Background and objectives : Growing urbanization has led to several changes in the healthcare sector. While on one hand, access to healthcare services are being provided to the community thereby resulting in the better health for all, improper management of biomedical waste emanating from these healthcare establishments has also given rise to many environmental and health problems. Although awareness in this issue has considerably increased over the last few years, sensitivity to this problem has been limited. Most hospitals are not actively involved in addressing this problem. Also, the staffs are not trained in the proper waste management procedures.
The present interventional study was conducted to assess the knowledge, attitude and practice about hospital waste management, to provide training programme on hospital waste management and to assess the effect of training among the staff of dental teaching hospitals in Bangalore city.
Methodology: A specially prepared and pre-tested structured questionnaire was given to assess the knowledge, attitude and practices among the staff of dental teaching hospitals and collected personally. One day training programme on the hospital waste management was organized at each dental college. Intervention was evaluated by assessing improvements in their knowledge, change in attitude and practice scores after intervention in comparison to the base line scores.
Results : Two months after intervention there was a 24.4% improvement in knowledge among the dentists, 18.7% improvement among auxiliaries and 23.3% improvement (p<0.001, significant) among the attenders when compared to the baseline knowledge. There was 36.2% change in attitude among the dentists, 33.3% change among auxiliaries, 56.42% and among the attenders (p<0.001, significant) when compared to the baseline attitude. There was a 17.6% change in practice among the dentists, 16.4 % change among auxiliaries, and 4.4 % among the attenders when compared to the baseline practice.
Conclusion : The findings of this study suggest that a training programme increases the knowledge as well as the sense of responsibility resulting in change in attitude and practices. However, to implement an effective and sustainable hospital waste management system: budget support, allocation of resources and technical guidance is required. Large volumes of workload bureaucratic culture and slow percolation of decisions delays the changes that are mandated.
Keywords : Biomedical waste, Hospital waste management, Knowledge, Attitude, Practice.
It is with supreme sincerity, deep sense of gratitude and heartfelt appreciation, I thank my esteemed Teacher and Guide Dr.Naganandini .S., professor, Department of Preventive and Community Dentistry, Oxford Dental College Hospital and research centre, Bangalore, for her valuable guidance, support and encouragement to bring this dissertation to a successful completion.
It is my privilege and honour to express my most sincere and heartfelt thanks to Dr.M.R .Shankar Aradhya, Professor and Head, Department of Preventive and Community Dentistry, Oxford Dental College, Hospital and research centre, Bangalore, for his guidance and for providing the opportunity to carry out this study.
I extend my sincere thanks to Dr. Pruthvish.S, Professor and Head, Department of Preventive and Community Medicine, M.S.Ramaiah Medical College, Bangalore, Dr. Lalitha K.S ,Dr. Shalini Pradeep, Dr.Arjunan Isaac for their guidance and advice that has helped me in accomplishing this task.
Special thanks to Dr. Chitra Nagaraj, Dr. Usha .S for their…..
I am also thankful to Dr.Majunath. C., Dr.Shabana.A.G and Dr.Shilpa Shree.K.B for their timely help, valuable suggestions in this dissertation.
I extend my humble thanks to our Principal, Dr. K.S. Ganapathy for providing the opportunity to carry out this study.
I am grateful to Dr.Suresh K.P, Statistician, for his valuable assistance, guidance and his help in statistical analysis.
I would also like to express my thankfulness to all hospital authorities, staff, who have dedicated part of their valuable time for my study.
I would like to express my gratitude to all My Colleagues for their help, support, and co-operation throughout this study.
I shall be forever indebted to all my Family Members who have been constant sources of inspiration and encouragement. I wish to regard my deep appreciation for their immeasurable support, innumerable sacrifices, unstinted help and prayers without which I would not have been what I am today.
Above all I bow my head in gratitude to Almighty for bestowing his blessings on me and helping me make this effort a reality.
“Nothing on earth is more international than disease ”
-- Paul Russel
Health and disease have no political or geographical boundaries. In the early Greek, Roman, Egyptian civilizations, the temple of god was used as hospitals. So, hospital is a place of almighty, a place to serve the patient. These are complex institutions which were frequented by people from every walk of life in the society without any distinction between age, sex, race and religion1.
Growing urbanization has led to several changes in the healthcare sector. While on one hand, access to healthcare services are being provided to the community thereby resulting in the better health for all, improper management of hospital waste emanating from these healthcare establishments has also given rise to many environmental and health problems, thereby negating the benefits of the expanding health sector.
It is reported that for the first time the hospital waste management issue was discussed at a meeting convened by the World Health Organization regional office for Europe at Bergen, Norway in 1983. The seriousness of the issue was brought to limelight during the “beach wash- ups” of summer 1988. Investigation carried out by the Environment Protection Agency (EPA) of USA in this regard culminated in the passing of Medical Waste Tracking Act (MWTA), November 19882. With the passage of time the problem has evolved as a global humanitarian issue.
Until fairly recently, hospital waste management was not generally considered an issue. In 1980s and 1990s concerns about exposure to human immunodeficiency virus (HIV) and hepatitis B virus (HBV) led to questions about potential risks inherent in hospital waste3. Thus hospital waste generation has become a prime concern due to its multidimensional ramifications as a risk factor to the health of patients, hospital staff and extending beyond the boundaries of the hospital establishment to the general populations. The management of hospital waste is still in its infancy all over the world. Now hospital waste management is one of the trust areas which are drawing the attention of health authorities and the Government. There is a lot of confusion and problems among the generators, operators, decision-makers and the general community about the safe management.
Hospital waste management has been brought into focus in India recently, particularly with the notification of the biomedical waste management and handling rules. The ministry of environment and forests, government of India notified the bio-medical waste (management and handling) rules on 27 th July 19984 .These rules have been formed in exercise of the powers conferred by sections 6, 8 and 25 of environmental protection act 1986. The rule makes it mandatory for the health care establishment to segregate, disinfect and dispose their waste in eco friendly manner. Clearly, statutory safeguards for biomedical waste management practice in Indian hospitals have still not achieved the desired standards.
Since last few years there has been rapid mushrooming of dental health care set ups catering the needs of people and thereby there is definite increase in the quantity of waste generated. According to a WHO report, around 85% of the hospital wastes are actually non hazardous, 10% are infective (hence, hazardous), and the remaining 5% are non-infectious but hazardous (chemical, pharmaceutical and radioactive). Dental Hospitals generates waste similar to other health care set ups which includes a large component of general waste and a smaller proportion of hazardous waste.
Biomedical waste generated in dental hospitals include sharps, body tissues, chemicals –fixers , mercury, silver thiosulfate, lead foils, fresh mix of amalgam, scrap amalgam etc. and used dental materials. To ensure compliance with the law, these materials must be properly handled, recycled, treated and/or disposed. But more often, in dental hospitals the general wastes and biomedical wastes are allowed to mix thereby rendering the general waste also toxic and hazardous. Most dental hospitals are not actively involved in addressing this problem.
In spite of the fact that the biomedical waste is a great health hazard, the awareness and knowledge regarding biomedical waste handling and disposal is abysmally low and scientific literature search show significant gap in the knowledge, attitude and practice among the staff about hospital waste management 6. Also, the staffs are not trained in the proper waste management procedure which is the need of the hour. Recognizing this need we have to address these issues and provide training programme to impart training, knowledge dissemination, and provide an excellent platform for mooting innovative strategies to integrate “hospital waste management” as a corporate social responsibility, instead of mere social cost.
So, in this view, this study was the first of its kind to assess the knowledge, attitude and practice about hospital waste management and to impart training in proper hospital waste management procedure and to assess the effect of training among the staff of dental teaching hospitals in Bangalore city.
Let the wastes of “the sick” not contaminate the lives of “the healthy”.
To study the knowledge, attitude and practice about hospital waste management and to assess the effect of training among the staff of dental teaching hospitals in Bangalore city.
1. To study the knowledge, attitude and practices towards hospital waste management among staff of dental teaching colleges in Bangalore city.
2. To provide training programme on hospital waste management for the staff of dental teaching colleges in Bangalore city.
3. To assess the effectiveness of hospital waste management training programme on knowledge, attitude and practices among staff of dental teaching hospitals in Bangalore city.
REVIEW OF LITERATURE
Literature search show very limited scientific literature on the knowledge, attitude and practice about hospital waste management among staff of dental teaching hospitals, and also there are no studies done to assess the effectiveness of the training programme on hospital waste management among the staff of dental teaching hospitals. Hence only the related knowledge, attitude and practice studies are considered here.
A national survey7 was conducted to investigate current procedures in New Zealand dental practices for disposal of clinical waste. A questionnaire was sent out to all dental practices in New Zealand. From three mailings 767 useable questionnaires were returned (71.3%) of those sent out, 79.0%, of those potentially valid. Responses indicated that 56.4% of dental practices disposed of bloody swabs into the waste paper bin, and 24.4% disposed of contaminated sharp items into the general household refuse collection. Qualitative interviews with dental practitioners revealed a lack of concern about disposal of contaminated waste into the general waste. The existence of legislation governing waste disposal was not sufficient to motivate many practitioners to comply with guidelines. In some areas there was no specialized waste disposal service available, but some dentists had rejected a specialized service on the grounds of cost or inconvenience.
A study8 investigated the disposal of clinical waste within dental surgeries in Bangkok, Thailand. A questionnaire was sent to all dental practices in the Bangkok Metropolitan Area. The response rate was 57.7 per cent. Few dentists complied with all recommendations for the disposal of waste. Most waste was disposed of into the domestic rubbish stream.
A survey9 was undertaken among 64 dentists working in a teaching hospital of New Delhi. A pre-tested self-administered questionnaire was used to assess knowledge and practices of biomedical waste management and infection control among these dentists. Questionnaire comprised question on disposal of infectious waste, legislation of biomedical waste management, usage of personal protective equipment and measures adopted to limit the spread of infection. The results showed that not all dentists were aware of the risks they were exposed to and only half of them observed infection control practices. In addition to this, majority of them were not aware of proper hospital waste management.
An investigation 10 at 37 randomly selected clinics in Ramallah and AI-Bireh cities: 31 private practices and 6 public/NGO clinics was done to know about disposal of dental waste. Dentists were interviewed regarding their disposal of different forms of dental waste. Disinfectants and X-ray processing solution were thrown down the drain. For sharps, 13.5% of dentists used puncture-resistant containers (only in the public/ NGO clinics), 45.9% discarded needles directly in the garbage after being recapped and 40.5% placed the used needles and blades in closed plastic bottles before throwing in the general garbage. Blood-soaked dressings and amalgam waste were also thrown in the garbage. While 10.75% of dentists were vaccinated against hepatitis B, 47% of the staff at private clinics were not.
A cross-sectional study11 of 432 private dental practitioners in Bangalore City using a self-administered questionnaire was done to assess the knowledge, attitude and behavior of private dental practitioners on health care waste management in Bangalore City. 64.3% do not segregate waste before disposal and 47.6% hand over health care waste to street garbage collectors; 42.1% felt that there was a lack of waste management agency services and 16.9% felt that a lack of knowledge were the main hurdles. Dentists need education regarding health care waste disposal methods to improve their knowledge. A large proportion of the dentists are not practicing proper methods of health care waste disposal. The existence of legislation governing healthcare waste disposal is not sufficient alone to motivate many practitioners to comply with guidelines.
There is limited relevant scientific literature available with respect to knowledge, attitude and practice about hospital waste management among the staff of dental teaching hospitals, and since dental settings are a part of health care set ups the related studies on health care set ups are considered for review.
A research12 project was conducted to compare waste management in five different European hospitals. The project examined disposal practices, applicable regulations, available infrastructure, and the organization of waste collection and disposal in the hospitals. Regulation and guidance documents relevant to waste management were collected and compared and analysis of waste was undertaken to obtain more detailed information about waste composition and waste segregation. Workshops were held to compare disposal practice in the different hospitals, the influence of legal stipulation and available local infrastructure. The study included basic consideration such as the health and safety of patients and personnel, handling, level of staff knowledge and available infrastructure.
A Survey13 was conducted in Pondicherry, Karaikal, Mahe and Yanam to determine the awareness about waste management policy and practices. Attitude related to the issue was also ascertained. Data was collected from all sections of employees in health care settings. To document the practices, photographs were also taken. Overall response rate was 82%. More than half (52%) of the respondents were not aware of the existence of a legislation and majority (72%) not aware of authorization. Vast majority (74%) did not use any color coding and only a very small percentage (15%) used the bio-hazard symbol. Maintaining a register and auditing virtually did not exist. Majority (80%) regarded this as an issue that needs to be tackled.
A study14 was conducted to know the management of bio-medical waste: awareness and practices in a district of Gujarat. With the objective of assessing the level of awareness about the various aspects of biomedical waste and disposal practices by the medical practitioners this study was conducted. It was a cross sectional study done in 30 hospitals which were randomly selected from Sabarkantha district, Gujarat. The doctors and auxiliary staff of those 30 hospitals were the study population. While all the doctors knew about the existence of the law related to biomedical waste but details were not known. Doctors were aware of risk of HIV and Hepatitis B and C, whereas auxiliary staff had very poor knowledge about it. There was no effective waste segregation, collection, transportation and disposal system at any hospital in the district. There is an immediate and urgent need to train and educate all doctors and the staff to adopt an effective waste management practice.
A study15 on Knowledge, Attitude and Practice (KAP) was carried out in a tertiary level teaching hospital. The KAP study enrolled 156 respondents, representing doctors and nurses from selected patient care areas. Here, a significant gap was observed in the knowledge, attitude and practice of the consultants, residents and scientists with regard to biomedical waste disposal, to their Knowledge/understanding on the subject. Nursing professionals on the other hand, had an edge over the clinicians as far as attitude and practice of biomedical waste management is concerned although their knowledge on the subject was relatively low. The paramedical staff including laboratory and housekeeping staff had least understanding on the subject, but had higher positive attitude with more practical habits, which may be attributed to strict instructions by authorities and fear for any punitive action.
A cross-sectional survey16 was conducted in eight teaching hospitals of Karachi to evaluate the current practices of segregation approaches, storage arrangements, and collection and disposal systems. The instrument of research was a self administered questionnaire, with four sections, relating to the general information of the institution, administrative information, information regarding Health Waste Management personnel and a check-list of Hospital Waste Management activities. Out of eight hospitals visited 2 (25%) were segregating sharps, pathological waste, chemical, infectious, pharmaceutical and pressurized containers at source. For handling potentially dangerous waste, two (25%) hospitals provided essential protective gears to its waste handlers. Only one (12.5%) hospital arranged training sessions for its waste handling staff regularly. Five (62.5%) hospitals had storage areas but mostly it was not protected from access of scavengers. No record of waste was generally maintained. Only two (25%) hospitals had well documented guidelines for waste management and a proper waste management team.
A cross sectional study17 was conducted in Hamidia hospital to assess the knowledge of the personnel (working staff including doctors, nurses, ward boys, and sweepers). Although the level of knowledge was more among doctors and nurses as compared to ward boys and sweepers. Almost all the respondents among doctors and nurses were aware that improper management of waste causes health hazards while 40-60% of ward boys and sweepers were aware about this fact. All respondents felt that closed containers should be used for collecting waste.
A survey18 was conducted to study the existing medical waste management (MWM) systems in Tanzanian hospitals during a nationwide health-care waste management-training programme conducted from 2003 to 2005. The aim of the programme was to enable health workers to establish MWM systems in their health facilities aimed at improving infection prevention and control and occupational health aspects. During the training sessions, a questionnaire was prepared and circulated to collect information on the MWM practices existing in hospitals in eight regions of the Tanzania. The analysis showed that increased population and poor MWM systems as well as expanded use of disposables were the main reasons for increased medical wastes in hospitals. Some hospitals were using untrained casual laborers in medical waste management and general cleanliness. The knowledge level in MWM issues was low among the health workers. It is concluded that hospital waste management in Tanzania was poor. There was need for proper training and management regarding awareness and practices of medical waste management to cover all carders of health workers.