Knowledge and Practices of Health-Care Waste Management among Health Workers in Lassa Fever Treatment Facility in Southeast Nigeria.

BACKGROUND: The threat of endemic, emerging, and reemerging infectious diseases, especially the viral hemorrhagic fevers demands effective health-care waste management (HCWM) among health-care workers. The study was intended to assess the knowledge and practices of HCWM among the cleaning staff in a Lassa fever (LF) treatment facility.
MATERIALS AND METHODS: This was a cross-sectional descriptive study of 234 cleaning staff of Federal Teaching Hospital Abakaliki recruited by systematic random sampling. Data collection was with semi-structured questionnaires. Knowledge and practices of respondents were assessed using cutoff score of 75%; score of 75% and above being interpreted as good and <75% as poor. Data were analyzed using Epi™ Info Version 7.2.
RESULTS: There were 177 (75.6%) female and 57 (24.4%) male cleaning staff with a mean age of 33.4 years (±8.3). Among all the respondents, 18 (7.7%) had no formal education, while others had varying levels of education (primary, 43 [18.4%]; secondary, 133 [56.8%]; tertiary, 40 [17.1%]). Only 134 (57.3%) of the respondents had ever been trained on HCWM, of which 77 (57.5%) of them were trained in 2018. The proportion of respondents with good knowledge of HCWM was 41.5%. In addition, only 83 (35.5%) properly categorized the body parts, body fluids, and fetuses as pathological waste. About one-third, 77 (33.3%), had knowledge of steps in HCWM and 45.3% knew of diseases transmitted through health-care waste with 171 (62.8%) identifying LF as one of the diseases. The proportion of respondents with good practices of HCWM was 53.9% with only 131 (56.0%) segregating waste in specified color-coded containers. Among the factors examined, none was significantly associated with knowledge and practice of participants on HCWM.
CONCLUSION: The proportions of the cleaning staff with good knowledge and practices of HCWM were low. There is a need to train and retrain hospital staff on proper HCWM as well as need for proper supervision and monitoring. Copyright:

INTRODUCTION

The threat of endemic, emerging, and reemerging infectious diseases, especially the viral hemorrhagic fevers (VHFs), demands effective infection control practices among health-care workers (HCWs) and other caregivers.1 There are many materials/equipment used in hospitals for the diagnosis and treatment of patients. These materials may come in contact with blood, bodily fluids, and tissue of patients which may contain infectious microorganisms. These materials when contaminated by microorganisms have the potential to transmit diseases and thus require proper management and disposal following use.2 Among the diseases that can be transmitted from improper waste management and disposal, Lassa fever (LF) currently poses a serious threat in Nigeria, as it is increasingly endemic in many parts of the country.

The burden of LF has continued to increase in Nigeria with cases now being recorded in states that had not reported these in the past. At the moment, LF is endemic in Ebonyi State and has also been reported to have the highest incidence and case-fatality rate among health-care workers.3 This situation has presented challenges in case management and infection prevention and control (IPC), especially among HCWs who have developed fear toward management of suspected LF cases. As a result, there is a strong need for training and supportive supervision of HCWs on IPC so as to allay their fears and reduce the nosocomial spread of the disease. The mainstay of control of VHF outbreaks is prevention of human-to-human transmission of VHFs through standard IPC measures during the care and management of suspected or confirmed VHF patients within health facilities and in the community.1

In promoting IPC in the context of LF, standard precautions are essential, as a patient may present to the health facility often when the possibility of exposure to transmission is highest with specific cause of the illness yet unknown. Standard precautions are aimed at preventing direct contact between the HCW and blood, all other body fluids, and mucous membranes. These precautions include waste management, hand hygiene, appropriate personal protective equipment, respiratory hygiene, cough etiquette, safe use, and disposal of sharps.1 Others are aseptic technique, environmental cleaning, linen management, and patient care equipment.1

Management of health-care waste entails all the activities and actions required to manage health-care waste from its inception to its final disposal. Importantly, the concept of “waste-management hierarchy” is core to the entire process of managing these wastes. Although to a large extent, waste management is based on the concept of 3Rs which are Reduce, Reuse, and Recycle, most hospital wastes are generally not reused or recycled to ensure IPC. Basic steps in managing hospital waste include waste minimization, waste segregation, waste collection/storage, waste transportation, treatment, and waste disposal. In relation to the guiding principles of health-care waste management (HCWM), the “duty-of-care” principle stipulates that any person that generates waste has a duty to dispose of the waste safely.4 Another principle important to HCWM is the “precautionary” principle which requires that as a health worker, one must always assume that waste is hazardous until shown to be safe.4 Taking necessary precautions in the course of generating and handling waste could reduce the risks associated with hazardous waste as well as their spread to other health workers, patients, and the environment.

Health-care waste handlers are at the greatest risk of infectious hazards. We, therefore, assessed the knowledge and practices of HCWM among the cleaning staff in Federal Teaching Hospital Abakaliki (FETHA).

MATERIALS AND METHODS

The study was carried out between July and August in 2018 at FETHA, a tertiary health-care facility that has a dedicated LF diagnostic and treatment center for management of VHFs. FETHA was established to train specialists and middle-level health workforce, conduct research, and provide tertiary level clinical services to the inhabitants of Ebonyi State and its environs. It serves as a reference center for management of VHFs in Southeast Nigeria; therefore, making it a focal point for management of cases from the region and also neighboring states from South-South and Northcentral parts of the country.

We conducted a cross-sectional study among the cleaning staff working in all the wards and clinics in the hospital. The sample size was determined using the formula for estimating minimum sample size for descriptive studies;

and nf= n/1 + n/N where n = desired sample size when population is >10,000, nf= desired sample size when population is <10,000, z = standard normal deviate set at 1.96 which corresponds to 95% confidence limit, P = 0.46 as proportion of respondents with good knowledge of HCWM in a similar study in Nigeria,5 d = desired level of precision set at 0.05. Based on the calculation, the minimum sample size was 234. Participants included cleaning staff who had been in the health-care facility for at least 1 month and gave consent to participate in the study. Participants were selected using systematic random sampling. Those absent on the days of the study were excluded. Pretested semi-structured questionnaires were administered by trained research assistants to the selected participants.

Data entry and analysis were done using Epi™ Info version 7.2 (Atlanta, USA). Descriptive statistics were presented in tables. The level of knowledge and practice of waste management staff on HCWM were estimated and presented in proportions using cutoff score of 75%; score of 75% and above being interpreted as good and <75% as poor.6 The factors associated with knowledge and practice of health-care health management were assessed using Chi-square test and level of significance were set at P < 0.05. Ethical approval was obtained from the Research and Ethics Committee of FETHA, Ebonyi State, Nigeria. Informed consent was obtained from all the participants, and confidentiality was ensured. The participants could withdraw from the study any time within the study period.

RESULTS

Out of 234 that participated in the study, 177 (75.6%) were female [Table 1]. The mean age of the participants was 33.4 ± 8.3 years. Majority 147 (62.8%) of the participants were married and predominantly Christians 224 (95.7%). Eighteen (7.7%) had no formal education, while 40 (17.1%) had tertiary education. Only 134 (57.3%) of the respondents had received any form of training on HCWM, and of these, 77 (57.5%) of them were trained in the current year (2018).

Table 1

Sociodemographic characteristics of respondents (n=234)

	Frequency, n (%)
Gender
Male	57 (24.4)
Female	177 (75.6)
Marital status
Single	73 (31.2)
Married	147 (62.8)
Divorced/separated	14 (6.0)
Level of education
No formal	18 (7.7)
Primary	43 (18.4)
Secondary	133 (56.8)
Tertiary	40 (17.1)
Religion
Christianity	224 (95.7)
Islam	7 (3.0)
Traditional religion	2 (0.9)
Others	1 (0.4)
Previous training on HCWM
Yes	134 (57.3)
No	100 (42.7)

HCWM – Health-care waste management

The proportion of respondents with good knowledge of HCWM was 41.45%. About one-third 78 (33.3%) had knowledge of steps in HCWM [Table 2]. In addition, only 83 (35.5%) properly categorized the body parts, body fluids, and fetuses as pathological waste [Table 3]. Only 106 (45.3%) correctly identified diseases transmitted through health-care waste with 147 (62.8%) identifying LF as one of the diseases [Table 4]. On awareness of location of waste segregation, 151 (64.53%) of the respondents knew it should be at the source of waste generation [Table 5].

Table 2

Knowledge of health-care waste management among respondents (n=234)

Knowledge of HCWM	Frequency, n (%)
HCWM guideline
Yes	153 (65.38)
No	81 (34.62)
Principles of HCWM
Yes	147 (62.82)
No	87 (37.18)
Hazardous health-care waste
Yes	200 (85.47)
No	34 (14.53)
Steps in HCWM
Yes	78 (33.33)
No	156 (66.67)
Health-care waste generation from diagnosis, immunization, and treatment
Yes	207 (88.46)
No	27 (11.54)
WHO’s color coding for waste containers in HCWM
Yes	141 (60.26)
No	93 (39.74)
Factors contributing to poor HCWM
Yes	83 (35.47)
No	151 (64.53)

HCWM – Health-care waste management

Table 3

Knowledge of categories of health-care waste

Categories of health-care waste	Waste form of paper, food, plastic, and bottles, n (%)	Waste form of soiled cotton wool, swab, and gloves, n (%)	Waste form of body parts, body fluids, and fetuses, n (%)	Waste form of needles, scapels, and syringes, n (%)
General (domestic)	170 (72.5)	11 (4.70)	14 (5.98)	7 (2.99)
Infectious	21 (8.97)	118 (50.43)	102 (43.59)	23 (9.82)
Pathological	20 (8.55)	43 (18.37)	83 (35.47)	9 (3.85)
Pharmaceutical	16 (6.84)	47 (20.09)	9 (3.85)	5 (2.14)
Radioactive	2 (0.25)	13 (5.56)	22 (9.40)	7 (2.99)
Sharps	5 (2.14)	2 (0.85)	4 (1.71)	183 (78.21)

Table 4

Knowledge on disease transmission through health-care waste

Diseases transmitted through health-care waste	Frequency, n (%)
Lassa fever
Yes	147 (62.82)
No	87 (37.18)
HIV
Yes	100 (42.74)
No	134 (57.26)
Hepatitis B
Yes	71 (30.34)
No	163 (69.66)

Table 5

Knowledge on location of waste segregation

Location of waste segregation	Frequency, n (%)
At source of generation	151 (64.53)
Sorting outside waste bin	55 (23.50)
I don’t know	28 (11.97)

The proportion of respondents with good practices of HCWM was 53.9%, with only 131 (56.0%) segregating waste in specified color-coded containers [Table 6]. Among the factors examined, none was significantly associated with knowledge and practice of participants on HCWM.

Table 6

Practices of health-care waste management among respondents (n=234)

	Frequency, n (%)
General health-care waste handled as hazardous if accidentally mixed with infectious waste
Yes	190 (81.20)
No	44 (18.80)
Minimization of generation of health-care waste while working
Yes	190 (81.20)
No	44 (18.80)
Segregation of health-care waste in specified color-coded containers
Yes	131 (55.98)
No	103 (44.02)
Specific secured area for health-care waste storage
Yes	183 (78.21)
No	51 (21.79)
Poor disposal of health-care waste
Yes	128 (54.70)
I don’t know	106 (45.30)

DISCUSSION

The knowledge and practices of health waste management in this study were low. This is worrisome as the hospital is a dedicated institution for LF management where harmful wastes are generated. In addition, there has been intensive advocacy and training on IPC since the first epidermic of LF, although this is the only extensive qualitative and quantitative feedback assessment generated from the center. Possible reason for the low knowledge and practices of health waste management may be that some health workers, especially junior staff like cleaning staff do not avail themselves of this training opportunity offered to all hospital staff possibly because of literacy level and ignorance. It may also be that they feel the trainings are for doctors and nurses who handle patients directly.

We observed that only a small proportion of cleaning staff had been trained on HCWM. A little over half (57.3%) of the participants had been previously trained on HCWM. Out of those that had ever been trained, 57.5% of them were trained in 2018. The proportion of respondents trained in 2018 may have been due to an interventional training by Médecins Sans Frontieres, an international nongovernmental organization that assisted the study facility during LF outbreak in 2018. A study in a Regional Hospital in Ghana noted a similar finding of 61.0% of health-care workers in its facility who had not received any training on HCWM.7 A poorer situation was reported in a study in a LF endemic area in Edo State, where only 1 out of 12 facilities surveyed, had a waste handler that had been trained on HCWM.8 Other studies also showed low proportion of training among health workers.59 Importantly, achieving infection control in health facilities will require proper HCWM through education and training of health workers to equip them with requisite knowledge, skills, and attitudes for good infection control practices.10

The proportion of respondents with good knowledge of HCWM was 41.45%. Sharma et al. noticed in a study in India that there was poor knowledge of HCWM with proportion ranging between 25.0% and 45.0% across different professions of respondents.11 However, a study done by Oli et al. in Southeastern Nigeria showed that over two-thirds (69.5%) of its respondents from selected hospitals were aware of HCWM. Another study highlighted the disparity in knowledge between core health workers and sanitary staff in health facilities as sanitary staff had lower mean of 8.30 compared to 12.80 in health staff.12 For a health facility in a LF endemic area, its hygiene staff needs to have more knowledge of waste management so as to protect themselves and others in the facility from spread of VHFs and other infectious diseases. Just 62.8% of the respondents identified LF as one of the diseases that could be transmitted through poor hospital waste management. About 63% of respondents were aware of HCWM guidelines which is similar to a finding in Ghana where 59.3% of the study participants knew about HCWM plan or guideline.7 It, therefore, seems that availability of waste management guidelines in health facilities is not enough. Implementation of these plans or guidelines could be pivotal to achieving better hospital waste management.

In categorizing health-care waste, approximately 73% correctly categorized paper, food, plastic, and bottles as general waste; about 50% correctly categorized soiled cotton wool, swab, and gloves as infectious waste; only 35.47% rightly classified body parts, body fluids, and fetuses being pathological waste; and 78.21% correctly identified needles, scalpels, and syringes as “sharps.” The findings in a similar study had 69.5%, 69.5%, 58.1%, and 69.5%, respectively, compared to findings on categorization of waste in this study.13 This shows that there is still a significant number of health workers with poor knowledge of waste categorization which is a key step in HCWM to reduce and control infections. Furthermore, 64.5% of the respondents knew that the location of waste segregation should be at the source of its generation. A study in Lagos identified only 61% of participants who knew segregation should be at the source of waste generation.13 Segregation of health-care waste at the source of generation is a key to achieving a sound HCWM, as it ensures better handling of infectious component of these wastes.

The proportion of respondents with good practices of HCWM was 53.9%. Only about 56.0% of the cleaning staff segregated waste in specified color-coded containers. This finding is similar to that of Mokuolu et al. who noticed waste segregation practice in 60% of health workers studied in a tertiary health facility.14 Practices of hospital waste management seem to be better than the respondents' knowledge of same. This may be due to provisions of some materials by the hospital management to aid waste management. About 81% of the study participants agreed to minimize waste while working. Waste minimization is aimed toward reducing waste to the extent it can. This can be achieved by avoiding wasteful ways of working in health-care facilities. This way, health-care waste is reduced at its point of generation. Approximately 56% segregated health-care waste in specified color-coded containers. This is quite poor as segregation is pivotal to IPC. Importantly, in line with the duty of care principle, it is the responsibility of the individual that produces any waste to segregate it into its proper place as close as possible to the point of generation of the waste. Segregation of waste into different fractions is on the basis of their potential hazard and route of disposal.4

CONCLUSION

This study has shown the need for improved knowledge and practices of hospital waste management among health workers in the study location. Workers will benefit from training and retraining on HCWM so as to increase their knowledge of waste management and also improve waste management practices. There is a need for supportive supervision of waste management practices for better implementation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.