their containers ?

YES / NO

7 Do you dispose hospital waste in open

places.

YES / NO

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8 If NO, what do you do to them ? A). BURN THEM

B). BURY THEM

C). PUT THEM IN INCINERATOR

D). LAND FILL THEM

E). OTHERS SPECIFY ................

9 The trucks you use to dispose hospital

wastes are :

A). COVERED TRUCKS

B). OPEN TRUCKS

10 Where do you dump the hospital wastes. A). MUNICIPAL DUMPSITES

B). RIVERS

C). OTHERS SPECIFY...............

11 Have you had needle stick injury in the

past one year ?

YES / NO

12 If YES, how many times?

13 How did you treat the needle stick injury?

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APPENDIX VI : WORK PLAN

Research

Activity

Weekly Work Plan

1 Recruitment and

Training of Data

Collectors

2 Pre-testing and

Refining of

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Questionnaire

3 Community

entry/Recruitme

nt of Subjects

4 Data Collection X X X X X

5 Data Entry X X

6 Data Analysis X X X

7 Dissertation

Write-up

X X X

8 Submission to

College

1 2 3 4 5 6 7 8 9 1

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