BAHIRDAR UNIVERSITY

COLLAGE OF AGRICULTURE AND ENVIRONMENTAL SCIENCE

Departement of Natural Resource Management

Assessment of Biomedical Waste Management Practice and Factors that affect it on Private and
Public Hospitals, in Bahirdar city

Research proposal submitted by: Sefiager Assefa ID, No_BDU 1401322

Advisor: Melese G. (PhD)

A Research Proposal to be Submitted to Bahirdar University, College of Agriculture and

Environmental Science; Department of Natural Resource Management in Partial Fulfillment of
the Requirements for the Degree of Master in Environment and Climate Change

Bahir Dar University, Ethiopia

November, 2022
 TABLE OF CONTENTS

Contents Pages

LIST OF FIGURE...........................................................................................................................................iii
LIST OF TABLE........................................................................................................................................iii
CHAPTER ONE..........................................................................................................................................1
1. INTRODUCTION..............................................................................................................................1
1.1 BACKGROUND...........................................................................................................................1
1.2 Statement of the problem...............................................................................................................2
1.3. Significance of the study...............................................................................................................4
1.4. Objectives of the study.................................................................................................................4
1.5. Research questions........................................................................................................................5
1.6. Scope and limitation of the study..................................................................................................5
1.7. Ethical considerations...................................................................................................................5
1.8. Definition of Terms......................................................................................................................6
1.9. Thesis Chapter Outline.................................................................................................................6
CHAPTER TWO.........................................................................................................................................8
RELATED LITERATURE REVIEW.....................................................................................................8
2.1. Conceptual and theoretical frameworks on BMWM.....................................................................8
2.2 Types and sources of biomedical waste.........................................................................................8
2.3 Treatment and disposal mechanisms of biomedical waste...........................................................10
2.4 Major factors that influence biomedical waste management practice..........................................12
CHAPTER THREE...................................................................................................................................14
METHODS AND MATERIALS...........................................................................................................14
3.1. Description of study area............................................................................................................14
3.2. Study design and period..............................................................................................................15
3.3 Sampling Technique and Procedure.............................................................................................15
3.4 Sample size determination...........................................................................................................16
3.6 Population....................................................................................................................................16
 3.7 Data Collection tool and technique..............................................................................................17
3.8. Data Sources...............................................................................................................................18
3.9 Data analysis and Presentation.....................................................................................................18
3.10 Data Quality Control..................................................................................................................18
3.11. Expected Outcomes..................................................................................................................19
3.12. Dissemination of the Result......................................................................................................19
3.13. Ethical Consideration................................................................................................................19
4. Work plan..............................................................................................................................................20
5. Budget Breakdown................................................................................................................................21
REFERENCES..........................................................................................................................................23
APPENDIX...............................................................................................................................................26
LIST OF FIGURE
Figure 1 Biomedical waste management mechanisms.................................Error! Bookmark not defined.
Figure 2 Study area......................................................................................Error! Bookmark not defined.

LIST OF TABLE
Table 1: Types of Biomedical waste..............................................................................................................9
Table 2: Sources of biomedical waste......................................................Error! Bookmark not defined.10
Table 3: Work plan.....................................................................................................................................21
Table 4: Budget breakdown-----------------------------------------------------------------------------------------------------------22
CHAPTER ONE
1. INTRODUCTION
1.1. BACKGROUND
Healthcare facilities are one of the significant sectors that have been showing improvement
throughout the world during recent decades. 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(Assemu et al., 2020). Hospitals, clinics, research centers and health care centers use
wide variety of drugs including antibiotics, radioactive substances, corrosive chemicals, which
ultimately contribute in Bio medical waste(Tiwari, 2014). Biomedical waste is a relevant
problem for several countries and poses serious public health threats worldwide. Nearly 3.2
million tons of biomedical waste is generated by hospitals alone annually and the Environmental
Protection Agency (EPA.2019) estimates that 10% to 15% of all biomedical waste is potentially
hazardous (Mitiku et al., 2022).

Currently, there are several terms used to explain the waste generated from the HCFs such as;
health facility waste, clinical waste, healthcare waste, medical waste, and biomedical waste.
However, healthcare waste (HCW) is most frequently used by the articles published so far(Yazie
et al., 2019). According to the World Health Organization (WHO), nearly 85% of waste
generated by the hospitals is general waste and about 15% of waste is biomedical waste,
composed of 10% of infectious wastes and 5% of non-infectious wastes like radioactive and
chemical wastes. In developing countries, especially in Africa, BMW has not received the
attention it deserves(Mitiku et al., 2022). Improper management of infectious waste is associated
with various occupational infections and injuries. Among healthcare workers, waste handlers
have the highest incidence of exposure to biomedical waste. Improper healthcare waste
management is responsible for the transmission of more than 30 dangerous blood borne
pathogens(Theogene Uwizeyimana et al., 2021).

In the Ethiopian context, there was no separate regulation specific for the HCFs to enforce them
for the proper management of the hazardous waste. Though currently they are not updated and
lacked proper compliance on their implementation(Yazie et al., 2019). Limited knowledge
toward handling healthcare waste is a major cause for improper handling of healthcare
waste(Chercos et al., 2018). The healthcare facilities have treated sick people but there was little
awareness about the fact that hospitals generate a lot of hazardous bio-medical waste, which had
been disposed without proper guidelines. Lately, it has been a proven thing that bio-medical-
waste is a potential hazard for heath-personals, and environment. Therefore, it must be disposed
in a proper manner(Behnam et al., 2020).

According to (Pasupathi et al., 2011), sources of biomedical waste are as a result of diagnosis,
treatment or immunization of patients and associated biomedical research. Biomedical waste
(BMW) is generated in hospitals, research institutions, health care teaching institutes, clinics,
laboratories, blood banks, animal houses and veterinary institutes. Although very little disease
transmission from medical waste has been documented, both the American Dental Association
(ADA) and Center for Disease Control recommend that medical waste disposal must be carried
out in accordance with regulation. The amount of biomedical waste being generated in our
country is increasing day to day. As there is a significant expansion of the health care facilities in
our country, the amount of biomedical waste being generated is also increasing . Health care
workers in our country are still not fully aware about proper BMW handling and disposal, though
increasing global awareness on it(Rao et al., 2018).

According to BMW Rules the proper management of Hospital/Healthcare/Biomedical waste has

become a topic of enormous concern having global implications and attention. It is of course
well known and documented that hospital waste is a potential health hazard to the health care
workers, public, flora and fauna of the area. Hence, Biomedical waste must be properly managed
and disposed-off to protect the environment, general public and workers, especially healthcare
and sanitation workers who are at risk of exposure to biomedical waste as an occupational
hazard(Njiru et al., 2013). The appropriate biomedical waste management (BMWM) process
includes vital steps (segregation, storage, transportation, treatment, and disposal), which requires
special attention. The World Health Organization has prepared a BMWM guideline to ensure
safe management of the wastes from the HCFs(Knowledge et al., 2020).

Systematic planning to improve hospital waste management in each country requires

implementation of a comprehensive plan of the current status of waste(Hasan & Rahman, 2018).
According to the WHO 2018 report, the biomedical waste generation rate in low-income
countries was 0.2kg of hazardous waste per hospital bed per day(Lemma et al., 2021). However,
the Biomedical waste generation rates vary across different hospitals in Ethiopia where the
generation rate ranges from (0.164–1.94) kg/bed/ day, and (0.396–0.866) kg/bed day
(0.92kg/bed/day and/or 0.75kg/) patient/day hazardous waste. Health facilities in Ethiopia have
chosen incineration to treat BMW but 80% of hospital incinerators used low-temperature
``technology that generates air pollutants(Lemma et al., 2021).

1.2 Statement of the problem

Health care waste is a unique category of waste by the quality of its composition, source of
generation, its hazardous nature and the need for appropriate protection during handling,
treatment and disposal(Dey & Das, 2020). Hospitals, clinics, research centers and health care
centers use wide variety of drugs including antibiotics, radioactive substances, corrosive
chemicals, which ultimately contribute in Bio medical waste. Mismanagement of the waste
affects not only the generators, operators but also the common people too. HCW is an
environmental as well as public health issue that attracts attention in both industrialized and
developing countries. It can not only impair the quality of life of the community, but can also
affect the welfare of the entire population and the national economy(Tiwari, 2014).

Assessment studies on medical waste management in developing countries show the same
problems in the management of medical waste in health care facilities such as the handling and
storage process is not done properly(Wulansari & Muhammad, 2020). Health care workers in
our country are still not fully aware about proper BMW handling and disposal, despite increasing
global awareness on it(Rao et al., 2018). Management of healthcare waste is becoming an issue
of growing concern particularly in urban areas. The blood and other body fluid, placentas, used
syringes and scalpel blades are randomly dumped in the general waste landfill sites and rarely to
rivers from health institutions so that to confirm the fact that healthcare wastes are being
mismanaged and it is also an indication that there is urgent and critical need for the proper
disposal of healthcare waste(Mmereki et al., 2017).

On the other way according to BMW Rules the proper management of Hospital/Healthcare/
Biomedical waste has become a topic of enormous concern having global implications and
attention. It is of course well known and documented that hospital waste is a potential health
hazard to the health care workers, public, flora and fauna of the area. Hence, Biomedical waste
must be properly managed and disposed-off to protect the environment, general public and
workers, especially healthcare and sanitation workers who are at risk of exposure to biomedical
waste as an occupational hazard(Njiru et al., 2013). Appropriate biomedical waste management
has become a prime concern worldwide as it may affect environment and living organisms up to
a great extent. The problem has been increased many folds because of unexpected generations of
hazardous biomedical waste which needs extraordinary attentions(Kanwar et al., 2022).

Health care institutions in recent times have increased tremendously in number, capacity and
specialty with increasing health care services and number of hospital beds. As there is a
significant expansion of the health care facilities in our country, the amount of biomedical waste
being generated is also increasing(Rao et al., 2018). Total of medical waste generation from
health care activities increased every year(Wulansari & Muhammad, 2020). Most of the health
institutions and hospitals are concentrating around the specially cities. These increasing
healthcare institutions results in increasing load of medical waste generation, because of the
increased consumption of disposable materials as a result of the spreading trend of (HIV/ ADIS),
Hepatitis B Virus (HBV) and other agents associated with blood borne diseases including Ebola
and COVID-19 (Kanwar et al., 2022).

In Ethiopia, there are not many studies that show the current practices of HCWM. The few
studies available are based on observation and are descriptive in nature. There is not sufficient
recorded information on HCW management methods, quantity of HCW generation and
technologies or infrastructures for treatment or disposal and this fact hinders the planning,
implementation for better management of HCW. Lack of onsite segregation practices, proper
disposing system, and in general carelessness and least attention given on scientific medical
waste management practice by healthcare facilities.

In addition, in local situation of Ethiopia, especially Bahirdar city, legislations and regulations
concerning HCWM that are ratified were remained on paper and yet not implemented as
expected more from the respective bodies: poor monitoring, supervision and enforcement of the
laws. So, it is necessary for Ethiopia to examine such HCWM in broader perspectives from
generation to collection, storage, transportation, treatment and disposal. The management of
medical waste therefore, should be of major concern due to potentially high risks to human
health and the environment context of healthy medical facility decrease the number of health-
care settings associated infections.
Safety is an important element of quality system essentials and studies in the area of BMWM
have been wide internationally. Reliable evidences showed that BMWM across Ethiopian health
institutions are still inadequate (Azage and Kumie, 2010). Studies conducted did not specifically
report their result among professional categories of HCWs to establish specific strategy to
mitigate issues related mismanagement of BMWs. The current study aimed at filling these gaps
and will help to different organizations, stakeholders and policy makers to correct and improve
the existing situation of Healthcare waste legislation and enforcement.

Therefore, assessing the practice of biomedical waste management and its associated factors that
affect it is the critical element to break/stop this problem. Even though, there were studies related
to the practice of biomedical waste management in private and government hospitals, in the best
of my knowledge, there is the limitation of studies related to the practice of biomedical waste
management practices. So, this study is planned to investigate the practice of biomedical waste
management and the factors that affect it in private and public hospitals of Bahirdar city,
Northwest Ethiopia.

1.3. Significance of the study

Addressing biomedical wastes situation in healthcare facilities is big worth for farther
management practices. In line with this concept, the findings from the study will benefit
healthcare facilities to identify the level of BMWM practice among healthcare workers and
factors contributing to noncompliance with waste management guidelines. So that the health care
facilities could design targeted interventions to ensure the safety of the patient it serves, its staff
and other clients. The study also provides information for policy makers, hospital administrators
and stakeholders about existing situations of BMWM to plan measures to mitigate improper
waste management. In addition, it will be helpful in providing information as base line for future
studies either in public or private health institutions.

1.4. Objectives of the study

1.4.1. General objective

General objective of the study is biomedical waste management practices and the factors that
affect it in Bahirdar city, Northwest Ethiopia
1.4.2. Specific objectives
This study contains three specific research objectives. Among these, the following may be
considered to be the primary objectives.

More specifically, the study aimed to:

 Assess types and sources of biomedical waste

 Investigate the treatment and disposal mechanisms of biomedical waste

 Identify the existing major factors that influence biomedical waste management practice

1.5. Research questions

1. What are the types and major sources of BMW in the study area?

2. Which type of treatment and disposal mechanisms used by healthcare workers and waste
collectors?

3. What are the existing factors that affect the management practices in the study area?

1.6. Scope and limitation of the study

The study has spatial, temporal and analytical scopes. Spatially this study was limited and
undertaken in Ethiopia, Amhara Region, Bahirdar city. The study has a cross-sectional study will
considering two time data collection through semi-structured questionnaires and observational
check-list, and secondary data sources. The study encompasses zone level; the extent of the
research is limit to an area. The data collection for the study will be conducted in different
departments of private and public hospital in Bahirdar city. The data will have a cross sectional
data including the types and sources; the management practices; and the factors that affect
management practices of biomedical waste. The study will examine the existing factors that
influence the management systems. Although, this study will not be free from limitations,
specifically arising from data collection problems like, unwillingness of some respondents in
supplying the right data. The most serious problem may face might be lack of accurate, reliable,
tangible, updated and consistent data and also the absence of trained data collector and
cooperativeness or encouragement of stakeholders in the hospital/city.

1.7. Ethical considerations

Ethical clearance will be obtained from the ethical review board of Bahir Dar University. Before
starting data collection, the participants will read the objective, benefits, and risks of the study to
get informed verbal consent of participants. The right of the respondent to withdraw from the
interview or not to participate will be respected. To keep the confidentiality of any information
provided by study participants. There are a number of key phrases that describe the system of
ethical protections that the existing social and medical research establishments have created to
try to protect better the rights of their research participants. The principle of voluntary
participation requires that people not be forced into participating in research. In my investigation
related to biomedical waste management, ethical consideration/confidentiality needs a care,
because it integrates human elements which need high care for them. Regarding this fact the
study will be planned to get the agreement key formant interviews and field observations. First
about the objectives and the end results of the research somehow sufficiently need information.

1.8. Definition of Terms

Biomedical waste, medical waste, healthcare waste, and hospital waste: are terms that have
been used interchangeably. However, healthcare waste has been more frequently used by
published articles so far(Mitiku et al., 2022)(Yazie et al., 2019).

Waste segregation: Systematic separation of wastes generated from the HCFs according to their
type (non-infectious, infectious and sharps) using color-coded containers for specific treatment
and disposal requirements.

Color-coding: A system for relating the contents of waste containers by using different colors.

Biohazard symbols: A symbol that is universally recognized as a warning against substances

that poses a threat to human health.

Waste disposal: Waste disposal is the final placement of treated wastes using environmentally
acceptable methods of final storage (burial, deposit, discharge, dumping, placing or release of
any waste into or onto the environment) appropriate to national requirements.

1.9. Thesis Chapter Outline

The research report will be organized into five chapters. Chapter one is concerned with the
preliminary section of the study including: introduction, problem statement, objectives, research
questions, significance of the study, scope and limitation of the study, and operational definition
of terms. Following this is review of past works (theoretical contexts and empirical evidences)
on issues related to biomedical waste management practices and the factors that affect it and
literature gaps. Chapter three deals with research methodology including research design,
sampling and methods of data analysis and description of the study area which discuses about
physical, socio economic aspects, population and social structure and tools of data collection.
Result and Discussion will be presented under the fourth chapter. Based on the objectives of the
study, summary, conclusion and recommendations will present in chapter five.

CHAPTER TWO
RELATED LITERATURE REVIEW
2.1. Conceptual and theoretical frameworks on BMWM
Biomedical waste (BMW) is any waste that is generated during the diagnosis, treatment, or
immunization of human beings or animals or from research activities, and contains potentially
harmful microorganisms which will infect hospital communities and the general public.(Mitiku
et al., 2022) BMW includes sharps, non-sharps, blood, body parts, chemicals, pharmaceuticals,
medical devices, and radioactive materials. Common sources of biomedical waste include
hospitals, nursing homes, clinics, laboratories, offices of physicians, dental, and veterinarians,
home health care, and funeral homes. BMWs are considered because they represent the second
hazardous waste globally after radiation waste (Mitiku et al., 2022).

Biomedical waste handling is a hazardous activity that requires a high standard of training and
skill. It calls for specific training that depends on the nature of the work in the service delivery
unit, the hazards and possibility of worker exposure, and the responsibilities of individual
workers(Derso et al., 2018). During the healthcare delivery process, hazardous wastes can be
generated from the health facilities. Improper healthcare waste management is responsible for
the transmission of more than 30 dangerous blood borne pathogens(Yazie et al., 2019). Hospital
waste management is a serious issue because of its intrinsic toxic and infectious nature;
therefore, mismanagement or unsafe disposal of hospital wastes poses risks to all front-line
workers.

Waste management is defined as the action starting from the collection from source, sorting,
storing, transporting and treating the waste from the activity. The purpose of waste management
is to reduce the volume, concentration and hazard of waste through physical, chemical or
biological processes. However, efforts to reduce or reduce waste are efforts that must be carried
out first because they are preventive and provide benefits in the form of cost efficiency of waste
management. Assessment studies on medical waste management in developing countries show
the same problems in the management of medical waste in health care facilities such as the
handling and storage process is not done properly(Wulansari & Muhammad, 2020). The
management of healthcare waste requires increased attention and diligence to avoid the
substantial disease burden associated with poor practice, including exposure to infectious agents
and toxic substances. Medical waste may contain highly toxic chemicals and can present a
mechanism for transmission of diseases. The growth of the medical sector around the world over
the last decade combined with an increase in the use of disposable medical products has
contributed to the large amount of medical waste being generated(Demissie & Science, 2017).
Improper healthcare waste management might lead to the pollution and contamination of soil,
air, and surface and groundwater (Behnam et al., 2020). Appropriate biomedical waste
management has become a prime concern worldwide as it may affect environment and living
organisms up to a great extent. The problem has been increased many folds because of
unexpected generations of hazardous biomedical waste which needs extraordinary
attentions(Kanwar et al., 2022).

2.2 Types and sources of biomedical waste

2.2.1 Types of biomedical waste

According to bio-medical waste (management and handling) rules, 1998 types of biomedical
waste are as follows:

Human Anatomical Waste (human tissues, organs, body parts)

Animal Waste (animal tissues, organs, body parts carcasses, bleeding parts, fluid, blood and
experimental animals used in research, waste generated by veterinary hospitals colleges,
discharge from hospitals, animal houses)

Microbiology & Biotechnology Waste (wastes from laboratory cultures, stocks or specimens of
microorganisms live or attenuated vaccines, human and animal cell culture used in research and
infectious agents from research and industrial laboratories, wastes from production of biological,
toxins, dishes and devices used for transfer of cultures)
Waste sharps (needles, syringes, scalpels, blades, glass, etc. that may cause puncture and cuts.
This includes both used and unused sharps)

Discarded Medicines and Cytotoxic drugs (wastes comprising of outdated, contaminated and
discarded medicines

Solid Waste (Items contaminated with blood, and body fluids including cotton, dressings, soiled
plaster casts, lines, beddings, other material contaminated with blood)

Liquid Waste (waste generated from laboratory and washing, cleaning, housekeeping and
disinfecting activities)

Incineration Ash (ash from incineration of any bio-medical waste)

Chemical Waste (chemicals used in production of biological, chemicals used in disinfection, as

insecticides, etc.)

Table 1: Types of Biomedical waste

No. Types of biomedical waste

1 Human Anatomical Waste
2 Animal Waste
3 Microbiology & Biotechnology Waste
4 Waste sharps
5 Discarded Medicines and Cytotoxic drugs
6 Solid Waste
7 Liquid Waste
8 Incineration Ash
9 Chemical Waste
Source: (Kanwar et al., 2022).

2.2.2 Major sources of biomedical waste

At sources, it is categorized into five major categories:

 Sharps,
 Pathological waste,
  Chemical waste,
 Pharmaceutical waste and
 Radioactive wastes.

Generation sources of BMW

Table 2: Sources of biomedical waste

Primary sources Secondary sources

Hospital Medical collage Clinic
Nursing home Immunization center Ambulance service
Dispensaries Animal research center Home treatment
Maternity home Blood bank Slaughter homes
Dialysis center Industries Funeral service
Research lab Educational institutions
Source: (Sachan & Chaurasia, 2006)

2.3 Treatment and disposal mechanisms of biomedical waste

The main concerning points in the management mechanisms are that, the management
component of HCW depends on good governance as one of the main strategic factors that need
consideration for the success of raising the standard of HCW management in HCFs. The others
are institutional arrangements which include framing of appropriate HCWM policies, laws,
regulations, guidelines, standards and enabling instruments. Other factors suggested includes
clear cut roles and responsibilities, capacity building through knowledge sharing, enabling policy
framework addressing economic and market-based instruments, facilitation or providing accurate
and timely information to all stakeholders and financing which is considered a fundamental
issue.(Hasan & Rahman, 2018).

Acceptable management of biomedical waste management begins from the initial stage of
generation of waste, segregation at the source, storage at the site, disinfection, and transfer to the
terminal disposal site plays a critical role in the disposal of waste(Provisions, 2017)(Sharma &
Deori, 2020). The segregation of this waste is a foremost step of biomedical waste management
which reduces the quantity of hazardous waste requiring special treatments(Behnam et al., 2020)
(Verma et al., 2020). Medical waste should be managed according to its type and characteristics.
For waste management to be effective, the waste should be managed at every step, from
acquisition to disposal(Biomedical Waste Management Hegde V, Kulkarni RD, Ajantha GS - J
Oral Maxillofac Pathol, n.d.)

Steps involved in Bio-medical Waste Management

According to(CPCB, 2016) the first five steps (Segregation, Collection, pre-treatment,
Transportation and Storage) is the exclusive responsibility of Health Care Facility. While
Treatment and Disposal is primarily responsibility of CBWTF operator except for lab and highly
infectious waste, which is required to be pre-treated by the HCF. The responsibilities of HCF for
management and handling of bio-medical waste:

1. Biomedical Waste should be segregated at the point of generation by the person who is
generating the waste in designated color coded bin/ container.

2. Biomedical Waste & General Waste shall not be mixed. Storage time of waste should be as
less as possible so that waste storage, transportation and disposal are done within 48 hours.

3. Phase out use of chlorinated plastic bags (excluding blood bags) and gloves by 27/3/2019.

4. No secondary handling or pilferage of waste shall be done at healthcare facility. If CBWTF

facility is available at a distance of 75 km from the HCF, bio-medical waste should be treated
and disposed only through such CBWTF operator.

5. Only Laboratory and Highly infectious waste shall be pre-treated onsite before sending for
final treatment or disposal through a CBWTF Operator.

6. Provide bar-code labels on all color coded bags or containers containing segregated bio-
medical waste before such waste goes for final disposal through a CBWTF.
Figure 1: Biomedical waste management mechanisms

Source: (Hasan & Rahman, 2018)(Ojha et al., 2022)

2.4 The existing major factors that influence biomedical waste management practice
The healthcare facilities have treated sick people but there was little awareness about the fact that
hospitals generate a lot of hazardous bio-medical waste, which had been disposed without proper
guidelines. Lately, it has been a proven thing that bio-medical-waste is a potential hazard for
heath-personals, and environment. Therefore, it must be disposed in a proper manner (Behnam et
al., 2020). The cost and complexity of medical waste management has been aggravated by lack
of public awareness, weak legislation, indifferent attitude of hospital operators and lack of
financing(Zafar, n.d.). Lack of training, awareness, staff resistance, managerial poor
commitment, lack of adequate resources, negligence, and unfavorable attitude of the healthcare
staff were the main potential challenges in Ethiopia(Yazie et al., 2019). According to (CPCB,
2016)(David et al., 2014) Health-care waste is labeled as hazardous because of the serious direct
threat it poses to human health, the situation of poor MWM is still common in developing
countries like Africa. Generally,

 lack of awareness about health hazards,

 poor management practice,
 insufficient financial and human resources and
 Poor controls of waste disposal are the most common problems connected with MWM in
developing countries like Africa.

In addition to this, according to (Demissie & Science, 2017) the major factors that affect
BMWM systems are as follows:

 Lack of awareness about health hazards of healthcare waste,

 Inadequate training,
 Absence of waste management and disposal systems,
 Insufficient financial and human resources,
 Low priority given to the topic and
 Lack of awareness about legislative act; are the most common problems connected with
healthcare waste management.

Therefore, efforts have to be exerted on creating awareness about internationally ratified

conventions, the existing related laws and the regulations of healthcare waste management that
are produced in regional and national level.

Safe and effective management of waste is not only a legal necessity but also a social
responsibility. Lack of concern, motivation, awareness and cost factor are some of the problems
faced in the proper hospital waste management(Biomedical Waste Management Hegde V,
Kulkarni RD, Ajantha GS - J Oral Maxillofac Pathol, n.d.).
CHAPTER THREE

METHODS AND MATERIALS

3.1. Description of study area
The study will be conducted at health facilities in Bahir Dar city. Bahir Dar is the capital city of
the Amhara National Regional State in the Federal Democratic Republic of Ethiopia. Bahir Dar
is located at the exit of the Abbay from Lake Tana at an altitude of 1,820 metres (5,970 ft) above
sea level. The city is located approximately 578 km north-northwest of Addis Ababa. The city is
bordered by Lake Tana in the north, South Gondar in the east and by West Gojjam in the south
and west. The study will conducted one public and one private hospital. According to the
Amhara Bureau of Finance and Economic Development (BOFED), the population of Bahir Dar
city is estimated to be 390,429 persons with Population density of Bahir Dar is 13,943.89
persons/[Link]². The city population data is collected from official population sources and
publicly available information resources. It has one specialized, one referral and one primary
government hospitals (Tibebe Giwon, Felege Hiwot, and Adiss Alem respectively), 11 health
centers (including one private health center), 10 health posts and one family guidance association
clinic, 4 private general hospital, and 35 medium private clinics.

Geographical location

Bahir Dar town is located in the Northwestern Ethiopia at a physical distance, latitudinal
and longitudinal coordinates of 11035’ 30’’N and 370 23’E, respectively.-
Figure 2: Map of study area

3.2. Study design and period

Institutional based cross-sectional study will be conducted from October to November 2022 in
Bahirdar city. This study will employ a descriptive survey research strategy and both quantitative
and qualitative research approach will be employed. Because, the combination of the two
research approach gives better interpretation as the information missed by one might be captured
by the other and thus an better and integrated result may emerge from the analysis. The
quantitative data will be employed by closed ended questions, while qualitative data will be
employed in open-ended questions, observation.

3.3. Sampling Technique and Procedure

The sampling techniques of this research will be used both random and non-random sampling
techniques. One private and one public hospital will be selected by simple random sampling
techniques. Thereafter, stratified sampling technique will be used to make a stratum for different
professionals, and a separate sample was taken by proportion to allocate the professionals based
on their numbers independently from each stratum by systematic random sampling technique to
select study subjects among health care professionals who are working at the selected private and
public hospitals.

For this study, all private and public hospitals in Bahir Dar city will be included. The
respondents were stratified by their department and profession, and then the study participants
will select from each group using systematic random sampling. Proportional to size allocation
will be used to select the sample from each private and public hospital and from each types of
department. The study will be included the selected healthcare workers who on duty at the time
of the data collection period.

3.4. Sample size determination

The sample size will be calculated using Yamane formula for the healthcare waste management
practice level, which is p1 = 40% and p2 = 55%, with 1:1 ratio between public and private
hospitals respectively, at confidence level = 95% (1.96) and sampling error=5%.

Yamane sample size determination: n=N/1+N (e) 2

N=Total population, n= Sample size, e= sampling error and p= prevalence of good management
practice

n= n1 + n2 (where, n1= sample size of public hospital, at p 1=40% and n2=sample size of private
hospital p2=55%.

Total sample size (n) = n1 + n2= N1/1+N1 (e) 2+N2/1+N2 (e) 2

N=N1+N2 (total population of public and private hospitals)

n=n1+n2 (total sample size of public and private hospitals)

e=0.05, e2= (0.05)2

3.6. Population
Target population

All populations that live in Bahirdar city.

Source population

All healthcare workers that work in randomly selected private and public hospitals from target
population.

Study population

All stratifically selected health workers from source populations (i.e. from randomly selected
private and public hospitals).

Inclusion and exclusion criteria

Health care workers in private hospitals who were employed 6 months or longer were included
in the study. However, health care workers who were unable to communicate due to illness will
be ignored from the study.

3.7. Data Collection tool and technique

Data will be collected through interview using semi-structured questionnaire, interview and
observation via check list. Structured questionnaires, comprising of different section such as
socio-demographic characteristics, method of biomedical waste management, knowledge
towards BMW management, reuse and recycling, and factors affecting it.

Questionnaires

Best semi-structured open ended and closed ended questionnaires will be distributed to the
selected private and government hospitals. The questionnaires will be prepared in English
language and then translated into language of the respondents (Amharic). So that certain
inconveniencies and communication barriers will be avoided.

Interviews

To obtain more detail and meaningful information on the topic structured and semi-structured
interviews will be held with selected hospitals including the manager and guards. This intended
to get further information related to challenges associated with biomedical waste management
activities in the city.

Observation
 The study will use field observation to see the current biomedical waste disposed in open
landfills. The reason for choosing personal observation is to generate information about
observable practice and facts.

Document Analysis

Secondary data will be collected from published and unpublished written documents. This
written secondary data will be gathered from the internet, books, journal, documents and reports
obtained from different sources.

3.8. Data Sources

Primary Data Sources

Under the primary data collection the main data sources will be all randomly selected healthcare
workers including cleaner/waste handlers and food cooker from study populations.

Secondary Data Sources

Secondary data will be collected from published and unpublished literatures; previous studies
done by researchers, data from relevant bodies that have been working in related discipline in the
city.

3.9. Data analysis and Presentation

The collected data will be analyzed by using R-software, Microsoft Excel and descriptive
statistics such as frequency distribution tables, averages, percentages and ratios. These will be
later be interpreted by using tables, graphs, bar charts and pie charts. In addition to interpretation,
conceptual generalization will be used for analyzing the qualitative data.

3.10. Data Quality Control

The questionnaire was first prepared in English and later it will be translated into Amharic. The
Amharic version will be pre-tested for quality and clarity of translation. Pre-testing will also be
used to train on interviewing techniques. Data collectors will also be trained to have
understanding on the interpretation of key terms.
 3.11. Expected Outcomes

In this research the environmental impacts will be identified and assessed. In addition to this,
the economic effects of the finding will be analyzed. This entails the recommendations for the
development of environmentally friendly, economically viable and socially acceptable
conditions.

3.12. Dissemination of the Result

The product and finding of this study will be shared to end users and other community by using
different mechanisms like preparing workshop, distributing the print out copy for concerned
body, through publication, etc. In addition, the immediate dissemination of the finding will be
done for the study areas in collaboration with our university and local leaders.

3.13. Ethical Consideration

There are several reasons why it is important to adhere to ethical norms in research. It promotes
the aims of research, promotes values essential to collaborative work, ensures researchers can be
held accountable to the public, helps build public support for research, and promotes other
important moral and social values such as social responsibility, human rights, and safety (David
and Resnik, 2011).
 4. Work plan
Table 3: Work plan

No Activities to be Time of accomplishment

performed

Sep Oct Nov Dec Jan Feb Mar Apr May Jun July Au
g

1 Reviewing Literatures  
..

2 Developing and  
submitting proposals .
Secure fund and
3 discuss arrangement
with local government

4 Designing data
collection tool

5 Preparation for field

work

6 Select data collectors

7 Training for data

collectors and
supervisors

8 Pre-testing of the
survey instrument

9 Data collecting

10 Data entry and

cleaning

11 Data analyzing

12 Writing the first draft

of the paper

13 Submitting the final

paper

14 Presenting the result of

the paper
5. Budget Breakdown

Table 4: Budget breakdown

No Budget category Unit cost Multiplying Factor

Total cost

1 Car transport Cost per day No. of staff No. of days

50 15 15 750

2 Supplies Measurement Cost per item Amount

unit

Questionnaire 30 3 150 450

duplication

Printing 50 3 150 450

and binding

Grand total 1,650

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APPENDIX
Questionnaires

I. Participants’ Information Sheet

My name is Sefiager Assefa and I am MSc student in Bahir Dar University, Collage of
Agriculture and Environmental Science and Department of Natural Resource Management I am
conducting survey on the assessment of healthcare waste management practice in your hospital
in Bahirdar. The result that will come out of this study will be used by the government and the
city health office to base their rational decision to develop appropriate strategies to combat this
problem. The research is intended to benefit the hospitals including the health workers that will
be participating in this research and will introduce no risk to the participant. The interview
requires the maximum of 15 minutes to complete. The hospital is selected by random sampling
from governmental and private hospitals in the city by the researcher. Your participation is
entirely voluntarily, and you can quit from the study any time you want. You will have no
penalty if you fail to show desire to participate. I, however, do hope that you will participate in
the study since the data that will come from you will be important for us. The information we
will collect from you will completely be kept confidential and will not be disclosed to any third
person other than the people participating in this study. For any question you want to ask us, you
can use the contact address here under.

May I now begin the interview?

If yes, continue interviewing

If No, thank and stop interviewing

Name of the interviewer: -------------------------Sign: ---------- Date: ----------

Name of the supervisor: ---------------------------Sign: ----------- Date: --------

Addresses Tel: +251988012590

Email: sefiagerassefa2127@[Link]
I. Data collection Tools

Bahir Dar University Faculty of Agriculture and Environmental Science and

Department of Natural Resource Management

A. healthcare waste management observational checklist for walk through survey

assessment of the hospital Assessment date: --------------------------------

1. Name of Hospital: ------------------------------[Link]:----------------Tel: ----------

Specialty: ----------------------------------------case teams: -----------------------------

No. of beds: ------------------no. of occupied beds: -------------total no of staff---

No. of health professional staff: --------------------no of sanitarian: ---------------

No. of waste handlers: ------------------------no of catering workers: --------------

No. of laundry workers: -----------------------no of admitted patients in last year: ----

No. QUESTIONS RESPONSE

HCW Segregation and Interim storage 1. Yes 2. No

1 Is waste segregated at the point of generation? 1. Yes 2. No

2 Is general HCW collected using black bin? 1. Yes 2. No R
3 What type of container is used for sharps, needle waste? 1. Puncture proof 2.
2. Non -puncture proof
4 Are all types of bins are located in every service unit 1. Yes 2. No
convenient/accessible site for users?
5 Do all color-coded bins are clearly marked or labeled? 1. Yes 2. No
6 Is infectious HCW collected using yellow bin? 1. Yes 2. No
7 Is interim HCW storage bin with cover available? 1. Yes 2. No
8 Are HCW storage bins made from washable, leak proof 1. Yes 2. No
puncture proof, plastic or galvanized materials?
9 Is interim HCW storage bin easily cleanable 1. Yes 2. No
10 Are visual aids/ instructions present near the waste 1. Yes 2. No
 receptacles for the proper segregation
HCW Handling, Collection and Transportation

1 Does the facility have waste collection point? 1. Yes 2. No

2 Is the waste collection do with time table of the frequency of 1. Yes 2. No
collection?
3 Are HCW bins/ safety boxes securely closed or seal when ¾ 1. Yes 2. No
full respectively?
4 Are HCW bins/ safety boxes emptied and dispose 1. Yes 2. No
respectively when ¾ full?
5 Are the bins washed clean with disinfectant solution when 1. Yes 2. No
necessary?
6 Do all waste handlers wear PPE while handling 1. Yes 2. No
7 What is the equipment for on-site transport HCW? 1. cart/trolley 2. Open bin
3. Closed bin
4. other specify----
8 Does infectious HCW and non-risk HCW transported in 1. Yes 2. No
separate transportation equipment?
9 Where HCW transported on-site? 1. Municipal garbage
2. treatment facilities
3. Dug whole
4. other specify---
10 Is HCW stored on site for more than a few days before final 1. Yes 2. No
disposal?
11 If yes how long? -------------------------------------
12 Who transport the HCW off site? 1. HCF
2. Municipal service [Link]
company
13 How often off-site transport of HCW made? 1. Once a week 2. twice a week 3.
other specify------
On site HCW Storage

1 Does the facility have dedicated place for onsite storage? 1. Yes 2. No
2 If yes does it have fence not o access animal unauthorized? 1. Yes 2. No
3 Is HCW stored based on segregation without mixing? 1. Yes 2. No
4 Is the healthcare waste stored for more than 24 hours before 1. Yes 2. No
being treated/ disposed?
Treatment and disposal of HCW

1 What method is used for onsite HCW treatment? 1. Crushing 2. Disinfection 3.

Incineration 4. Sterilization 5.
burning 6. other specify----
2 Where HCW are finally disposed? 1. On-site 2. Off-site 3. Both
3 What on site disposal method is used for HCW disposal? 1. Open dumping 2. Sanitary
landfill 3. Small burial Shallow pit
burning [Link], specify-----------
4 If incinerator is used, does it have sufficient air inlets the 1. Yes 2. No
side?
5 What type of HCW is burned in the incinerator? 1. Infectious 2. Pathological 3.
Syringes 4. Plastics 5. All
6 Is there ash pit? 1. Yes 2. No
7 Is there needle pit? 1. Yes 2. No
8 Is there placenta/ amputation pit? 1. Yes 2. No
9 Is disposal area/incinerator fenced to prevent community 1. Yes 2. No
access?
10 Is the existing treatment/ disposal facility adequate? 1. Yes 2. No
11 Is the hospital in compliance with applicable regulation? 1. Yes 2. No
12 Is open burning prohibited? 1. Yes 2. No
HCW Recycle and Reuse

1 Does the facility have HCW recycling/reusing program? 1. Yes 2. No

2 What are HCW components recycling? 1. Paper 2. plastic3. Metals 4.
Cardboard 5. Pallet, 6. food waste
3 Are drugs supplied in reusable shipping containers? 1. Yes 2. No
4 Is food waste used for compost /recycled? 1. Yes 2. No
5 Is there a program to collect and recycle batteries? 1. Yes 2. No
Radiology

1 Has the facility investigated using nontoxic x-ray developing 1. Yes 2. No

/digital system?
 2 Do you capture and recycle silver x-ray film from radiology? 1. Yes 2. No
Pharmacy

1 Is inventory maintained as first in/ first out? 1. Yes 2. No

2 Where expired drug supplied for disposal? 1. Manufacturer
2. other specify---------
3 Is there any procedure for the safe handling or dispose of 1. Yes 2. No
cytotoxic drugs?
Environmental Health

1 Is HCW generation assessment done last year? 1. Yes 2. No

2 If yes, how much? -------------------------------
3 Is the hospital performing a waste audit in last 3 years? 1. Yes 2. No
4 Do you have HCW reduction strategy? 1. Yes 2. No
5 If incineration is used, is there a plan not to use incineration 1. Yes 2. No
as waste treatment method?

II. Key Informant Interview Guide for interviewing of health care workers, Cleaning staff
and Administrators to assess practicability of HCWM
A. For Health Workers
1. Work experience in the hospital----------------------------------------------------------------
2. Name of working department/case teams---------------------------------------------------------
3. Do staffs trained about infectious waste management practices? -------------------------------------------
4. Do staffs have waste collection bins or sharp boxes as used properly in the working area?
----------------------------------------------------------------------------------------------------------------------------------
5. Do health workers segregate HCW according to the guideline for disposal of waste?
----------------------------------------------------------------------------------------------------------------------------------
--------
6. Do the staffs use PPE (personal protective equipment) while handling infectious waste?
----------------------------------------------------------------------------------------------------------------------------------
----
7. Do staffs know about HAI (hospital acquired infection) due to mishandling HCW?
----------------------------------------------------------------------------------------------------------------------------------
 ----------
8. Do workers injured with infectious waste, sharp and syringe which handling HCW in the last six months?
How many? -----------------------------------------------------------------------------------------
9. What measures taken after injury?
----------------------------------------------------------------------------------------------------------
10. What are the types of waste generated in your working area? List them
-----------------------------------------------------------------------------------------------------------
-----------------------------------------------
11. Do workers separately collected infectious and non- infectious wastes?
-----------------------------------------------------------------------------------------------------
12. What type’s wastes are mainly generated in this department/case team?
------------------------------------------------------------------------------------------------------------------
----------------------------------------
13. In what color-coded container do you collect these wastes?
----------------------------------------------------------------------------------------------------------
B. For cleaner/ waste handler
1. Do staffs trained about infectious waste management practices?
----------------------------------------------------------------------------------------------------
2. If yes, do you handle and manage wastes according guideline?
----------------------------------------------------------------------------------------------------------
3. Do you have appropriate PPE (personal protective equipment) and waste segregation collection and
transporting materials and commodities for waste handling?
-----------------------------------------------------------------------------------------------------------
-----------------------------------------------------------
4. Do you clean your waste handling materials properly with 0.5% chlorine solution?
----------------------------------------------------------------------------------------------------------
5. Do staffs know about HAI (hospital acquired infection) due to mishandling HCW?
----------------------------------------------------------------------------------------------------------
6. Do workers injured with sharp and syringe which handling HCW in the last six months?
----------------------------------------------------------------------------------------------------------
7. What measures taken after injury? -----------------------------------------------------------------
---------------------------------------------------------------------------------------------------------
8. What are the types of waste you handle in this
 hospital-----------------------------------------------------------------------------------------------------------
----------------------
9. What is the frequency of waste collection from the sources of the waste per day?
-----------------------------------------------------------------------------------------------------
10. What is the average storage period at the temporary facility?
-----------------------------------------------------------------------------------------------------
11. Are the infectious waste collected and transported by enclosed compaction vehicles/trolley from source to
disposal site in the hospital?
-----------------------------------------------------------------------------------------------------
12. How is waste transported from source to disposal site? --------------------------
----------------------------------------------------------------------------------------------------
13. What is the final destination of the infectious waste? ------------------------------
----------------------------------------------------------------------------------------------------
14. Does the dump site pose any danger to public health? -----------------------------
---------------------------------------------------------------------------------------------------
15. Do you weigh and keep record of the waste generated? ---------------------------
----------------------------------------------------------------------------------------------------
16. What are the methods used in treatment of health care wastes in this hospital?
------------------------------------------------------------------------------------------------------
-----------------------------------
C. For Administrators
1. Do you trained about infectious waste management? --------------------------------------
----------------------------------------------------------------------------------------------------
2. Is there any policy or guideline about infectious waste management? -------------------
---------------------------------------------------------------------------------------------------
3. Is adequate budget allocated for infectious waste management? -------------------------
----------------------------------------------------------------------------------------------------
4. Do your hospital has annual plan about infectious waste management? -----------------
---------------------------------------------------------------------------------------------------
5. Is there any periodic supervision carried out in each health care service unit? How often?
------------------------------------------------------------------------------------------------------ ------------------------
6. Do you recruit adequate staff for waste management in the hospital?
-------------------------------------------------------------------------------------------------