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ORIGINAL ARTICLE: DR. S. D. GAUR BEST PAPER AWARD ON ENVIRONMENTAL HEALTH
Year : 2021  |  Volume : 65  |  Issue : 4  |  Page : 345-351  

Assessment of knowledge, attitude, and practice about biomedical waste management among healthcare workers during COVID-19 pandemic in a health district of West Bengal


1 Assistant Professor, Department of Community Medicine, R. G. Kar Medical College and Hospital, Kolkata, India
2 Senior Resident, Department of Community Medicine, AIIMS, Nagpur, Maharashtra, India
3 Principal and Professor, Department of Community Medicine, Arambagh Government Medical College, Arambagh, West Bengal, India

Date of Submission30-Nov-2021
Date of Decision01-Dec-2021
Date of Acceptance02-Dec-2021
Date of Web Publication29-Dec-2021

Correspondence Address:
Anirban Dalui
20 C Sri Gopal Mullick Lane, Flat 3, 1st Floor, Kolkata - 700 012, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_2103_21

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   Abstract 


Background: Efforts to combat Coronavirus disease (COVID-19) pandemic have significantly increased the quantity of bio-medical waste (BMW) generation. Objectives: A cross-sectional study was performed to assess the knowledge, practice, and attitude and factors affecting knowledge on BMW management among Health Care Workers (HCWs) when taking care of patients with COVID-19. Methods: This cross-sectional study was conducted among 384 HCWs, actively involved in caring of COVID-19 patients in Healthcare settings of North 24 Parganas Health District, West Bengal. Data were collected using a structured self-administered questionnaire (through Google Forms) and an observational checklist after selection criteria and having consent. The Questionnaire included four sections like the sociodemographic information, knowledge related to BMW management, observational questionnaire assessing the practice of HCWs on BMW management and rating scale related to attitudes towards BMW management. Results: 166 HCWs (43.2%) had an excellent knowledge with overall mean score 13.5 ± 3.6. A high mean score (14.4 ± 3.2) was obtained by doctors followed by nurses (13.6 ± 3.8). Regarding practice, the majority of HCWs (52.8%) followed the color-coding of BMW and 49.5% followed policies in separating the wastes according to hazard. Doctors (91%) and nurses (81%) had more favorable attitude than others. There was a statistically significant association found among knowledge level and educational qualification (P = 0.0001), gender (P = 0.001), and work experience (P = 0.05) and work area (P = 0.05). Conclusion: Emphasis should be given to aware and train all HCWs regarding proper BMW management during this pandemic to prevent infection transmission.

Keywords: Attitude, biomedical waste, COVID-19, healthcare workers, knowledge


How to cite this article:
Dalui A, Banerjee S, Roy R. Assessment of knowledge, attitude, and practice about biomedical waste management among healthcare workers during COVID-19 pandemic in a health district of West Bengal. Indian J Public Health 2021;65:345-51

How to cite this URL:
Dalui A, Banerjee S, Roy R. Assessment of knowledge, attitude, and practice about biomedical waste management among healthcare workers during COVID-19 pandemic in a health district of West Bengal. Indian J Public Health [serial online] 2021 [cited 2022 Jan 16];65:345-51. Available from: https://www.ijph.in/text.asp?2021/65/4/345/333979




   Introduction Top


The term “Bio-Medical Waste” (BMW) includes all the wastes from any medical procedure in healthcare facilities, research centers, and laboratories during diagnosis, treatment, immunization of human beings and animals, and production or testing of biological materials.[1] BMW must be managed by a safe and proper method, which should be known and practiced by every healthcare Workers (HCW) to reduce the transmission of infection and to prevent various health and environmental hazards.[2]

The World Health Organization (WHO) declared COVID-19 as the sixth public health emergency of international concern.[3] The outbreak of COVID-19 has engendered a global health crisis along with diverse impacts on economy, society and environment. This pandemic has also significantly shot-up the quantity of BMW generation and has been gradually creating a major challenge.[4] Moreover, Health Care Workers (HCWs) who handle such BMW should follow an adequate dress code, including wearing PPE, masks, splash-proof apron, gloves, gum boots, and safety goggles. Due to this pandemic, there was an unexpected increase in the amount of disposable personal protective equipments.[5] Healthcare waste generation has been increased 6 times in the middle of COVID-19 outbreak in Wuhan of China.[6] Restriction in recycling to prevent the spread of the virus, increase in generation and improper treatment has posed alarming situation.[7] In the Kingdom of Saudi Arabia, the generation rate of BMW is approximately 15 million tons per year with an average rate of 1.4 kg/capita/day and due to pandemics, this number is increasing dramatically.[8] The improper practice of segregation at the site of origin has also been observed, which causes the mixing of infectious and noninfectious waste.[9]

In response to the COVID-19 pandemic in India, the Central Pollution Control Board, Ministry of Environment, Forest and Climate has published guidelines for the management of waste generated during treatment/diagnosis/quarantine of COVID-19 patients.[10] These guidelines have advocated use of double layered bags (using two bags), mandatory labelling of bags and containers as “COVID-19 waste,” regular disinfection of dedicated trolleys, separate record keeping of waste generated from COVID-19 isolation wards, in addition to the recommendation for following existing practices of BMW Management Rules, 2016. As the virus has the potential ability to survive on face masks and gloves,[11] adequate knowledge and proper techniques of handling these contaminated wastes and practice of safe disposal can protect the community from infection during this pandemic. This paper has attempted to assess the knowledge, practice; and attitude regarding BMW management among HCWs during COVID-19 pandemic in healthcare sectors of North 24 Parganas District and to determine the factors affecting the knowledge level.


   Materials and Methods Top


Study design and area

This descriptive design-based cross-sectional study was conducted to assess the knowledge, attitude, and practice of BMW management among HCWs who were actively involved in caring of COVID-19 patients from May 2020 to April 2021 in the Public and Private Healthcare settings, situated in North 24 Parganas Health District, West Bengal.

Study units/population: Sampling and selection

All HCWs including doctors, nurses, pharmacists, internees (both medical and nursing) laboratory technicians including intensive care unit (ICU) technicians, X-ray technicians, etc. who were aged 20 years and above, both males and females, worked at government or private healthcare sectors with a minimum 6 months professional experience and cared for COVID-19 patients, were included as study participants. HCWs who provided informed consent and available during data collection were included in the study.

Considering percentage of HCWs with precise knowledge, good practice and a favourable attitude on BMW management (75%) in other similar study,[12] with an allowable margin error of 5%, at a 95% confidence interval and accounting for the finite population for 1430 HCWs, a minimum sample size of 240 was calculated. Considering the design effect of 1.5 for multistage sampling and considering the probable sample loss, it was calculated to recruit 384 samples.

Among all COVID-19 healthcare facility centres of North 24 Parganas District, 12 hospitals (six government and six private) were chosen randomly using random sampling. List of HCWs in each healthcare facility was taken and HCWs were chosen based on the probability proportional to size selection from each hospital. In case of nonresponse, a new person of same fraternity has been recruited in this study. Thus, 384 HCWs were included from twelve hospitals of the district.

Data collection tool and procedure

The data were collected using a structured self-administered questionnaire (through Google Forms) and an observational checklist reviewing the literature and international BMW management guidelines.[13] The questionnaire consisted of four sections. The first section included the sociodemographic information of HCWs. The second section included knowledge related to BMW management. The third section was an observational questionnaire assessing the practice of healthcare professionals (HCPs) on BMW management; and the fourth section included the rating scale related to attitudes towards BMW management.

The tool used that was developed in English. The pilot study was performed among 10 HCWs to test the tool. Therefore, the liability of the questionnaire was tested (r = 0.935) using Cronbach's alpha. The time used to fill in the questionnaire ranged from 20 to 25 min. The objectives of the study were explained clearly to the participants before data collection. The privacy of respondents was assured by not asking their identity information such as their name, employee identity numbers in the questionnaire. We used all data for the purpose of the research, and they were encrypted and stored electronically in a secure location, with a password used by the principal investigator to ensure privacy and confidentiality. Informed consent was obtained from each participant, and then a structured questionnaire was distributed to collect all the data, except the practice tool. After the completion of the tool, using an observational method, the practice questionnaire was filled by researcher.

Demographic information

The parameters of demographic data of HCWs included age, gender, educational qualification, occupation, professional experience; and working area.

Knowledge questionnaire

This tool consisted of 20 multiple choice questions, each of which had four options in which there were three incorrect with one correct option. The structured knowledge questionnaire was scored as either 1 for a correct response or 0 for an incorrect response. The total knowledge score was summed and computed for analysis. The score interpretations were counted from 75% to 100% (15–20) as excellent knowledge, from 50% to 74% (10–14) as good knowledge; and below 50% (<10) as poor knowledge.

Practice questionnaire

The observation questionnaire was used to assess the practice of HCWs in healthcare sectors. It contained ten questions with the options “always,” “sometimes,” and “never.” The investigator observed the practice of HCWs and filled in the questionnaire directly. The overall practice was calculated and interpreted using the frequency distribution table in the results section.

Attitude scale

The questionnaire on attitude towards BMW management was developed comprising of ten questions. Responses were measured in 5-point Likert scale to represent the scores; “strongly agree;” “agree;” “neutral;” “disagree;” and “strongly disagree,” which was scored as 5, 4, 3, 2, and 1 respectively and for negatively phrased statements, scores were reversely coded during the data entry period as 1, 2, 3, 4, and 5, respectively. The overall score of attitude was calculated by adding all scores of HCWs and the mean was computed by dividing the overall attitude score by the number of study participants. Finally, attitude scores below the mean and above or equal to the mean score were assigned for unfavourable and favourable attitudes, respectively.

Ethical considerations

Ethical clearance for the study was obtained from the Institutional Ethics Committee of RG Kar Medical College and Hospital, West Bengal (RKC/517). Participation of the subjects in the study was voluntary and informed consents were obtained from all participants. Confidentiality and anonymity of information were maintained.

Statistical analysis

The collected data were checked for completeness and consistency and entered into the computer in the excel datasheets. The data analysis was done using SPSS version 20.0 (SPSS Inc., Chicago, Illinois, USA). The frequency distribution was calculated using descriptive analysis and expressed in the form of mean ± standard deviation as well as median with range. Chi-square analysis was used to test the association between the knowledge of HCWs on BMW management and their demographic characteristics. P ≤ 0.05 was considered significant for all statistical analyses.


   Results Top


Background characteristics

Out of 384 HCWs included in the study, 184 (47.9%) were under 30 years, and the majority of the participants were females (63.3%). Most of the participants, 228 (59.4%), had bachelor's degrees as their highest educational qualification. Regarding the occupational status of the HCWs, 91 (23.7%) were doctors and 151 (39.3%) were nurses. Furthermore, 211 (54.9%) HCWs had a <3 years of experience. Concerning the working facility, most of the participants, 233 (60.7%), worked in a government hospital. About 41.7% of participants were working at wards and 31.8% were working at ICUs.

Knowledge level of the health care workers on bio-medical waste management

Among the HCWs 166 (43.2%) had excellent knowledge, 148 (38.5%) had good knowledge and 70 (18.2%) had poor knowledge. The overall mean score was 13.5 ± 3.6. A high mean score (14.4 ± 3.2) was obtained by doctors followed by nurses (13.6 ± 3.8) [Table 1].
Table 1: Knowledge of healthcare workers about bio-medical waste management (n=384)

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Practice of health care workers in bio-medical waste management

[Table 2] shows the pattern of practice of HCWs in BMW management. Most of the HCWs (303/384, 78.9%) always followed the guidelines specified by the Ministry of Health and Family Welfare and Ministry of Environment, Forest and Climate Change for BMW management. 296 study subjects (77.1%) always adhered to the infection control policies while treating COVID-19 patients. Most of the HCWs sometimes used PPEs during BMW handling (47.9%) and sometimes discarded all PPE while handling BMWs (53.9%). 203 (52.8%) HCWs followed the colour coding of containers according to the type of waste during the disposal of BMW and 190 (49.5%) followed policies in separating the wastes into nonhazardous, hazardous; and sharp waste always. In addition, 90.6% of study population maintained BMW records sometimes or always. Regarding preventing sharps-related injury such as avoiding recapping used needles, 209 (54.4%) HCPs were always cautious and 193 (50.3%) HCWs always prevented contamination while handling items of COVID-19 patients and other non-COVID-19 patients.
Table 2: Practice of healthcare workers about bio-medical waste management (n=384)

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Attitude of the healthcare professionals toward bio-medical waste management

The results showed that 284 (74.1%) had a favorable attitude, and 100 (26.9%) had an unfavorable attitude towards BMW management. Among them, most of the physicians (91%) and nurses (81%) had a more favorable attitude than others. As shown in [Table 3], 288 (75%) HCWs strongly agreed that the safe disposal of BMW was necessary for healthcare sectors. 60.2% HCWs strongly agreed that BMW management required teamwork. However, only 21.6% strongly disagreed that BMW management created an extra burden on their work. Most of the study subjects (44.2%) disagreed that BMW management risked transmitting infectious diseases. However, 29 (7.5%) strongly disagreed that the segregation of hospital waste into different categories was time consuming. 143 (37.2%) HCWs strongly felt that PPE must be used while handling BMW, and 42.4% strongly felt that decontamination and disinfection reduced infection. Almost half of the study subjects (50.3%) felt strongly that upgraded knowledge on BMW management was mandatory [Table 3].
Table 3: Attitude of the healthcare professionals towards bio-medical waste management (n=384)

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[Table 4] shows that there was a significant association between the level of knowledge and factors such as gender (P < 0.001), educational qualification (P < 0.0001), work experience (P < 0.05), and duty area (P < 0.05).
Table 4: Association of the knowledge of healthcare workers with demographic variables (n=384)

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   Discussion Top


This study showed that 166HCWs (43.2%) had excellent knowledge, 148 (38.5%) had good knowledge and 70 (18.2%) had poor knowledge. This finding was supported by Jalal et al. in Saudi Arabia as they showed that majority of the healthcare workers had sufficient knowledge on COVID-19 and infection control measures.[12] Another cross-sectional study performed across 10 hospitals in Henan, China, reported that 89% of HCWs had sufficient knowledge regarding corona virus disease 2019 (COVID-19).[14]

A study by Mugabi et al. at a tertiary hospital in Gaborone, Botswana, proved that there was a significant agreement among the participants on the proper segregation of medical waste to be carried out at the point of generation, with a mean score 4.43 out of 5, and on the color-coding system, with a mean score of 4.59 out of 5.[15] In the present study, the overall mean score was 13.5 ± 3.6 for the knowledge questionnaire regarding BMW management. A high mean score (14.4 ± 3.2) was obtained by doctors followed by nurses (13.6 ± 3.8) and this result also reflected the similar results found in previous studies.[12],[16]

In the present study, most of the HCW (78.9%) always followed the BMW management guideline published by the Department of Health and Family Welfare and 52.8% of the participants carried out the colour coding of containers during the disposal of BMW according to the type of waste. Pandey et al. also showed that though awareness (knowledge) about segregation of BMW was seen in 90% of the HCW, 30%-35% did not practice this.[17] Another study by Parida et al. revealed that regarding practice, 68% of HCWs knew that the most important step in waste management is waste segregation, and 82% of the participants working in this setup knew the different colour-coded bins used for segregation.[18] The current study showed that 77.1% of HCWs always adhered to the infection control policies while treating COVID-19 patients though HCWs in Aseer Region showed a poor understanding of the protocols and policies of PPE disposal.[19] However, in our study, most of them always used and discarded all personal protective equipment while handling biomedical waste, and 190 (49.5%) followed policies in separating BMW into nonhazardous, hazardous; and sharp waste.

In our study, it has been shown that 284 (74.1%) HCWs had a favorable attitude and 100 (26.9%) HCWs had an unfavorable attitude towards BMW management. Among them, most of the physicians (91%) and nurses (81%) had a more favorable attitude than others. This was supported by a study in India where doctors (100%) were found to be more positive towards the need for actions for safe biomedical waste management than nurses (60%) and other healthcare workers.[20] On the contrary, Sunmeet et al. in Gujrat showed that the highest overall scores for attitudes to waste disposal were observed among housekeepers compared to physicians or Lab Technicians.[21] A study performed by Albalushi et al. found that the majority of LTs (92.7%) considered BMW as an issue as compared to nurses (87.3%), doctors (80.5%); and housekeeping staff (80%), although it was statistically insignificant (P = 0.639). Moreover, a significantly higher percentage of nurses (92.7%) than doctors (83.2%); and LTs (64.3%), agreed that BMW management requires teamwork, and no single class of people was responsible this (P = 0.024).[22] However, in current study, 75% of HCWs strongly agreed that the safe disposal of BMW was necessary for the healthcare areas and 60.2%of HCWs strongly agreed that the BMW management required teamwork. However, only 21.6% strongly disagreed that BMW management created an extra burden on their work.

Previous studies showed that many of healthcare workers (93.3%–98.9%) were aware of improper waste management causing various health hazards; (79.8%–97.9%), the importance of regular educational programs on BMW management; (75.7%–82%), the amount of generated BMW in hospitals or clinics and (52.8%–87.6%) that maintaining BMW records is mandatory in hospitals orclinics.[23],[24] In this study, most HCWS (44.2%) disagreed that BMW management was risks transmitting infectious diseases. However, nearly half of the HCWs strongly felt that upgraded knowledge on BMW management was essential.

In our study, there was also a significant association between the level of knowledge and factors such as gender (P < 0.001), educational qualification (P < 0.0001), work experience (P < 0.05), and duty area (P < 0.05). Kumar et al. showed that the sociodemographic information such as age, gender, level of education; and experience, when compared with the practices, was found to be statistically significant (P < 0.05).[25] This impetuous COVID-19 situation changed healthcare systems, and the pandemic crisis forced many hospitals to reorganize their healthcare systems.[26]

Limitations

There was a chance for recall bias in this study as it needed to recall for knowledge-related questions. However, randomization was done to select hospitals as well as participants to reduce the bias. The practice was observed directly by the researcher which might have been biased. The participating HCWs were mostly females which might affect the inferences. This study could be repeated as an interventional investigation with larger samples, including all kinds of healthcare workers from a larger area.


   Conclusion Top


In this pandemic situation, Bio-Medical Waste management is extremely important to consider as HCWs being frontline workers in the COVID-19 crisis have been facing a greater risk of contamination due to their direct contact with patients and specimens. Accordingly, HCWs must have adequate knowledge regarding the proper handling of BMW, prevention of infection, and prevention of transmission of diseases. A high level of practice regarding the proper handling of PPE is recommended in the present study. The present findings raise the necessity to organize continuous training programs in the form of symposia, seminars; and workshop son BMW management to develop awareness among HCWs in all the Healthcare setups. Standard guidelines on BMW management should be updated time to time considering the nature of pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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