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Knowledge of health workers at a Riyadh hospital of health care waste management

Healthcare activities such as immunizations, diagnostic tests, medical treatments, and laboratory examinations are inevitably followed by the generation of Health Care Waste (HCW). The management of HCW poses a major and ongoing problem in most countries, including the Kingdom of Saudi Arabia. Adequate knowledge of health care workers of the steps of waste management is crucial for the success of any HCW management program.
This study investigates the knowledge of health workers at a Riyadh hospital of the types of waste and steps of HCW management. This was implemented through a descriptive cross-sectional study among health care workers at the hospital. Data was collected by means of a pre-prepared questionnaire, inquiring on basic demographic data and the knowledge of health workers of the types of HCW, their segregation, storage, and transport inside and outside the hospital, and whether the participant had received previous training on HCW management. The questionnaire included 44 knowledge questions, a correct answer was given a score of 1 and an incorrect answer 0. A composite score based on these 44 questions was developed and used for further analysis. In the absence of any standard criteria of scoring for such knowledge questions, the median of the composite score was used as a cutoff point to split the workers into two categories: high knowledge group and low knowledge group. Data was collected during July 2004, then entered and analyzed using SPSS version 10 software.
The study population was 321 health workers. Their mean age was 35.7 years (SD ± 8.6), the highest age group between 30-40 years old (41.7%). There were 216 (70.3%) females, and 91 (29.6%) males; 66 (22.8%) Saudis and 223 (77.2%) non-Saudis; 73 (23.4%) doctors and 239 (76.6%) nurses. The highest percentage were working in the Medicine department 118 (44.7%), followed by the Surgery department 64 (24.2%), Emergency Room 13 (4.9%), and other departments 69 (26.1%). Knowledge of health workers about the classification of each type of waste material is shown in table 1.
Regarding waste segregation, correct responses were: HCW is segregated at the source of generation 72.9%, medical staff are responsible for waste segregation at its generation site 75.9%, sharp waste should be segregated in special containers 98.1%, color coded bags are used for segregation 96.8%, and liquid medical waste should not be disposed-off with domestic waste 91.7%.
Regarding the color of bag used for segregation of each type of waste, 91.3% knew that yellow bags should be used for infectious waste, red bags for pathological waste 80.4%, and black bags for non-risk waste 83.8%.
Regarding collection of HCW, only 22.9% knew that bags should not be closed by stapling before transport, waste should be collected from the generation site at least once daily 83.2%, and black and yellow bags should not be collected at the same time 79.4%.
Regarding transport of HCW inside the hospital, 74.5% knew that color-coded bags should be used for transport of HCW inside the hospital. Only 3.2% knew that certain allocated workers should be responsible for transport of HCW inside the hospital. However, 84.3% of the study participants did not know which personnel are responsible; 54.7% didn't know by what means HCW are transported inside the hospital; and only 37.2% knew that designated trolleys should be used for that purpose. However, most workers (91.5%) knew that yellow bags should not be carried with black bags in the same trolleys inside the hospital.
Regarding correct knowledge of storage of HCW inside the hospital, only 67.9% knew that there should be designated central storage points; 81.6% knew that bags containing waste should not be compressed at the storage point, 91.7% knew that cytotoxic waste should be separated from other types of HCW, and 74.9% knew that yellow and black bags should not be kept together at the storage point. Regarding transport of HCW, only 68.6% knew that it should be transported away from the hospital by special trucks.
The most important cited health consequences of improper HCW management or accident were Hepatitis B (97.8%), Hepatitis C (97.5%), and Acquired Immunodeficiency Syndrome (96%).
Of the total study population, only 23.5% had received previous training on HCW management.
Based on the knowledge questions, the median score of knowledge based on the composite score was 31. This was used to divide health workers into two groups; low knowledge group (below 31), and high knowledge group (31 and above). The low knowledge group included 139 (43.3%), and the high knowledge group included 182 (56.7%). On examining the association between knowledge and other related variables, the proportion of high knowledge was greater among females, nurses, non-Saudis, and those with previous training (Table 2).

Editorial note:

HCW poses a serious public health problem. According to a WHO report, around 85% of hospital waste is non-hazardous, 10% is infective (and hence, hazardous) and the remaining 5% is non-infectious but hazardous -whether chemical, pharmaceutical or radioactive.[1] In recent years, medical waste disposal has posed even more difficulties with the appearance and widespread use of disposable needles, syringes, and other similar items. This type of waste has a deleterious effect on the environment by contaminating the land, air, and water resources.
The World health Organization has classified HCW into different categories: infectious, sharps, pathological, pharmaceutical, chemical and radioactive waste.[1,2] Appropriate handing, treatment, and disposal of waste by type reduces cost and does much to protect public health. The cornerstone to effective management of HCW is segregation (separation) and identification of the waste. Segregation of waste is defined as the separation of the two kinds of wastes (hazardous and non-hazardous) while performing the job (providing healthcare services) and not afterwards, by sorting the waste into color-coded plastic bags or containers.' This should always be the responsibility of the waste producer, should take place where the waste is generated, and should be maintained in storage areas and during transport.[1]
One category of HCW that causes an extreme health risk are namely the sharps (e.g. needles, scalpels, razor blades, glass such as ampoules), which may be contaminated with blood. Many studies emphasize the risk of transmission of HIV and other blood-borne viruses like Hepatitis B through needle-stick injuries.[3] Other problems include the scavenging and re-use practices that occur in some countries, and exposing the populations to health risks.[3]
The Kingdom of Saudi Arabia is also faced with the problem of HCW management, particularly following the rapid expansion of health services in the past two decades. It has been estimated that the mean amount of all healthcare risk waste generated in the Kingdom was 25,207 tons/year. The mean hospital healthcare risk waste rate of generation was 1.13 ± 0.96 kg/bed/day, and that of the primary healthcare centers and clinics was 0.08 ± 0.08 kg/visitor/day.[4]
It is well known that HCW management problems in many countries over the world are usually caused more by lack of information than by financial or technical difficulties.[5] A study in India reported that medical consultants, residents and scientists had respectively, 85%, 81% and 86% knowledge of biomedical waste management regulations. The knowledge component among nurses was 60%.[6]
A previous survey in Saudi Arabia conducted among medical staff of King Fahad Hospital, Al Khobar, for their awareness of the hospital's generation and handling of waste, reported lack of awareness, ignorance of policy and procedure on handling of HCW and failure to attend educational activities as major defects among health care staff in the study.[7]
It is clear from the study findings that knowledge of participant health care workers of HCW management has still not achieved the desired standards. Improving the awareness of health care workers of the HCW management rules implemented in Saudi Arabia, in general, and in their respective hospitals, in particular, is urgently required. Extensive training and retraining programmes should help in changing the attitudes and risk behavior of health care workers for the effective implementation of HCW management in practice. Teaching and demonstration sessions with both the nursing domestic and portering staff are also required.
  1. World Health Organization. Eastern Mediterranean Region, Center for Environmental health activities (CEHA), Regional Guidelines for the Safe Management of Healthcare waste, Final Draft, Amman, Jordan, 1998.
  2. Mecklem RL, Neumann CM. Defining and managing biohazards waste in U.S. Research oriented Universities: a survey of environmental health and safety professionals. J Env Health. 2003 Jul-Aug; 66 (1) : 17-22
  3. Needle stick and infection control policies for education and waste management. Communication. D. Morgan Health Care waste management seminar. June 17th and 18th 1999. London, UK.
  4. Al-Zahrani MA, Fakhri ZI, Al Shanshauri MA, Al-Ayed MH. Healthcare risk waste in Saudi Arabia: rate of generations. Saudi Med J 2000; 21:245-50.
  5. Halbwachs H. Solid Waste Disposal in District Health Facilities. World Health Forum 1994; 15: 363-367.
  6. Sarma RK, Nagarajan SS, Saini S. Waste: Attitudes and Actions: Asian Hospital & Healthcare Management
  7. AlJabre S, et al. Hospital generated waste: An assessment of the awareness of hospital staff. J Fam Comm Med 2002; 9(1): 47-50.