Healthcare Waste Management Practice and Associated Factors among Private and Public Hospitals of Bahir Dar City Administration

Background Lack of an appropriate management practice of healthcare waste is a potential threat to the healthcare workers, patients, and nearby communities of the health institutions. Objective The study aimed to assess the healthcare waste management practices (HCWMP) and associated factors among healthcare workers of private and public hospitals of Bahir Dar city administration, Ethiopia. Methods A facility-based comparative cross-sectional study was conducted from January 2016 to April 2017. The systematic random sampling technique was employed to recruit 460 healthcare workers. The collected data entered into the EpiData software (version 3.1). The analysis was done by using SPSS software (version 20). Descriptive statistics were computed; logistic regression model was run. The model fitness was checked using Hosmer and Lemeshow goodness of fit (p > 0.05). A p value of <0.2 at univariate analysis was included in the multivariable logistic regression analysis. Variables with a p value of <0.05 were statistically associated with healthcare waste management practice at 95% CI (AOR). Results A total of 418 healthcare workers who participated in the study yielded a response of 90.9%. About 65% (95% CI: 61, 70) of the total respondents had good practice of healthcare waste management. More private hospitals, 79.2% (95% CI: 73, 85), had good healthcare waste management practice compared to public hospitals, 53.5% (95% CI: 47, 60). Male healthcare workers (AOR = 6. 43, 95% CI: 1.82, 22.77) and having a functional healthcare waste management committee (AOR = 6. 47, 95%CI: 1.93, 21.76) were significantly associated with HCWMP at private hospitals. For public hospitals, having a healthcare waste management committee (AOR = 1. 80, 95% CI: 1.03, 3.15) and a manual/guideline on HCWMP (AOR = 2. 43, 95% CI: 1.20, 4.91) was significantly associated with HCWMP. Conclusions This study revealed there is a great discrepancy in HCWMP between private and public hospitals. Male healthcare workers and having a functional healthcare waste management committee and a manual/guideline were the identified factors of HCWMP.


Background
Healthcare facilities are one of the significant sectors that have been showing improvement throughout the world during recent decades [1]. However, healthcare activities can lead to the generation of various types of waste that may have adverse effects on human health and on the environment [2].
Healthcare wastes are wastes produced by health service delivering facilities and laboratories [3]. ese wastes are sharps, nonsharps, blood, body parts, chemicals, pharmaceuticals, medical devices, and radioactive materials [4]. Most of these are toxic, harmful, carcinogenic, and infectious materials [5,6].
Healthcare wastes account for around 1-2% of urban wastes, which is a critical public health issue as they jeopardize human and environmental health [7]. Even though the current medical waste management practices vary from hospital to hospital, the awkward areas are similar to all health service delivering facilities [8]. Healthcare waste management survey in 22 developing countries revealed that the proportion of healthcare facilities that used inappropriate waste disposal method varies from 18% to 64% [9].
Proper healthcare waste management practice can prevent transmission of infectious diseases, environmental pollution, unpleasant smells, multiplication of insects, rodents, and worms [6,17,21]. However, healthcare waste management has not received enough attention in recent decades in economically developing countries [22]. Many findings in developing countries on healthcare wastes management revealed that segregation, collection, and storage of waste in isolated area were not satisfactory [18]; furthermore, healthcare wastes originating from healthcare facility dumped either into their backyard in a simple pit or put in open garbage to bins on the roads [23][24][25][26].
In Ethiopia, nowadays, healthcare facilities are becoming greater than ever to address the basic health needs of the community and to achieve the sustainable development goals (SDG). A few studies in Ethiopia revealed that there was no waste segregation in most studied healthcare facilities. But, they were stored, transported, treated, and disposed wrongly [26,27]. e proper healthcare waste management practice thought the best strategy to halt the spread of the infectious disease. However, there is a scanty study of the healthcare waste management practice in Amhara region. Hence, determining the healthcare waste management level and identifying its determinants is important to understand the gap and strengthen the existing strategies.
ough the healthcare waste management practice was low in Ethiopia, there is also an unclear discrepancy between the public and private healthcare facilities. erefore, the purpose of this study was to determine and compare the healthcare waste management practice level between private and public hospitals and to identify its associated factors in Bahir Dar city hospitals.

Study Design Area and Period.
e institution-based cross-sectional study was conducted in Bahir Dar city hospitals from January 2016 to April 2017. Bahir Dar city is the capital city of Amhara National, Regional State [28], and is located about 570 km northwest of Addis Ababa. e city is bordered by Lake Tana in the north, South Gondar in the east and by West Gojjam in the south and west. e city has 9 subcities and 12 rural kebeles with a total population of 308,887 [28]. e city has one university, two referral hospitals, one district hospital, ten health centers, and two private hospitals. e number of healthcare workers in both public and private facilities is 823. e study was conducted two public hospitals (one referral and one district) and two private hospitals.

Population.
e source populations were all healthcare workers working in public and private hospitals in Bahir Dar city administration, while the study populations were selected healthcare workers in each healthcare facility working at least six months in the current hospital during the data collection period. Employed healthcare workers who are working less than six months in the current hospital were excluded.

Sample Size Determination.
e sample size was calculated using the formula for two population proportions of the healthcare waste management practice level in public hospitals which is p1 � 40% [29] and in a private hospital is p2 � 55%, with 1 : 1 ratio between private and public hospitals, power � 80%, and confidence level � 95% (1.96). e formula can be seen as follows.
Accordingly, the required total sample size was 418. By considering a 10% nonresponse rate, the final sample size was 460 healthcare workers, 230 from private and 230 from public hospitals.

Sampling Procedures.
For this study, all private and public hospitals in Bahir Dar city administration were included. Proportional to size allocation was used to select the sample from each private and public hospital and from each type of healthcare workers. e respondents were stratified by their department and profession, and then the study participants were selected from each group using systematic random sampling. e study included selected healthcare workers who were on duty at the time of the data collection period ( Figure 1).

Knowledge of Healthcare Waste Management.
Healthcare workers who had a median score or above on the assessing questions regarding the knowledge of healthcare waste management were considered having a good knowledge of healthcare waste management. Otherwise, they were considered having poor knowledge of healthcare waste management.

Healthcare Waste Management Practice.
Healthcare workers who had a mean score or above on the assessing questions regarding the healthcare waste management practice were considered having good healthcare waste management practice. Otherwise, they were considered as having poor healthcare waste management practice [30].

Data Collection
Procedure. Data were collected by using a structured interviewer-administered Amharic (indigenous language) questionnaire, which was adapted from different literature [31][32][33]. e questionnaire is comprised of sociodemographic, knowledge, and healthcare institution related characteristics. e questionnaire was developed in English and translated to Amharic and then back to English to keep the consistency. Pretest was done by 40 healthcare workers (20 from private and 20 from the public) in Bure town. A one-day training was given for four data collectors (having a bachelor in nursing) and two supervisors (having a bachelor in public health). At the end of every data collection day, the supervisors examined each questionnaire and gave pertinent feedback to the data collectors.

Data Processing and Analysis.
e collected data were checked for completeness and consistency. e data were cleaned, coded, and entered into EpiData software. Analysis was done using SPSS (version 20) software. Descriptive statistics were computed. Simple logistic regression model was used to identify the association between the explanatory variables and HCWMP. Adjusted odds ratio (AOR) with 95% CI (confidence interval) was used to measure the strength of association between explanatory variables and the HCWMP. e model fitness was checked using Hosmer and Lemeshow goodness of fit (p > 0.05). A p value <0.2 at bivariate analysis was considered for variables to be included in multivariable analysis. Backward logistic regression method was used, and variables with a p value of <0.05 at multivariable analysis were considered as statistically significant predictors of HCWMP.

Sociodemographic Information of Respondents.
A total of 418 healthcare workers who are working in the private and public hospitals participated in the study and yielded a response of 90.9%. e overall mean age of the respondents was 28.81 (±7.29) years. About 35.9% of the private hospital healthcare workers were diploma holders, while 151 (36.1%) of the public hospital healthcare workers were degree graduate. More than one-third, 67 (34.9%), of the private hospital healthcare workers and majority of the public hospital healthcare workers, 123 (54.4%), were nurses. e majority of the private hospitals, 119 (62%), and public hospitals, 136 (60.2%), healthcare workers had a work experience of less than five years. More than two-thirds, 130 (67.7%), of the respondents were from GAMBY hospital, and more than three-fourth (85%) of the respondents were from Felegehiwot referral hospital (Table 1). e study showed that 83 (43.2%) of private hospital and 100 (44.2%) of public hospital healthcare workers had training for the healthcare waste management, respectively. 161 (83.9%) of private hospital and 179 (79.2%) of public hospital healthcare workers had responded as there are the rules and regulations regarding healthcare waste management in their hospital. 133 (69.3%) of private hospital and 140 (61.9%) of public hospital healthcare workers had healthcare waste management team/committee (Table 2).
When assessing the knowledge level of healthcare workers regarding healthcare waste management practice using the composite index, 321 (72.2%) of healthcare workers had good knowledge of healthcare waste management practice. 147 (76.6%) of healthcare workers from private hospitals and 155 (68.6%) from public hospitals had good knowledge of the healthcare waste management (Table 3). e overall good healthcare waste management practice was 65.3% (95% CI: 61, 70). More private healthcare workers, 79.2% (95% CI: 73, 85), had good healthcare waste management practice than public healthcare workers, 53.5% (95% CI: 47, 60), respectively ( Figure 2).

Factors Associated with Healthcare Waste Management in
Bahir Dar City Hospitals. Multivariable logistic regression analysis was conducted to identify independent predictors of healthcare waste management practice of Bahir Dar city hospitals. On univariate logistic regression model ownership of the hospital, having legislation/regulation in the hospital, reporting system related to waste handling injury/accident, healthcare waste management committee, good knowledge of healthcare waste management, and guideline/ manual regarding the healthcare waste management was associated with healthcare waste management practice at p-value of less than 0.2. However, in the multivariable logistic regression, healthcare facility ownership and having a healthcare waste management committee and a manual/guideline related to waste handling were significantly associated with healthcare waste management practice at p value of less than 0.05.    Accordingly, for healthcare workers working in a private hospital, the odds ratio of healthcare waste management practice was about two (AOR � 2.89, 95% CI: 1.85, 4.51) times higher compared to those working in public hospitals. Similarly, for healthcare workers who had a committee of healthcare waste management, the odds ratio of healthcare   (Table 4). Multivariable logistic regression analysis was conducted to identify independent predictors of healthcare waste management practice of Bahir Dar city private hospitals. In the univariate logistic regression, sex, having a healthcare waste management committee, functional healthcare waste management committee, reporting system related to waste handling injury/accident, and HCWMP included in the job description were associated with healthcare waste management practice at p-value of less than 0.2. However, in the multivariable logistic regression, only sex and having a functional healthcare waste management committee were significantly associated with healthcare waste management practice at p-value of less than 0.05.
For male healthcare workers working in a private hospital, the odds ratio of healthcare waste management practice was about six (AOR � 6.43, 95% CI: 1.82, 22.77) times higher compared to female healthcare workers. Similarly, for healthcare workers who have functional healthcare waste management committee, the odds ratio of healthcare waste management practice was about six (AOR � 6.47, 95% CI: 1.93, 21.76) times higher compared to those who did not have one (Table 5).
Multivariable logistic regression analysis was conducted to identify independent predictors of healthcare waste management practice of Bahir Dar city private hospitals. In the univariate logistic regression, sex, having rules and regulation/legislation on HCWM, a manual/guideline related to waste handling, and a healthcare waste management committee, and HCWMP included in the job description were associated with healthcare waste management practice at p-value of less than 0.2. However, in the multivariable logistic regression, only having a manual/guideline related to waste handling and healthcare waste management   committee were significantly associated with healthcare waste management practice at p-value of less than 0.05. Accordingly, for healthcare workers who had healthcare waste management committee, the odds ratio of healthcare waste management practice was about two (AOR � 1.80, 95%CI: 1.03, 3.15) times higher compared to those who did not have one. Similarly, for healthcare workers who have a manual/guideline related to waste handling, the odds ratio of healthcare waste management practice was about two (AOR � 2.43, 95%CI: 1.20, 4.91) times higher compared to those who did not have one (Table 6).

Discussion
e World Health Organization has organized a healthcare waste management guideline to warrant safe healthcare waste management. Furthermore, a Quality and Standard Authority of Ethiopia (in 2004) and the Federal Ministry of Health of Ethiopia (in 1997) had also prepared a guideline on healthcare waste handling and disposal within healthcare facilities [34].
is study determined the level of healthcare waste management practices among private and public hospitals and identified the associated factors in the Bahir Dar city. More private hospitals (79.2%) had a good healthcare waste management practice than public hospitals (53.5%). Male healthcare workers, having a functional healthcare waste management committee in private hospitals, and availability of healthcare waste management manual/guideline and committee in public hospitals were significantly associated with healthcare waste management practice. e current study revealed that 79.2% (95% CI: 73, 85) of private hospitals had good healthcare waste management practice. e result of this study was higher than other studies on private hospitals in Addis Ababa, Ethiopia (40.48%) [35], Bahawalpur City, Pakistan (41.6%) [36], and Nigeria (62%) [37]. e possible justification for this discrepancy could be the variation of the study time. e former study was carried out recently, where the healthcare management practice is improving due to the increased awareness and attitude of the healthcare workers via IEC (behavioral change communication). e other possible justification for this variation could be using different healthcare waste management practice assessing tools across different studies. e study also determined the healthcare waste management practice of public hospitals, which was 53.5% (95% CI: 47, 60). is finding was consistent with the findings of other studies on public hospitals in Addis Ababa 57.37% [38] (59.22%) [35] and Bangladesh (54%) [39]. However, the result of this study was lower than other studies done in Bahawalpur City, Pakistan (66.6%) [36] and Nigeria (98.4%) [40].
is might be due to the difference in healthcare system/policy and the healthcare planners towards the healthcare waste management practice. is finding might also be justified as a result of the ignorance of the healthcare workers regarding healthcare waste management practice.
In contrast, the result of the current study was higher than other studies on Adama Hospital, Ethiopia, 34.9% [41],   [42,43], Nigeria, 42.1% [44], Burundi, 29.5% [45], and Bangladesh, 36.03% [46]. e possible reason for this variation could be the difference in the study period, study area, and sample size used. e current study also identified various factors associated with healthcare waste management practices. Ownership of the hospital was also correlated with healthcare management practices. Healthcare workers working at private hospitals were more likely to be having good healthcare waste management practice than public hospital healthcare workers. is could be explained by the tendency that the private hospitals are more business-oriented and they need to attract the attention of the clients or patients with their clear and neat compound. ey are also supposed to engage in the free market and should have the current standard equipment and this might allow good practice of healthcare waste management. Also, in the private hospitals, the community might expect safer and infection-free services as a result, and this might help them to best practice healthcare waste management.
is study has revealed that hospitals which had a healthcare waste management committee and manual/ guideline related to healthcare waste handling had about 2fold good healthcare waste management practice compared to those which did not have any.
is finding was also observed in this study of public hospitals. is could be due to the fact that hospitals staff was advised on the importance of healthcare waste management practice by the committee members or by reading the manuals/guidelines of the healthcare waste management protocol.
Male sex was one of the explanatory variables statistically associated with good healthcare waste management practice at the private health facility, but not in the public health facilities.
e other significant predictor of healthcare waste management practice in private hospitals was having a functional healthcare waste management committee. Privately owned hospitals, which had functional healthcare waste management committee, were correlated with good healthcare waste management practices. However, no correlation was found at public hospitals. is might be due to the fact that healthcare workers in private hospitals have strict follow-up and supervision and evaluation programs, which in fact allow the formed committee to be well functional in practicing healthcare waste management, and as a result, private hospitals could have a better experience of healthcare waste management practice.

Strength and Limitation of the Study.
Even though this study has provided valuable evidence regarding the level of healthcare waste management practice and the possible associated factors, it could not avoid the chicken-egg dilemma.
ere was also a challenge of having standard measuring cut-points for healthcare waste management practice. It was also difficult to collect the previously published articles related to healthcare waste management to make comparisons, particularly, in the currently identified predictors.

Conclusion
e study revealed that there was a great discrepancy between private and public hospitals in healthcare waste management practice. More private hospitals, 79.2% (95% CI: 73, 85), had a good healthcare waste management practice compared to public hospitals, 53.5% (95%CI: 47, 60). Male healthcare workers and having functional healthcare waste management committee were significantly associated with healthcare waste management practice in private hospitals, whereas having a healthcare waste management committee and a manual/guideline on healthcare waste management was significantly associated with healthcare waste management practice in public hospitals.

Recommendations.
e Amhara Regional Health Bureau should do the following: (1) Focus on strategies regarding the healthcare waste management committee establishment in each hospital and the provision of enough healthcare waste management related manuals/guidelines to the hospitals (2) Organize short-term training and an orientation program on healthcare waste management for their staff e private hospitals should do the following: (1) Share their best experiences on how they are practicing the healthcare waste management with the public hospitals (2) Train the public hospital healthcare workers on how the healthcare waste management committee is functioning (3) Train their female healthcare workers to have a better healthcare waste management practice