According to the Bio-Medical Waste (Management and Handling) Rules, 1998 of India, "bio-medical waste" refers to any waste, which is generated during the diagnosis, treatment, or immunization of human beings or animals, or in research activities pertaining thereto, or in the production or testing of biologicals. Around 75-90% of the waste produced by health-care providers is non-risk or "general" health-care waste, which is comparable to domestic waste. It is generated mostly out of the administrative and housekeeping functions of health-care establishments, and may also include waste generated during the maintenance of health-care premises. The remaining 10-25% of health-care waste is considered to be hazardous, and may lead to a variety of health risks. The waste produced during the course of health-care activities carries a higher potential for infection and injury, compared to any other type of waste. Therefore, it is essential to follow safe and reliable methods for its handling. Inadequate and inappropriate handling of health-care waste may have serious public health consequences and a significant impact on the environment. Thus, appropriate management of health-care waste constitutes a crucial component of environmental-health protection, and should become an integral feature of health-care services [1].

COVID-19 has had serious impacts on all aspects of our society, and waste management is no exception. An increased amount of potentially infected waste has been generated, which requires additional, careful handling, as well as treatment processes to safeguard waste handlers and sanitation workers associated with    such health-care facilities. For instance, foot-operated lids must be introduced for color-coded bins to avoid contact. General solid waste should not be contaminated by secretions and body fluids of patients. Wet and dry solid waste bags must be tied securely. All waste-handlers must follow preventive measures such as hand-washing, use of gloves and masks, and use of other personal protective equipment [2].

The role of sanitation workers has always been indispensable for human society, but their perceived importance in India has increased tremendously only in the recent past, especially since the arrival of the COVID-19 pandemic in the country in early 2020. The success of a BMWM program depends upon the knowledge levels and practices of the sanitary staff [3].

This study was planned in a tertiary care hospital among its sanitary staff with the following objectives.

Objectives

• To assess knowledge levels and attitudes about BMWM among the sanitary staff of the tertiary care hospital

• To describe the practices of BMWM among the sanitary staff of the tertiary care hospital

• To study socio-demographic variables related to the practice of BMWM

Study Design 

This study was a hospital-based cross sectional study.

Study Duration 

The study was carried out from September 2022 to October 2022.

Study Setting

This study was carried out at a tertiary care hospital in Tirupati, in the Chittoor district of Andhra Pradesh state, in South India.

Study Population 

The study was conducted among sanitation staff working in various departments, wards, and laboratories of this tertiary care hospital. Out of the total number of 560 sanitation staff, all those who were handling bio-medical waste and gave their consent, were included in the study.

Sample Size 

A total of 236 sanitation workers, who were willing to participate in this study, were included.

Inclusion Criteria

Inclusion criteria consisted of sanitation workers, who were handling bio-medical waste, and were willing to give consent for participation in the study.

Exclusion Criteria

Exclusion criteria referred to unwillingness to participate in the study.

Data Collection Methods 

Data was collected through interview techniques, using a pre-tested, structured format. Informed consent was obtained from all the willing participants, after the purpose and procedure of the study was explained to them. Sanitation staff were interviewed, during their free time.

Study Instrument

The structured interview format included two sections:

• Section 1: Comprising socio-demographic profiles of the study participants, such as age, gender, educational levels, residence, workplace (department/ hospital ward/ laboratory), and duration of work experience

• Section 2: Comprising questions to test awareness, attitudes, and practices regarding BMWM

Statistical Analysis 

The data collected was entered in a Microsoft Excel sheet, and was analyzed using the IBM SPSS Statistics for Windows, Version 26.0 software. Statistical tests such as simple proportions were used for analysis, and the chi-square test was used to determine the association between socio-demographic variables and the practice of BMWM. A p-value of less than 0.05 was considered as statistically significant.

Ethical Issues

Ethics approval was obtained from the Ethics Committee of the institution. Prior informed consent was taken from each participant. Further, they were assured of the confidentiality and anonymity of their identity throughout the study.

A total of 236 sanitary staff (study participants) participated in this study. Majority of them belonged to the age group of 36-50 years (151, 64.0%), followed by staff aged<35 years (60, 25.4%), and staff aged>50 years  (25, 0.6%). Women sanitary staff 174 (73.7%) were greater in number than men staff (62, 26.3%). With regard to their educational status, majority of them had received education up to the secondary level (108, 45.8%), whereas 23 (9.7%) staff had received higher secondary education. Also, 63 (26.7%) had received primary level education, and 42 (17.8%) were illiterate. With respect to their work, the majority of staff, that is, 113 (47.9%) were working in medical branches such as General Medicine, Community Medicine, Pediatrics, Nephrology, Endocrinology, and Cardiology. Further, 67 (28.4%) study participants were working in surgical branches such as General Surgery, ENT, Ophthalmology, Obstetrics and Gynecology, Urology, and OT complex. This was followed by sanitary staff from the Intensive Care Unit, various laboratories, as well as Pre- and Para-clinical departments, which was 28 (11.9%), 24 (10.2%), and 4 (1.7%) respectively. In the present study, with respect to work experience, majority of the sanitary staff, 81 (34.3%), had work experience of more than 10 years, followed by 72 (30.5%) staff, who had work experience of 6-10 years. Also, 60 (25.4%) staff members had work experience of one year, and only 23 (9.7%) sanitary staff members had work experience of less than one year. It was found that the majority of sanitary staff, that is 200 (84.7%), were familiar with the term “bio-medical waste” and had basic knowledge of what constitutes bio-medical waste. On the other hand, 36 (15.3%) staff were found to be unfamiliar with the term, and reported that they were not aware of it. Among the staff, 229 (97.0%) reported that they had undergone training in BMWM before joining the institution, and 157 (66.5 %) of them were willing to attend any future training regarding BMWM, whereas 79 (33.5%) participants were not willing to participate in any such training program (Table 1).

Table 1: Socio-Demographic Information of the Study Respondents (n = 236)

Table 2: Knowledge of BMWM among Study Respondents (n = 236)

* Multiple responses

Table 3: Waste-Management Practices Among Study Respondents (n = 236)

Table 4: Knowledge of Study Participants about Waste Management (n = 236)

HICC-Hospital Infection Control Committee

Table 5: Attitudes of Study Participants towards Waste Management (n = 236)

Table 6: Association of Knowledge of Bio-Medical Waste with Socio-Demographic Variables

In the present study, 211 (89.4%) sanitary staff reported that bio-medical wastes are risky, but 24 (10.2%) participants responded that there is no risk associated with bio-medical wastes. When asked about the source of generation of health-care waste, the most common recorded response was medical colleges and hospitals (94.4%), and other responses were laboratories (24.5%), primary health centres (7.6%), dental clinics (3.8%), and veterinary clinics (3.3%) (Table 2).

Only one staff reported that he or she did not know of the risk associated with handling bio-medical waste. Further, 228 (96.6%) study participants were aware that needles and broken glassware are a potential source of injury. Again, six (2.5%) staff responded that there is no risk associated with needles and broken glassware, while two (0.8%) staff responded that they had no idea about it. Majority of the sanitary staff, that is, 230 (97.5%) reported that safe management of bio-medical waste benefits health-care personnel, patients, attendants, and the public as a whole. Among the respondents, 234 (99.2%) reported that they wore protective gear such as masks, gloves, head-covers, and foot-covers during the collection of bio-medical waste. It was found that 173 (73.7%) sanitary staff knew that immunization against Hepatitis B and Tetanus is necessary for health-care workers, whereas 63 (20.7%) staff members had no knowledge that vaccination is needed to protect against diseases attributable to BMWM. Majority of the participants, 189 (80.08%), were found to be vaccinated with COVID-19 vaccine. More than half of the participants, 148 (62.7%), were vaccinated against Tetanus, 81 (34.3%) participants were vaccinated against Hepatitis B, whereas 22 (9.3%) were not vaccinated against diseases caused by handling of bio-medical waste. It was observed that 38 (16.1%) sanitary workers had no knowledge about diseases transmitted by bio-medical waste (Table 2).

Knowledge about color-coding and segregation was found among more than 90% of study participants. Also, 223 (94.5%) sanitary staff had correct knowledge of disposal of human anatomical and animal wastes in yellow bags, while 197 (83.5%) reported that expired drugs are disposed in yellow bags. Again, 223 (94.5%) participants reported that soiled dressings are disposed in yellow bags, whereas 217 (91.9%) were aware of disposal of microbiological wastes in yellow bags. Over 95% of sanitary staff had correct knowledge about the type of waste such as gloves, saline bottles, catheters, and plastic syringes to be collected in red bag. Also, 220 (93.2 %) sanitary staff members were aware that sharps and blades need to be disposed in blue bins, whereas 234 (99.2%) sanitary staff members responded correctly about general wastes to be disposed off in black bags (Table 3).

In the present study, 209 (88.6 %) sanitary staff members had knowledge of waste management plans in the health-care setting, whereas 27 (11.4%) participants were not aware of the same. All the 236 (100%) sanitary staff members were aware that waste is collected after segregation. The majority of them, that is 225 (95.3%) members, were aware of the segregation of waste into infectious and non- infectious categories, while only 11 (4.7%) were not aware of the same (Table 4). It was found that 176 (74.6%) study participants knew about bio-hazard labelling, whereas 60 (25.4%) had no idea about it. Further, 91 (38.6%) participants were aware of disinfection of liquid waste before disposal, whereas 128 (54.2%) were not aware of the same. Again, 17 (7.2%) participants reported that they did not have any idea about it. Only 87 (36.9%) study participants were aware of the maintenance of the waste disposal register. It was found that only 167 (70.8%) study participants reported adverse events such as injury and infection during handling of wastes to the HICC (Table 4).

Attitudes towards BMWM were assessed through a few questions. Majority of the sanitary  staff, that is 234 (99.2%) members, agreed that BMWM is a team work. Also, 124 (52.5%) members agreed that safe management of bio-medical waste was not an issue, whereas 201 (85.2%) sanitary staff members reported that safe management of bio-medical waste was not an extra burden on work. However, 35 (14.8%) staff members felt that safe management of bio-medical waste was an extra burden on their routine work. Again, 172 (72.9%) study participants agreed that safe management of bio-medical waste is the responsibility of government. Most of them, that is 230 (97.5%) members, reported interest in and felt that undergoing training for safe management of bio-medical waste was necessary (Table 5).

Sanitary staff aged less than 35 years were found to have better knowledge regarding disposal of human anatomical and animal wastes (96.6%), disposal of soiled dressings (98.3%), and disposal of microbiological waste (93.3%). Sanitary staff in the age group of 36-50 years had better knowledge regarding disposal of expired drugs (84.7%). Among both genders, women had better knowledge regarding disposal of waste in yellow bags. Also, sanitary staff, who were educated up to secondary level, had better knowledge regarding disposal of human anatomical waste and animal waste (95.3%). For other kinds of bio-medical wastes, knowledge levels were better among sanitary staff, who had completed primary education. Staff with 6-10 years of work experience had better knowledge of disposal of wastes in yellow bags (Table 6).

This study was carried out in a tertiary health-care facility. We assessed the knowledge levels, attitudes, and practices regarding BMWM among sanitary staff.

In this study, the total number of respondents was 236. Women sanitary workers accounted for 174 (73.7%) staff members, while 62 (26.3%) were men. Majority of our respondents belonged to the age group of 36-50 years. Further, 151 (64.0%) respondents belonged to the age group of 36-50 years, followed by 60 (25.4%) in the<35 age group, and 25 (10.6%) in the>50 years age group. Regarding educational status, majority of the respondents, that is, 108 (45.8%), had completed secondary education, whereas 23 (9.7%) had received higher secondary education. Again, 63 (26.7%) respondents had received primary education and about 42 (17.8%) respondents were illiterate. Similarly, a study conducted by Elamin M.O. et al. [4] indicated that the majority of sanitary health workers (74%) were women with low levels of education, and 51.9% were illiterate.

A study by Degavi G. et al. reported that the majority of respondents were women, which accounted for 95.78% of the study sample. Most of the study subjects had education between 9-12 grades (45.21%), followed by grades 5-8 (22.34%), and grades 1-4 (14.36%). The number of illiterate respondents amounted to 13.82% [5]. On the contrary, a study by Kumar J.S. et al. reported that the majority of sanitary workers (62.9%) were men. Most of the participants (42%) belonged to the 30-39 years age group, followed by 40-49 (31.5%), 18-29 (20%), and above 50 (6.5%) years age groups. The majority of the participants had qualifications up to matriculation (90%) [6]. Also, a study by Akoijam S.D. shows that most of the subjects, that is, 34 (68%) were men, followed by 16 (32%) women. Majority of the respondents were in the age group of>34-year years (36%), followed by those in the 29-34 years (26%), 17-22 years (24%), and 23-28 years (14%) age groups. Most of the subjects (40%) were illiterate; 24% had received primary education, 28% had high school education, and 8% had obtained secondary education [7].

In the present study, with respect to their work experience, majority of the sanitary staff, that is 81 (34.3%) members, had work experience of more than 10 years, followed by 72 (30.5%) sanitary staff with work experience of 6-10 years, whereas 60 (25.4%) staff members had work experience of 25.4%, and only 23 (9.7%) sanitary staff had work experience of less than one year. A similar study by Akoijam S.D. revealed that 66% sanitary staff had work experience between 0-2 years,18% had>6 years of experience, and 16% had 3-4 years of experience [7].

Further, this study found that the majority of sanitary staff, that is 200 (84.7%) members, were familiar with the term “bio-medical waste” and had basic knowledge of what constitutes bio-medical waste, whereas 36 (15.3%) study participants were found to be unfamiliar with and reported lack of awareness about the same. A study by Elamin M.O. et al. [4] revealed that, 42.4% of the respondents had excellent knowledge about hazardous waste. Similarly, a study by Kumar S. et al. revealed that, majority (48%) of the sanitation staff had poor knowledge, and only 6% had good knowledge regarding BMWM [8]. However, Singh A. et al., in their study, found higher levels of knowledge (71.3%) regarding bio medical waste among sanitary staff, as compared to this study [9].

Also, in this study, 229 (97.0%) sanitary staff members reported that they had undergone training in BMWM before joining the workplace, and only 7(3.0%) reported that they had not undergone any training before joining the institution. However, a study by Degavi G. et al. revealed that, only 77 (42.6%) solid waste handlers were trained before starting work [5]. Again, a study conducted by Patil S.P. et al. found that, only 12 (32.4%) sanitary workers were trained for BMWM [10].

In the present study, 157 (66.5 %) sanitary staff reported that they are willing to attend any training regarding BMWM in the future while 79 (33.5%) participants reported that they are not willing for any such training program. In this study, when asked about the source of generation of health-care waste, the most common recorded response was medical colleges and Hospitals (94.4%) which is followed by laboratories (24.5%)

This study found that, 211 (89.4%) sanitary staff reported bio-medical wastes as being risky. Further, 228 (96.6%) sanitary staff members were aware that needles and broken glassware are a potential source of injury. Also, 6 (2.5%) participants reported that needles and broken glassware posed no risk, while 2 (0.8%) participants reported that they did not know anything about the same. A study conducted by Bansal et al. showed that, only 43% of sanitary workers were aware of the hazards associated with bio-medical waste [11]. Again, a study conducted by Balamurugan S.S. et al. showed that, only 60% and 46.6% of sanitary workers respectively, were aware of injuries and diseases caused by bio-medical waste [12].

In this study, majority of the sanitary staff, that is 230 members (97.5%), reported that safe management of health-care waste benefits health-care personnel, patients, attendants and the public community as a whole.

Also, 234 (99.2%) study participants reported wearing protective gear such as masks, gloves, head covers, and foot covers, during the collection of bio-medical waste. Kumar S. et al. revealed that sanitation staff had highest knowledge in the areas of waste generation and prevention against bio-hazards. Overall, the knowledge levels of sanitation staff regarding BMWM were poor [8].

This study also found that, 173 (73.7%) sanitary staff members were aware that immunization against Hepatitis B and Tetanus is necessary for health-care workers, whereas 63 (20.7%) respondents had no knowledge that vaccination was needed to protect them against diseases attributable to bio-medical waste. Majority of the study participants, that is 189 (80.08%) members, were found to be vaccinated against COVID-19. More than half of the sanitary staff, that is 148 (62.7%), were vaccinated against Tetanus; 81 (34.3%) sanitary staff members were vaccinated against Hepatitis B, whereas 22 (9.3%) members were not vaccinated against diseases caused by handling of bio-medical waste.

Similarly, Anand P. et al. [13] observed the lowest vaccination with hepatitis B among Class IV employees [13] while in a study by Soyam et al, only 64.5% health-care workers were vaccinated against HBV [14]. In a study by Patil S.P. et al. [10], 89.2% (33) sanitary workers had no vaccination of Hepatitis B. On the contrary to this, Pandave et al [15] and Shivalli S. et al. [16] reported high level of hepatitis B vaccine coverage in their study.

The present study also observed that, 38 (16.1%) sanitary workers had no knowledge about diseases transmitted by bio-medical waste. This may be due to their illiteracy and lack of training. On the contrary, Elamin M.O. et al. [4] study showed that nearly half (45.2%) of the respondents had excellent and very good knowledge concerning waste-transmitted diseases. According to Mathur V. et al., knowledge regarding the potential transmission of disease through bio-medical waste was observed only among 27% of sanitary workers [17], whereas a study conducted by Chaudhuri A. et al. reported that 59 (49.17%) sanitary workers had knowledge of waste-transmitted diseases [18].

This study found knowledge of color coding and segregation among more than 90% of the sanitary staff. Out of the total number of participants, 223 (94.5%) sanitary staff had correct knowledge of disposal of human anatomical and animal wastes in yellow bags, while 197 (83.5%) reported that expired drugs are disposed in yellow bags. Again, 223 (94.5%) participants reported that soiled dressings are disposed in yellow bags; and 217(91.9%) were aware of the disposal of microbiological wastes in yellow bags. Over 95% sanitary staff had correct knowledge about the type of waste such as, gloves, saline bottles, catheters, and plastic syringes to be collected in red bags. Further, 220 (93.2 %) sanitary staff were aware that sharps and blades need to be disposed off in blue bins, whereas 234 (99.2%) sanitary staff responded correctly about the disposal of general waste in black bags. On the contrary, Patil S.P. et al study found that, only 11 (29.7%) sanitary workers had correct knowledge about the type of waste to be collected in red bags. It was found that, only 55 (35.9 %) respondents had correct knowledge about the collection of body parts in yellow bags. Only a minimum number of 7 (18.9%) sanitary workers had correct knowledge of waste disposal in blue or white containers [10]. A study by Azam F. et al. showed that, with regard to knowledge about the color coding of waste, 60.33% knew about color coding and 30.67% did not [19].

In the present study, 209 (88.6 %) sanitary staff members had knowledge of waste management plans in the health-care setting, while 27 (11.4%) participants were not aware of the same. All the 236 (100%) respondents were aware that waste is collected after segregation. Majority of them, that is 225 (95.3%) members, were aware of segregation of waste into infectious and non-infectious categories. But, as per a study by Patil S.P. et al., sanitary workers were generally not aware of the measures for safe collection and final disposal of bio-medical waste [10]. Pandve H.T. et al. study found that, all the study participants (100%) knew that bio-medical waste should be segregated at the very source where it is generated [15]. In a study conducted by Chaudhuri A. et al. knowledge of segregation of bio-medical waste at the site of generation was found among 79.16% of the study population [18].

In this study, 176 (74.6%) sanitary staff members knew about bio-hazard labelling, while 60 (25.4%) had no idea about it. Again, 91 (38.6%) sanitary staff members were aware of the disinfection of liquid waste before disposal, whereas 128 (54.2%) were not aware of liquid waste disposal. Further, 17 (7.2%) participants reported that they did not have any idea about it. Only 87 (36.9%) study participants were aware of the maintenance of the waste-disposal register. It was found that only 167 (70.8%) study participants reported adverse events such as injury and infection during handling of bio-medical wastes to the HICC. On the contrary, Shivalli S. et al. [16] study revealed that, all the waste handlers would report to a higher authority, if there was any risky exposure to health-care waste. Mathur V. et al. and Saini S. et al. revealed that, knowledge levels about BMWM rules were low among the sanitary staff [17, 20]. However, according to a study conducted by Sekar M. et al., sanitary workers were highly ignorant regarding BMWM [21].

Attitudes towards BMWM were assessed on the basis of a few questions. Majority of sanitary staff, that is 234 (99.2%) members, agreed that BMWM is a teamwork. Also 124 (52.5%) members agreed that safe management of bio-medical waste is not an issue, while 201(85.2%) sanitary staff members reported that safe management of bio-medical waste is not an extra burden on their routine work. However, 35 (14.8%) staff members felt that safe management of bio-medical waste is an extra burden on work. Again, 172 (72.9%) sanitary staff members agreed that safe management of bio-medical waste is the responsibility of the government. Most of them, that is 230 (97.5%) respondents, reported interest in and felt that undergoing training for safe management of bio-medical waste is necessary. Lavanya K.M. et al. revealed in their study that, only 39 (46.4%) housekeepers opined that a hospital policy for BMWM is needed [22]. Saini S. et al. observed that, though sanitary staff generally have very poor knowledge about the Bio-Medical Waste Act and related rules, a good percentage of them have positive attitudes and practice healthy habits in this regard [20].

The present study also observed that, sanitary staff in the<35 years age group had better knowledge (96.6%) regarding disposal of human anatomical and animal wastes. Sanitary staff in the age group of 36-50 years had better knowledge regarding disposal of expired drugs (84.7%), whereas staff with age less than 35 years had better knowledge of the disposal of soiled dressings (98.3%), and of microbiological waste (93.3%).

Among all the respondents, women had better knowledge regarding disposal of waste in yellow bags. Staff, who had received secondary education, had better knowledge (95.3%) regarding disposal of human anatomical waste and animal waste. For other types of bio-medical wastes, the knowledge levels were better among persons with primary education. Sanitary staff with 6-10 years of work experience had better knowledge regarding disposal of waste in yellow bags.

Almost all the sanitation staff reported that they wore protective gear during the collection of bio-medical waste. It was found that, some of the sanitary staff were not vaccinated. Vaccination is very important for prevention of certain diseases, and it should be made compulsory for all the sanitary staff at the time of recruitment. More than 90% of the staff had knowledge of waste-segregation, but were not aware of how waste management plans are implemented in the health-care setting. Attitudes among staff regarding BMWM were generally positive. A majority of them showed interest in and felt that undergoing training for safe BMWM was essential. Younger age-group staff had better knowledge regarding disposal of various types of wastes. Among both the genders, women had better knowledge regarding disposal of waste in yellow bags. Staff who were educated up to secondary level had better knowledge regarding disposal of human anatomical waste and animal waste. Staff with 6-10 years of work experience had better knowledge of disposal of wastes in yellow bags. On the whole, knowledge levels and practices with regard to BMWM need to be improved among sanitary staff. Regular training in and periodic evaluation of BMWM as well as handling of its hazards are needed for all sanitary staff.

Acknowledgements

We would like to thank all the sanitary staff, who participated in this study.

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