Abstract
Healthcare waste which consists of waste materials generated at healthcare facilities is hazardous to both the environment and human life. However, many people are unaware of the dangers of medical wastes. Previous studies have neglected the assessment of the level of awareness and attitude of health workers toward healthcare waste. Therefore, this study assesses the level of awareness of healthcare workers about the dangers and their attitude toward the waste and its implications. The study, which employed cross-sectional design with 334 participants, was conducted in Southeast Nigeria. Data collection was through questionnaire and in-depth interview guide. Data analyzed through descriptive statistics revealed that the level of awareness of health workers about the dangers of healthcare waste is high; their attitude toward healthcare waste is poor; and that the consequences of mismanaged healthcare waste are devastating. Therefore, healthcare facilities should have a functional waste management policy, train their staff on ways of handling waste and educate the public about dangers of healthcare waste.
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Keywords
Introduction
The percentage of hazardous waste generated from healthcare activities may appear low (15%) but they are highly infectious, radioactive and toxic. In actual fact, healthcare wastes usually have long-lasting impact on the health of humans: healthcare staff, waste managers, visitors of healthcare centers and/or even the entire society. The environment is not spared especially when fresh water and the soil are affected. Therefore, the growth rate of healthcare waste management costs is estimated to rise from $11.77 billion in 2018 to $17.89 billion in 2026. In the same vein, about 16,000 million injection drugs are used globally annually. Most of the injection-drug-containers, syringes and even needles used are not appropriately disposed after use (Akkajit et al., 2020; Oli et al., 2016). In 2020, the already uncontrolled rise in the generation of healthcare waste was sudden exacerbated by the COVID-19 pandemic. This resulted to severe threat and burden which if not properly handled safely will cause public health crisis (Janik-Karpinska et al., 2023; Singh et al., 2022).
Definitions and Categorization of Healthcare Waste
Healthcare waste consists of all forms of waste generated at various healthcare centers, medical research facilities and medical laboratories. These wastes come in form of solids or semi-solids derived from healthcare centers during the process of diagnosis of sick persons, patients’ review and/or treatment of humans and animals (Askarian et al., 2010). Similarly, Gajurval (2014) believes that healthcare wastes are those waste materials produced during diagnosis, treatment/care and vaccination of humans and/or animals, or when one is carrying out a study/research.
Healthcare waste is usually grouped into eight categories: general waste, radioactive waste, pathological waste, chemical waste, infectious waste, sharp objects, pharmaceutical waste as well as waste in form of pressurized containers (Chamberlain, 2020; Gajurval, 2014; Mathur et al., 2012). To further clarify this, Awodele et al. (2016) explained that hospital wastes come in the form of general waste and medical waste. According to them, general waste comes from production of food, office jobs, sweeping, maintenance jobs and even landscaping. The medical waste on the other hand are wastes derived from cultures, blood/fluids, sharp objects, surgery, laboratory discards, radioactive wastes and waste from dialysis procedures and treatment procedures including chemotherapy, autopsy, biopsy and dialysis injection among others (Alagöz & Kocasoy, 2008a, 2008b). The result is the generation of non-hazardous waste (75%–95%) and hazardous waste (10%–25%). However, even the ones regarded as non-hazardous waste are as dangerous as domestic waste (Askarian et al., 2004; Sapkota et al., 2014). Oli et al. (2016) added heavy metal waste to the categories of waste generated in healthcare facilities. Summarily, healthcare waste can be categorized as hazardous and non-hazardous waste (Mohamed et al., 2009; Pruss et al., 1999; Yong et al., 2009). Healthcare waste categorization is a key issue in deciding an effective healthcare waste management practice. This is because the issue of segregation actually dwells on appropriate classification of the generated waste (Adnane et al., 2013; Leonard et al., 2022). All these are important indices of healthcare waste management.
Healthcare waste management (HWM) therefore is the whole process involving collecting, transporting, treating/processing and disposing of wastes generated in healthcare centers and research laboratories. Healthcare waste management is an aspect of hospital hygiene and maintenance activities. As a result, HWM has currently been found to be a major issue not only to the healthcare facilities, nursing home authorities, medical laboratories but also to the environmentalists. Healthcare waste is also an issue of concern to the socio-cultural wellbeing of humans since healthcare and illness are aspects of human culture (Akkajit et al., 2020; Mathur et al., 2012). This is why Awodele et al. (2016) explained that managing waste in health facilities is a critical issue because it creates potential risks to heath of humans, the environment and causes obstruction to the social and cultural patterning of human society.
Handling of Healthcare Waste
Healthcare wastes come from government hospitals, private hospitals, nursing homes, physician’s office, dentist’s office, dispensaries, mortuaries, blood banks and collection centers, animal houses, laboratories, veterinarian clinics, funeral home and home care and research organizations (Gajurval, 2014; Reinhardt & Gordon, 1991). Similarly, V. Thakur and Ramesh (2018) after their study among selected hospitals in Uttarakhand India posited that the rate of healthcare waste generation varies according with season and that the composition is as has been noted above. However, they noted that lack of knowledge about the amount and composition of waste generated in health facilities prevents effective handling of waste in hospitals and increases the level of risk it poses.
As a result of these risks, it is pertinent to ensure that healthcare wastes are properly handled and disposed in order to ensure that the environment and human lives are properly protected (Reinhardt & Gordon, 1991). Therefore, excellent management of healthcare waste is presently seen as a serious humanitarian matter globally. Harms resulting from improper handling of healthcare waste have raised much global attention, particularly with regards to their pervasive effects on the health of persons and the ecosystem. As such, the problem of disposal of waste in healthcare centers is an issue that requires major attention (Chandra et al., 2002; Chisholm et al., 2021; Mathur et al., 2012).
The report on human settlement produced during a United Nations conference on that matter shows that, almost half of wastes generated in many towns in poor countries are not adequately managed. Such wastes are thrown away as illegal dumps on roads, footpaths, open spaces and water-ways (UNCHS, 1996; George, 2016). This is why Gill et al. (2022) posited that managing healthcare waste is among the greatest problems that the world is expected to encounter in the near future. However, their revelation is being fulfilled as a result of the rapid global increase in the quantity of waste generated by healthcare facilities during the peak of the COVID-19 pandemic. This is why D. V. Thakur (2022) opined that there is need to take extra care in the handling of healthcare waste especially during pandemics.
In their own view, Mathur et al. (2012) explained that healthcare waste are expected to be adequately collected, separated, moved and treated before disposal to avoid the possibility of nosocomial infections. Generally, healthcare waste is a mixture of different materials, which is quite hard to handle ordinarily. However, this issue could be simplified and the different angles minimized with adequate planning of waste management scheme. As a result, the processes of managing healthcare waste are as follows: generation/collection, segregation (separation), transportation/storage and treatment (using modern incineration technology, non-incineration technology, autoclaving, microwave irradiative, and plasma pyrolysis) (Gravers, 1998; Mathur et al., 2012; Surjit, 2007; Thornton et al., 1996).
According to Awodele et al. (2016), segregation/separation of healthcare waste at the place it is generated is very important in achieving an excellent healthcare waste management practice. Such segregation could be achieved by using labeled containers or colored liners to segregate hazardous waste from non-hazardous waste. Unfortunately, Oli et al. (2016) in their study observed that, the rate at which waste is segregated at the point of its generation is inadequate both in the public and private healthcare facilities. This has also been supported by Leonard et al. (2022) when they posited that in developing countries, the practice of poor segregation of hospital waste is common. V. Thakur and Sharma (2021) from their study in Pradesh India found that most hospitals do not have adequate method of segregation of waste, marking zones and bags for carrying infectious wastes, adequate means of transporting the waste, effective handling and storage practice. This in effect makes the management of waste in healthcare facilities quite difficult. Earlier, Bassey et al. (2006) had studied some hospitals in Abuja and discovered that waste segregation/separation was zero. Similarly, Longe and Williams (2006) and Ngwuluka et al. (2009) studied healthcare establishments in Lagos and Jos respectively and discovered that none of the hospitals practised waste segregation.
A lot of reasons have been given why it is difficult to manage healthcare waste in healthcare facilities. These include low level of awareness about harms posed by hospital waste, lack of awareness about standard segregation patterns, inadequate training of staff, insufficient fund, lack of protective devices, lack of waste management policies in healthcare facilities, and leaving HWM in the hands of poorly educated and ill-trained workers who perform without proper guidance and adequate protective devices (Akkajit et al., 2020; Awodele et al., 2016; Diaz et al., 2005; Pépin et al., 2014; Shinee et al., 2008; V. Thakur et al., 2022).
Dangers of Healthcare Waste
The problems emanating from hospital facilities because of waste are burns from radiation, injuries from sharps, poisoning/pollution during waste incineration (WHO/UNICEF, 2015). In his own case, Gajurval (2014) established some diseases that when associated with waste items can be injurious to human health. These include viruses (e.g., HIV/AIDS), bacteria (e.g., Streptococcus Typhoid) and parasites (e.g., wucheraria bancrofti). In their own view, Thornton et al. (1996) posited that healthcare waste can cause pollution of the environment, stench, and rapid production of vectors such as rodents/worms, which are likely to cause diseases like typhoid, cholera, plague, rabies and AIDS as a result of contaminated syringe-needle injuries coming in contact with human blood or fluids. This is why Awodele et al. (2016) concluded that healthcare waste, if not properly managed, could result to more severe harm than the initial diseases. This was echoed by Leonard et al. (2022) when they pointed out that poor handling of healthcare waste is an indication of a serious threat/danger to the health of hospital staff, their patients and even the entire community.
In spite of all these, in Nigeria, not many people are aware that medical wastes are potential dangers to their health, environment and socio-cultural wellbeing. This results from the absence of knowledge and specific HWM policy, which is necessary for addressing the challenges of healthcare waste, some of which are known to be hazardous (Akinwale et al., 2009; Awodele et al., 2016). Therefore, V. Thakur et al. (2022) opined that sufficient awareness of the dangers of healthcare waste among the citizens is basic to achieving sustainable healthcare waste management practice even in developing nations.
This low level of awareness is very bad because it has been established that healthcare wastes if not adequately managed could expose humans to several health problems (Adedigba et al., 2010; Manyele & Mujuni, 2010). This ignorance is sometimes derived from cultural experience in that among the Igbo of Southeast Nigeria, waste is a waste and must be thrown away. In other words, the culture of segregating waste as hazardous and non-hazardous is lacking. This cultural belief may have led to the retrospective inhibition being experienced in the style healthcare waste is managed in Southeast Nigeria.
Despite the presence of dangers posed by healthcare waste and the individuals’/government’s concerns about these wastes; waste in healthcare facilities are yet to be properly managed in Nigeria, especially in Southeast Nigeria. From observations, waste in healthcare centers are just gathered, transported and dumped at dump sites. This arrangement does not take care of hazardous waste or sharps as recommended by World Health Organisation.
On the other hand, most of the studies on healthcare waste had been carried out outside Nigeria. The few studies conducted in Nigeria were done outside Southeast Nigeria (Awodele et al., 2016; Bassey et al., 2006; Longe & Williams, 2006). Only Oli et al. (2016) seem to have studied healthcare waste management in Southeast Nigeria. Yet, none of these studies has attempted to investigate the level of awareness and the consequent attitude of health workers to healthcare waste in Southeast Nigeria. Apart from the dearth of research in Southeast Nigeria, other problems abound, such as complaints of inadequate waste management and/or control in healthcare facilities in the area. There have also been issues of heaps of waste found in hospital settings and/or surroundings. Sometimes, there have been complains from the public about putrid odor coming from healthcare facilities. Again, the inadequacies of the strategies adopted to solve these problems give credence to the conduct of this study.
As a result, the objectives of the study are to assess the level of awareness of healthcare workers about the dangers of healthcare waste, their attitude toward this waste as well as the consequences of poorly managed healthcare waste in healthcare facilities in Southeast Nigeria. Putting it differently, the study sought to find out the attitude of the healthcare workers toward healthcare waste in Southeast Nigeria. Second, the study sought to examine the healthcare staff’s level of awareness of the dangers posed by healthcare waste in Southeast Nigeria. Third, the study sought to identify the consequences of poorly managed healthcare waste in Southeast Nigeria. Fourth, the study sought to find measures that can be taken to ensure proper management of healthcare waste in healthcare centers in Southeast Nigeria.
This study is necessary because adequate waste management is a shorthand reflection of a country’s level of socio-economic development, medical advancement and quality life. These are indices used for monitoring and assessing the quality of health in a particular society. The study is also significant with its theoretical utility and new insights, which it is expected to contribute to social action theory (SAT) and health belief model (HBM); thereby forming a basis of evaluating theoretical positions on health, waste management, change and acceptance of interventions. Of importance is the fact that the study will create more public awareness and understanding of the unobserved aspects of healthcare waste management, thereby charting some policy suggestions for attending to the problem of healthcare waste disposal and its associated health conditions.
Research Methodology
Study Design and Setting
This investigation utilized cross-sectional design which involved the use of quantitative research method complemented by qualitative method. The study was conducted in Abakaliki (Ebonyi State) and Owerri, (Imo State), Southeast Nigeria between January and June 2022. It involved eight (8) healthcare facilities, that is, four from each state. The two states (Ebonyi and Imo) were selected out of the five southeast states through simple random sampling technique.
Population of the Study, Sample Size, and Sampling Technique
The population for the study was made up of all health workers (doctors, nurses, pharmacists, laboratory scientists and waste management staff) from private, primary, secondary and tertiary hospitals in Abakaliki and Owerri, Southeast Nigeria. It was difficult to obtain accurate figures for these populations because of absence of a comprehensive document containing list of health workers in the area even at the Ministries of Health of the selected states.
Eight (8) healthcare facilities were chosen for the investigation, using three sampling techniques: stratified, simple random and purposive. First, healthcare institutions were stratified according to ownership into two: private and public hospitals. The method assisted the researchers to ensure that various categories of health facilities operating within the two towns are included in the research and coding of the hospitals was done to achieve anonymity and confidentiality. Second, the public hospitals were further stratified into primary, secondary and tertiary healthcare facilities. Where there is only one type of health facility in a stratum, it was purposively selected. However, where there are many healthcare facilities in a stratum, simple random sampling technique was used to select one from each city.
In essence, one tertiary healthcare facility was selected from each city; one secondary healthcare facility was also selected from each of the towns and one primary healthcare facility was selected from each of the towns. Again, through the use of simple random sampling technique, one private hospital was chosen from each town for the study. This makes a total of four (4) healthcare facilities from each of the two towns. In general, a total of eight (8) healthcare facilities were studied, that is, four from Abakaliki and four from Owerri.
Apart from the primary healthcare facilities, other hospitals involved are those that give general medical, surgical, pediatric, gynecological/maternity and a host of other specialized services. After the selection process, the health institutions selected were given codes: A, B, C, D, E, F, G, and H. The two tertiary healthcare facilities in both towns were tagged A and B, and others followed in that order.
Since it was difficult to obtain the total number of healthcare staff in the study area, the researchers collected the list of staff from the selected healthcare centers. Therefore, from these hospitals’ staff records, it was found that their number of staff were as follows: the tertiary healthcare facilities—1,304, secondary healthcare facilities—810, private hospitals—58, and the primary health centers—43. This gives a total number of 2,215 persons working at the selected healthcare facilities. This figure (2,215) was used to calculate for the sample size using Taro Yemani’s formular. The formular goes thus:
where n = sample size
N = total population of the sudy
e = the error margin
1 = constant
Therefore, n = 2215/5.54 = 399.8
n = 400 (approximate)
As a result, the sample size for the study was 400 subjects. These workers (400) were selected for the study. It was discovered that as the time of the study, 46 of these healthcare workers selected were away from duty due various forms of leave (casual, sick, maternity, and annual leaves). As such, only 354 subjects were available for the study. In other words, from these hospitals, a total of 354 subjects were finally selected from all the selected healthcare facilities in the two towns. Out of this number, 20 persons declined to participate in the study; 310 were given copies of the questionnaire; and 24 persons took part in the in-depth interviews. In other words, all the participants in the study were 334 which represented 83.5% of the initial sample size (400). With the aid of the healthcare facilities’ staff register, as sampling frames, simple random sampling technique was adopted to select participants for the study.
Data Collection Technique and Instrument
Three research instruments were used for the study. They are participant observation (site visitation), questionnaire and in-depth interviews. In the case of participant observation the researchers visited the hospitals and watched the way waste is taken care of in such facilities. The researchers also followed the waste from point it is generated to the final point when it is disposed. We also observed the activities of scavengers at the dump sites to understand the direct dangers that the public may face when healthcare waste is not properly managed. Data were collected using a self-structured questionnaire. The instrument was pretested 21 days to the beginning of the actual investigation among 12 healthcare workers in a general hospital in Imo State and another 12 in another general hospital in Ebonyi State. The final copies of the research instrument (questionnaire) were served on the healthcare workers. The questionnaire captured the following: demographic information, the level of awareness of the healthcare workers about the dangers of healthcare waste, attitude of the workers toward healthcare waste, consequences of poor management of healthcare waste and possible ways of ensuring adequate management of healthcare waste. The questionnaire was administered on 310 participants, who were selected through simple random sampling. The distribution of the questionnaire was as follows: tertiary hospitals 100 copies each, general hospitals 25 copies each, primary healthcare centers 10 copies each, and private hospitals 20 copies each.
The in-depth interviews were conducted with management staff of the hospital (2), the heads of nurses (2), sanitary workers (4), heads of pharmaceutical staff (2), and laboratory officers (2) in each town. Therefore, a total of 24 in-depth interviews were conducted in the two towns. The interviewees were purposively selected based on their operations in each hospital.
Measurement of Research Variables
Nominal scale (the 5-point Likert rating scale system) was used to measure the variables involving quantitative data. The 5-point Likert scale was used because it is simple to understand and takes less time to complete. It also fits mobile device screens better than higher-point scales and allows lower margin of error (Worktango, 2020). Specifically, participants were required to rate each of the six items on attitude toward healthcare waste scale, eight items were on the level of awareness scale, 11 items on consequences of poor management of waste scale and each one of the 12 items was on ways to achieve proper healthcare waste management scale. Participants’ responses were collected, arranged, evaluated and used for the computation of descriptive statistics of the variables that were being investigated. The descriptive statistics so computed were in various forms—frequencies, weighted scores, mean, and standard deviations. At the end a grand mean, that is, single index was established for the variables. As a result, any score (mean and/or grand mean) that is between 1.00 and 1.99 indicates very low variable; 2.00 to 2.99 indicates of low variable; 3.00 to 3.49 indicates moderate variable; 3.50 to 3.99 shows high variable; and 4.00 to 5.00 indicates very high variable.
The data from quantitative instrument was complemented by data from the qualitative instrument which were thematically reported in the discussion.
Method of Data Analysis
A total of 310 copies of questionnaire were distributed to the participants but only 296 were returned. Out of this number, four copies were not properly filled. That means only 292 were valid and those were used for the analysis. The analysis of resultant data was done through the use of descriptive statistics. The strength of relationship between research variables relating to healthcare waste management was determined through the logistic regression analysis. Variables with ≤.05 as p-value were believed to be statistically significant at the level of 95% confidence.
The qualitative data were first transcribed. These transcripts were thoroughly read at the beginning of data analysis. This actually helped to determine the various themes that are therein. It also assisted in determining the link between the themes as well as the link between the qualitative and the quantitative data. The data were later inspected in order to understand the views and experiences of each of the interviewees. These data went through additional analysis through the use of content descriptive statistics. They were used to complement the quantitative data during discussion of findings.
Ethical Consideration and Participants’ Consent
Ethical approvals for the study were obtained from Alex Ekwueme Federal University Teaching Hospital, Abakaliki and Federal Medical Centre, Owerri Nigeria. Thereafter, the various health institutions’ health research and ethical committee approval were obtained. Study procedure was vividly made known to potential respondents. Then, they expressed their consent to take part in the research by filling the consent forms. Those who declined to participate in the investigation were removed. To ensure high level of confidentiality, names of all the health facilities studied as well as the names of all the participants were not indicated.
Results
The results are presented in this section of the paper. This will be followed by the discussion of research findings which comes afterward.
Demographic Characteristics of the Participants
From Table 1, it can be seen that the total number of subjects who participated in the study was 292. Out this number, 114 (39%) were male while 178 (61%) were female. The participants who were below 21 years of age were three (1%); those who were between 21 and 30 years were 92 (31.5%) and majority of the participants (119) which represent 40.8% were between the age of 31 and 40 years. The least (0.7%) were those who were above 60 years.
Demographic Characteristics of Respondents.
Source. Fieldwork 2022.
In terms of marital status, majority of the participants (58.9%) were married while 25.3% were single. Participants who were divorced and widowed are 35(12%) and 11(3.8%) respectively. On the other hand, majority of the participants (46.3%) were earning more than #100,000 on monthly bases. It was found that only nine (3.1%) participants earned less than #20,000. The study also assessed how long the participants had worked in the healthcare sector. It was found that 102 (34.9%) had worked in the healthcare sector for less than 6 years, 83 (28.4%) had worked for 6 to 10 years while 22.9% had worked for 11 to 15 years. That means 65.1% of the participants had got experience of over 6 years in the healthcare sector.
Level of Awareness About Dangers of Healthcare Waste
Data in Table 2 show the mean scores for each of the eight determinants of the level of awareness about the dangers of healthcare waste in the studied facilities. Using a five-point scale, the mean score for healthcare waste can cause diseases is 4.71 (SD = 0.611), healthcare waste can cause harm to hospital workers is 4.72 (SD = 0.533), healthcare waste can cause harm to patients is 4.63 (SD = 0.562), healthcare waste if not properly disposed can harm the public is 4.61 (SD = 0.613), healthcare waste not transported in the right vehicle can cause harm to the public is 4.43 (SD = 0.745), healthcare waste not properly disposed can cause harm to human scavengers is 4.42 (SD = 0.776), healthcare waste contains microorganisms which can cause death is 4.49 (SD = 0.760), and healthcare waste can cause harm to the environment is 4.49 (SD = 0.583).
Level of Awareness About Dangers of Healthcare Waste.
The result indicates that the level of awareness of the participants toward the dangers of healthcare waste is very high on each of the eight danger indicators. In other words, healthcare waste is believed to cause diseases; cause harm to healthcare workers/patients in the hospitals; cause harm to the public, human scavengers and the environment if not properly disposed.
Generally, the result shows that healthcare waste if not properly handled or disposed can cause harm to different persons and the environment. Therefore, it can be seen that there is a strong relationship between the way healthcare waste is managed and its ability to cause harm to the people and the knowledge about this is very high (Grand mean = 4.56).
Attitude of Health Workers Towards Healthcare Waste
The result in Table 3 indicates the mean scores for each of the six determinants on the way hospital workers handle healthcare waste in the study area. Using a five-point scale, the mean score for healthcare waste is like any other waste is 1.35 (SD = 0.632), healthcare waste can be collected by any person is 1.74 (SD = 0.846), all healthcare waste are dumped in one place is 1.85 (SD = 1.148), all healthcare waste do not require special treatment is 1.84 (SD = 1.004), bare hands are used to pack healthcare waste is 1.67 (SD = 0.986), and healthcare waste segregation is waste of time and resources is 1.52 (SD = 0.910).
The Way People Handle Healthcare Waste in Southeast Nigeria.
The result indicates that the attitude of healthcare workers toward healthcare waste is poor on each of the six attitude indicators. That is, healthcare waste in spite of its consequences is treated like any other waste, is collected by any person, is gathered and dumped in one place, do not require any special treatment, are packed with bare hands and their segregation is believed to be a waste of time and resources.
Generally, the result revealed that healthcare waste are poorly handled in the studied facilities (Grand mean = 1.66).
Consequences of Poor Management of Healthcare Waste
The result as can be seen in Table 4 revealed the mean scores for each of the 11 determinants of the consequences of poor management of healthcare waste. Using a five-point scale, the mean score for spread of drug resistant microorganisms is 4.51 (SD = 0.639), leads to virus, bacteria and parasitic diseases is 4.64 (SD = 0.559), healthcare workers are directly exposed to dangers is 4.54 (SD = 0.705), the public are also affected is 4.47 (SD = 0.507), leads to patients acquiring additional health problems is 4.55 (SD = 0.557), have harmful effects on humans is 4.58 (SD = 0.499), harmful to the environment is 4.54 (SD = 0.499), dumping of waste into rivers is harmful to aquatic life is 4.48 (SD = 0.701), leads to growth/multiplication of vectors is 4.48 (SD = 0.645), sharps can cause injury leading to tetanus is 4.65 (SD = 0.581), and lack of waste management policy leads to poor management of healthcare waste is 4.46 (SD = 0.558).
Consequences of Poor Management of Healthcare Waste.
This result indicates that the consequences of healthcare waste are very high on each of the 11 consequence indicators. In other words, poorly managed healthcare waste can lead to the spread of drug resistant microorganisms, virus, bacteria and parasitic diseases. It can also expose healthcare workers, patients, the public and even the environment to danger. It can also lead to growth/development of vectors and tetanus. All the poorly managed healthcare waste is believed to occur when and where there is no adequate policy on waste disposal/management.
Generally, the result showed that poorly managed healthcare waste has devastating consequences on health workers, patients, the public, the environment and even aquatic life. Therefore, lack of healthcare waste policy leads to poor healthcare waste management which leads the adverse health consequences for humans, the environment and aquatic life (Grand mean = 4.54).
Ways to Achieve Proper Healthcare Waste Management
Data on table 5 revealed the mean scores for each of the 12 determinants of measures to be taken to achieve proper healthcare waste management. Using a five-point scale, the mean score for every healthcare facility should have waste management policy is 4.62 (SD = 0.533), constant orientation programs for all healthcare workers on standard practice for waste management is 4.56 (SD = 0.580), segregation of healthcare waste at the point of generation is 4.37 (SD = 0.829), putting waste sharps into plastic is 4.08 (SD = 1.116), coding of waste containers using colors or numbers is 4.42 (SD = 0.623), putting up notices for patients to identify infectious waste is 4.47 (SD = 0.500), putting up notices for patients and visitors to know how to handle waste in hospitals is 4.41 (SD = 0.493), adequate training for those who manage healthcare waste is 4.52 (SD = 0.500), provision of standard protective devices for those handling waste is 4.59 (SD = 0.500), treatment of hospital waste before disposal is 4.38 (SD = 0.696), transportation of healthcare waste in specialized trucks is 4.53 (SD = 0.582), and the public must be properly educated about dangers of healthcare waste is 4.49 (SD = 0.501).
Measures to Achieving Proper Healthcare Waste Management.
This result indicates that the level of acceptance of the measures is very high on all the solution indicators to the management of healthcare waste. Therefore, healthcare waste can be properly managed if there is a healthcare waste management policy and constant orientation programs for all health workers on international best practices of managing wastes in hospitals among other solutions.
Generally, it is accepted that all the suggested solutions are relevant to the successful management of healthcare waste in Nigeria. Therefore, if the solutions are adequately applied, the dangers posed by healthcare waste may be eliminated or reduced (Grand mean = 4.45).
Discussion of Findings
The study investigated the level of awareness of health workers on the dangers of healthcare waste. It was found that the level of awareness of the health workers toward the dangers of healthcare waste is very high. In other words, they are aware that healthcare waste can cause diseases, cause harm to workers/patients, the public (including scavengers) and even the environment if it is not properly disposed. This result agrees with the report obtained from the qualitative aspect (in-depth interviews) of the study. These data align with the findings of Asomugha et al. (2022) in their research among Hungarians in which they found that majority of the healthcare workers demonstrated excellent knowledge of the risk posed by healthcare waste. This result also supports the opinion of Oli et al. (2016) that hospital wastes have infectious/destructive microorganisms that can be detrimental to the lives of patients, health staff and the entire human society. The result also clarifies the view of Gajurval (2014) that some diseases associated with hospital waste can be injurious to human health. Similarly, the findings also align with the reasoning of Thornton et al. (1996) and Awodele et al. (2016) that healthcare waste can cause environmental pollution, unpleasant smell, growth and multiplication of vectors which lead to transmission of diseases such as cholera, typhoid, plague, rabies and AIDS. In other words, healthcare waste may pose more danger and hazard than the original diseases that patients brought to the hospital.
In the same vein, the study assessed the attitude of the healthcare workers toward healthcare waste based on the fact that they are aware of the dangers posed by healthcare waste. Contrary to expectation, the result indicates that the attitude of the healthcare workers toward healthcare waste is poor and carefree. This was also confirmed during the observation studies. It was found that in spite of the agreed consequences of healthcare waste, hospital workers still carry hospital waste with bare hands and any one could pack the waste including patients’ relatives. The waste were gathered and dumped in one place without segregation and they believed that segregating waste is a waste of time and resources. It was also found that health workers do not believe that hospital waste requires special treatment before disposal. This finding aligns with the report made by Omoleke et al. (2021) when they noted that their study revealed a poor level of medical waste management practices in Kebbi State, Nigeria. The whole process is gathering the waste, moving them to dump sites and dropping them there. However, this result failed to measure up to the suggestions of Surjit (2007), Mathur et al. (2012), and Gravers (1998) when they noted that the ideal process of managing healthcare waste are generation/collection, segregation, transportation/storage, and treatment using modern methods before disposal. The result also did not live up to the expectation of Awodele et al. (2016) when they pointed out that segregation of healthcare waste at the point of generation is key to eliminating the negative impacts of healthcare waste on humans and the environment. It was also found during in-depth interviews that the general and tertiary hospitals do segregate waste but not at the point of generation. The waste is usually dropped into common waste bins at the wards and clinics, which were later carried by ward-maids to the waste department where they were segregated. In other words, between points of generation up to its travel to the waste department, a lot of harm could be caused by the conveyed waste. Even at the waste departments, standard containers were not used for storing the waste. In some places, they used cartons or baskets as containers for waste. It was noticed that some liquid from the waste sometimes wets the base of the cartons and staff carry these cartons with bare hands. According to reports from the in-depth interviews, labeling/coding was non-existent in all the health facilities studied. Findings from the in-depth interviews revealed that private hospitals and primary healthcare centers studied did not segregate waste. It was also found that incineration and burying were the only methods used for disposing infectious waste at the private hospitals and primary healthcare centers. This result aligns with the findings of Adu et al. (2020) and Chisholm et al. (2021) that in Ghana and other developing nations the often favored method is incineration. However, they warned that incineration if not used with the right technology could lead to harmful emissions and residuals. The findings and observations from the current study further confirm that the attitude of health workers toward hospital waste was poor and carefree in the healthcare facilities studied. The reason for this lukewarm attitude toward proper management of healthcare waste are not far from the opinions of Shinee et al. (2008), Diaz et al. (2005), Pépin et al. (2014), and Awodele et al. (2016) as they said that poor management of healthcare waste results from inadequate training of staff, insufficient fund, lack of protective devices, leaving healthcare waste management in the hands of poorly educated laborers and lack of waste management policies in most hospitals. This result also agrees with the views of UNCHS (1996) and George (2016) that hospital waste is not properly managed in low and middle-income countries. The result also aligns with the report of Chisholm et al. (2021) that improper management of waste in hospitals has resulted from unfunded healthcare systems, poor training and absence of policies on healthcare waste management. The evidence from this study also aligns with the view of V. Thakur et al. (2021) that effective healthcare waste management depends on three basic factors—health facility’s capabilities, economic issues, and available technology/knowledge. This is particularly relevant in guiding health administrators in sustainable management of healthcare waste.
Arising from the above, the study investigated the actual consequences of poorly managed healthcare waste. The resultant data revealed that the consequences of poorly managed healthcare waste is quite high. All the interviewees during the in-depth interviews also agreed that the negative impact of healthcare waste is enormous. In other words, a poorly managed healthcare waste can lead to the following: spread of drug resistant microorganisms, viruses, bacteria and parasitic diseases and expose hospital workers, patients, the public, environment and aquatic life to danger. This result aligns with the findings of Awodele et al. (2016) and Khan et al. (2019) that healthcare waste poses potential health risks, damage to the environment and obstruction to the social patterning of human society. The result also supports the views of Akkajit et al. (2020) and Oli et al. (2016) when they posited that healthcare waste can affect both human health, the community and environment because it contains harmful microorganisms. The result also supports the findings of Tilahun et al. (2023) that unsafe healthcare waste management practice poses great risk to healthcare staff, patients and the entire public especially in low-income nations.
The study attempted to identify measures that can be taken to ensure proper management of healthcare waste. The findings indicate that certain measures can help to address the problems of poor healthcare waste management in the study area. One important measure identified was the development and adequate implementation of waste management policies in healthcare facilities. This is in line with the view of Tilahun et al. (2023) that functional healthcare waste manual containing the waste management policy is essential factor that could lead to effective management of healthcare waste. This policy if effective adhered to will help to solve the problem identified by Chisholm et al. (2021) that some countries including Nigeria, Ethiopia, Botswana, and Algeria do not have national guidelines to make people adhere to international best practices on healthcare waste management. Other measures include constant orientation programs for all health care staff on standard practices of managing waste in hospitals, ensuring that the principle of segregation is adhered to at all stages, all sharps must be put inside plastic containers, waste containers must be properly coded using colors with adequate notices for patients and visitors among others. The result provided answers to the problems that were noticed in hospitals in Abuja, Lagos, and Jos where the practice of waste segregation was zero (Bassey et al., 2006; Longe & Williams, 2006; Ngwuluka et al., 2009).
Furthermore, the result is also anchored on the position of V. Thakur (2021) as it relates to healthcare waste management policy formulation in which he said that the PESTEL approach should be used. Here, PESTEL stands for political, economic, social, technological, environmental, and legal. According to him, this approach will help hospital managers and policymakers to understand the whole circumstances surrounding healthcare waste management before formulating a sustainable and practicable waste management policy.
Furthermore, the results have provided support for social action theory (SAT) in that there is usually an underlying reason(s) for people’s action. In this case, inadequate training of health workers, lack of fund and absence of protective devices have been the major underlying reasons for the inability of the healthcare facilities to achieve proper waste management. Again, anchoring on the principles of this same theory, solutions can be found and standard waste practices may be achieved if healthcare staff are provided with adequate training and information which would engineer positive actions toward healthcare waste management.
In the same vein, the findings support the ideas of health belief model (HBM) that the more susceptible that people are to a disease, the more they are willing to take action to prevent and/or treat such diseases. Therefore, this study by exposing the consequences of poor management of healthcare waste is expected to raise the level of consciousness of the health workers, patients and the public on the dangers that await them if hospital waste is mismanaged. As a result, the people will understand that their level of susceptibility to diseases from hospital waste is high if proper measures are not taken. This will help to ensure that the people comply with directives that may be provided by hospitals, healthcare agencies, and others who are involved in healthcare waste matters.
Conclusion
The study revealed that the healthcare workers’ level of awareness about the dangers of healthcare waste is very high. Therefore, it can be said that the hospital workers are fully aware that healthcare waste pose a lot of harm to the hospital workers, the patients, hospital visitors, the public especially scavengers and even the environment. In other words, healthcare waste holds a lot of danger to patients to the extent that it exposes patients to other diseases outside the ones that brought them to the hospital. This means that healthcare waste can lead to hospital-acquired diseases if not checked.
It was found that the resultant data show that in spite of the fact that healthcare workers’ level of awareness about the dangers of hospital waste is very high, their attitude toward such waste is poor and carefree. Therefore, it can be said that the way healthcare workers handle healthcare waste is below the expected international best practices. As such, we can posit that awareness alone does not necessarily translate to positive attitude toward expected action(s). A lot needs to be done to ensure that beliefs do not overshadow awareness. In this case, the belief that healthcare waste is just a waste that should be thrown away is part of the problem. This fact controls the attitude of the healthcare workers toward hospital waste. For them, once the waste is gathered and thrown away at the dump sites, they have done enough waste management. This is very dangerous because the dangers inherent in hospital waste manifest from point of generation through storage through transportation up till the point of dumping at the dump site. At each of these stages, harms do occur to humans, animals and the environment.
After investigating the actual consequences that could arise from poor handling of healthcare waste, it was revealed that the consequences are enormous. Again, apart from humans, both terrestrial and aquatic creatures can be affected. As a result, it can be said that human survival most of the time depends to a great extent on how healthcare waste is managed within an area. This is because every normal person is expected to be ill once in a while and may visit any healthcare facility. Sometimes, people visit their loved ones in hospitals. If healthcare waste is mismanaged in any of these healthcare facilities, such a patient or visitor has a chance of being a victim of any of the consequences of healthcare waste. In the same vein, poor management of healthcare waste will make elimination and/or prevention of certain diseases very difficult if not impossible. This is because as the symptoms are controlled in the hospitals, they still spread through expected agents: healthcare wastes, dump sites, contaminated streams/rivers and even wild animals.
As a result of all these, the study recommends that every healthcare facility no matter its location, ownership or size should have a functional waste management policy. The policy should outline all the processes of waste handling from the stage of generation up to the point of treatment and subsequent disposal. Such policy should state clearly the role of each hospital staff, patient or visitor in the process of waste management. In the waste management policy emphasis should be placed on the issues of segregation and treatment of waste before disposal. It is important to suggest that because of the low level of literacy in Nigeria, segregation should be done by using colors to code the covered plastic containers in this order: Red color (for anatomical waste such as blood), Yellow color (for highly clinical/infectious waste), Purple color (cytotoxic and/or cytostatic products such as chemotherapy medicines), Orange color (for clinical/infectious waste), Blue color (for unused medicines), Black color (for municipal/general waste), and White color (for dental waste). This is the World Health Organisation recommended standard that should be used globally. It should be noted that healthcare waste policy can only succeed if it is fully implemented.
Similarly, healthcare waste should be transported using specialized vehicles that have containers at the back where the wastes are packed for onward conveyance to dump sites or for burial. It is also important that necessary safety devices such as rubber hand gloves, plastic foot wears, disposable nose masks and aprons among others are sufficiently provided for those who carry waste at every healthcare facility.
It is also necessary that there is regular orientation/enlightenment programs for hospital staff. Such programs should be extended to patients, hospital visitors and the general public (who are potential patients) on how waste should be handled in hospitals as well as the dangers that come from being in contact with hospital waste. In the process, the belief that healthcare waste is just waste would be positively adjusted.
In the same vein, healthcare waste management should be incorporated into the curriculum of Physical and Health Education subject of both primary and secondary schools in Nigeria. This will go a long way to educate even the young ones, who are likely to become future health workers or even patients, about the dangers that can result from poorly managed healthcare waste.
Generally, it is pertinent to state that healthcare waste is a dangerous substance that should be handled with utmost caution for the continued survival and healthy development of human society. The driving tool for effective handling of healthcare waste is the healthcare waste management policy which should be implemented following international best practices. The health and life of hospital workers, patients, hospital visitors, scavengers, the general public and even flora and fauna depend wholly on proper management of hospital waste.
Limitations of the Study
The study assessed on the attitude of healthcare workers toward waste management and its consequences. The study could not examine the opinion or attitude of patients toward waste management. The study did not engage in any laboratory examination to determine the inherent diseases that could result from hospital waste. As a result, more research is needed to examine the attitude of patients toward healthcare waste and the impact it may have on their healing process. Similarly, laboratory studies should be carried out to determine specific diseases that could result from certain kinds of healthcare waste.
Footnotes
Acknowledgements
We are very grateful to the management and staff of Alex Ekwueme Federal University Teaching Hospital, Abakaliki Nigeria and Federal Medical Centre, Owerri Nigeria for giving us the permission and support to carry out the research. Our appreciation also goes to the staff members of all other health facilities used for the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Data Availability Statement
Data is available but can be obtained on request from the corresponding author.