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134]
Original Article
Assessing Knowledge, Attitudes, and Practices of Healthcare Workers

Regarding Medical Waste Management at a Tertiary Hospital in
Botswana: A Cross‑Sectional Quantitative Study
B Mugabi, S Hattingh1, SC Chima2
Programme of Bio and Background: Medical waste management (MWM) is of concern to the medical
Abstract
Research Ethics and Medical
Law, School of Nursing and
and general community. Adequate knowledge regarding management of
Public Health, University healthcare waste is an important precursor to the synthesis of appropriate attitudes
of Kwazulu-Natal, Durban, and practices of proper handling and disposal of medical waste by healthcare
1
Department of Advanced workers (HCWs). Aims and Objectives: This study was designed to investigate
Nursing Sciences, University knowledge, attitudes, and practices of doctors, nurses, laboratory technicians,
of South Africa, Pretoria, and housekeeping staff, regarding MWM at a tertiary hospital in Gaborone,
2
Programme of Bio and
Research Ethics and Medical
Botswana. Materials and Methods: This was a cross‑sectional quantitative study
Law, School of Nursing and using a self‑administered questionnaire involving 703 participants. Data were
Public Health, and Nelson R analyzed using SAS software. Descriptive statistics were used to summarize the
Mandela School of Medicine, data. Responses for attitude of respondents were analyzed using nonparametric
College of Health Sciences, tests. Results: The completion rate for this study was 90% with (632/703)
University of KwaZulu-Natal, questionnaires analyzed. Majority of respondents were nurses 60% (422/703),
Durban, South Africa
followed by housekeeping staff 24.3% (171/703), doctors 10.95% (77/703), and
laboratory technicians 4.7% (33/703). The study showed that 66.9% (423/632)
of respondents had some training in MWM, and 90.5% (572/632) claimed to
have knowledge regarding the consequences of poor MWM, particularly health
risks. There was a significant agreement among the respondents that segregation
of medical waste should be done at the point of generation (mean score = 4.43
out of 5). Majority of respondents reported that the healthcare facility had a
color‑coding system (mean score = 4.59) and identified “lack of knowledge of
the dangers of improper waste management by HCWs” as the major obstacle to
MWM. Conclusion: This study showed that MWM practice at this facility was
above average, although improvements were required in accessing waste disposal
points and availability of personal protective equipment. Ongoing training should
be provided to HCWs on MWM, with more attention to knowledge of regulatory
requirements, and involvement of HCWs in development of MWM policies to
enhance compliance.
Date of Acceptance: Keywords: Africa, biohazards, color‑coding, developing countries, ethics,

20-Aug-2018 healthcare laws, hospitals, medical errors, regulation, risk management
Introduction Address for correspondence: Dr. SC Chima,

School of Nursing and Public Health, and Nelson R Mandela
M edical waste is defined as “Any waste which

is generated in the diagnosis, treatment or
immunization of human beings or animals or in
School of Medicine, College of Health Sciences, University of
Kwazulu‑Natal, Durban, South Africa.
E‑mail: [email protected]
research” in a place where healthcare is provided.[1]

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DOI: 10.4103/njcp.njcp_270_17
How to cite this article: Mugabi B, Hattingh S, Chima SC. Assessing
knowledge, attitudes, and practices of healthcare workers regarding
PMID: ******* medical waste management at a tertiary hospital in Botswana: A
cross-sectional quantitative study. Niger J Clin Pract 2018;21:1627-38.
© 2018 Nigerian Journal of Clinical Practice | Published by Wolters Kluwer ‑ Medknow 1627

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Mugabi, et al.: Knowledge and practices of healthcare workers regarding medical waste in Botswana
treatment to patients as well as all items contaminated the environment.[5] For waste segregation to be done
by hazardous fluids, for example, blood, urine, adequately, proper receptacles (containers) must be
feces, and other body fluids. Medical waste poses an available and accessible to the waste generators. These
important global challenge because of potential hazards must be of correct specification including labeling. The
to the environment and public health. Healthcare World Health Organization (WHO)[10] recommends that
workers (HCWs) are exceptionally at a high risk to best practices require that visible posters indicating
potential contamination from medical waste by the the kind of waste to be disposed should be placed on
nature of their work and proximity to this kind of adjacent walls, such reminders reinforce behavior of
waste. While hhealthcare wastes are generated during proper waste segregation. Further, it is recommended that
all processes of provision of healthcare services, the for segregation to be successful, containers of sufficient
quantities of waste produced vary with the type of sizes be provided to avoid unpredictable fill‑ups before
health facility, the level of services offered; and the collection and disposal of waste. There are specifications
economic status of a given country. As an example, a for appropriate healthcare waste receptacles according
general medical practice facility would not generate the to the type of waste that they are intended to hold
same medical waste quantities as does a day surgery; including the recommended color. The color‑coding
likewise, an eye hospital may not generate as much system that is internationally accepted is as follows:
hazardous waste as an obstetric practice.[2] Globally, it is yellow – sharps; red – anatomical and infectious
estimated that 7–10 billion tons of waste are generated materials; dark green – pharmaceutical and chemical;
per annum, out of this only 2 billion tons are municipal and black – domestic waste, as shown in Figure 1.[11]
solid waste, of which medical waste contribute but
In addition, other forms of medical waste are not
a small fraction.[3] It is estimated that 75%–95%
color coded but are by law required to carry specific
of bio‑medical waste are non–hazardous, whereas
symbols denoting or identifying the waste involved
10%–25% are hazardous waste.[2] However, when both
such as radioactive and chemical wastes.[12] Arguably,
types of medical waste are mixed together, then all types
medical waste is a global concern because the hazards
of medical waste may become harmful and detrimental
of poor management of waste may have far‑reaching
to humans, animals, and the environment. Unfortunately,
consequences on health and the environment.[13]
reports suggest that almost 80% of medical waste are
mixed with general waste, especially in developing Disposal of medical waste
countries.[3] Proper and adequate management of Disposal of healthcare waste in general may involve
medical waste is, therefore, of great importance during one of the following methods, the choice depending on
healthcare service delivery. In the course of providing the category of waste and probably cost and availability
healthcare services (preventative, promotive or curative), of the technology. These include incineration, landfill
it is inevitable that medical waste will be generated. disposal, or deep burial.[14] There could be exceptions
When waste is not handled in the correct manner, it may and special cases, for example, waste containing
lead to serious health consequences for both humans,[3,4] recognizable body parts or foetal materials such as
animals, and may have a significant negative impact on placentae, religious and cultural preferences should be
the environment.[5,6] Further, the rapid environmental considered and such waste should be disposed using
degradation associated with global warming and climate acceptable and sensitive modalities.[15]
change is a critical challenge to the global community.[7]
Waste management and safety at the workplace
Therefore, waste disposal is a major concern in most
As noted in the foregoing text, injuries may result
communities especially in developing countries that lack
at the workplace because of exposure to waste. The
environmental awareness education programs.[2‑4,8] It has
International Labor Organization (ILO)[16] estimates
been suggested that minority populations and people in
that globally, up to 2.2 million people die from
poverty are exposed to environmental health hazards at
occupation‑related disease and injuries and 170 million
a disproportionately high rate when compared to affluent
experiences nonfatal albeit serious injuries. Further,
communities.[9]
5%–7% of deaths in established economies are a result
Classification and management of medical waste of occupational related diseases.[16] The economic cost to
Medical waste is generally subdivided into general companies and individual workers is staggering; mostly
waste and hazardous waste. General waste from in terms of absenteeism, health and treatment costs,
healthcare facilities is considered safe for disposal compensation, and legal costs. It is recommended that
via the general municipal waste stream. On the a safety culture should be created at the work place
other hand, hazardous waste stream requires special to prevent injuries; which would involve training and
handling given its potential to affect public health and behavioral changes; aimed at prevention of exposures
1628 Nigerian Journal of Clinical Practice ¦ Volume 21 ¦ Issue 12 ¦ December 2018
at the workplace.[16] The resultant effect translates to Management of healthcare waste then, like all other
good waste management practices such as efficient forms of waste, must conform to the waste hierarchy as
segregation of waste and use of personal protective illustrated in Figure 2.[22]
equipment at work. Ethical dilemmas regarding medical waste
Potential impact of improper disposal of medical The moral and legal concerns of waste management
waste in Botswana and other developing countries are diverse; they range from breach of privacy and
Among the major diseases that afflict Batswana is confidentiality, through duty of care to matters concerned
tuberculosis (TB), and this is exacerbated by the synergy with negligence, compensation, and restorative justice.[23]
provided by the dual infection with HIV/AIDS. In Several legislations are in force in most countries that
addition, there is a high burden of HIV/HBV coinfection. are enacted for the purpose of ensuring environmental
The attendant immunosuppression resulting from HIV integrity, proper waste handling, and human health and
infection increases the viral replication of HBV as well well‑being. These include acts of parliament and other
as enabling transmissibility of HBV. This also increases legal instruments.[10‑12,14‑16,19‑21] Furthermore, international
the risk of acute HBV infection progressing to the ethical instruments, such as the UNESCO Universal
chronic state and subsequent latent infections.[17] With Declaration on Bioethics and Human Rights,[24] have
the growing population and the inevitable increasing identified fifteen core principles of bioethics, which
number of patients and the medical waste they generate, include “protecting future generations” and “protection
waste management and especially medical wastes need of the environment, the biosphere, and biodiversity.”[23,24]
attention and action. Waste, especially medical waste is Therefore, doctors and other healthcare professionals
particularly important because improper handling can have a moral and ethical obligation to act in a value‑ and
be a risk to both healthcare providers and the general duty‑based manner to assist in the proper disposal of
population alike because of exposure to infectious and medical waste as part of virtue ethics and duty‑based
or contaminated objects.[4,18,19] Besides the increasingly ethical obligations.[23‑25]
health risks, improper waste management may Duty of care
contaminate the pristine water sources in Botswana,
The duty of care holds important responsibility on the
which is already a water scarce country.[20] Therefore,
healthcare waste generator. This obligation holds the
the government has instituted strict measures, which
waste generator responsible for the welfare of HCWs,
govern the management of waste disposal.[20]
patients, visitors to healthcare facilities, the public,
Ethical and legal implications of healthcare waste and environment.[10] It is, therefore, the duty of the
management generator of healthcare waste to ensure that waste
According to the Health Professions Council of South is properly handled from generation up to disposal.
Africa (HPCSA),[21] healthcare waste may be defined as Various process and activities, such as proper labeling
of receptacles and adequate segregation, proper storage,
Any undesirable or superfluous by product, emission,
and ultimately disposal, must be conducted in a manner
residue, or remainder generated in the course of health
that meets ethical and legal requirements. This process
care by healthcare professionals, healthcare facilities,
is enhanced by color coding of the receptacles.[10‑11,26]
and other nonhealthcare professionals, which is
Although waste management involves, minimization
discarded, accumulated, and stored with the purpose of
of waste and proper segregation, collection, storage,
eventually discarding it or is stored with the purpose of
transportation, disposal, and record keeping. The duty
recycling, reusing, or extracting a usable product from
of care entails much more, including the provision of
such matter.[21]
appropriate education, training, and the commitment of
Waste management refers to the processes involved from the HCWs and healthcare managers within an effective
the point of generation to disposal or reuse of generated policy and legislative framework.[12] Properly segregated
waste. Proper handling of biohazardous waste must meet waste minimizes potential injuries that otherwise result
minimum requirements for disposal which include[10] from inadvertent mix‑up and erroneous handling.[2]
i. Segregation from other waste Furthermore, segregation ensures cost effectiveness in the
ii. Securely packaged waste handling process, therefore, preventing resource
iii. Labeling indicating source, type of waste, and the wastage. Regarding responsibility toward the workers, the
nature of treatment required employer has a duty toward their safety and must provide
iv. Transportation by appropriately trained personnel adequate personal protective equipment and should
v. Treatment and elimination of the biohazard; and provide vaccination against blood borne infections such
vi. Documentation and records. as hepatitis B virus.[27] A good example to illustrate the
Nigerian Journal of Clinical Practice ¦ Volume 21 ¦ Issue 12 ¦ December 2018 1629
consequences of potential dereliction of duty in handling Study location

waste disposal is the 2000 incident as reported by The study was conducted at the biggest hospital in
Nwachukwu and others,[28] in which 6 Russian children the country with 500 beds capacity and the national
contracted small pox (though a mild form) after coming referral hospital. It also acts as the main referral hospital
in contact with discarded vaccine ampoules at a garbage for local healthcare clinics and has the only 24‑hour
dump in Vladivostok, Russia.[27] Such an environment is emergency medical services in Gaborone, which is also
a danger and not conducive to healthy well‑being. The the nation’s capital city. It provides services for all the
South Africa Medical Research Council (SAMRC) states clinical disciplines. Nationally, the facility has the largest
that “unnecessary or avoidable exposure to such hazards is numbers of HCWs per each of the four categories of
ethically unacceptable.”[29] From the foregoing discussion, participants in the study.
it is vital that HCWs are aware of the required ethical and Objectives
legal standards and that an understanding of their role in
The aim of this study was to assess the knowledge,
the management of medical waste is made clear.
attitudes, and practice among four categories of
Risk management implications of healthcare HCWs, namely doctors, professional nurses, laboratory
waste management technicians, and housekeeping staff with regard to waste
Risk management is derived from law and professional management. The study site was purposively selected.
standards and is expressed through institutional policies Study population and sampling methodology
and standard operational procedures.[23] When legal and
For each respondent group (doctors, nurses, laboratory
risk management issues arise in the delivery of healthcare,
technicians, and housekeepers), a sample size was
there may also be ethical concerns. Conversely, what is estimated separately, since these groups were the primary
originally identified as an ethical problem may raise legal strata. Sample size calculations were done in G*Power
and risk management issues.[23,30] The risk management based on the estimation of a 50% proportion, at a 5%
implications of improper healthcare waste management significance level and 5% precision.[31] The formula used
or the failure to handle medical waste properly could to estimate the sample size for each group was
lead to medical errors and allegations of negligence. For
example, improper handling of healthcare waste could n = (z2r (1 − r) N)/(Ne2 + z2r (1 − r),
lead to each of three classifiable types of medical error where n = calculated sample size, N = population
as outlined below.[23,30] size, z = critical value at the chosen significance level,
a. Errors of omission, for example, where medical r = proportion to be estimated, and e = precision.
waste is not disposed at all or aggregated with
regular waste leading to infectious disease or Thus, for example, for the category of doctors: N =46,
z = 1.96, r = 0.50 (50%), and e = 0.05 (5%), and n is,
nosocomial infection or infection amongst HCWs or
thus, 41.096, which is rounded to 42. Response rates
to environmental pollution
for surveys of this kind are estimated at about 50%.
b. Errors of commission, for example, where waste
The calculated sample sizes were, therefore, doubled to
is disposed into the wrong containers, resulting
estimate the number of respondents to be approached to
ultimately in improper disposal and the attendant
participate in this study. The calculated sample sizes, as
consequences, for example failure to incinerate
well as the actual number of respondents approached, per
or autoclave infectious materials that ought to be
group are shown in Table 1. Given the low number of
incinerated or autoclaved before proper disposal
doctors and laboratory technicians, all available doctors
c. Errors of unawareness, for example, where HCWs
and technicians were approached to participate in the
are improperly trained regarding the proper
study. Likewise, because of the response rate estimation,
method of disposing medical waste, leading to
all the housekeepers were approached to participate.
attendant consequences and the need for sanctions
As for the nursing professionals, 79% (=470/598) were
and vicarious liability against the employers and approached to participate in the study.
employees for failure to obey laws or regulations
regarding waste management.[23,30] The target number of participants in each group was
estimated as follows: 90 doctors, 469 professional
Materials and Methods nurses, 256 housekeepers, and 46 laboratory technicians.
Research design However, the study recruited following number of
This study was a descriptive cross‑sectional study participants for each category of HCWs: 80 doctors, 432
conducted at a single tertiary government healthcare professional nurses, 40 laboratory technicians, and 198
facility in Gaborone, Botswana. housekeeping personnel.
Study instrument and data collection The final version of the questionnaire consisted
The data collection instrument was a semistructured of following four sections: knowledge of waste
questionnaire, comprised of three sections, management, attitudes toward waste management,
namely, ‑knowledge of waste management section, practice of waste management, and biological
which comprised 11 questions aimed at establishing information. Collection of data took place from
the respondents’ understanding of waste management January 13 to February 10, 2014. The data collected
techniques and methods of waste disposal in the were analyzed using SAS software G*Power 3.1.[31]
hospital. The second section was about attitudes toward The results are presented in percentages, medians, and
waste management consisting of nine questions that means.
investigated the respondents’ attitudes toward waste Ethical considerations
disposal strategies. The third section on practice of Before commencing the study, ethical clearance was
waste management was subdivided into four subsections, sought from the College of Human Sciences Higher
namely, ‑general inquiry about the practice, challenges in Degrees Committee of the University of South
the process of segregation and management of medical Africa (UNISA) and granted. Further permission was
waste, and obstacles to waste management; possible obtained from the Botswana Ministry of Health and
solutions for restructuring of waste management; the hospital under study. Thereafter, each participant
and the type of waste handled. Finally, biographical was ascertained to be of age of consent according to
information covered the respondents’ biographical data, the laws of Botswana, which is 18 years of age. They
including age, gender, educational background, duration were then required to sign an informed consent form
of employment at the hospital, and area of the hospital before completing the questionnaire. In addition, the
where they worked. principal investigator (PI, BM) held various meetings
Inclusion criteria at departmental levels with the potential respondents
The following were the inclusion criteria for this study. where he discussed the aspects of the study. Voluntary
i. Participants had to be employed by the hospital participation and the right of the respondents to enrol
under study or withdraw from the study were emphasized. The
ii. Willingness to participate in the study after signing researcher explained to all potential respondents that
the consent form if they agreed to participation in the study, they would
iii. Be literate in English language. have to sign the consent form in the presence of the
researcher or his assistants before they could take the
Exclusion criteria
questionnaire to complete at their own convenience,
The following HCWs were excluded from the study: within a set period. Three weeks was suggested as
i. All professional HCWs not permanently employed adequate, but most questionnaires were returned within
by the hospital. a few days. Confidentiality was maintained by ensuring
ii. Any staff members who were not willing to sign the anonymity since there were no identifiers obtained from
consent to participate. the research respondents. The completed and collected
Data analysis questionnaires were kept under lock and key.
Data were collected using a self‑administered
questionnaire. The questionnaire was pretested to Results
ascertain ease of understanding and to determine if Demographic characteristics of the study
it was worded to elicit all the materials of interest population
for this research study. Therefore, this process was Overall, 703 respondents participated in the study.
concerned with assessing content validity of the Majority of these respondents were nurses 60% (422/703),
questionnaire. Participants for the pretesting stage followed by housekeeping staff 24.3% (171/703), doctors
were drawn from the heads of department at the 10.95% (77/703), and laboratory technician 4.7% (33/703)
study hospital which included doctors and nurse as shown in Figure 3. However, only 90% (632/703) of
practitioners. Pretesting of the questionnaire was the completed questionnaires were deemed acceptable
conducted at the same hospital as the study; however, for analysis. Further, these results showed that female
those involved in the pretesting phase were not respondents were the majority with 71.5% (452/632),
allowed to participate in the actual study. Findings whereas males were 28.5% (180/632). Majority of
from this process showed that all respondents were respondents from each category of HCWs were aged
satisfied and that the questionnaire was adequate for between 25 and 34 years (62.5%) (n = 395/632) as
the purpose of the study. shown in Figure 4. Doctors were predominantly in age
Healthcare Pharmaceutical Chemical Sharps Infectious Anatomical

general waste e.g. waste and e.g. waste e.g. waste e.g.
waste e.g. Tablets heavy metal Needles Used cotton Human
Paper waste e.g. swabs tissues
packaging amalgam
Transparent
packaging Green Yellow Red
Green Red
Black container container Container
container Packaging
container
Municipal Waste
Waste Management
Disposal Contractor
Figure 1: Flowchart for proper segregation and disposal of healthcare waste. Adapted from SANS
respondents 93.6% (592/632) had worked at the hospital

for <10 years, whereas the remaining 6.4% (40/632)
reported having worked at the hospital for ≥11 years,
as shown in Figure 5. With regards to education,
56% (354/632) of all respondents had diplomas, mainly
professional nurses and laboratory technicians, as shown
in Figure 6. The majority of doctors 80.6% (54/67) had a
bachelor’s degree, whereas most nurses 85.2% (334/392)
had only diploma level education and none of the
housekeeping staff had attained a diploma level
education.
Knowledge regarding medical waste management
Table 1 reveals the knowledge of the study participants
Figure 2: Hierarchy of waste management regarding waste management. Results showed that a
majority of doctors 83.6% (56/67) had some training
in waste management, followed by nurses with
69.4% (272/392). All the categories of HCWs had poor
knowledge regarding presence of recycling services in
the hospital, the worst being doctors with 13% (9/67).
Approximately half of the participants 49.8% (315/632)
stated that HCWs received training in medical waste
management (MWM).
Attitude toward waste management
Figure 3: Distribution of participants in each category of HCWs. Analysis of the responses for attitudes of
MD=Medical doctors; PN=Professional nurses; HS=Housekeeping staff; respondents was at 95% confidence interval using a
LT=Laboratory technicians nonparametric test equivalent to one‑way analysis of
variance (ANOVA). Thus, the outcome was presented
group 25‑34 years. Whereas for the nurses, laboratory in terms of medians rather than means. This was due to
technicians, and housekeeping staff, the distribution was the fact that the negative skewness of the data results
predominantly within the 25–34 age bracket as follows, obtained from the assumptions of the one‑way ANOVA
60.7% (238/392), 67.9% (19/28), and 68.2% (99/145), for the between‑group tests were not being met. In
respectively. Only 58.2% (39/67) of doctors were within other words, the population under study was found to
the 25‑ to 34‑year age bracket [Figure 4]. Regarding the be nonsymmetric; therefore, it was preferable to use
duration of work at the healthcare facility, the majority of a nonparametric equivalent to one‑way ANOVA (the
Figure 5: Graph showing the duration of work at the health facility
Figure 4: Age brackets distribution within categories of healthcare

workers
Figure 7: Mean scores regarding attitudes to medical waste (n = 632)
Figure 6: Educational level of participants by professional group
Figure 9: Challenges faced by respondents regarding medical waste

management
Figure 8: Mean scores of responses regarding practice of medical waste Practice of waste management
management (n = 632)
Regarding practice of waste management, participants
Kruskal–Wallis test), based on advice from an expert were asked questions in three parts. Each of these
statistician. Results regarding attitude toward medical parts had a distinct set of questions with a unique
waste are shown in Figure 7. The best overall scoring format of answers. The results of the first part of this
item was in favor of segregation of waste being done at section were presented in terms of mean scores as
the point of generation, with a median score of 4.43. On shown in Figure 8. This illustrates the overall mean
the other hand, the item inquiring about whether waste score for each of the different statements that were
was separated according to the policies of the hospital presented to the respondents. The error bars denote
resulted in a median score of 2.76 out of 5. the 95% confidence interval for the mean. We found
Table 1: Knowledge of healthcare workers regarding medical waste management

Variable Doctors, % Nurses, % Housekeeping Laboratory
(n=67) (n=392) staff, % (n=145) technicians, % (n=28)
Did any of your training cover waste management? 83.6 (56/67) 69.4 (272/392) 54.5 (79/145) 57.1 (16/28)
Do you know the category of waste that is called 97.0 (65/67) 95.9 (376/392) 91.0 (132/145) 78.6 (22/28)
medical waste?
Is it possible for you to tell the difference between 91.0 (61/67) 96.9 (380/392) 90.3 (131/145) 100.0 (28/28)
the different categories of medical waste?
Have you been trained with regard to waste 74.6 (50/67) 87.2 (342/392) 66.2 (96/145) 82.1 (23/88)
differentiation?
Do you know about the policies in this hospital 92.5 (62/67) 96.2 (377/392) 82.8 (120/145) 82.1 (23/28)
about reporting needle stick injuries?
Is there an infection control department in this 80.6 (54/67) 93.1 (365/392) 91.0 (132/145) 89.3 (25/28)
hospital that deals with waste management?
Are you aware if recycling of medical waste is done 19.4 (13/67) 49.5 (194/392) 29.0 (42/145) 17.9 (5/28)
at this hospital?
Do you think that if waste is not properly handled it 94.0 (63/67) 94.4 (370/392) 82.1 (119/145) 71.4 (20/28)
can be a risk to healthcare workers and patients?
Do you know what happens to waste after it is 47.8 (32/67) 80.6 (316/392) 79.3 (115/145) 57.1 (16/28)
picked up from the station where you work?
Do you always know what type of waste you are 77.6 (52/67) 81.6 (320/392) 82.1 (119/145) 75.0 (21/28)
dealing with?
Are staff given training workshops regarding waste 40.3 (27/67) 53.1 (208/392) 50.3 (73/145) 25.0 (7/28)
management?
Figure 11: Respondents agreeing to suggested solutions for restructuring

medical waste management (%)
Figure 10: Barriers to medical waste management reported by
respondents (n = 632) be viewed as alien by these HCWs, and therefore not
followed as required.
that respondents generally agreed that there was a
color coding system, waste was placed in designated Challenges to waste management
containers immediately after use, and waste disposal The second part of the section on the practice of
points were accessible, “very often.” Respondents waste management required participants to select
indicated that challenges were faced with respect to from a set of challenges; those that they encountered
segregation of medical waste; often, different types of at their workstations. It is notable that there were no
waste were found mixed. Institutional policies were challenges that stood out; all the items received a
seldom followed, and waste was adequately segregated, moderate level of support (30%–50%). The challenge
“sometimes.” Finally, participants indicated that they with the highest support was that regarding the ease
had experienced the consequences of poor waste of access to waste bins with 47% (300/632) score.
management and participated in making waste handling This was followed by “waste is not removed when the
policies, “rarely.” Surprisingly, participation in process available bins are full” with 43.7% (276/632), whereas
of formulating waste management policies in the the lowest support was for the “other” response with
hospital scored worst. Consequently, such policies may 1.9% (12/632).
Similarly, blood and fluids was the type of waste

most handled by housekeeping staff and laboratory
technicians at 73.8% (107/145) and 96.4% (26/28),
respectively. The percentage of respondents who
handled or generated different types of medical waste
are shown in Figure 12.
Discussion
This study aimed to study the knowledge, attitude, and
practices of HCWs at a tertiary hospital in Gaborone,
Botswana, regarding management of medical waste.
Findings revealed that there were differences in
Figure 12: Types of medical waste generated by respondents (%)
knowledge, attitudes, and practice of waste management
among the four categories of HCWs at the hospital
Barriers or obstacles to medical waste handling
under study. There were deficiencies in the knowledge
The most common obstacles reported was “lack of levels of waste management among all the categories of
knowledge and training” identified by 63.1% (399/632) HCWs in this study. The agreement observed with regard
respondents; followed by the fact that majority of nurses to possible remedial importance of educating HCWs
do not see waste separation as their area of concern in waste management in this study was consistent with
according to 52.2% (330/632) of nurses. The least of the the 70% (n = 89) overall agreement found in another
recorded obstacles was that of laboratory technicians’ study from the United Kingdom.[32] The results from
view of waste separation at 9.2 (58/632). Responses our own studies did not reveal a statistically significant
indicating inadequacy of appropriate color coding was association between postbasic training and performance
29.0% (183/632). Obstacles to waste management of members of each category of HCWs. However, there
reported are shown in Figure 9. was a strong relationship between the performance of
Potential solutions toward restructuring waste each group of HCWs and the demographic characteristics
management practice of the respondents. For example, there was a strong
Overall, the percentage of respondents who agreed relationship between highest level of education and
with each of the different statements regarding location of basic training for doctors, when compared
restructuring of waste management practices is shown in with nurses and laboratory technicians, in favor of
Figure 10. The most popular solutions were providing those that had obtained their postbasic training outside
better education (to workers and cleaners), chosen Botswana.
by 70.7% (447/632); and empowering the infection Knowledge of waste management
control department with better facilities, selected by
Regarding knowledge of waste management, high scores
65% (411/632) respondents.
were recorded by most HCWs regarding knowledge
Types of medical waste generated or handled at of the basics of MWM and handling aspects, such as
the healthcare facility the categorization of different types of waste, policies
This study considered 11 different kinds of medical on needle‑stick injury, existence of infection control
waste, which were listed so that HCWs could select as department within the hospital, and the health risks
many as possible of those that they either handled or associated with poor waste handling. However, previous
generated in the process of conducting their work are training, availability of training, and awareness of
depicted in Figure 11. The most handled/generated of recycling of medical waste scored lowest. About half,
medical waste was blood and body fluids as reported 49.8% (315/632) of participants stated that they received
by 92.2% (582/100) of participants, whereas the some training in MWM. This was much higher than
least handled waste type was genotoxic waste with the findings of another study done in India,[33] which
2.5% (16/632). Majority of doctors 98.5% (66/67) reported that only 16.3% of participants had received any
reported handling and/or generating blood/body fluids training in MWM. Further, an intermediate score was
during their practice. Conversely, only 7.5% (5/67) observed regarding aspects of knowledge concerning
of doctors reported handling or generating genotoxic waste differentiation and training and disposal of waste
medical waste. Most nurses 97.7 (383/392) reported after collection. Most nurses 96.2% (377/392) reported
handling blood and body fluids, whereas only knowledge of needle‑stick injury reporting policies,
2% (40/392) reported handling genotoxic waste. which is consistent with the findings of an Indian study
where 88.6% of nurses were also aware of needle‑stick personnel had the lowest at 53.8% (340/632). The
injury reporting policies.[34] However, our findings are in least scoring obstacle was “laboratory staff do not see
contrast with those reported from a study done in South waste separation as their concern” with 9.2% (58/632)
Africa, which found that only 47.2% of HCWs had responding affirmatively. It should be noted that this
adequate knowledge of correct disposal of healthcare might be explained by the low numbers of HCWs in this
waste and only 36.0% employed appropriate disposal category, as well as the fact that laboratory staff do not
practices of medical waste.[35] share workstations with most respondents from the other
categories of HCWs in this study.
Attitude and practice regarding waste management
Attitude toward waste management among respondents: Solutions for restructuring
Most respondents agreed that medical waste should be This subsection provided six prestated choices, whereas
segregated at the point where it is generated. This was the seventh option required respondents to suggest a
consistent with the results from a study in India,[33] solution. There was an overall 50%/50% response for
where 96.9% of respondents agreed that waste should the item “the waste disposal department does not have
be segregated. Pertaining to the practice of waste to be changed.” The highest “yes” responses was from
management, the study established presence of high housekeeping personnel with 57.2% (361/632), and the
level of agreement that there was a colour‑coding lowest from doctors with 35.8%. The most agreed‑upon
system in the hospital under study. Nonetheless, solution was “provide waste management education
segregation of medical waste was problematic with to the cleaners” scoring 70.7% (447/632), followed
mixing of the different types of waste. Segregation by 71.6% (452/632) for “provide waste management
was found to be high in Indian studies conducted by workshops to the workers.” This likely implied some
Chudasama et al.[36] and Charania and Ingle,[37] who degree of the self‑assessment by the HCWs concerning
found that the correct response was as high as 86.9% their preparation regarding proper waste management
and 82.4% respectively. In addition, adherence to practices. Only 1.7% (11/632) of respondents gave
MWM policies in this study was found to be poor, responses in the subsection to suggest a solution for
and HCWs were rarely included in the development restructuring the waste management at the hospital. The
of waste handling policies. There was evidence that highest scoring of the seven was “encourage HCWs to
the different departments involved in medical practice view waste as their concern” with 27.3%.
do not synergise with each other towards proper
MWM. For example, waste was often found mixed up, Conclusions and Recommendations
although the institution has a colour coding system, This study was done at a selected tertiary hospital in
and placement of waste is not in proper receptacles Gaborone, Botswana, and was conducted among doctors,
“all the time or always.” This is similar to another nurses, laboratory technicians, and housekeeping
study from South‑Eastern Nigeria, where Anozie and personnel. It was a prospective, descriptive and
others reported that 98.1% of hospitals in this region cross‑sectional study using a self‑administered
practiced indiscriminate waste disposal, with only questionnaire. The objective of the study was to
40% of healthcare managers reporting having received establish the level of HCWs knowledge, attitudes, and
any training on MWM.[38] However, in a study done practices regarding MWM. Results showed that there
in Chennai India, 28% of respondents did not adhere were gaps in knowledge and practice of MWM by
to disposal of waste into appropriately color‑coded respondents across all categories of HCWs. Inadequacy
receptacles.[37] Respondents reported several challenges of knowledge was reported as the most common
to proper practice of MWM. Half of the participants obstacle to MWM. We would like to recommend that
reported inadequacy or inappropriate receptacles. The all categories of HCWs practising in Africa should have
next most reported challenge was absence of protective ongoing training on proper MWM. Further, university
gear, such as heavy‑duty gloves for the cleaners, and college educated HCWs, such as doctors and nurses
followed by doctors’ failure to dispose of waste after should have at least one lecture included in the medical
medical procedures.[36,37] and nursing curricula regarding MWM, and a session
Obstacles to proper MWM on proper waste management should be included at all
induction or orientation programmes for all categories of
The most recognized obstacle to MWM in this study was
HCWs, before assumption of duty.
the “lack of knowledge of the dangers of improper waste
management by the HCWs” with a 63.1% (399/632) Acknowledgments
“yes” response. Doctors contributed the highest This manuscript is derived in part from a dissertation of
response of 67.2% (425/632), whereas the housekeeping limited scope submitted by BM in partial fulfillment of
the requirements for the award of the MPH degree at Development of a National Programme of Occupational Safety
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[Downloaded free from http://www.njcponline.com on Tuesday, November 29, 2022, IP: 107.161.22.

Assessing Knowledge, Attitudes, and Practices of Healthcare Workers

Date of Acceptance: Keywords: Africa, biohazards, color‑coding, developing countries, ethics,

Introduction Address for correspondence: Dr. SC Chima,

M edical waste is defined as “Any waste which

research” in a place where healthcare is provided.[1]

© 2018 Nigerian Journal of Clinical Practice | Published by Wolters Kluwer ‑ Medknow 1627

consequences of potential dereliction of duty in handling Study location

Healthcare Pharmaceutical Chemical Sharps Infectious Anatomical

respondents 93.6% (592/632) had worked at the hospital

Figure 5: Graph showing the duration of work at the health facility

Figure 4: Age brackets distribution within categories of healthcare

Figure 7: Mean scores regarding attitudes to medical waste (n = 632)

Figure 6: Educational level of participants by professional group

Figure 9: Challenges faced by respondents regarding medical waste

Table 1: Knowledge of healthcare workers regarding medical waste management

Figure 11: Respondents agreeing to suggested solutions for restructuring

Similarly, blood and fluids was the type of waste

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