An Assessment of Knowledge, Attitude and Practice about Biomedical Waste Management among Health Care Workers in Primary Health Care Facilities in a District of West Bengal

Knowledge of health care workers about BMWM

While assessing knowledge it was revealed from Table 2, only one fourth of the health care workers had correct knowledge i.e could utter all the types of BMW and 68.5% could identify the hazardous and non hazardous waste. Here 80% of the nursing staff and 45% doctors had correct knowledge. While assessing colour coding, only 67% could tell all the coloured bags (correct knowledge), out of which 100% of nursing staff had correct knowledge. About the hazards of BMW, only 38% of HCW could tell all the hazards like HIV, Hepatitis B and injuries, where more than half of the doctors didn't have the correct knowledge.

Correct steps of BMWM are Segregation -Collection & Storage -Transport & Measurement -Treatment& Disposal. This is known to only one fourth of HCWs, but more than 60% could tell that segregation should be done at source. While enquired about disposal of waste, little higher than half (55%) could mention correctly disposal of sharp waste in white puncture proof container and 46% about disposal of anatomical or pathological waste in yellow bags. Regarding collection, storage and transport of the BMW, very few had correct knowledge. So far as treatment of BMW before disposal was concerned, less than half (46%) had idea about disinfection by bleaching solution and one third could tell that plastic materials would be disinfected or shredded or recycled before final disposal. Similarly 54% could tell the disposal of sharp materials in to sharp pit, but only 27% had idea about the disposal of anatomical waste in deep burial pit.

Attitude of the health care personnel towards BMWM

While assessing the attitude of the HCWs towards BMWM, more than 75% had positive attitude about the necessity of disinfection of hospital waste before disposal and 88% agreed about the necessity of BMW rule, but only 37% agreed that BMW management is essentially a team work. On the other hand, more than 50% HCWs completely agreed about the importance of segregation at source and about the fact that the improperly managed BMW might spread infection to the community. But while asked whether BMWM added an extra burden of work to them, 47% had positive attitude as they totally don't think it as burden, where as 41% agreed partially.

Practice of the health care personnel towards BMWM

The practice of the Health Care Workers was assessed by using an observation check list.

While assessing the disposal of BMW maintaining the colour code, only one fourth (25.7%) of the HCWs had correct practice. Regarding use of PPE (Personal Protective Equipment) during BMW handling, only one nurse was seen to have correct practice, that means she used all components of PPE. More than 70% had partially correct practice (those who used 2-3 essential components) and rest 27% had not used PPE (Table 3).

As per the guidelines of BMWM, all HCWs should have completed vaccination of Hepatitis B and Tetanus Toxoid. It was observed that 47% had any one vaccine long time before and 53% had no vaccination at all. So far as regular medical check up was concerned, only 23% had irregular check up i.e at least one check up by medical practitioner in his/ her total service and 66% had never undergone any check up. More than 50% had no training on BMWM in last 1 year.

The study findings were evaluated across three domains (Knowledge, Attitude and Practice) for all the cadres of the study population. Six questionnaires in all the domains were selected for scoring with the opinion of three experts in public health.

It was revealed from Table 4 and Figure 1 that, knowledge and attitude score was seen better than practice score. The attitude score was very appreciable among the all categories of HCWs, whereas the knowledge score was highest among the nurses and very poor among the LTs & PHs and Housekeeping staff. In spite of good knowledge and attitude the practice was very poor among the all HCWs.

Close

FIGURE 1:

DISTRIBUTION OF MEDIAN SCORE AMONG DIFFERENT CATEGORIES OF STUDY PARTICIPANTS

Export to PPT

While finding association between the knowledge, attitude and practice score with age of the HCWs, those belong to the age group of < 30 years had the highest median knowledge and attitude score compared to 31-44 and in ≥ 45 years of age group, but the difference was not statistically significant. Similarly, the HCWs who had working experience for ≤10 years had the highest median knowledge score and those who were working for 11-19 years had the highest median score in attitude. But the practice score remained same among all of them. But in all cases the difference was not found statistically significant.

Gaps were found in selected primary health care facilities related to knowledge, attitude and practices of HCWs towards Bio-Medical Waste Management. Although nurses and doctors were knowledgeable, overall knowledge among other categories of the health care workers especially house keeping staffs was seen to be poor. Most of the HCW thought that BMW management added extra burden to them. Practice was seen to be poor inspite of having good knowledge and attitude. Training status, supervision and monitoring by higher officials were deficient.

Knowledge of the HCWS:

There were certain inadequacies in the different items of knowledge component among the HCWs in the present study. Less than two thirds of HCWs have correct knowledge about different categories of BMW and steps of BMW management, only 38.6% knew about hazards arising out of it. However, knowledge was comparatively better regarding colour coding (67%) and segregation at source (61.4%). In all respects nurses were most knowledgeable compared to doctors, HS & ANMs, paramedical workers and Housekeeping staff. In a study conducted in Sudan, HCWs had very good knowledge about categories of BMW and health hazards, but deficient in steps of management.⁹ Lavanya et al in Andhra Prodesh also found similarly, but knowledge was seen unsatisfactory in colour coding and principle of segregation.¹⁰ Choudasama et al in Rajkot however found better knowledge about health hazards, colour coding, steps of management, but deficient in identification of categories of BMW.¹¹ Anand P et al in Haryana observed satisfactory knowledge about all the components among doctors than the nursing staff, lab technicians and sanitary staff.¹² This difference might be due to different study setting, different categories of study population and due to difference in focus imparted on various components of BMWM during training.

Regarding disposal of different types of BMW, the present study found poor knowledge among the HCWs, except the general waste. In all aspects, housekeeping staff had very poor knowledge about all components of BMWM. Different studies conducted in India or abroad had similar findings.^9-10,12-14 This finding is might be due to low educational level of these categories of staff, but is of high concern because they are mainly involved in transport and disposal of BMW. Again, nurses were found to have more correct knowledge in present study similar to Rao et al in Mysuru and Mondal R in Andhra Prodesh¹⁵. However, several studies^17-18 found better knowledge among doctors due to better professional knowledge. Better knowledge among nurses can be explained by the discipline inherent in this nursing category of HCW, more involvement of them in applied work and task given by higher authority.

Attitude of the HCWS:

In the present study, the study participants showed positive attitude towards BMW management. Similar favourable attitude was shown in different studies. ^9-10,13-14 But considering the BMWM as a team work, only 30% of the study participants agreed to it in present study. Contrary to that, almost 80% doctors and nurses in primary health care facilities in Lucknow, 90% of HCWs in a hospital of Sudan and 95% in Bihar considered it as team effort.^9,14,19 In Lucknow 70% of the nurses and 90% of housekeeping staff thought BMWM as an extra burden to them.¹⁴ Similar to the present study (47%) around 40 to 50% of hCws in Sudan and Haryana of HCWs didn't consider it as burden.^9,12 In the resource constrained primary health care facilities, the whole responsibility of BMWM is actually borne by the nursing and housekeeping staff, might be the possible reasons for their unfavourable attitude. Practice of the HCWS: Practice related to BMWM was seen to be very poor in the present study. Only one fourth of the HCWs were seen to dispose BMW maintaining colour code, practice was comparatively better among doctors and nurses. Contrary to that, in Sudan and Lucknow, more than 80% HCWs maintained disposal by colour codes.^9,14 Use of PPE, status of vaccination and periodic medical check up were seen to be alarmingly poor in the present study, where as 75% and 62% of HCWs used PPE and took vaccination against Hepatitis B respectively in the study in Sudan.⁹ In Lucknow, vaccination was good among doctors, but not satisfactory among other staff.¹⁴ Similar was the picture of training in Lucknow¹⁴, where about 45% in the present study received training in last 1 year. A study in Rajkot also had similar finding.¹¹

While scoring, the present study observed median score for domain of knowledge, attitude and practice being 8, 8, 3 respectively. Sekar M et al in a tertiary care hospital of Puducherrey found mean score as 6.04, 6.78 and 6.20 respectively.²⁰ In Bangladesh the average score was found as 6.8± 1.2 varying from 7.3 (doctors) to 6.5 (internees).¹⁷ Knowledge was highest among nurses, followed by doctors, but very poor among paramedical and housekeeping staff in the present study. Ranu R et al however found doctors and Lab technicians as more knowledgeable than nurses and non medical staff in a tertiary setting in Trivandrum.¹⁸ So far practice was concerned, the present study observed very poor practice in all categories of HCWs in spite of having satisfactory knowledge and attitude. Sekar M in Puducherry found order of decreasing knowledge and practice among postgraduates followed by laboratory technicians, interns, nurses and sanitary staffs. Decreasing order of attitude was postgraduates, interns and laboratory technicians with same score, followed by nurses and sanitary staffs.²⁰ However in few studies^15,21,22 like the present one, nurses were seen to have better knowledge and practice compared to other categories. Reason might be due to more involvement of them in biomedical waste disposal.

Ranu R et al found significant increase in knowledge and practice level as the professional category level increases, but no relation with attitude.¹⁸ A statistically significant relationship was discovered between knowledge level and educational qualification, gender, work experience by Hossain F et al in Bangladesh.¹⁷ The present study found highest knowledge score in <=30 years age category and with the less years (<=10 years) of working experience than other groups, but no statistical significance was found. The difference might be difference of sample size as less number of study participants were available in primary health care facilities. The present study found gaps as in spite of having good knowledge and attitude, practice was seen to be poor. Similar finding was seen by Rao et al and Haque et al.^15,19 Limitation of the study included less sample size of HCWs and lack of in depth interview of the staff to find out the reasons for poor knowledge and practice, which could not be contemplated due to pandemic situation.