Perceptions of medical waste exposure prevention among medical waste handlers in Hadiya zone, Ethiopia: a mixed-methods study using the health belief model

According to world health organization (WHO), wastes produced by the health-care providers are broadly categorized as general (non-hazardous) and hazardous waste [1, 2]. General waste constitutes about 85% of the total waste produced in the health care facilities (HCFs) and it is comparable to domestic waste. Medical waste is the waste produced during medical procedures such as diagnosis and treatment and includes things like syringes, needles, dressings, and plastics. It is infectious, hazardous, and poses serious health risks to patients and the public if not managed properly [3‐6]. According to the World Health Organization, every year, 16 billion injections are given globally, but not all needles and syringes are disposed of safely, which can lead to injury, infection, or even reuse [2]. More recently, 16 million unsafe injections or exposure to contaminated needles and syringes resulted in 4.5 million new HBV infections, 160,000 new HCV infections, and 160,000 new HIV infections annually [7]. Thus, improper management of medical waste poses a serious health hazard and can spread diseases like hepatitis B, and HIV [7‐9].

Medical waste handlers and healthcare workers are particularly susceptible to these diseases through the occupational exposure risk of needle injuries and blood-borne pathogens [8, 10, 11]. Preventing the spread of infection in healthcare settings means preventing exposure to medical waste. This can be done by consistently using personal protective equipment, practicing good hand hygiene, getting vaccinated for hepatitis B, and properly segregating waste in designated bins [12, 13]. Workers in charge of handling medical waste face exposure to hazardous materials and accidents due to manual handling and unfavorable conditions [14, 15]. This is due to poor handling practices, inadequate use of personal protective equipment (PPE), and improper waste segregation methods, which increase the risk of infection [16]. The risk of infection is increased in developing countries, including Ethiopia, where there is a lack of adequate resources, policies, and training [14]. A lack of awareness and access to personal protective equipment in low- and middle-income countries, which can contribute to the spread of diseases acquired through medical waste [17]. Studying preventive health behavior based on theory and models, such as the Health Belief Model (HBM), can help improve infection prevention efforts [4, 18]. In Ethiopia, there is a lack of attention to medical waste management (MWM), and healthcare staffs don’t have adequate knowledge about the hazards associated with handling medical waste [19]. Preventive actions, such as wearing personal protective equipment (PPE) and taking recommended measures, are important in reducing the risk of infection and injury. Understanding MWM and perceptions towards medical waste exposure (MWE) are crucial in achieving infection prevention [13].

The risk of healthcare-associated infections (HCAIs) due to exposure to medical waste remains high in Ethiopia despite the availability of several infection prevention trainings and guidelines [12, 20, 21]. However, the reason for the continuous exposure to infectious waste in health facilities may be due to individual risk perception and a lack of preventive behavior. To address this, assessing individual perceptions to facilitate effective infection prevention in hospitals is important. This is an important area of study in health psychology, as interventions based on theory and models are more effective [17].

In order to understand preventive health behavior, HBM scientists carried out numerous research that considered a variety of viewpoints, including health motivation and the individual’s perception, which can be impacted by past experiences as predictors of what an individual will and will not do. Accordingly, the HBM addresses how a person perceives the threat of a health issue (susceptibility, severity), the benefits of avoiding the threat, and the elements that affect the decision to take action (barriers, cues to act, and self-efficacy). The reasoning and prediction in HBM are now used to explain and predict preventative health and illness behaviors and are applied to many studies of all types of health behaviors, based on the understanding that a person will take a health-related action (medical waste exposure prevention) if this waste handlers that a negative health condition [injury] can be avoided. If the waste handler believes that medical waste exposure prevention reduces the risk of developing diseases or injury, he/she will use waste exposure prevention method and thus prevents injury or diseases. HBM is employed in this study because it is a health education model that looks into the factors that influence people’s health behaviors, particularly preventive behaviors. Individuals will engage in preventative behaviors if they perceive risk and believe the behavior is beneficial. The model predicts that individuals will engage in recommended preventative activities when perceived benefits surpass perceived barriers to the behavior [4, 22]. The concept of self-efficacy is also part of the HBM. Medical waste handlers (MWHs) have weaker risk perception, higher vulnerability to medical waste, and low practice of medical waste management [4, 17, 22]. However, medical wastes handling has received less attention in practice, and existing research is inconclusive as well [11, 14, 17] and health research emanating from Africa is scarce, despite the continent’s share of 18% of the world population and 25% of the disease burden [23]. Therefore, the study aims to assess the likelihood of engaging in medical waste exposure prevention among medical waste handlers working at public hospitals in Hadiya Zone, Ethiopia, using the Health Belief Model (HBM) framework [4, 22]. This will provide evidence for developing interventions and identifying barriers, which will help hospitals, create infection-prevention strategies and strengthen their programs (Fig. 1).

This study assessed medical waste exposure prevention among medical waste handlers in terms of the perception of individuals to threat acquiring, seriousness, and averting efficaciousness using the health belief model in Hadiya Zone, Ethiopia. According to the health belief model, individuals’ perceived susceptibility to and severity of a disease condition is a baseline to take the next step to avert this condition, which by far helps to develop self-confidence to stand for tackling this problem, which in turn helps individuals to go through the effective method, which adds value for his/her health (response efficacy), provided that people are already aware of a particular health threat since the model best works in situations where respondents have a higher level of awareness than motivational variables [4, 22].

In this study, the overall likelihood of performing medical waste exposure prevention behavior was 56.3%., and work experience, taking training, having adequate knowledge, perceived susceptibility, and perceived severity of medical waste were independent predictors of the likelihood of taking part in medical waste exposure prevention behavior.

This study showed that the benefits of performing preventive actions that are considered good for improving IP, such as using all PPE, hand washing and sanitizing, taking vaccinations, and appropriate waste segregation to prevent oneself from disease-causing microorganisms during working hours, outweigh the possible barriers that hinder engagement in preventive measures. In line with the study conducted in Ethiopia [16]. Many previous studies confirm that perception of individual preventive behavior is one of the determining factors for engagement in good behavioral practices, which helps to take recommended health action [5, 29, 30]. This might be having a perception of self-susceptibility and severity as well as a good attitude of using the recommended responses, which has universal importance in averting medical waste exposure.

A supportive result from a qualitative study reported that “most of the time there is a shortage of PPE supply in our facility. But in these conditions, I take care of myself.” [MWH, age 28]. Also, another report revealed that “if there was not enough equipment, I did not even touch any waste.” [MWH, age 34] also says an Amharic proverb, “Feri le-inatu,” which means I want to live. Additionally, “I always put sanitizer in my pocket for the time of the protective equipment shortage.” [MWH, age 34] ” In agreement with this finding, the Elvis E. Tarekegn study reported that a person would take preventive action if they had a positive expectation of following the recommended action [31]. The possible reason for the higher significant acceptance of recommended responses among waste handlers might be related to the fear of the threat of immediate injury from the wastes seen immediately.

In the present study, the likelihood of engaging in medical waste exposure preventive behaviors increased by decreasing possible barriers, and high barriers can be obstacles and prevent the adoption of desirable health behaviors. Similarly, this is supported by a study conducted in Egypt [32] and at Alexandria University [33].

Accordingly, this study showed that perceived susceptibility to medical waste increases the medical waste handler’s likelihood of taking part in medical waste exposure preventive behavior. In agreement with this, the study conducted in Debre-Berhan found that perceived susceptibility increases the utilization of personal protective equipment [34]. Tarekegn’s study showed that individuals were more likely to take preventive action if they believed that they had a chance of getting a disease [31]. It is also supported by a study conducted in Egypt [32]. In general, workers who perceive themselves as highly susceptible to MWE-related illness and injury are more likely to engage in preventive measures and apply good MWEPB. A depth interview with a 38-year-old female medical waste handlers indicated that “waste handling activities are more vulnerable to diseases induced by medical waste, and there is continuous exposure because of our job.” An environmental health expert and IPPS leader at a certain hospital also strengthens the idea, saying, “Since waste handling is directly related to waste, they are more susceptible to disease.” Also supported by a qualitative study conducted in India, they said that our chances of acquiring the disease were high [35]. This discrepancy might be due to study area differences and socio-cultural and socio-economic variation in the study area.

In this study, the perceived severity of medical waste showed a positive effect on the likelihood of performing preventive measures. Similarly, findings showed that perceived severity was a significant determinant of preventive health behaviors [5, 36]. Similarly, perceived severity increased personal protective equipment utilization [34]. Waste handlers’ beliefs about the seriousness of the infectious MW and the possible outcome of the disease were a good influencing factor in enhancing preventive measures. This is also supported by a qualitative study of female MWH who have worked in hospitals for more than five years. She said that nosocomial infections are more severe than any other because once you get the disease, there is no medication for it.

In this study, the year of experience had a positive effect on the likelihood of performing medical waste exposure prevention behavior. Thus, more experienced medical waste handlers were more likely to engage in medical waste exposure prevention behavior. A study conducted on the sharp injuries of medical waste handlers in eastern Ethiopia concluded that total service year had a significant effect on health care workers management and the probability of exposure decreased with an increase in work year [37].

It is obvious that health care waste handling is a dangerous activity that requires training in order to prevent exposure. In this study, the training status of the medical waste handlers was confirmed as one of the significant factors contributing to their likelihood of engaging in MWEPB. Thus, trained medical waste handlers have a greater likelihood of engaging in MWEPB. This is higher than a similar study done in Nepal, where the perceived risk of healthcare waste was higher among those who attended training than among those who didn’t attend the training [29]. The implementation of different initiatives by the ministry of health, like CASH and IPPS, in HFs may increase it. In line with this, the findings concluded that training HWs in implementing the MWM program is critical [38]. The training should aim at developing awareness of health and safety issues relating to MW and how these can affect them. This is supported by an in-depth interview: “I think formal training should be given to all employees to create a better understanding of prevention behavior [IPPS focal]. Also, another interview with a 34-year-old MWH reveals that “I perform preventive behavior occasionally, and I do not follow the instructions given to me carelessly.” Also, having adequate knowledge of MW made them more likely to perform preventive measures. This is similar to this finding in Addis Ababa [39], which concluded that safety practice with good knowledge was higher. But much higher than the other finding of a study conducted in Ethiopia, which shows that having good knowledge regarding IP makes people more likely to have good infection prevention practices [16]. This was supported by a qualitative study that stated, “I do not have enough awareness of medical waste and its exposure prevention.” [MWH, aged 34]. This shows adequate knowledge is a key factor in effective MW exposure prevention.

As strength, this study has advantages in that it used both quantitative and qualitative methods to support findings, and it utilized a health belief model that has been effective in predicting preventive behavior. However, a limitation of the study is that it was cross-sectional and therefore unable to determine whether the behavior or the predicting variables happened first. Another limitation, the health belief model, is entitled to understanding only an individual’s perception, and it is limited to addressing the social, environmental, and economic factors that are broadly affecting the system.

In conclusion, the likelihood of realizing the desired results in practice of preventive measures against medical waste exposure in low-income countries is unlikely to occur unless there is a strong focus on creating awareness and building health-seeking behavior. Most importantly, work experience, training, and knowledge, perceived susceptibility, and severity also have positive effects on adopting preventive behaviors and were found to predict the likelihood of taking preventive measures. However, there are still areas for improvement regarding access to tools and addressing knowledge and perception gaps. The findings urged to recommend for zonal health department, hospitals, and infection prevention and patient safety officer separately. The zonal health department should develop strategies on current identified predictors and give training to provide adequate personal protective equipment in the hospitals. Hospitals should train waste handlers on medical waste handling and ensure the regular provision and use of personal protective devices. Finally, infection prevention and patient safety officers should do regular follow-up, supervise, and give on-the-job direction on proper waste handling methods, and they should also provide special emphasis to susceptibility and severity of infectious disease due to exposure to medical waste and needle stick injuries. They should also focus on increasing perceived benefits of preventive measures and reducing barriers to preventive measures.