Knowledge, Attitude and Practice of Biomedical waste management among health care personnel in a tertiary care hospital in Puducherry

Background: Studies in India and other developing countries has shown lack of knowledge and poor practice of Biomedical waste management (BMW). Hence this study was undertaken to know the KAP of BMW in our hospital, to identify the gaps and to take necessary steps for rectification. Materials & Methods: This was an observational descriptive hospital based cross sectional study. The study group included the 337 healthcare personnel which included doctors (residents), nurses, laboratory technicians and multi-purpose workers. The study was done using a pre-tested semi-structured questionnaire. The data was analysed using software SPSS 20 version . Proportions were used for interpretation. Results: It showed that <50% of nursing staff and <25% of MPWs had the knowledge of colour coding and segregation. There was also poor knowledge regarding disposal of sharps among technicians and MPWs. It also brought to our notice that only 50% of the doctors (residents) and nursing staff and 26% of the laboratory technicians have undergone training in BMW management. None of the MPWs had received training regarding BMW management. They had good knowledge regarding the diseases transmitted through improper bio medical waste handling. Conclusion: This study revealed that there is the need to continue the training programme for BMW and to include technicians and MPWs in the programme. It also shows that the administration needs to put protocols, provide PPE and other resources for better compliance of BMW rules.


1.Introduction
Bio Medical Waste means 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. [1] It is the duty of every person working in a health care institution to take all steps to ensure segregation, safe handling & disposal of biomedical waste (BMW), without causing any adverse effect to human health and the environment. [1] It is estimated that 10-25% of the healthcare waste generated is hazardous & causes serious health problems. [2] The waste generated in the hospital has significant health impact not only on the healthcare workers but also on the general public. Improper handling of waste not only poses significant risk of infection due to pathogens like HIV, Hepatitis B & C virus but also carries the risk of water, air & soil pollution thereby adversely affecting the environment and community at large. [3] [4] BMW management is currently a burning issue more so with the increasing health care facilities and increasing waste generation. [5] Therefore knowledge regarding the segregation & IJBR (2015) 6 (03) www.ssjournals.com disposal of BMW is essential for the health care workers(HCW). Government of India has notified the Biomedical Waste (Management and Handling) rules 1998 with subsequent amendments (June 2nd 2000, September 2003 and 2011). India generates around three million tonnes of medical wastes every year and the amount is expected to grow at eight per cent annually. [5] Increasing population and increasing health awareness has led to increase in the number of health care facilities and increased generation of health care waste. [6] The purpose of BMW is mainly to reduce waste generation, to ensure its efficient collection, handling, as well as safe disposal. Lack of awareness and inadequate knowledge has led to the hospitals becoming the hub for spreading illness.
Our hospital is a tertiary care centre functional since four years where the protocols & policies are in a budding stage and yet to be put in place. Hence this study was undertaken with the objective to assess the knowledge regarding the BMW, to identify gaps in the practice of effective BMW management by the healthcare workers in our hospital, so that training of the HCW can be planned and necessary steps can be taken to put protocols in place.

Materials and methods
This study was an observational descriptive hospital based cross sectional study, among health care workers in different category. The hospital is a government hospital in Puducherry, a 750 bedded tertiary care centre. The study was done for a period of two months June & July 2014.
The study group included the healthcare workers who were grouped into four strata/subgroups as doctors(residents), nursing staff, laboratory technicians and multipurpose workers (class IV employees).All the HCW working in the institution for >6 months were included in the study and those who were not willing to participate in the study were excluded. The study population included 90 doctors (residents), 155 nursing staff, 25 laboratory technicians and 100 multipurpose workers (MPWs). Stratified random sampling method was used and the criterion was to use a minimum of 50% of the staff in each strata for the study. The study was done by using a pre tested, semi-structured questionnaire. Informed consent was obtained from the study participants and ethical clearance was obtained from the institute ethics committee. The data was coded and double checked into a work sheet on Microsoft excel 2013. Data compilation and analysis was done using software SPSS 20 version. Proportions and percentage were used to interpret the result.

Observations and Results
The study was conducted in two months June &July 2014. A total of 63 doctors, 154 nurses, 23 laboratory technicians and 97 MPWs(n=337 ) took part in the study , which represented >50% in each strata/sub group. Their knowledge, attitude & practice regarding BMW was assessed by using semistructured questionnaire. The data was analysed using proportions and percentages. The details are presented in Table 1, 2 and 3. Table 1 shows that <50% of nursing staff and <25% of MPWs had the knowledge of colour coding and segregation. It also shows poor knowledge regarding disposal of sharps among technicians and MPWs. All the categories of health care workers have good knowledge about infectious diseases transmitted due to improper management of waste and the responses received were, HIV, HBV, HCV, air borne infections, TB, Water borne infections.
Majority of the HCWS desired to increase their knowledge regarding BMW as shown in Table 2. Questionnaire on the practice of BMW as in Table 3 showed that segregation & colour coding was not followed properly. Nearly 41% of nursing staff and 10% of technicians revealed that they recap the needle. 50% of the doctors (residents) and nursing staff and 74% of the laboratory technicians have not undergone training in BMW management. None of the MPWs have received training regarding BMW management. Majority of the HCWs had not received Hepatitis B vaccine.
All the categories of health care workers had good knowledge about infectious diseases transmitted due to improper management of waste and the responses received were HIV, HBV, HCV, air borne infections, TB, Water borne infections.
Regarding the problems faced by doctors and staff nurses, the responses obtained were poor availability of gloves & gowns and plastic bags, needle destroyers, less man power, less strict rules, lack of team work and busy work schedule.
Suggestions provided by lab technicians mentioned that they require more training in biomedical waste management.
The suggestions provided by staff nurses included that guidelines should be implemented at all levels and training was needed in bio-medical waste management. They stressed on team work, inspection and supervision of BMW management and protective devices to be provided for MPWs.
IJBR (2015) 6 (03) www.ssjournals.com All the categories of health care workers have good knowledge about infectious diseases transmitted due to improper management of waste and the responses received were, HIV, HBV, HCV, air borne infections, TB, Water borne infections.

Discussion
The waste generated during the delivery of health care services carries a high potential of infection and injury than any other type of waste and 10-25% of them are infectious in nature. [ The BMW is generated by various sources. The major sources are Govt. hospitals and private hospitals, primary health centers, medical colleges and veterinary colleges and animal research centers. [7] There is particular concern about infection with human immunodeficiency virus (HIV) and hepatitis viruses B and C, for which there is strong evidence of transmission via health-care waste, especially sharp injuries.
The study showed that >95% of the doctors had knowledge regarding BMW management IJBR (2015) 6 (03) www.ssjournals.com guidelines & segregation. However most of the nursing staff (50%) and MPWs(80%) had poor knowledge regarding the colour coding for segregation of waste and also were not aware that segregation had to be done at the point of generation.
The study also revealed that the technicians and nursing staff were not aware about the reporting of needle stick injury and neither were practicing needle destruction or avoiding recapping of used needles. This was similar to the findings of studies done in Rajkot, Jaipur and Karnataka. [4][8] [9] With respect to the attitude regarding the waste management, majority felt that it was a team work and all were responsible for safe disposal. About 45% of doctors & MPWs felt that it increases their workload.
The study showed that nearly 50% of residents and nursing staff and almost all the laboratory technicians and MPWs had not received any kind of training in BMW management. We conduct training programme once in a year for the residents and nursing staff emphasizing on standard precautions and BMW management. The laboratory technicians and MPWs were not included in the programme. This study has helped us in identifying this gap and the necessity for training them. This study has also made us realize that such training programmes should be conducted regularly and make it compulsory for all the HCWs to attend.
A multicentric study conducted in 20 states across India showed that most of the healthcare centres had unsatisfactory practices with respect to BMW management. At the global level 16-84% of the hospitals did not stick to norms. This has been attributed to lack of awareness, inadequate resources and poor disposal mechanisms. [10] Around 82 per cent of primary, 60 per cent of secondary and 54 per cent of tertiary care health facilities were in the 'RED' category which meant that there was no credible BMW management system in place. [10] While most of the studies have shown poor knowledge & practices, few studies like that of Yadannanavar et al in Bijapur, Karnataka [11] has shown that HCWs have good knowledge & practices of BMW and also a report submitted by Rao. [12] Studies in other developing countries like Iran, Bangladesh and Pakistan also have similar findings, showing lack of knowledge, insufficient availability of personal protective equipment (PPE), insufficient separation of hazardous & non-hazardous waste, lack of policy and laws for waste management. [13] [14][15] Similar findings were recorded in our study where the HCWs expressed their difficulty in following norms due to non-availability of gloves, gowns(PPE), needle destroyers, lack of coloured bins and covers/bags, lack of supervision.
Our study showed that >90% of HCWs including the MPWs had the knowledge of health hazards due to improper waste management.
With the findings in our study, the BMW management needs to be improved in our hospital. This can be achieved by conducting regular training programmes for the HCWs and updating them, providing the necessary resources like PPE, coloured bags for disposal, having enough supply of disinfectants and to develop protocols for disinfection, transportation & disposal of waste. By displaying posters of colour coding & segregation of waste at various points of generation of waste in the hospital. Regular surveillance and monitoring of the practices is also needed.
This study also showed that about 35% of nurses and technicians and 43% of MPWs are not vaccinated against Hepatitis B. The institute has to take necessary steps and ensure that they are vaccinated.
Common bio waste treatment facility in each city/town with strict monitoring of these facilities by regulatory agency should be implemented [16]. Our hospital uses the treatment facility of Government hospital, Puducherry. Such common facility utilization reduces the economic burden. It is the primary responsibility of Health administrators to manage hospital waste in most safe and eco-friendly manner [2].
The limitations of the study was since it was based on semi-structured questionnaire, every aspect of KAP could not be assessed and not much details on problems faced by HCWs and their suggestions could be obtained.

Conclusion
This study shows that there is lack of knowledge regarding segregation & colour coding of waste among nurses and MPWs. It also reveals that enough precautions are not being taken for preventing needle stick injuries. The technicians and MPWs have not undergone any training in BMW handling & disposal. Many of the HCWs have not received Hepatitis B vaccine. The multi-purpose workers have got positive attitude and not a good practice due to lack of knowledge. Further intervention can be done by providing training programmes, so that the knowledge on the biomedical waste management can be improved. Constant supervision and implementation at each level of waste management is needed.
IJBR (2015) 6 (03) www.ssjournals.com If we need to protect our environment and health of community we must sensitize ourselves, motivate ourselves to this important issue not only in the interest of HCWs but also in the interest of community.