CHAPTER ONE INTRODUCTION Background to the study Increase in population

CHAPTER ONE
INTRODUCTION
Background to the study
Increase in population, changes in eating habits and lifestyle, high standards of living and increased awareness on health-related issues have contributed to the significant rise in the number of hospitals and other healthcare institutions around the globe, which has resulted in an increase in a clinical solid waste generation (Fei-Baffoe, 2010). Subsequently, the management of clinical solid waste has received huge attention from many writers due to its toxicity and infectious nature.
In the United States, clinical wastes emerged as a major problem when the public became concerned over the improper disposal practices particularly, wastes contaminated with communicable disease agents like AIDS, hepatitis B and C Viruses (Kau-Fui & Ramarathnam, 1994).
The development of a separate means of managing clinical waste within the municipal waste stream can be traced back to the late 1970s where clinical waste (syringes and bandages) were washed on the Eastern United States coast (Frost & Sullivan, 2009). Holmes, (2009) opined that the formation of the United States Medical Waste Tracking Act (MWTA) was because of the public outcry on the washing of the waste on the coast and this became a working document on November 1, 1998. In 1999, the World Health Organization (WHO) released its first global and comprehensive document offering guidance on safe management of wastes generated from healthcare activities, which tackled aspects of regulatory framework, waste minimization, recycling and treatment and disposal options (Acheampong, Dzodzomenyo, Godi, Carboo, Clarke & Tarkang, 2015).
Yawson, (2014) affirms that effective management of clinical solid waste starts at the point of generation since 10-25% of the waste is hazardous, and hence require special attention. These wastes include pathological, pharmaceutical, sharps, non-sharps and chemical wastes. WHO in 2005 also conducted a research in Bhutan which reveals that out of approximately 365 tons of healthcare waste generated annually, only 20% were infectious and hazardous whiles 80% were not (WHO, 2005). The World Bank report in 2008 also indicates that only 10%-25% of clinically generated wastes were infectious and hazardous. Despite the fact that a small proportion of the clinical waste is infectious (10%-25%), the non-segregation and improper handling of the waste, especially in most developing countries, renders the whole clinical waste (100%) infectious.
Therefore, the improper management of these wastes has direct effects on the community, individuals (workers) as well as the natural environment(air, land and water pollutions) in which these facilities are located (WHO, 2000). For example, clinical wastes contain pollutants which can be classified as biological, chemical and radioactive (Manyele, 2004). Thus, it is necessary to handle and manage clinical wastes with care (Riyaz, Asima, & Subhas, 2010).
Numerous studies have revealed poor management of clinical wastes in healthcare facilities in the developing countries (Udofia & Nriagu, 2013; Wiafe, Nooni, Nlasia, Diaba &, Fianko, 2015). Udofia and Nriagu (2013) and the WHO (2014) estimated about 67,000 healthcare facilities on the African continent, and that these facilities generate over 283, 000 tonnes of clinical waste annually. However, a survey conducted by the WHO (2005) in 22 developing nations revealed that about 18% to 64% of the healthcare facilities use inappropriate clinical waste treatment and disposal technologies. Some of the factors accounting for this include financial sustainability (Wiafe, Nooni, Appiah Boateng, Nlasia & Fianko, 2016) and lack of skilled expertise to manage the waste, as well as over-reliance on obsolete technology (Coker, Sangodoyin, Sridhar, Booth, Olomolaiye & Hammond, 2009).
In Ghana, the management of clinical solid waste is a major challenge due to it’s associated environmental and health issues. There are a number of policies and regulatory frameworks that aimed at addressing hazardous wastes in general. These included the Public Health Act 851 (2012), the Local Government Act (Act 426 of 1993, as replaced by the Local Governance Act, Act 936 of 2016), and the National Environmental Sanitation Policy (1999, amended in 2010). The Ghana Environmental Protection Authority also developed some guidelines for the management of healthcare and veterinary wastes in 2002 but there were no policies providing a legal context for implementation (Acheampong et al, 2015). It is in this deficiency that the Ghana Ministry of Health (MoH) in 2006 developed its first guidelines to ensure effective management of clinical wastes in adherence to international standards and practices. The policy indicates that each health facility shall be responsible for the separation, storage, labelling, treatment, transportation and disposal of all wastes in the manner prescribed by the policy and other equally defined laws so as to preserve the safety and well-being of workers, clients, and the environment.
To achieve these objectives, the guideline stipulated the necessary steps to be followed, starting from the point of generation of clinical waste to its disposal by the healthcare facilities. In this regard, the guideline requires every healthcare facility to estimate (amount) their daily generated waste which includes clinical care, routine, and mass immunization, and that waste segregation should be done at the point of generation into colour coded plastic bags and corresponding containers (Achempong et al, 2015). Thus, Ghana adapted from the WHO, its color-coding scheme (Williams, 2012) and these are; black for general wastes, yellow for infectious and radioactive wastes, and brown for hazardous wastes.
The steps stipulated in the guideline for managing clinical waste are illustrated in Figure 1 below. The guideline indicates that the collection, transportation, and storage of clinical waste occur at the source of generation. This is preceded by the segregation and containerization of clinical waste at the source of generation. The clinical waste is then treated and residues or unwanted substances transported to the final disposal sites.

Figure 1: Schematic Diagram for managing clinical waste
Source: MoH Guidelines (2006).
Acheampong et al, (2015) indicated that the labelling on waste receptors must be done permanently to identify source and content and clinical waste storage at internal storage sites should not exceed 24hours to reduce its potential risk of infection to healthcare workers and the disposal staff.
Despite the efforts to provide effective clinical waste management in healthcare facilities, Jamu, Magashula, and Muller (2009) observed that numerous aspects of clinical waste management are found to be haphazard and challenging to the hospitals. The situation is not different in Ghana despite the existence of national guidelines on the safe and proper management of clinical waste. Transportation of clinical solid waste is contracted mostly to private waste management companies whose main objective is profit maximization (Wiafe et al., 2016). The 37 Military Hospital in Ghana was also in the news on 25th January 2012 with a title dabbed ”Medical Waste Scandal at 37 Hospital”. The news indicated that for more than a year, highly infectious liquid waste had been flowing freely into the regional (Accra) gutters and the authorities paid no heed to the lamentations of residents close to the gutters. Similar issues were identified in the Sunyani Municipality with the contracting of private waste companies and burning of clinical wastes in pits (Wiafe et al, 2015). Even though this issue is taking a central place in the national health policies of Ghana currently and much attention been directed to it, less effort is seen at the subnational level, especially in the Ketu South Municipality (KSM) where the situation is now considered a major setback to the health facilities in the municipality. Annually, the Ketu South Municipal Assembly (KSMA) budgeted approximately Gh¢ 378,380 for health-related issues (2015 Composite Budget of KSMA) yet the Municipality is facing major challenges in managing its wastes, particularly clinical waste. According to Tuani (2008), urban planners or development managers are basically concerned with solving only real-life problems associated with utilities like water, electricity and communication services but have side-lined the problems associated with waste management and this can be observed in the case of KSMA. Even at the national level, the MoH exhibited its side-lining of waste management and this can be evident in their Sector Medium Term Development Plan, 2014-2017. The objectives set for their 2014-2017 strategic plan were to bridge the equity gaps in geographical access to health services, ensure sustainable financing for health care delivery and financing protection for the poor, improve efficiency in governance and management of the health system, improve quality of health services delivery including mental health services, enhance national capacity for the attainment of the health-related Millennium Development Goals (MDGs) and sustain the gains and intensify prevention and control of non-communicable and other communicable diseases (MoH, 2015). None of these goals was targeted at addressing the issue of clinical waste management in the sector.
The disposal of syringes, sharps and other clinical solid wastes at public dumpsites in the Ketu South Municipality through the mixing of clinical wastes collected from private health facilities with the municipal wastes is one trait associated with clinical waste management in Africa (Manyele, 2004).
However, since waste management is location specific, it is prudent to understand and evaluate current practices in clinical waste management in order to improve clinical waste management in the Ketu South Municipality.
Statement of the Problem
The management of clinical solid waste has received huge attention from many writers due to its toxicity and infectious nature. It is worth noting that hospitals and other healthcare facilities are responsible for delivering health care services to their clients and in the process of their duty, waste is generated. Clinical solid waste is potentially dangerous because it may contain infectious materials and sharps. In addition, clinical waste containing human organs and body parts may be offensive in nature. It is therefore important to exercise special caution in handling and management of these wastes in order to minimize its potential danger to public health or pollution to the environment (Suwannee, 2002).
Thus, improper management of clinical solid waste can have serious health implications on waste handlers (workers) and other healthcare professionals (nurses, doctors, pharmacists, laboratory technicians) as well as their clients (patients), waste scavengers and the public. A high percentage of waste handlers and individuals who live near disposal sites are infected with gastrointestinal parasites and other related diseases like cholera, malaria, yellow fever and salmonellosis characterized by violent diarrhoea and abdominal pain (Fei-Baffoe, 2010).
Over the years, Ketu South Municipality, which is the third populous municipality in the Volta Region with an estimated population of 181,881 (projected from the PHC, 2010), has seen improvement in health care delivery with the sprouting of health facilities across the Municipality. There are 33 health facilities including one public hospital and three private hospitals. The position of the Municipality makes it an area of utmost strategic importance in terms of Ghana’s international trade and therefore, it experiences huge human and vehicular traffic daily to and from neighbouring countries like Togo, Benin, Nigeria, and beyond. In effect, both locals and foreigners patronize the health facilities, leading to potential high generation of clinical solid waste.
With no engineered landfill in the Municipality, it is pertinent to examine the clinical waste solid management practices adopted by health facilities in the Municipality. Other researchers have written on the subject; for example, Wiafe et al (2015; 2016) assessed clinical solid waste management in the Sunyani municipality, Awodele, Adewoye and Oparah (2016) also wrote on assessment of medical waste management in Lagos. El-Emad (2011) researched on assessment of medical waste management in the main hospitals in Yemen and Acheampong et al (2015) conducted a study on waste management practices of a regional hospital in Ghana. Despite the existence of these studies, they cannot be related to the KSM because every social setting exhibits varied characteristics and this will contribute to the theoretical and practical gap that exists because of the non-adherence to lay down principles for clinical waste management. It is against this background that this study was conducted to assess clinical solid waste management practices adopted by healthcare facilities in the Ketu South Municipality.
Research Objectives
The main objective of this study is to assess the clinical solid waste management practices adopted by healthcare facilities in the Ketu South Municipality. Specifically, the study seeks to;
1. Examine the characteristics of clinical solid waste generated by the health facilities in the Municipality.
2. Assess the methods of clinical solid waste treatment and disposal adopted by these facilities.
3. Explore the perceptions of health workers on the clinical solid waste problem in the facilities.
4. Assess challenges in clinical solid waste management in the Ketu South Municipality.
Research Questions
1. What are the characteristics of clinical solid wastes generated in the Ketu South Municipality?
2. What methods are adopted in the treatment and disposal of these clinical solid wastes?
3. What are the perceptions of health workers on the clinical solid waste problem in the Municipality?
4. What challenges does the Municipality face in the management of clinical solid wastes?
Significance of the Study
The outcome of the study will contribute to ensuring proper management of clinical solid waste, as pertinent aspects will be considered in the course of the study. It will also provide adequate information on clinical solid waste management practices to healthcare facilities, institutions, and organizations in the Ketu South Municipality. This will help understand the theoretical and practical adherence gap in clinical solid waste management. It will again contribute to knowledge and literature on clinical solid waste management and serve as reference material for students and scholars in academia. Additionally, some measures will be suggested to improve the present conditions and solve or reduce the identified problems. It is hoped that the findings of this study will be used to better understand and improve on clinical solid waste management practices in Ghana.
Delimitations
The study was limited to the Ketu South Municipality and focused on clinical solid waste management practices as well as challenges encountered in managing clinical solid wastes. This included solid wastes generated from healthcare facilities. Institutions, organizations, and individuals whose jobs are not concerned with the generation and management of clinical solid waste were not included in the study.

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CHAPTER TWO
LITERATURE REVIEW
Introduction
Events of the 20th and early into the 21st century indicates that waste in whatever form or classification be it solid, liquid, or toxic, have become a major consequence of modernization and economic development (Tsiboe & Marbell, 2004). In the quest for ‘Western-styled’ development, humanity did not budget for the associated problems related to the management of waste (Puopiel, 2010). This chapter explores the available literature on clinical waste management in healthcare facilities and discusses the impact of clinical waste on the health worker and the environment as well as the challenges of clinical waste management and perceptions of health workers on clinical waste management.
Waste
There is a lot of literature available on the term waste. However, all the various authors have given no one definition. Gilpin (1996) defined waste as “all unwanted and economically unusable by-product or residuals at any given place and time and any other matter that may be discarded accidentally or otherwise into the environment”. According to him, in as much as a waste is an unwanted substance that is unusable, the amount, weight and its effect on society are all areas that must be looked at when defining waste. Gourlay (1992) argued that we can only classify something as a waste when it has lost its value or is no longer useful to the owner and therefore, fails to fulfill the purpose hence; waste is more easily recognized than defined. Davies (2008) also describes waste to be
“Unwanted or unusable material that emanate from numerous sources from industry and agriculture as well as business and households and can be liquid, solid or gaseous in nature and hazardous or non-hazardous depending on its location and concentration” He further notes that “what some people consider being waste material or substances are considered a source of value by others”. (p. 4-5)
He gave a detailed description of waste including the various types as well as their effect either been hazardous or non-hazardous which is based on their places of location and their level of concentration. “Just as a material becomes a resource when it gains use-value, it also becomes waste when it loses its use-value” (Baabereyir, 2009).
The discipline of waste management is associated with the control of generation, storage, collection, transfer, and transport, processing, reuse, recovery and disposal of waste in a manner that is in accordance with the best available technology (BAT) and also environmentally friendly and responsive to public attitude (Fei-Baffoe, 2010).
Types of Waste
There are different types of waste based on their source and mode of generation and their content. The Environmental Protection Agency (EPA, 2012) categorized wastes arising from sources such as nuclear, agricultural, construction and demolition, industrial, radioactive, sewage sludge, electronic, municipal and clinical sources. From these sources, the various classifications of waste are deduced as;
• Biodegradable waste (food and kitchen waste, green waste and paper waste)
• Recyclable waste (paper, glass, bottles, cans, metals, batteries, fabrics)
• Inert waste (construction and demolition waste, dirt, rocks, debris)
• Electrical or Electronic waste (electrical appliances, TVs, computer, screens)
• Composite waste (tetra packs, waste plastics such as toys)
• Hazardous waste (most paints, chemicals, light bulbs, fluorescent tubes, sprays cans)
• Toxic waste (pesticides, herbicides, fungicides)
• Clinical waste
Clinical solid waste
The term “clinical solid waste” covers all wastes produced in health-care or diagnostic activities (ICRC, 2011). The Pakistan Antimicrobial Resistance Network (PARN, 2007), defines it as “any waste which is generated in the diagnosis, treatment or immunization of human beings or animals or in research” in a hospital.
Anil and Anupem, 2005 also defines clinical waste as any waste, which is generated during the diagnosis, treatment or immunization of human beings, animals or during research activities. In this same vein, Hem (1999) also refers to clinical waste as all forms of waste generated and are discarded with the intent of not using them again in the hospital.
Klangsin and Harding (1998) also expressed their opinion on the matter as quoted by Varapong (2009) referring to clinical waste as all waste materials that are generated at healthcare facilities (hospitals, clinics, physician’s offices, dental practices, blood banks, veterinary facilities as well as medical research facilities).
The WHO (2005, 2014) reiterated their definition of clinical waste as “Healthcare waste includes all waste that is generated by healthcare waste establishments, research facilities, and laboratories. In addition, it includes the waste originating from “minor” and “scattered” sources, such as that produced in the course of healthcare undertaken in the home (dialysis, insulin injections, etc.)”.
It is worth noting that there are many synonyms to clinical waste and these synonyms are used interchangeably in other parts of the globe (Moritz, 1995). Some of these include hospital waste and bio-medical waste.
Similar definitions were given by Kau-Fui and Ramarathnam (1994), Phillips (1999), Habibur and Mansooor (2000), Visvanathan and Radha (2006) ; Abor and Bouwer (2008).
In effect, clinical solid waste includes all waste generated by health-care establishments, research facilities, and laboratories. It also includes wastes originating from “minor” or “scattered” sources for instance waste produced in the course of healthcare undertaken in the home (dialysis, insulin injections, etc.).
Sources of clinical solid waste
The sources of clinical waste can be grouped into two categories thus major and minor sources. This categorization is based on the quantities of waste produced by the facilities. Table 1 gives the various facilities under the two categories.

Table 1: Sources of Clinical Solid Wastes
Major sources (hospitals and medical centres)
Sharps Infectious and pathological waste Chemical, pharmaceutical and cytotoxic waste Non-hazardous or general waste
Medical ward Hypodermic needles, intravenous set needles, broken vials and ampoules Dressings, bandages, gauze, and cotton contaminated with blood or body ?uids; gloves and masks contaminated with blood or body ?uids Broken thermometers and blood pressure gauges, spilt medicines, spent disinfectants Packaging, food scraps, paper, ?owers, empty saline bottles, non-bloody diapers, non-bloody intravenous tubing and bags
Operating
theatre Needles, intravenous
sets, scalpels, blades, saws Blood and other body ?uids; suction canisters; gowns, gloves, masks, gauze and other waste contaminated with blood and body ?uids; tissues, organs, foetuses, body parts Spent disinfectants
Waste anaesthetic gases Packaging; uncontaminated gowns, gloves, masks, hats and shoe covers
Laboratory Needles, broken glass, Petri dishes, slides, and coverslips, broken pipettes Blood and body ?uids, microbiological cultures and stocks, tissue, infected animal carcasses, tubes and containers contaminated with blood or body ?uids Fixatives; formalin; xylene, toluene, methanol, methylene chloride and other solvents; broken lab thermometers Packaging, paper, plastic containers
Pharmacy store Expired drugs, spilt drugs Packaging, paper, empty containers
Radiology Silver, fixing and developing solutions; acetic acid; glutaraldehyde Packaging, paper
Chemotherapy Needles and syringes Bulk chemotherapeutic waste; vials, gloves and other material contaminated with cytotoxic agents; contaminated excreta and urine Packaging, paper
Vaccination
campaigns Needles and syringes Bulk vaccine waste, vials, gloves Packaging
Environmental
services Broken glass Disinfectants (glutaraldehyde, phenols, etc.), cleaners, spilt mercury, pesticides Packaging, ?owers, newspapers, magazines,
cardboard, plastic and glass containers, yard and plant waste
Engineering Cleaning solvents, oils, lubricants, thinners, asbestos, broken mercury devices, batteries Packaging, construction or demolition waste, wood, metal
Food services Food scraps; plastic, metal, and glass
containers; packaging
Minor sources
Physicians’ offices Needles and syringes,
broken ampoules and
vials Cotton, gauze, dressings, gloves, masks and other materials contaminated with blood or other body ?uids Broken thermometers and blood pressure gauges, expired drugs, spent disinfectants Packaging, of paper, newspapers, magazines, uncontaminated gloves and
masks
Dental offices Needles and syringes,
broken ampoules Cotton, gauze, gloves, masks and other materials contaminated with blood and other body ?uids Dental amalgam, spent
disinfectants Packaging, of paper, newspapers, magazines, uncontaminated gloves and
masks
Home healthcare Lancets and insulin
injection needles Bandages and other material contaminated with blood or other body ?uids Broken thermometers Domestic waste
Source: WHO, 2014

Characteristics of clinical solid waste
This section presents key characteristics associated with clinical wastes. These include the various classifications of clinical waste as well as the quantity of clinical waste generated in healthcare facilities.
Classification of clinical solid wastes
The ICRC (2011) and WHO (2014) classified clinical solid waste into five (5) and nine (9) categories respectively. The WHO classification was an expanded form of the ICRC. Each of the various classifications is presented in Tables 2 and 3 respectively.
Table 2: ICRC Classification of Clinical Solid Waste
1 Sharps Waste entailing risk of injury
2 (a) Waste entailing risk of contamination
(b) Anatomical waste
(c) Infectious Waste (a) Waste containing blood, secretions or excreta entailing risk of contamination.
(b) Waste containing large quantities of material, substances or cultures entailing the risk of propagating infectious agents (cultures of infectious agents, waste from infectious patients placed in isolation wards)
3 (a) Pharmaceutical Waste
(b) Cytotoxic waste
(c) Waste containing heavy metals
(d) Chemical waste (a) Spilled/unused medicines, expired drugs and used medication receptacles
(b) Expired or leftover cytotoxic drugs, equipment contaminated with cytotoxic substances.
(c) Batteries, mercury waste (broken thermometers or manometers, fluorescent or compact fluorescent light tubes).
(d) Waste containing chemical substances; leftover laboratory solvents, disinfectants, photographic developers, and fixers.
4 Pressurized containers Gas cylinders, aerosol cans.
5 Radioactive waste Waste containing radioactive substances: radionuclides used in laboratories or nuclear medicines, urine or excreta of patients treated.
Source: ICRC, 2011

Table 3: WHO Classification of Clinical Solid Waste
Waste category Description and examples
Infectious Waste Waste suspected to contain pathogens e.g. laboratory cultures; waste from isolation wards; tissues (swabs), materials, or equipment that have been in contact with infected patients; excreta
Pathological waste Human tissues or fluids e.g. body parts; blood and other body fluids; fetuses
Sharps Sharp waste e.g. needles; infusion sets; scalpels; knives; blades; broken glass
Pharmaceutical Waste Waste containing pharmaceuticals e.g. pharmaceuticals that are expired or no longer needed; items contaminated by or containing pharmaceuticals (bottles, boxes)
Genotoxic waste Waste containing substances with genotoxic properties e.g. waste containing cytostatic drugs (often used in cancer therapy); genotoxic chemicals
Chemical waste Waste containing chemical substances e.g. laboratory reagents; film developer; disinfectants that are expired or no longer needed; solvents
Waste with a high content of heavy metals Batteries; broken thermometers; blood-pressure gauges; etc
Pressurized containers Gas cylinders; gas cartridges; aerosol cans
Radioactive waste Waste containing radioactive substances e.g. unused liquids from radiotherapy or laboratory research; contaminated glassware, packages, or absorbent paper; urine and excreta from patients treated or tested with unsealed radionuclides; sealed sources
Source: WHO, 2014
There is yet another category which is not always included in the broad categories of clinical waste. This is the clinical wastewater. WHO (2014) defined it as any water that has been adversely affected in quality during the provision of healthcare service. Its content is mainly liquid and sometimes contains solids produced by humans (health workers and patients) or during healthcare related processes like cooking, cleaning, and laundry. It is categorized as;
1. Blackwater (sewage) – heavily polluted wastewater that contains high concentrations of faecal matter and urine
2. Greywater (sullage) – contains more dilute residues from washing, bathing, laboratory processes, laundry and technical processes such as cooling water or the rinsing of X-ray films.
3. Stormwater is technically not a wastewater itself but represents the rainfall collected on hospital roofs, grounds, yards and paved surfaces. This may be lost to drains and watercourses and as groundwater recharge or used for irrigating hospital grounds, toilet ?ushing, and other general washing purposes.
The risk associated with this particular waste is not given the needed attention it deserves (WHO, 2014) because the known practice (common in developing countries) of pouring untreated liquid clinical waste into the sanitary sewer and other water bodies as well as on bare soil is seen by many as normal. The WHO and Centre for Disease Control (CDC), USA have shown that this waste contains a large number of microorganisms that are very harmful to humans and other living things that come into contact with it (Agarwal, 1998; WHO, 2014).
Eigeheer and Zanon (1991)’s classification included both the solid and liquid clinical wastes but was not detailed. Their classification is illustrated in Table 4 below.
Table 4: Eigeheer and Zanon (1991) classification of clinical solid waste
Type Typical examples
Liquid Waste
Biological waste Blood, excrement, body fluid etc.
Chemical waste Solutions, inorganic salts etc.
Over-date medicines Over-date drugs, unused drugs
Radioactive waste Wastes from radiology (iodine 125, iodine 131 etc.)
Solid Waste
Perforating and cutting wastes Needles, syringes, scalpels, blades, broken glass, vials
Non-perforating and non-cutting wastes (a) Wastes from treatment (dressings, stool napkins, plaster cast etc.)
(b) Parts of the body: organs, placentas, tissue etc.
(c) Household-type wastes: other wet and dry waste
(d) Over-date medicines (expired drugs)
Source: Eigeheer and Zanon, 1991
Quantification of clinical solid waste
The quantity of waste produced in a hospital depends on the level of national income and the type of facility concerned. A university hospital in a high-income country can produce up to 10 kg of waste per bed per day, all categories combined (ICRC, 2011).
Studies in Pakistan show that large hospitals generate 2.0 kg of waste, per bed per day of which 0.5 kg can be categorized as biomedical risk waste (Khan, 2006).
Hanumatha (2009) estimated the daily generation rate of clinical waste at the Outdoor Department of Baripada district hospital in South Indian City to be ranging from 9.9 to 14.0 kg with an average of 11.6 kg and out of this, 22.4% thus 2.5 kg was infectious.
Anil and Anupem (2005) also presented their finding that the total amount of clinical waste generated in Taj City (India) is approximately 9.4 metric ton per day. Ravi (1998) also estimated a daily generation rate of 60 tonnes per day for Delhi with about 40,000 beds.
Inferring from the various quantities of the clinical solid waste generation above, it is clear that about 2 kg of clinical waste is generated daily per day. The EPA (USA) estimated that there are approximately 2,400 Municipal Waste Institutions (MWIs) in the US which are burning approximately 846 thousand tonnes of clinical waste annually. A study conducted in Karachi, Pakistan revealed that the hospital’s studied produced about 427 kg of waste per bed annually (less than 1.5 kg per day).
The quantity of wastewater produced in a healthcare facility depends solely on the amount of water used and this is measured by water consumption. The various wards at healthcare facilities generate the highest wastewater (Wiafe et al, 2016). A study conducted by Wiafe et al in Sunyani, Ghana revealed that wards generate about 7,817 Litre of wastewater daily of which 199L is pathological and 7,618L is infectious.
The rate of wastewater generation is often measured as the sum of the number of inpatients and outpatients. WHO (2008) gave some guidelines on the minimum water required in every healthcare facility (40-60L per inpatient plus 5L per outpatient and 100L per surgical procedure).
Water saving programmes can efficiently minimize the amount of wastewater produced at healthcare facilities to reduce the inadequate supply of water for commercial use, which can be attributed to high wastewater generation rates at healthcare facilities (WHO, 2008).
Clinical solid waste management practices and procedure
Hem (1999), has given the need or rationale for spending so many resources (money, manpower, material, and machine) for the management of clinical waste as follows:
• Those injuries from sharps could lead to infection to all categories of hospital personnel and waste handlers.
• Nosocomial infections in patients from poor infection control practices and poor waste management.
• Risk of infection for waste handlers and scavengers and those living near healthcare facilities.
• The risk associated with hazardous chemicals, drugs to persons handling wastes at all levels.
• “Disposable” being repacked and sold by unscrupulous elements without even being washed.
• Drugs which have been disposed of, being repacked and sold off to unsuspecting buyers.
• Risk of air, water and soil pollution directly due to waste, or due to defective incineration emissions and ash.
Proper management of clinical waste is still in its infancy all over the world and there is a lot of confusion among generators, operators, decision makers and the public about the safe management of these clinical wastes (Arvind & Girish, 2010).
In Goa (India), only the Goa Medical College Hospital treats its own waste in addition to wastes generated from two district hospitals. One hundred and fifty other hospitals in Goa either dump clinical waste within their premises or dispose of them with the municipal waste and this makes the management of clinical waste an intractable problem in India (Hanumantha, 2009; Times of Indian, 2008).
Proper management of clinical waste ensures that infectious and other hazardous wastes are handled in accordance with established and accepted principles and procedures from point of generation to final disposal (Sawalem et al., 2009) and this can be achieved by exercising utmost care when dealing with clinical waste. It is ethical to have concern for public health through safe handling, segregation, storage and subsequent disposal of clinical waste to ensure mitigation and minimization of the health risks involved through contact with potentially hazardous materials (Vijaya et al., 2007). In contrast, Rolando, Loido, and Danilo (1997) opined that there appears to be no safe way of managing all the hazardous clinical wastes generated in Metro Manila.
Waste segregation and colour coding
The key to minimization and effective management of clinical waste is segregation (separation) and identification of the waste. Appropriate handling, treatment, and disposal of waste by type reduce costs and do much to protect public health. Segregation should always be the responsibility of the waste producer and must be done at the point of generation.
Segregation is a very important step in clinical waste management because errors at segregation stage present a threat to those managing wastes. Effective segregation at the source of generation is a key factor in the waste management strategy and it will enable hospital authorities to save money on waste disposal Vorapong (2009).
The recommended colour-coding scheme according to the WHO is given in Table 5. Ministry of Health, Ghana also proposed in their 2006 policy and guidelines for health institutions the approved colour coding for storage and transportation of clinical waste (Table 6).
Table 5: Recommended colour-coding for clinical solid waste
Type of waste Colour of container and markings Type of container
Highly infectious waste YELLOW, marked “highly infectious” Strong, leak-proof plastic bag or container capable of being autoclaved
Others (infectious, pathological and anatomical waste) YELLOW Leak-proof plastic bag or container
Sharps YELLOW, marked “sharps” Puncture-proof container
Chemical and pharmaceutical waste BROWN Plastic bag or container
Radioactive waste labelled with the radioactive symbol Lead box,
General clinical waste BLACK Plastic bag
Source: WHO, 2014

Table 6: Colour Coding for Storage and Transportation
Waste
Type Description of Waste Colour Code
A General Waste BLACK plastic bag and a container of appropriate size
B Infectious Waste
B1 sharps YELLOW puncture-resistant containers and plastic bags
B2 Patient Waste YELLOW plastic bags, bins and other containers
B3 Culture/Specimen YELLOW plastic bags, bins and other containers
B4 Pathological/Organic Human Tissues YELLOW plastic bags and bins
C Pharmaceutical Waste BROWN plastic bags, bins, and containers
D Chemical Waste BROWN plastic bags, bins, and containers
D1 Photographic Chemical Waste
– Photographic developer
– Fixer solution
– X-ray photographic film BROWN plastic containers
– To be recycled/reused
– To be neutralized
D2 Laboratory Waste
– Acids
– Alkalis
– Solvent
– Organic Substances
– Heavy metal e.g. Mercury BROWN containers with appropriate labels
– Acid label
– Alkali label
– Solvent label
– Organic substances label
– Heavy metal label
E Radioactive waste
– Solid-combustible/non-compactable
– Non-combustible/non-compactable
– Liquid-Aqueous
– Spent sealed sources YELLOW containers with the radioactive symbol:
– Durable plastic bags which can be sealed
– Puncture-resistant containers (metal)
– Thickly walled polythene bottles or organic glass containers but should have a secondary container to prevent them from breaking
– The container in which the source was originally received.
F Incinerator Ash and Sludge Where separated,
YELLOW metal containers labelled “Ash”
YELLOW metal containers labelled “Sludge” Otherwise
YELLOW metal containers labelled “Ash and Sludge”

Source: MoH Policy and Guidelines for Health Institutions, 2006

Greeta (2005) opined that infectious waste should be segregated into sharps and non-sharps and colour coding for infectious should be Red while yellow remains the colour coding for sharps. Wastes should further be segregated into biodegradable and non-biodegradable.
Anant and Dwinedi (2002) also expressed their view on the segregation of clinical waste that the most important technique to identify the waste in a later stage of disposal is by means of colour coding of specific types of clinical waste. Waste management facilities can work faster if there are characterization and segregation of clinical waste where there is proper identification of each type of waste at generation points.
Hem (1999) also noted that the essence of waste management is segregation hence this should be done at the source of generation of clinical waste. The same idea was also professed by Prus et al. (1999) regarding segregation at generation points according to the characteristics of clinical wastes.
Collection
The collection of daily generated clinical waste is the gathering of all waste from points of generation to a storage site or facility within a healthcare facility.it is the responsibility of health workers to make sure that waste bags are tightly closed or sealed when they are three-quarters full (WHO, 2014). Light-gauge bags can be closed by tying the neck, but heavier-gauge bags probably require a plastic sealing tag of the self-locking type. MoH (2006) policy states that sealed sharps containers should be placed in a labelled, yellow infectious health-care waste bag before removal from the hospital ward or department and that clinical waste should not be allowed to accumulate at generation points. A routine programme for their collection should be established as part of a healthcare facility’s management plan.
There are varied types and brands of waste containers made from different materials. Many modern ones are designed for automated systems that empty their contents into the waste disposal system, wash and disinfect the containers mechanically. Others are also made from reused plastics and metals (WHO, 2007).
The Ministry of Health, Ghana in its 2006 policy and guideline for healthcare waste management prescribed general requirements for every clinical solid waste collection container. These are;
1. They should be non-transparent.
2. They should be impervious to moisture.
3. They should be of sufficient strength to prevent damage during handling or use.
4. They should be leak proof.
5. They should have close fitting lids.
6. They should be fitted with handles for easy manipulation.
7. They should be lightweight and convenient for lifting.
8. They should be designed to minimize physical contact.
The World Health Organization in 2007 also gave certain recommendations that should be followed by the ancillary workers in charge of the waste collection.
1. Waste should be collected daily (or as frequently as required) and transported to the designated central storage site.
2. No bags should be removed unless they are labelled with their point of production (hospital and ward or department) and contents.
3. The bags or containers should be replaced immediately with new ones of the same type.
A supply of fresh collection bags or containers should be readily available at all locations where waste is produced (ICRC, 2011).
Storage
Waste storage is the act of storing or holding of clinical solid waste for a certain period of time after which it is sent for treatment and disposal (Yashpal ; Poonam, 2000). A storage location for any healthcare facility should be located within the facility and not outside.
According to Bio-Medical Waste Management and Handling Rules (1998), storage of waste is necessary at two points:
(i) At the point of generation and
(ii) Common storage for the total waste inside a healthcare organization.

The waste, in bags or containers, should be stored in a separate area, room, or building of a size appropriate to the quantities of waste produced and the frequency of collection (ICRC, 2011). Unless a refrigerated storage room is available, storage times for healthcare waste (i.e. the delay between production and treatment) should not exceed the following durations by ICRC (2011):
Temperate climate: 72 hours in winter
48 hours in summer
Warm climate: 48 hours during the cool season
24 hours during the hot season
Cytotoxic waste should be stored separately from other health-care waste in a designated secure location. Radioactive waste should be stored in containers that prevent dispersion, behind lead shielding. Waste that is to be stored during radioactive decay should be labelled with the type of radionuclide, the date, and details of required storage conditions (WHO, 2005). Recommendations for storage facilities for health-care waste according to the MoH (2006) policy includes the following.
1. The storage area should have an impermeable, hard-standing floor with good drainage; it should be easy to clean and disinfect.
2. There should be a water supply for cleaning purposes.
3. The storage area should afford easy access for staff in charge of handling the waste.
4. It should be possible to lock the store to prevent access by unauthorized persons.
5. Easy access for waste-collection vehicles is essential.
6. There should be protection from the sun.
7. The storage area should be inaccessible for animals, insects, and birds.
8. There should be good lighting and at least passive ventilation.
9. The storage area should not be situated in the proximity of fresh food stores or food preparation areas.
10. A supply of cleaning equipment, protective clothing, and waste bags or containers should be located conveniently close to the storage area.
Transportation of clinical solid waste
Transportation according to the Chambers 21st Century Dictionary is the act of transporting or the process of being transported. In this regard, clinical waste transportation is the act or process of transporting the wastes from their points of generation to their treatment and disposal sites.
Rolando et al, (1997) expressed that most transportation of clinical solid waste is done by the use of the traditional dump trucks and this is done often times with the municipal waste. Transportation of infected waste is done by the used of wheelbarrows even though air-conditioned vans with appropriate compartment is required and despite regulations made in the Municipal Solid Waste management rules, these covered vans are not provided and made accessible to healthcare facilities(Verma, 2010).
Hem (1999) also suggested that waste routes must be designated within healthcare facilities to avoid the passage of waste through patient care areas. Again, separate time should be assigned for the transportation of clinical waste to reduce chances of mixing with general waste. On the means of transportation, Hem (1999) was of the opinion that desiccated wheeled containers, trolleys or carts and plastic bags should be used to transport the waste to the storage and treatment sites.
However, during 1992 an increasing number of private hospitals have contracted a private hazardous waste management company, the Integrated Waste Management Incorporated (IWMI). This company supplies the plastic containers to their clients and hauls them to their incinerators (Yawson, 2014)
Treatment and disposal of clinical solid waste
The current practice of clinical solid waste treatment and disposal posed a great risk to the environment and health workers especially pharmaceutical waste, which accumulates and stay active in the aquatic environment for a very long time (Yawson, 2014).
The Institute for Environmental Chemistry, Germany in 2011 conducted a survey among the public randomly to investigate the household disposal of unused and expired pharmaceutical and this proves not to be the best.
The situation is the same in the developing countries. Indiscriminate disposal of clinical waste has put millions of lives at risk because these dump sites are visited by waste scavengers daily. One of the greatest risks African healthcare facilities pose to the public is through the disposal of infected sharps (needles, scalpel blades, blood vitals, glassware, etc.) at dumpsites instead of using safety boxes. This can be accrued to the high cost of these boxes (News Analysis, 2010; Yawson, 2014).
In India, with the exception of the large hospitals, most of the smaller hospitals and nursing homes including the government and municipal hospitals do not possess effective systems for safe disposal of their wastes (Ak-Dwividi, Pandey ; Shashi, 2009).
Mustapha and Anjum (2009) stated that clinical waste from healthcare facilities on Pakistan are simply disposed of anywhere or even mixed with the general and municipal wastes or sometimes, buried without any safety measures. This is evident in Ghana where waste from 37 Military Hospital was allowed to flow directly into the main gutters of Accra (Ghanaweb.com,25/1/2012). This means that many healthcare facilities dispose of their clinical wastes anyhow either by throwing on the ground indiscriminately or into water bodies.
Ghana was one of the countries surveyed under the 2009 Agenda in Africa on waste disposal issues and this revealed that disposal of waste at dumpsites through the municipal authorities is the most common method and this included clinical solid wastes as well. These dump sites are not engineered to serve as landfill sites hence possess a high risk of infection through runoffs and contamination of underground water (Yawson, 2014).
The MoH (2006) Policy and Guideline for Health Institutions stipulated certain guidelines for the treatment and disposal of clinical waste (Table 7)

Table 7: MoH Guidelines for clinical solid waste treatment and disposal
TYPE OF WASTE TREATMENT/LEVEL OF HEALTH SYSTEM FINAL DISPOSAL
General waste (food, paper, packing materials)
Bio-digestion, Composting, Incineration (controlled combustion n), Recycling (cardboard, paper, glass)
• Health centre/ Clinic– Composting, low-cost incineration
• District – Composting, Bio-digestion, incineration
• Regional Hospitals –Incineration, Bio-digestion
• Teaching Hospital – Incineration
• Recycling- All levels
Infectious waste/ Sharps • Incineration –All levels
• Chemical disinfection-All Levels
• Waste autoclaves– regional/tertiary levels Landfill
Patients’ waste Incineration – All levels Landfill
Culture/ specimen • Discontinuation by autoclaving/incineration – All levels Landfill
Pathological/ organic human tissue • Incineration –All levels
• Approved Burial Grounds, Health Centres Landfill
Hazardous Waste (Pharmaceutical tablets and capsules) Crushing – All levels
Landfill

Syrups and injectable • Crushing of injectable-All levels
• Syrups –Diluted and washed down the drains –All levels landfill
Cytotoxic drugs, Vaccines Incineration at high temperature -All levels Landfill
Photographic chemical waste (developer, fixer solution, and X-ray film) Incineration at high temperature (10000C) Landfill

Radioactive waste Compaction, storage decay immobilization – All levels Specially designed landfill
Laboratory Waste
Dilute with large volumes of water (12x)-For those that are infectious, chemical disinfection and incineration – All levels Sewage Landfill

Acids, Alkali
Dilute with large volumes of water (12x)– All levels Sewage

Solvents Chemical decontamination (EPA guidelines) Sewage
Organic Substances Chemical decontamination (EPA guidelines) Sewage
Heavy Metals Complexation Sewage
Source: Ministry of Health, Ghana (2006)

Other methods used in treating clinical solid waste include;
• Thermal processes (use of thermal energy to destroy pathogens in the waste and this is the widely used across the world).
• Chemical processes (use of disinfectants –dissolved chlorine dioxide, sodium hypochlorite, peracetic acid, lime solution etc.).
• Irradiation technologies (use of irradiation from electron beams, cobalt-60 or ultraviolet sources to destroy pathogens in the waste).
• Biological processes (use of enzymes to speed up the destruction of organic clinical waste containing pathogens).
• Mechanical processes (use of mechanical devices to reduce waste quantity and destroy needles and syringes through shredding. This is done after treatment to reduce the risk of infection).
• Incineration or combustion (high-temperature, dry oxidation process that reduces organic and combustible waste to inorganic, incombustible matter and results in a significant reduction of waste volume and weight).
The Stockholm Convention guidance on best available techniques and best environmental practices towards clinical waste management states that: “If medical waste is incinerated in conditions that do not constitute best available techniques or best environmental practices, there is potential for the release of polychlorinated dibenzodioxins (PCDD) and polychlorinated dibenzofurans (PCDF) in relatively high concentrations” (Stockholm Convention, 2006).
The World Health Organization has also reviewed small-scale healthcare incinerators and reported that there are significant problems associated with the siting, operation, maintenance and management of these incinerators and as a result of these and high costs for modern incinerators to meet the BAT standards, WHO viewed small-scale incineration as a transitional means for clinical waste disposal (WHO, 2014).
Clinical solid waste management policies/regulations/guidelines
Several policies, guidelines, regulations, and agreements have been in circulation which try to give clinical waste a legal backing and fundamental principles concerning public and environmental health as well as safe management of clinical waste.
Principles of Waste Management
There are five principles that are widely recognized as underlying the effect and control of waste are used by countries at the developmental stages of their policies. These principles according to WHO (2014), ICRC (2011) and MoH (2006) are;
The “polluter pays” principle
This implies that all producers of waste are legally and financially responsible for the safe and environmentally sound disposal of the waste they produce. This principle also attempts to assign liability to the party that causes damage.

The “precautionary” principle
This is a persuasive principle governing health and safety protection. It was defined and adopted under the Rio Declaration on Environment and Development (UNEP, 1972) as Principle 15: “Where there are threats of serious or irreversible damage to the environment, lack of full scientific certainty should not be used as a reason for postponing cost-e?ective measures to prevent environmental degradation”.
The “duty of care” principle
This principle stipulates that any person handling or managing hazardous substances or wastes or related equipment is ethically responsible for using the utmost care in that task. This principle is best achieved when all parties involved in the production, storage, transport, treatment and final disposal of hazardous wastes (including health-care waste) are appropriately registered or licensed to produce, receive and handle named categories of waste.
The “proximity” principle
It recommends that treatment and disposal of hazardous waste take place at the closest possible location to its source to minimize the risks involved in its transport. Similarly, every community should be encouraged to recycle or dispose of the waste it produces, inside its own territorial limits, unless it is unsafe to do so.

The “prior informed consent principle”
This principle as embodied in various international treaties is designed to protect public health and the environment from hazardous waste. It requires that a?ected communities and other stakeholders be apprised of the hazards and risks and that their consent is obtained. In the context of healthcare waste, the principle could apply to the transport of waste and the siting and operation of waste-treatment and disposal facilities.
International policies/regulations/guidelines
The Basel Convention
The Basel Convention of 1992 on the control of the trans-boundary movement of hazardous wastes and their disposal is the most comprehensive global environmental treaty on hazardous waste. Its main objective is to regulate the trans-boundary movement of hazardous and other wastes by applying the “prior informed consent” principle. It has 170 member countries (parties) and aims to protect human health and the environment against the adverse e?ects resulting from the generation, management, transboundary movements and disposal of hazardous and other wastes. Each party is required to introduce domestic legislation to prevent illegal trafficking of hazardous wastes and to ensure environmentally sound management of wastes. The convention has also produced a comprehensive document offering technical guidance on the environmentally sound management of biomedical and healthcare waste (UNEP, 2003; MoH, 2006 & WHO, 2014).

The Bamako Convention
The Bamako Convention has similar aims as the Basel Convention but has a strong prohibition on the importation of any hazardous waste into Africa. This was as a result of the fall short in the Basel Convention with regards importation of hazardous waste into less developed countries. The negotiation was executed by 12 nations of Organization of African Unity (OAU) at Bamako (Mali) in January 1991 and became recognized in 1998 (WHO, 2014; ICRC, 2011).
The Stockholm Convention
The Stockholm Convention on Persistent Organic Pollutants (POPs) (the Stockholm Convention) is a global treaty to protect human health and the environment from persistent organic pollutants (POPs). POPs are chemicals that remain unmodified in the environment for long periods. They become widely distributed geographically which accumulates in the fatty tissue of living organisms and are toxic to humans, wildlife, and examples are dioxins and furans. The Convention, therefore, seeks to reduce their production and use and eliminate the uncontrolled emission of these substances (ICRC, 2011 & WHO, 2014).
The Environment and Sustainable Development Conferences
The concept of the environment and the pattern of action at a national and international level to safeguard it evolved in the years leading up to the United Nations Stockholm Conference 1972 (WHO, 2014). According to WHO (2014), ten of such conferences were held in the mid-1980s and the concept of sustainable development was defined by the World Commission on Environment and Development (Brundtland Commission) to means “development that meets the needs of the present without compromising the ability of future generations to meet their own needs” (WCED, 1987).
Sustainable development was given new form and direction by the World Summit on Sustainable Development in Johannesburg in 2002 and this led to a 300-page plan for achieving sustainable development in the 21st century, called “Agenda 21”. It was adopted by 173 heads of states Ten years later earlier, the Earth Summit was held and a Plan of Implementation was agreed. The United Nations Commission for Sustainable Development was charged with carrying out the plan, based upon a strategy of two-year implementation cycles. The main aim of this plan was to minimize the generation of waste, to reuse and recycle, treat and dispose of all waste products by safe and environmentally sound methods placing all residue in sanitary landfills (ICRC, 2011 & WHO, 2014).
Other eminent committees and legislations worth mentioning are,
• United Nations Committee of Experts on the Transport of Dangerous Goods.
• United Nations Economic Commission for Europe
• Aarhus Convention of the United Nations Economic Commission for Europe

Available guidance
World Health Organization Guidance, 2014
World Health Organization recommends that countries conduct assessments before choosing health-care management methods. It suggests that government, organizations and other healthcare waste handlers adopt the strategies outlined below:
1. Short-term strategies
• Production of all syringe components (using the same plastic to facilitate recycling).
• Selection of polyvinyl chloride (free medical devices).
• Identification and development of recycling options wherever possible (e.g. for plastic, glass).
• Research into, and promotion of, new technology or alternative to small-scale incineration.
• Until countries in transition and developing countries have access to healthcare waste management options that are safer for the environment and health, incineration may be an acceptable response when used appropriately
2. Medium-term strategies
• Further e?orts to reduce the number of unnecessary injections, to reduce the amount of hazardous healthcare waste that needs to be treated.
• Research into the health e?ects of chronic exposure to low levels of dioxin and furan.
• Risk assessment to compare the health risks associated with (a) incineration, and (b) exposure to health-care waste.
3. Long-term strategies
• E?ective, scaled-up promotion of non-incineration technologies for the final disposal of health-care waste to prevent the disease burden from
(a) unsafe health-care waste management, and
(b) exposure to dioxins and furans.
• Support to countries in developing a national guidance manual for sound management of health-care waste.
• Support to countries in developing and implementing a national plan, policies, and legislation on health-care waste.
• Promotion of the principles of environmentally sound management of health-care waste as set out in the Basel Convention.
• Support to allocate human and financial resources to safely manage health-care waste in countries.
WHO also recommends the Core principles for achieving safe and sustainable management of clinical waste (WHO, 2007). These principles require that everyone associated with financing and supporting healthcare activities (governments, donors, NGOs and the private sector) should provide for the costs of managing clinical waste.

The International Solid Waste Association policy document on health-care waste management
The International Solid Waste Association (ISWA) is recognized as an international, independent and non-profit-making association, working in the public interest to promote and develop sustainable waste management worldwide. ISWA has national and individual members from around the world and promotes sustainable and professional waste management.
National legislation
A national policy document according to ICRC (2011) and WHO (2014) should form the basis for developing the law and should be complemented by technical guidelines developed for implementation of the law. National legislation constitutes a basis, which must be drawn on to improve waste treatment practices in a country. Many countries are currently drawing up national medical waste management plans. According to the Health Service Executive’s Waste Management Awareness Handbook in 2011 by Roban, all these policies are geared towards prioritizing clinical waste management options in terms of environmental impact. Figure 2 below illustrates the waste management hierarchy.

Figure 2: Waste Management Hierarchy
Source: Health Service Executive, 2011
The Indian Ministry of Environment and Forest ignored all international policies and recommends that all hospitals with 50 beds or more should install on-site incinerators. This provision was made in their first drafted rules and was issued in June 1995 (Ravi, 1998)
The Global Alliance for Vaccines and Immunization (GAVI) has been financing a project in collaboration with the WHO in this context since 2006 and the aim is to help 72 countries adopt a policy, strategy, and plan for managing the wastes generated in healthcare activities and Ghana is a member (ICRC, 2011).
Key Ghanaian policies in relation to waste management include;
The National Environmental Policy
This policy seeks to guide development in accordance with quality requirements to prevent, reduce and eliminate pollution and nuisance.

The National Environmental Sanitation Policy, 1999
This policy requires all healthcare institutions to establish institutional waste management systems for managing their wastes. It also requires health care facilities to pre-treat their wastes through autoclaving prior to storage. The polity further states that district assemblies shall provide for the collection of hazardous and clinical wastes
Public Health Act 851, 2012
This act is to revise and consolidate the law relating to public health to prevent disease, promote, safeguard, maintain and protect the health of humans and animals and to provide for related matters. It came into force on 9th October 2012. The Food and Drug Authority was established through this act. The coming into force of this Act repealed the following enactments
• Infectious Diseases Act, 1908
• Mosquitoes act, 1911
• Quarantine act, 1915
• The Food and Drugs Act, 1992 (PNDCL 305B)
Perceptions and waste management
The importance of actual behavioural control is self-evident. The resources and opportunities available to a person must to some extent dictate the likelihood of behavioural achievement and the greater psychological interest than actual control is the perception of behavioural control and its impact on intentions and actions (Ajzen, 1991). Perceived behavioural control refers to people’s perception of the ease or difficulty of performing the behaviour of interest.
Gibson and Tierney (2006) defined perception as the primary process by which human beings obtain knowledge of the world and this involves the actions of our senses thus sight, hearing, touch, taste, and smell in responding to external stimulations. Warner (2006) also explained perception to mean the emotional response (illogic and irrational) where cognition is the rational thought and behavioural tendency is to behave in a specific manner which depends also on culture. He argues that there is no right or wrong behaviour except within a cultural context and even there; the number of factors developed over time (Agyapong, 2012) influences our behaviours.
In relating perception to clinical waste management the WHO (2006) argues that cultural beliefs and perceptions are dynamic and vary from one geographical area to another hence it is not possible for a healthcare institution to adopt practices relating to waste collection, storage, treatment and disposal of another healthcare facility in a different environment.
Attitudes of an individual form part of his perceptions and are influenced by knowledge, resources, belief, values, and norms but they can be created without experience and knowledge of the individual. In effect, demand for clinical waste management is influenced by people’s attitudes through awareness building campaigns, education on negative impacts of waste on the environment and individuals and benefits associated with effective waste management. Bernstein (2004) opined that such education should also inform individuals of their responsibility as waste generators as well as their rights as citizens to waste management services. This means that the design and implementation of any waste management system require adequate analysis of existing behaviour (attitudes, perceptions, and values) of key stakeholders (Agyapong, 2012).
In managing clinical waste, healthcare facilities are always concern about what is in their immediate environment without paying attention to where such waste will be disposed and once the waste has been collected from their premises, they tend to care less. This is similar to issues raised by Bernstein (2004) and Klundert and Lardinois (2005).
Perception, therefore, sets a limit on one’s capability as regards what one can do and also what can be achieved (Holland & Rosenberg, 2002).
The influence of perception which describes how a person views himself or herself and the world around him or she explains that deviance can arise by accepting culturally determined goals without the acceptability of cultural means (Agyapong, 2012).
In this regard, the more knowledge one acquires on clinical waste management, the clearer our opinions tend to be and the stronger our perceptions (Agyapong, 2012).
Risks and impact of clinical solid waste on health workers and the environment.
This section concerns with identifying the types of hazards associated with clinical solid waste and those that may be at risk. It also describes the public and environmental health impacts that need to be controlled. Since a large component of clinical waste is non-hazardous, it possesses threats just as the municipal waste (WHO, 2014).
All persons who are in contact with hazardous clinical solid waste are potentially exposed to the various risks it entails. This includes persons inside the establishment generating the waste, those who handle it and persons outside the facility who may be in contact with hazardous wastes or their by-products. The following groups of persons are potentially exposed:
• Healthcare workers (medical doctors, nurses, auxiliaries)
• Patients in healthcare facilities or receiving home care
• Visitors to healthcare facilities
• Workers in support services (cleaners, porters, etc)
• The general public may also be at risk whenever hazardous clinical waste is disposed of improperly.
The ICRC (2011) and WHO (2014) report divided health risks associated with hazardous clinical solid waste into five categories thus the risk of trauma, the risk of infection, chemical risk, the risk of fire or explosion and risk of radioactivity. The incorrect management of clinical waste can have a direct effect on the environment as well (WHO, 2010)
Risks of Trauma and Infection
Clinical wastes are a source of potentially dangerous microorganisms that can infect hospital patients, personnel, and the general public. There are many di?erent exposure routes through which these organisms are transmitted injury (cut, prick), through contact with the skin or mucous membranes, through inhalation or through ingestion. Table 8 gives examples of infections that can be caused by hazardous medical waste.

Table 8: Types of infection
Type of infection Infective agent Transmission agent
Gastrointestinal
infections Enterobacteria (Salmonella, Vibrio cholera, etc.) Faeces, vomit
Respiratory
infections Mycobacterium tuberculosis, Streptococcus pneumonia, SARS virus (Severe Acute Respiratory Syndrome), measles virus Inhaled secretions, saliva
Eye infections Herpes virus Eye secretions
Skin infections Streptococcus Pus
Anthrax Bacillus anthraces Skin secretions
Meningitis Neisseria meningitides Cerebro-spinal ?uid
AIDS Human Immunodeficiency Virus (HIV) Blood, sexual secretions, other body ?uids
Haemorrhagic fever Lassa, Ebola, Marburg, and Junin viruses Blood and secretions
Viral hepatitis A Hepatitis A virus Faeces
Viral hepatitis B and C Hepatitis B and C viruses Blood and other biological ?uids
Avian influenza H5N1 virus Blood, faeces
Source: ICRC, 2011

As regards viral infections such as AIDS and hepatitis B and C, nursing staff are most at risk of infection through contaminated needles. Sharps and pathogenic cultures are regarded as the most hazardous medical waste (ICRC, 2011).
In 2000, the World Health Organisation (WHO) estimated that at world level, accidents caused by sharps accounted for 66,000 cases of infection with the hepatitis B virus, 16,000 cases of infection with hepatitis C virus and 200 to 5,000 cases of HIV infection amongst healthcare workers (Pruss-Ustun, Rapiti & Hutin, 2005 & ICRC, 2011)).
The year 2009 saw the outbreak of hepatitis B in Gujarat (India) which took about 60 lives and this was blamed on the reuse of injection equipment. This has led to the discovery of a black market where these used needle and syringes were repackaged and resold (Solberg, 2009).
There is, however, little data on the long-term health impacts of genotoxic clinical waste because of the difficulty in assessing human exposure to it. Studies undertaken in Finland, Canada, and the United States revealed many spontaneous abortions during pregnancy and malformations in children of females who have a working history of anticancer agents (Valanis, Vollmer & Steele, 1999).
The transmission of infection and its control is illustrated by a “chain of infection” diagram (Figure 3). Each link in the chain must be present and in the precise sequential order for an infection to occur and health workers must understand the significance of each link and the means by which the chain of infection can be interrupted. Consequently, good health-care waste management can be viewed as an infection-control procedure. It is also important to note that breaking any link in the chain will prevent infection, although control measures for healthcare waste are most often directed at the “mode of transmission” stage in the chain of infection (WHO, 2014).

Figure 3: Chain of Infection
Adapted from Korn & Lux, 2001
Survival of Microorganisms in the Environment
Pathogenic microorganisms have a limited capacity for survival in the environment. Survival depends on each microorganism and on environmental conditions (temperature, humidity, solar radiation, availability of organic substrate, the presence of disinfectants, etc.). Bacteria are less resistant than viruses. Very little is known now about the survival of prions and the agents of degenerative neurological diseases (such as Creutzfeldt-Jakob’s disease, Kuru, and so on), which seem to be more resistant than viruses (WHO, 2014).
Table 9 gives a summary of what is known about the survival of various pathogens
Table 9: Survival of pathogens
Pathogenic Micro-Organism Observed Survival Time
Hepatitis B virus • Several weeks on a surface in dry air
• 1 week on a surface at 25°C
• Several weeks in dried blood
• 10 hours at 60°C
• Survives 70% ethanol.
The infectious dose of hepatitis B and C viruses 1 week in a drop of blood in a hypodermic needle
Hepatitis C 7 days in blood at 4°C.
HIV • 3 – 7 days in ambient air
• Inactivated at 56°C
• 15 minutes in 70% ethanol
• l21 days in 2 ?l of blood at ambient temperature
• Drying the virus reduces its concentration by 90-99% within the next few hours.
Source: ICRC, 2011
Clinical liquid waste-related diseases
When an untreated liquid waste is discharged into the public sewer system it can cause water pollution hence, Saini and Dadhwal (1995) narrated that there are instances where dioxins are found from water systems near incinerator plants. Dioxins can also enter water bodies through the air.
The Eso-Consult conducted a study in 2014 to assess clinical waste management at Korle Bu Teaching Hospital and the Ridge Regional Hospital, all in Accra. The findings revealed that liquid waste from Korle Bu Teaching Hospital and Ridge Hospital are disposed of in the nearby lagoon because their sewage system was chocked and municipal communal sewage system respectively.
Improper management of liquid clinical waste and sludge will result in the pollution of local water sources with pathogens and this can cause numerous waterborne and vector-borne diseases like malaria and filariasis by providing breeding grounds for the vectors and favouring the spread of parasites like roundworm or Ascaris lumbricoides (WHO, 2014).
Nutrients are biologically degraded in the underground water, lakes, and rivers through the disposal of untreated liquid clinical waste into the environment. This leads to eutrophication (WHO, 2014) whereby a body of water becomes over-enriched with nutrients, from sewage disposal and run-off of agricultural fertilizers which results in overgrowth of algae and depleted oxygen levels in the water, leading to the death of aquatic animals (Chambers dictionary).
The algal blooms will favour potentially hazardous bacteria (e.g. Cyanobacteria) and might result in hazardous toxins forming that can cause illnesses such as from exposure to cyanotoxins. Nitrate in the groundwater from untreated wastewater can result in methaemoglobinaemia, particularly in babies. Wastewater discharged in an uncontrolled manner into the environment can lead to several waterborne diseases that are a threat to human life, especially in developing countries (WHO, 2014).
Challenges of clinical solid waste management
Despite the number of attempts by various organizations to curb the challenges faced in the attempts to manage waste in urban centres, the problem still persists.
Tuani (2008) has argued that urban planners or development managers are basically concerned with solving only real-life problems associated with utilities like water, electricity and communication services but have side-lined the problem associated with waste management.
Riyaz, Asima, and Subhas (2010) also stated that the management or handling of clinical solid waste is proving to be an overwhelming challenge for the government and the health sector. Hospital effluent not only has aberrant physico-chemical characteristics but also has high loads of multiple drug-resistant bacteria and discharging of the effluent in a municipal sewage system could be a grave public health hazard Yawson, 2014).
The major challenges to effective clinical solid waste management especially in developing countries are insufficient allocation of resources, lack of training and appropriate skills, unavailability of risk awareness, public apprehension and misinformation on exposure as well as incinerator capacity and the increasing need for a solid and sustainable national healthcare strategy (Abor ; Bouwer, 2008). These problems are because of the absence of trained healthcare workers on available issues of efficient clinical waste management and its associated hazards (Tsakona, 2007). Much attention is not given to waste management at these healthcare facilities (Abor ; Borwer, 2008).
Conceptual Framework
This section presents the conceptual framework that guided the study. The problem of effectively managing clinical waste was observed in terms of assessing the various methods that are in use for managing clinical waste at the healthcare facilities. This was done with reference to their cost and benefit and in relation to the nature and characteristics of behaviour and perceptions of people especially healthcare workers whose jobs concerns the generation and management of clinical waste as well as their application to issues related to clinical waste management. In light of these, the Integrated Waste Management approach and the theory of planned behaviour were selected as the basis for the study.
Integrated Waste Management Approach (IWM)
This deals with the volume of waste generated and a balance between the cost of reducing waste sources and the benefits associated with it. This concept was founded on the expectation that waste management is to prevent waste from causing harm to human health and the environment hence; it contains a conceptual analysis of waste, the activity upon waste and a holistic view of the goals of waste management (Pongracz, Phillips ; Keiski, 2004).
This approach was adopted for this study because it assisted in analyzing the cost and benefit of the current practices of clinical solid waste management in the KSM in order to adopt environmentally correct and analytically sound policies in addressing the issue. This helped in exploring the methods (recycling, reuse, landfill, and incineration) and challenges in managing clinical waste in the Ketu South Municipality.
Theory of planned behaviour (TPB)
Ajzen propounded this theory in 2002 and it provided a framework for studying human action (Figure 1). According to Ajzen (1991), human behaviour is predicted by three independent factors namely behavioural beliefs, normative beliefs and control beliefs. Behavioural beliefs relate to the likely outcomes of one’s behaviour and the evaluation of these outcomes, normative beliefs include expectations from others and the motivation to comply with these expectations and control beliefs deal with the presence of factors that may facilitate or prevent the performance of the behaviour, subjective norms and perception of behaviour. Perception is the primary process by which an individual obtains knowledge of the world and this involves use of the sense organs (sight, hearing, touch, taste, and smell) in responding to external stimulation (Gibson & Tierney, 2006).
The combination of these three determinants guides an individual to form a behavioural intention hence an individual’s intention to exhibit a particular behaviour is a fundamental factor in the TPB. In essence, a person’s intention to exhibit a particular behaviour is stronger when the attitude and subjective norms are favourable and the perceived control is greater hence, the intention is assumed to be the immediate antecedent of behaviour (Agyapong, 2012).

Figure 4: Theory of Planned Behaviour
Source: Azjen (2002)
The theory of Planned Behaviour was useful to this study. Perceptions of a person on clinical solid waste may not be explored only through the knowledge and experience of the person because these perceptions for instance behaviour are influenced by our knowledge, beliefs, values, and norms but can be formed without knowledge or experience of a person. In this regard, the more knowledge one acquires on clinical waste management, the clearer our opinions tend to be and the stronger our perceptions (Agyapong, 2012).
In addition, when one is informed about an issue, s/he is more likely to be influenced in behaviour as knowledge is gained from first-hand experience (Fazio & Zama, 1981 cited in Mariwah, Kendi & Dei, 2010). In effect, a healthcare facility’s methods in managing clinical waste and associated challenges encountered are influenced by their perception towards waste management.
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CHAPTER THREE
RESEARCH METHODOLOGY
Introduction
This chapter discusses the methodology adopted in carrying out the study. The methods and approaches as described in this chapter are presented under the following subheadings: study area, research design, sources of data, target population, sample size determination and distribution, sampling procedure, research instruments, data collection procedure, ethical issues and data analysis.
Study Area
Geographically, the area studied is the Ketu South Municipality, a relatively densely populated Municipality on the eastern border with the Republic of Togo. It is located in the Volta Region of Ghana and lies within latitudes 60 03″ N and 60 10″ N, and longitude 10 06″ E and 10 11″ E. It shares its Eastern boundary with the Republic of Togo, West with Keta Municipality, North with Ketu North and the Gulf of Guinea to the South. It has a total land size of approximately 779 square kilometres representing 3.8 percent of the regional land area. Major communities of the municipality include Denu, Aflao, Agbozume, Tokor, Adafienu, Klikor, Nogokpo, and Gaklikope (Figure 2).
With a population of about 181,881 (projected from the PHC, 2010) inhabitants of a cosmopolitan nature, Ketu South Municipality serves as a major commercial area on the eastern gateway to Ghana. It is heterogeneous in ethnicity, a feature that promotes development. The ethnic groupings include Ewes (who are in majority), Akans, Gas, Hausas and the Ga Adangmes. The urban population for the Municipality is 46.6 percent, which is higher than the regional average of 33.7 percent as well as the regional capital, Ho which has an urban population of 44.3 percent and it is the second most urbanized Municipality in the Volta Region after the Keta Municipality (53.3%) (Ghana Statistical Service, 2010). The KSM is selected on the basis of its population size, economic activities and the sprouting of healthcare facilities. There are thirty-three (33) health care facilities in the Municipality including one public and three (3) private hospitals. It has the second highest population density (206 persons per square kilometre) in the region and it is highly endowed with good arable soil suitable for the cultivation of different types of crops (GSS, 2010). Places that are not suitable for cultivation still yield materials for making mats, hats and local baskets (Kevi) (mofa.gov.gh). The built-up environment is currently confronted with the issue of waste management because the KSM has only two refuse trucks one of which belongs to the Zoomlion Company Limited hence managing of waste is a big challenge for the KSMA.

Figure 5: Study Map of Ketu South Municipality
Source: Ghana Statistical Service
Research Design
The research design adopted for the study was the concurrent triangulation approach. This deals with the collection and analyzing of both quantitative and qualitative data concurrently in a single study (Creswell, 2009). This makes it easy for a researcher to avoid problems that are usually associated with single theory, a single method, and single data studies. In the same vein, observations and in-depth interview were used to solicit qualitative data and the quantitative data was acquired by the use of a questionnaire.
In line with the approach, the descriptive research design was also used (Neuman, 2003). According to Cohen, Manion, and Morrison (2007), in descriptive survey design, researchers gather data at a particular point in time with the intention of describing the nature of existing conditions or identifying standards against which existing conditions can be compared. As recommended by Leedy and Omrod (2010), this design is suitable for purposes of generalizing from a sample to a population so that inferences could be made about the characteristics, opinions, attitudes, and experiences of the population. Descriptive survey design provides a more accurate and meaningful picture of an event or phenomenon and seeks to explain people’s perception and behaviour on the basis of data gathered at a particular time (Fraenkel & Wallen, 1993). Therefore, the design was considered appropriate for the researcher to elicit information from healthcare facilities on solid clinical waste management practices.
Irrespective of the strengths of the descriptive survey mentioned above, Fraenkel, Wallen and Hyun (2012) identified the weaknesses of the descriptive survey as (1) difficulty in ensuring that the questions to be answered are clear and not misleading, (2) getting respondents to answer questions thoughtfully and honestly is a setback, and (3) getting a sufficient number of questionnaires completed and returned so that meaningful analysis can be made is also a setback. Osuola (2001) in buttressing the points on the weaknesses of the descriptive research, pointed out that, “designing a quality investigation requires particular attention to two central factors: appropriate sampling procedures, and precision in defining terms in eliciting information” (p. 201). He continued by adding that, while descriptive research is a prerequisite for finding answers to questions, it is not in itself sufficiently comprehensive in providing answers and that it cannot provide cause-and-effect relationships. Creswell (2003) also critiqued that the descriptive design is narrow in scope and limits analysis of events, concepts and theories to only what they are without exploring their deeper components.
Notwithstanding the difficulties and setbacks of descriptive survey design indicated above, it was still deemed most appropriate and applicable for the study, because it is relatively easy and data are easy to obtain and interpret by using simple descriptive statistics (Sarantakos, 2006).
Sources of data
Both primary and secondary data were collected for the purpose of this study. The primary data was solicited with the use of questionnaires, interviews guide and observation checklist. The primary data were collected from medical doctors, directors, nurses, matrons and domestic workers (cleaners, sweepers). The secondary sources include data from journals, reports, and documents from the KSMA, hospitals and the internet.
Target Population
Population refers to the large general group of many cases from which a researcher draws a sample and which is usually stated in theoretical terms (Neumans, 2003). According to Amedahe (2004), the target group about which a researcher is interested in gaining information and drawing conclusions is what is known as the population. In this study, the target population consisted of the following;
? Ketu South Municipal Health Directorate (KSMHD)
Every metropolis, municipal or district (MMD) has a health directorate which oversees the daily activities of all health facilities. To understand the reality and effectiveness or lapses in the management of the generated wastes of any health facility, it was prudent to include the directorate in the study to grant the researcher an insight into issues that may not be privy to the other workers or facilities.
? Medical Doctors
? Nurses
? Physician Assistants
? Mid-Wives
? Pharmacists
Attending to patients and prescribing possible medications depends on the activities and expertise of doctors and nurses in the various health facilities. The ward assistants assist these experts in rendering their services to the patients. Midwives play the role of delivering babies and managing all related wastes from the labour room including placentas and other human tissues as well as the amniotic fluids. In discharging their duties, these health workers are supervised by a senior nurse officer usually titled as a matron. A certified pharmacist whose role is to dispense medicines to their clients manages the dispensary of any health institution. Majority of the wastes generated are from the activities of these workers ranging from plasters to medications. In carrying out a study on clinical waste management, the nurses, ward assistants and matrons must be included in the sources of data to enhance the researcher’s understanding of issues.
? Incinerator Operators
It is a requirement for every hospital to have an incineration site where certain categories of wastes are burnt. This is carried out by operators or technicians whose responsibilities include segregation and incineration of non-infectious and combustible wastes. An insight into the activities at the incineration sites can only be acquired from these operators or technicians hence their inclusion in the study.
? Ketu South Municipal Environmental Health Office (MEHO)
? Zoomlion Ghana Limited
The Ketu South Municipal Assembly has an office that plays a vital role in ensuring a clean environment and good health for its inhabitants. This office occupied by the Municipal Environmental Health Officer (MEHO) whose work includes supervising the management of all kinds of wastes, including clinical waste. In addition, private waste management organizations such as Zoomlion Limited are key stakeholders in waste management and were included in the study.
Sample size and sampling Procedure
A sample denotes a small and representative proportion of the population. The purposive sampling was used to select the municipal hospital due to its size and serving as the referral hospital for all other health facilities in the Municipality. Also, all the three (3) private hospitals in the Municipality were purposely selected. The selection of all hospitals was informed by their capacity and the nature of services rendered to the public as well as their amount of waste generation which can have a great impact on their surrounding communities. Health centres, clinics, and CHPS compounds were not included in the sample because they receive fewer patients and that their level of waste generation is minimal compared to the hospitals. Therefore out of the 33 healthcare facilities, four (4) have been selected and this will reflect virtually the same degree of accuracy as far as other aspects of the sampling design and procedures are the same (Fowler, 1993). There were one hundred and thirty-one (131) health workers in the four (4) hospitals whose jobs relate to the generation and management of clinical waste. Therefore, to obtain an adequate sample for statistical power, the census was employed to cover all the relevant staff in the four selected health facilities. The sample was considered adequate because, according to Hair, Anderson, and Tatham (1998), at a minimum of 100, a sample is considered adequate for any statistical analysis. The purposive sampling technique was again utilized to select four (4) respondents from heads of healthcare facilities and relevant stakeholders in clinical waste management, who served as key informants for the study. Thus, the sample size used for the study was 135, comprising 131 hospital staff and 4 key informants. Table 10 shows the distribution of the sample size for the study.

Table 10- Distribution of the Sample for the study
Target Group Sampled Size
Medical Doctors, Nurses, Midwives, Pharmacists, Physician Assistants and Domestic Workers (cleaners and sweepers) 131
Municipal Health Directorate 1
Incinerator Operators 1
Municipal Environmental Health Office 1
Zoomlion Ltd 1
TOTAL 135

Data Collection Instruments and Procedure
In line with the adoption of the mixed method in this study, the major instruments used in collecting data include an observation checklist, questionnaire and interview guide
Observation
Study visits were made to all storage facilities at the four hospitals in the Municipality. The incineration sites, on-site storage facilities, storage bins, transportation trucks, vans, containers as well as temporal storage bins at the various wards were also observed. The researcher accompanied one of the incinerator operators during incineration to observe how it is done. The observation was the major data collection technique because it granted the researcher first-hand knowledge of various methods of treatment and disposal as well as characteristics of the wastes. To achieve better and adequate results, the observation process was aided by an observation checklist that was prepared through which a list of items to be observed was indicated. Still, pictures were taken from some of the places visited.
Questionnaire
The reasons for choosing questionnaire were many; one because they were very effective in obtaining factual information about practices involved in managing clinical waste. Another reason was the time effective nature of questionnaires as compared to other instruments like interviews. This instrument was also chosen because it was effective in soliciting information from a large number of respondents at a time.
The questionnaire was used to source data from the nurses, midwives, physician assistants, pharmacists and cleaners at the four (4) selected healthcare facilities on some of the characteristics exhibited by the clinical solid wastes, the various methods and treatment options adopted by their respective healthcare facilities and their perspective of the clinical solid waste problem. It comprised of both closed and open-ended questions. For the open-ended questions, the respondents were given the opportunity to answer questions as they deem fit in their own words. This granted them the opportunity to express themselves on the issues. The use of closed-ended questions enabled respondents to respond to questions that demand fixed answers where respondents were expected to choose from options that best fit their answers.
The questionnaire had 57 items, sub-divided into 6 sections (A-F). it covered areas such as characteristics of the clinical solid waste, methods of storage, treatment and disposal, perceptions of healthcare workers, waste-related risks and perceptions and finally, challenges of managing clinical waste.
Since most of this group of respondents could read and write, they answered questions after briefing from the researcher. With the exception of a few cleaners who could not read, the researcher assisted by administering the questionnaire to them in the form of reading and translating into the local language (Ewe).
Interview Guide
Some selected heads of institutions related to clinical solid waste management were interviewed using an interview guide. Respondents who were interviewed include the Municipal Health Director, one incinerator operator, the Municipal Environmental Health Officer and one official from Zoomlion. The guide was prepared to solicit information from them on the characteristics of clinical wastes, methods of treatment and disposal as well as challenges involved in managing clinical wastes. Items of the guide were based on issues that were deemed important in providing answers to the research questions, which will help in achieving the objectives of the study. Questions were open-ended and this created room for changes and further probing during the actual fieldwork. Interviews thus provide more information that cannot be obtained any other way because people always provide more information in a one-on-one discussion than in a public forum (Bernstein, 2004).
Each of these respondents had a different set of questions since they are responsible for different sectors but they were all sub-divided into 4 sections thus characteristics of clinical waste generated, methods of storage, treatment and disposal, the perception of healthcare workers and finally, challenges involved in managing clinical wastes. The guide for Zoomlion had 17 questions. The Municipal Environmental Health Officer and Municipal Health Director were both interviewed with the same guide which had 8 questions and the incinerator operator’s had 14 questions on the guide.
To ensure validity and reliability of responses, the researcher reiterated responses by the interviewees to them for confirmation or modification. This was done to ensure that interviewees understood the issues very well and that their responses were not misrepresented. Audio recordings were done and also salient points were noted down to further ensure validity and reliability.
Pre-test of research instruments
To ascertain the reliability and the degree of consistency that the instruments demonstrate, the instruments were pre-tested through a pilot testing on respondents with same characteristics as that of Ketu South Municipality. The advantage of this procedure was to unveil areas where the main research project might fail or whether proposed instruments were inappropriate or too complicated. It also helps in determining what resources (finance, staff) are needed for a planned research (De Vaus, 1993).
The pilot test was conducted in the Ketu North District. Ten (10) health workers were selected for the pilot study. An official from the District Health Office was also interviewed. After the pre-test of the instruments, few changes were made to make the instruments more accurate and appropriate for the study.
Ethical Issues
Prior to data collection, ethical clearance was acquired from the Municipal Directorate of Health (Ghana Health Service). Permission was obtained from all organizations and institutions concerned as well as administrators of the various healthcare facilities. Proper consent was sought from individual respondents in the course of administering the questionnaire and interview guide. I also identified myself (use of school ID card and an introductory letter from the Department of Geography and Regional Planning) to the respondents and all institutions involved. Participation in the study was voluntary hence respondents were not coerced. Respondents were granted freedom to withdraw from the study at any time. The anonymity of respondents was also observed and all forms of identification (names, addresses and telephone numbers) were avoided.
Data Analysis
The responses to the questionnaires were edited, coded and entered into computer software. The editing was done to check whether respondents have followed directions correctly and whether all items have been responded to. The quantitative data was then compiled and processed using the Statistical Package for Social Sciences (SPSS) version 22.0 and analysis were done using descriptive statistics. This helped to achieve the first and second objectives of the study.
To achieve the third objective which was to explore the perceptions of health workers on the clinical waste problem, information from the analysis of the SPSS and responses from the interview guide were categorized into appropriate themes and discussed in relation to the theory of planned behaviour. Key observations were also included to create a clearer picture of the perceptions.
Objective four on the challenges in clinical solid waste management in the Ketu South Municipality was achieved by relating with responses from the study (questionnaire, interview guide, and observation). These responses were again placed under appropriate themes and discussed. Key statistical tools (frequencies, mean and percentages) were employed in relating issues into figures for easy comparison and presentation. To support the key themes during analysis, audio recordings from the interviews were transcribed manually. Selective pictures taken during observation were also used to illustrate some of the key issues arising from the responses.
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CHAPTER FOUR
RESULTS AND DISCUSSION
Introduction
This chapter presents the findings of the study and situates them in the context of the theoretical framework. The findings are presented under the following sub-headings: demographic characteristics of respondents, characteristics of solid waste generated by health facilities, methods of solid waste treatment and disposal by facilities, perceptions of healthcare workers about clinical wastes and the challenges in clinical waste management in the Ketu South Municipality.
Background characteristics of respondents
Background characteristics of respondents that have to bear on the study included the name of the facility, sex, age, units of the hospital they work in, job description as well as a number of working years of respondents.
The age of respondents ranged from 20 to 59 years (Table 11). Females dominated in the age cohorts 20-29 while their male counterparts dominated in the cohort 30-39. Out of the 131 respondents, females constituted the majority (52%) as against 48% males. Similarly, as shown in Figure 6, the majority of the respondents (51.9%) worked at the Ketu South Municipal Hospital, which is the major referral facility in the municipality while the least, (9.9%) worked at New Hope Specialist Hospital.
Table 11: Age and sex distribution of respondents
Sex Age (%) Total
20-29 30-39 40-49 50-59
Male 19 21 6 2 48
Female 31 12 7 2 52
Total 50 33 13 4 100
Source: Fieldwork, 2018

Figure 6: Distribution of respondents by facility
Source: Fieldwork, 2018
Inferring from Table 12, 63 out of the 131 respondents being majority worked in the ward with slight variations in the various facilities, representing 50%, 54.3%, 30.8% and 40% of respondents from KSMH, CAH, NHSP, and SAMH respectively. The different wards included in this category are males’, females; children, maternity and the special wards. ENT (Ear, Nose Throat), Mental Health and the Chest Clinic had 2.9% respondents each representing the least. Table 13 shows the distribution of respondents by their job descriptions. Nurses constituted the majority, with 63.2%, 38.5% and 33.3% from KSMH, NHSH, and SAMH respectively while health assistants were in majority (31.4%) at CAH.
Table 12: Units of the hospital where respondents worked
Unit of hospital Name of the facility (%)
KSMH CAH NHSH SAMH
OPD 11.8 22.9 7.7 13.3
Wards 50.0 54.3 30.8 40.0
Pharmacy 7.4 8.6 23.1 6.7
Laboratory 4.4 8.6 15.4 13.3
Emergency 5.9 0.0 0.0 0.0
Injection/Dressing room 2.9 0.0 7.7 6.7
Theatre 4.4 5.7 0.0 13.3
X-ray 0.0 0.0 15.4 6.7
Eye unit 4.4 0.0 0.0 0.0
ENT 2.9 0.0 0.0 0.0
Mental health unit 2.9 0.0 0.0 0.0
Chest unit 2.9 0.0 0.0 0.0
Total 100 100 100 100
Source: Fieldwork, 2018

Table 13: Job description of respondents
Job description Name of facility (%)
KSMH CAH NHSH SAMH
Doctor 5.9 2.9 0.0 6.7
Nurse 63.2 28.6 38.5 33.3
Pharmacist 7.4 8.6 23.1 6.7
Lab tech/ asst. 4.4 8.6 7.7 13.3
Health/ wards asst. 5.9 31.4 7.7 26.7
Cleaner 2.9 20.0 7.7 6.7
Radiographer 1.5 0.0 15.4 6.7
Biostatistics asst. 1.5 0.0 0.0 0.0
Optician 1.5 0.0 0.0 0.0
Midwife 5.9 0.0 0.0 0.0
Total 100 100 100 100
Source: Fieldwork, 2018
The study also sought to find out the number of years respondents had worked at a facility (Table 14). From the table (14), the majority of respondents, (60.3%, 74.3%, 61.5% and 73.3%) have been working in the four facilities for more than a year but less than 6 years. Only one (7.7%) respondent from NHSH has been working in the facility for more than 21 years (specifically, 25 years).

Table 14: Number of working years of respondents
Working years Name of facility (%)
KSMH CAH NHSH SAMH
Below 1 year 13.2 8.6 0.0 0.0
1-5 60.3 74.3 61.5 73.3
6-10 22.1 11.4 15.4 26.7
11-15 2.9 5.7 7.7 0.0
16-20 1.5 0.0 7.7 0.0
21 and above 0.0 0.0 7.7 0.0
Total 100 100 100 100
Source: Fieldwork, 2018
Characteristics of clinical solid waste generated in the Ketu South Municipality
In examining the characteristics of the clinical wastes generated by the health facilities in the Municipality, respondents were asked questions on the sources of clinical waste in the facility, the types of wastes, their nature as well as the weight of their daily generated clinical solid wastes.
Sources of clinical solid waste in the Municipality
The outstanding sources identified by the respondents were the medical wards, laboratories, radiology, pharmacies and the operating theatres. These sources of clinical wastes affirm those of WHO (2014) and ICRC (2011). Table 15 shows, the various sources identified with their corresponding responses from the study. The sixth (6th) identified source (vaccination campaigns) from KSMH had 58.8% respondents as they undertake projects such as public vaccination of children among others.
Table 15: Sources of clinical solid waste in the Municipality
Source of clinical waste KSMH (%) CAH (%) NHSH (%) SAMH (%)
Yes No Yes No Yes No Yes No
Medical wards 97.1 2.9 94.3 5.7 61.5 38.5 93.3 6.7
Dental office 5.9 94.1 2.9 97.1 7.7 92.3 0.0 100
Laboratory 92.6 7.4 71.4 28.6 69.2 30.8 93.3 6.7
Radiology 61.8 38.2 34.3 65.7 46.2 53.8 33.3 66.7
Pharmacy 88.2 11.8 74.3 25.7 76.9 23.1 93.3 6.7
Chemotherapy 8.8 91.2 8.6 91.4 0.0 100 6.7 93.3
Vaccination 58.8 41.2 37.1 62.9 7.7 92.3 33.3 66.7
Operating theatre 89.7 10.3 74.3 25.7 53.8 46.2 86.7 13.3
Source: Fieldwork, 2018
Types of clinical solid waste in the Municipality
With regards to the types of clinical waste generated by the facility, it was evident from Table 16 that sharps constituted the major type of wastes generated in the Municipality throughout the four hospitals, 82.4%, 85.7%, 69% and 93.3% respectively. Similarly, pharmaceutical and infectious wastes were the next highest in all the health facilities. These types of clinical waste identified confirmed the classification based on types by the WHO (2014) and Eigeheer and Zanon (1991).
Table 16: Types of clinical solid waste in the Municipal
Types of clinical waste KSMH (%) CAH (%) NHSH (%) SAMH (%)
Yes No Yes No Yes No Yes No
Infectious 55.9 44.1 57.1 42.9 53.8 46.2 46.7 53.3
Pathological 35.3 64.7 22.9 77.1 0.0 100 46.7 53.3
Sharps 82.4 17.6 85.7 14.3 69.2 30.8 93.3 6.7
Pharmaceuticals 67.6 32.4 42.9 57.1 46.2 53.8 40.0 60.0
Genotoxic 8.8 91.2 0.0 100 0.0 100 0.0 100
Chemicals 44.1 55.9 14.3 85.7 53.8 46.2 33.3 66.7
Waste with high metal content 2.9 97.1 0.0 100 7.7 92.3 0.0 100
Pressurized containers 19.1 80.9 2.9 97.1 0.0 100 20.0 80.0
Radioactive 16.2 83.8 2.9 97.1 0.0 100 26.7 73.3
Wastewater 35.3 64.7 45.7 54.3 46.2 53.8 40.0 60.0
General waste 2.9 97.1 2.9 97.1 0.0 100 0.0 100
Source: Fieldwork, 2018
The weight of clinical solid waste generated daily
The quantity of waste produced in a hospital depends on the level of national income and the type of facility concerned. A university hospital in a high-income country can produce up to 10 kg of waste per bed per day, all categories combined (ICRC, 2011). Khan (2006) also estimated a daily-generated waste per bed of a large hospital in Pakistan to be 0.5 kg while Hanumatha (2009) estimated a weight of 9.9 to 14.0 kg daily-generated clinical waste.
In soliciting information on the weight of waste generated daily by the health facilities in the Ketu South Municipality, it was revealed that majority of respondents do not know the weight of waste that is generated daily by their various facilities. An official of the Municipal Health Directorate affirmed this in his response when asked about the weight of daily-generated clinical waste;
“that’ll be very difficult to tell and I don’t want to tell lies but I must say that what we generated at the facility level fills the Zoomlion container in about a week or two but I don’t know the weight of the container. We divide the waste into two parts, the hazardous ones are managed at the KSMH and the general ones are deposited in the Zoomlion container” An official at MHD, Ketu South
An operator at KSMH in-charge of incineration at the time of the study was also asked about the weight of clinical waste generated daily by their facility and the response was;
“I cannot tell the weight of waste that we generate daily because we have never weighed it and it has never occurred to us to do so. Even the sharps that are incinerated, we have never weighed them” Incinerator operator, KSMH
Since there was no information on the weight of the wastes, the researcher decided to measure the weight during the four (4) visits made to the various facilities using scale (Plate1). From Table 17, the average weight of clinical waste generated per day by the health facilities in the Ketu South Municipality is estimated as 87.92 kilograms.
Table 17: Weight of wastes generated by facilities
Weight of waste generated by the facilities on 4 visits Name of facility (kg) Total (kg)
KSMH CAH NHSH SAMH
1 44.2 21 3.2 12.6 81
2 43.2 23.2 2.6 13.8 82.8
3 52.5 17.1 2.15 14.9 86.65
4 63.1 26.7 3.1 8.2 101.1
Total 203 88 11.05 49.5 351.55
Average 50.72 22 2.8 12.4 87.92
Source: Fieldwork, 2018

Plate 1: Measuring Scale
Source: Fieldwork, 2018
While estimating the daily-generated weight of the health facilities, information was sought on the number of patients who visit the various health facilities daily. This was done to ascertain whether there is a relationship between the number of patients that patronize the facilities and the weight of waste generated by these facilities as opined by the ICRC (2011). It could be inferred from Table 18 that the number of patients that visit these facilities has a bearing on the amount of waste generated by the facilities since it is through activities related to these patients that waste is generated. Comparing table 17 and 18, it is evident that hospitals that have fewer patients visiting have less weight generated while those with high patients have a higher weight of clinical waste generated daily.
Table 18: Number of patients who visit the health facilities daily
Number of patients who visited the facilities on 4 visits Name of facility (%) Total
KSMH CAH NHSH SAMH
1 181 62 41 32 316
2 179 78 30 41 328
3 186 91 31 42 350
4 183 67 33 36 319
Total 729 298 135 151 1313
Average 182 75 34 38 329
Source: Fieldwork, 2018
Clinical solid waste storage
A waste storage location for any healthcare facility should be located within the facility and not outside. According to Bio-Medical Waste Management and Handling Rules (1998), storage of waste is necessary at two points thus at the point of generation and common storage for the total waste inside a healthcare organization. The waste, in bags or containers, should be stored in a separate area, room, or building of a size appropriate to the quantities of waste produced and the frequency of collection (ICRC, 2011). Unless a refrigerated storage room is available, storage times for healthcare waste (i.e. the delay between generation and treatment) should not exceed three (3) days (ICRC, 2011). While examining the storage of clinical waste in the Ketu South Municipality, respondents were asked questions on the availability of waste bins, types of bins, labelling as well as colour coding.
Availability and types of waste storage bins
The majority of respondents (125, representing 95.4%) indicated that there are waste storage bins at every unit of their facility. It was evident from the observation that all the health facilities have waste bins though inadequate at all units of the facility.
In line with Ghana’s MoH policy (2006) that prescribed general requirements for every clinical waste container, respondents were presented with various storage bins to select from which described those available for use by their facility. The guidelines as stipulated by the MoH policy in 2006 state that the collection containers should be non-transparent, impervious to moisture, leak-proof, close fitting lids and it should be of sufficient strength to prevent damage during handling or use. Plate 2 shows some of the waste bins available for use at the health facilities in the Ketu South Municipality. In this regard, cardboard and paper bags were the bins in less use and the most widely used waste bins at the time of the study were polythene bags, plastic bin, paper boxes and metal bin.

Plate 2: Types of waste bins available for use in the Municipality
Source: Fieldwork, 2018
Labelling of waste bins
The respondents were also asked about the labelling of bins in accordance with the WHO (2014) and MoH, Ghana (2006) guidelines. Most of the respondents (87.8%) indicated that labelling is done for the bins while 14 respondents (10.7%) said no and two (2) respondents (1.5%) have no idea. Despite this assertion by the respondents, it was evident that only KSMH and CAH label their bins. Their responses revealed that bins are labelled as a) general waste, b) infectious waste, c) sharps and d) chemical and pharmaceuticals (see Plate 3).

Plate 3: Labelling of bins in the Municipality
Source: Fieldwork, 2018
While the respondents indicated that the bins are labelled, they were further asked whether these bins are covered. The majority of the respondents (89.7%, 77.1%, 69.2% and 73.3%) from KSMH, CAH, NHSH, and SAMH respectively indicated that the storage bins in their facilities were fully covered.

Table 19: Covering waste bins
Bins covered Name of facility (%)
KSMH CAH NHSH SAMH
Not covered 1.5 0.0 0.0 1.5
Not always covered 5.9 17.1 0.0 13.3
Fully covered 89.7 77.1 69.2 73.3
Partially covered 1.5 2.9 0.0 0.0
Don’t know 1.5 2.9 0.0 0.0
Total 100 100 100 100
Source: Fieldwork, 2018
Storage of hazardous wastes
WHO (2014) indicates that hazardous wastes of any kind should be marked and labelled with a yellow colour code. In conforming to WHO’s standards on colour coding, the MoH Policy and Guidelines for Health Institutions (2006) recommends the use of the yellow colour to indicate hazardous, infectious and sharps.
Since the health facilities produce hazardous wastes, it was prudent to inquire about their knowledge on how hazardous waste bins are stored. This study revealed that only 35 (26.7%) respondents know the right colour code for hazardous waste. This means that majority of the respondents, 96 (73.3%) do not know the right colour code to use in storing hazardous waste (Table 20). In contrast to respondent’s knowledge on storing hazardous waste, it was evident from the observation that the KSMH uses the yellow-labelled containers with the inscription of infectious in storing hazardous waste.
It is worth noting that, among the four (4) health care facilities in the Ketu South Municipality, only the KSMH use the yellow bin in storing hazardous wastes (Plate 4). The others use bins with no colour coding while CAH uses a different type of bin in storing hazardous wastes (see Plate 5).

Plate 4: Bin for storing hazardous waste at KSMH
Source: Fieldwork, 2018

Table 20: Storage of hazardous clinical waste
Storage of hazardous waste Name of facility (%)
KSMH CAH NHSH SAMH
Black refuse plastic bag 5.9 20.0 15.4 66.7
Red clinical waste plastic bag 27.9 45.7 0.0 0.0
Standard metal bin 14.7 2.9 46.2 0.0
Pedal bin 10.3 5.7 0.0 0.0
Yellow container 38.2 14.3 23.1 6.7
Don’t know 2.9 11.4 15.4 26.7
Total 100 100 100 100
Source: Fieldwork, 2018

Plate 5: Storage container for hazardous clinical solid wastes at CAH
Source: Fieldwork, 2018

Storage facility for clinical solid wastes in the Municipality
A storage location for any healthcare facility should be located within the facility and not outside. According to Bio-Medical Waste Management and Handling Rules (1998), storage of waste is necessary at two points thus (i) at the point of generation and (ii) common storage for the total waste inside a healthcare organization.
In this regard, the various storage sites of the healthcare facilities were visited and with the help of an observation checklist, the storage rooms were observed to see if the wastes are in good condition. Plate 6 and 7 show placenta pits, and some storage sites respectively. Table 21 revealed that all the health facilities had insecure storage sites coupled with waste spillage.

Plate 6: Placenta pits at CAH and KSMH
Source: Fieldwork, 2018
Table 21: State of clinical storage room
State of storage room Name of facility
KSMH CAH NHSH SAMH
Security of storage room insecure Insecure Insecure Insecure
Ventilation Yes Yes Yes Yes
Presence of worms, flies, animals Yes No No No
Waste spillage Yes No Yes Yes
Source: Fieldwork, 2018

Plate 7: Storage sites for clinical solid waste
Source: Fieldwork, 2018
In rating the storage of waste by the facilities, 44.1% and 40% from KSMH and CAH respectively rated it as good while 69.2% from NHSH rated it as excellent and 40% from SAMH rated it as very good.
Table 22: Rating storage of clinical solid waste
Rate storage of waste Name of facility (%)
KSMH CAH NHSH SAMH
Excellent 22.1 25.7 69.2 33.3
Very good 29.4 25.7 7.7 40.0
Good 44.1 40.0 23.1 20.0
Poor 4.4 8.6 0.0 0.0
Very poor 0.0 0.0 0.0 6.7
Total 100 100 100 100
Source: Fieldwork, 2018
Treatment of clinical solid waste
Treatment of clinical waste should be the focus of every healthcare facility because indiscriminate disposal of clinical waste poses greater risks to the environment. In assessing the methods adopted by the healthcare facilities in treating their clinical wastes, this section presents issues such as segregation of wastes, use of personal protection equipment (PPE) and the incineration of wastes.
Segregation of clinical solid wastes
Segregation of clinical waste is very essential in treating waste hence respondents were asked if they separate clinical waste from other wastes. Out of the 131 respondents, 84% affirmed that they separate clinical waste from the other wastes specifically the general/ domestic wastes (Table 23). Through observation, which was the major instrument in this study, it was realized that only two (2) health care facilities in the Municipality (KSMH and CAH) truly separate clinical waste from the general wastes.
Table 23: Segregation of wastes
Segregate of wastes Name of facility (%)
KSMH CAH NHSH SAMH
Yes 91.2 80.0 84.6 60
No 4.4 17.1 15.4 33.3
Don’t know 4.4 2.9 0.0 6.7
Total 100 100 100 100
Source: Fieldwork, 2018
The segregation as described by the respondents is done by using different containers that are labelled. This inference is made from Table 24 were 90.5%, 93.5%, 66.7% and 72.7% respondents from KSMH, CAH, NHSH, and SAMH respectively indicated that segregation is done using different containers.
Table 24: Methods of segregation
Methods of segregation Name of facility (%)
KSMH CAH NHSH SAMH
Different containers (not labelled) 7.9 6.5 33.3 27.3
Different containers (labelled) 90.5 93.5 66.7 72.7
Don’t know 1.6 0.0 0.0 0.0
Total 100 100 100 100
Source: Fieldwork, 2018
In rating the segregation of waste by the facilities, most of the respondents (48.5%, 34.4%, 66.7% and 54.5%) from KSMH, CAH, NHSH and SAMH respectively, rated it as very good while 33.3% from NHSH and 19.7% from KSMH rated it as excellent (Table 25).
Table 25: Rating segregation of clinical solid waste
Rate storage of waste Name of facility (%)
KSMH CAH NHSH SAMH
Poor 1.5 0.0 0.0 0.0
Good 24.2 50.0 0.0 27.3
Very good 48.5 34.4 66.7 54.5
Excellent 19.7 9.4 33.3 9.1
Don’t know 6.1 6.3 0.0 9.1
Total 100 100 100 100
Source: Fieldwork, 2018
Collection and transportation of clinical solid waste
Mostly Zoomlion Ltd does the collection of clinical waste as indicated by the majority of respondents (KSMH 55.9%; CAH 85.7%; and SAMH 60%). However, in NHSH, 84.6% of the respondents mentioned that their wastes are collected by cleaners of the facility (Table 26).

Table 26: Who collects clinical solid waste in your facility
Collection of waste in the facilities Name of facility (%)
KSMH CAH NHSH SAMH
KSMWMD 17.6 0.0 0.0 6.7
Zoomlion Ltd 55.9 85.7 15.4 60.0
Cleaners 22.1 11.4 84.6 33.3
Don’t know 4.4 2.9 0.0 0.0
Total 100 100 100 100
Source: Fieldwork, 2018
During an interview with an official at the Municipal Health Directorate, an interesting issue came up with regards who collects waste at KSMH and this was what he has to say;
“Could you believe that a whole municipal hospital has only one old woman who collects all the waste and she is not even paid by the government but rather by the hospital?” An official at MHD, Ketu South
Plate 8 shows a woman hauling waste from generation points to the storage site on a wheelbarrow.

Plate 8: A woman hauling clinical solid waste to a storage site at KSMH
Source: Fieldwork, 2018
The next issue related to the study is how often the collection of clinical is done. Relating to Table 27, KSMH, CAH, NHSH and SAMH with their respective percentages of 30.9, 14.3, 100 and 80 respondents indicated that the collection is done daily. However, 5.9% of respondents all from KSMH expressed their view that the collection of clinical waste is done only when the waste container being used gets full. These findings are in conformity with the observed outcomes where clinical waste is collected daily especially at NHSH and largely at SAMH.

Table 27: Frequency of clinical solid waste collection
Frequency of clinical waste collection Name of facility (%)
KSMH CAH NHSH SAMH
Daily 30.9 14.3 100 80.0
Once a week 19.1 48.6 0.0 13.3
Twice a week 7.4 22.9 0.0 6.7
Once a month 32.4 2.9 0.0 0.0
When the container is full 5.9 0.0 0.0 0.0
Don’t know 4.4 11.4 0.0 0.0
Total 100 100 100 100
Source: Fieldwork, 2018
After collection, the waste is transported mostly in bins and wheelbarrows (Table 28) within the facility. Through observation, it was realized that the wheelbarrows were hauled on the same routes used by patients and other health workers and at working hours (Plate 8). This practice does not meet the suggestion of Hem (1999) that waste routes must be designated within healthcare facilities to avoid the passage of waste through patient care areas. Again, separate time should be assigned for the transportation of clinical waste to reduce chances of mixing with general waste.

Table 28: Means of transporting waste within facilities
Transportation of waste within facility Name of facility (%)
KSMH CAH NHSH SAMH
Basket 1.5 0.0 0.0 0.0
Bins 29.4 71.4 30.8 86.7
Wheelbarrow 63.2 22.9 69.2 0.0
Tricycle 2.9 2.9 0.0 6.7
Trolleys 0.0 2.9 0.0 6.7
Don’t know 2.9 0.0 0.0 0.0
Total 100 100 100 100
Source: Fieldwork, 2018
Use of protective clothing by healthcare workers
The majority of respondents (92.6%, 88.6%, 100%, 80%) from KSMH, CAH, NHSH, and SAMH respectively agreed that they use personal protection equipment (PPE) during handling of clinical wastes (Table 29). In the same vein, the majority of the respondents (89.7%, 74.3%, 100%, 80%) indicated that the facilities provide for their protective clothing (Table 30). Safety boots, gloves, safety goggles, and coveralls were the main PPE that was in use by respondents at the time of the study (Table 31).

Table 29: Use of protective clothing
Use of PPE Name of facility (%)
KSMH CAH NHSH SAMH
Yes 92.6 88.6 100 80.0
No 5.9 11.4 0.0 20.0
Not applicable 1.5 0.0 0.0 0.0
Total 100 100 100 100
Source: Fieldwork, 2018
Table 30: Provision of PPE by facility
Facility provides PPE Name of facility (%)
KSMH CAH NHSH SAMH
Yes 89.7 74.3 100 80.0
No 7.4 17.1 0.0 20.0
Not applicable 2.9 2.9 0.0 0.0
Not always 0.0 5.7 0.0 0.0
Total 100 100 100 100
Source: Fieldwork, 2018
Table 31: PPE in the municipality
Types of PPE KSMH (%) CAH (%) NHSH (%) SAMH (%)
Yes No Yes No Yes No Yes No
Safety boots 70.3 29.7 41.9 58.1 30.8 69.2 66.7 33.3
Gloves 84.4 15.6 77.4 22.6 92.3 7.7 91.7 8.3
Safety goggles 87.5 12.5 64.5 35.5 84.6 15.4 75.0 25.0
Coverall/coats 45.3 54.7 12.9 87.1 50.0 50.0 35.8 64.2
Source: Fieldwork, 2018

Incineration of clinical solid waste
In accordance with the Ministry of Health’s (2006) guidelines for clinical waste treatment and disposal which states that all infectious wastes and sharps must be incinerated at all levels, respondents were asked whether their respective facilities have access to incinerators or possess one. In this regard, 92.4% of respondents from KSMH, 91.4% from CAH and 69.2% from NHSH affirmed that they have incinerators at their facility with 66.7% of respondents from SAMH saying no. Since observation was a major instrument for the study, it was revealed that only two facilities (KSMH and CAH) have incinerators installed and while NHSH and SAMH resort to open dumping and burning. Plate 9 shows incinerators at KSMH and CAH respectively.
Table 32: Presence of incinerator
Incinerator Name of facility (%)
KSMH CAH NHSH SAMH
Yes 92.4 91.4 69.2 33.3
No 6.1 5.7 23.1 66.7
Don’t know 1.5 2.9 7.7 0.0
Total 100 100 100 100
Source: Fieldwork, 2018

Plate 9: Incinerators at KSMH and CAH
Source: Fieldwork, 2018
An incinerator operator at KSMH has this to say with regards incineration;
“We separate and incinerate the sharps onsite but the other wastes including the infectious ones are stored at the storage site near the eye clinic for onward deposal at the final disposal site” Incinerator Operator, KSMH
The operator’s statement was confirmed by the presence of piled boxes of sharps at the incineration site illustrated in Plate 10 below.

Plate 10: Incineration of sharps at KSMH
Source: Fieldwork, 2018
The respondents who indicated that they do not incinerate clinical waste onsite stated the various means through which their wastes are treated. It was indicative of their responses that Zoomlion Ltd does the major incineration while cleaners also burn the wastes at open dump places. A cleaner in charge of burning clinical waste at NHSH has this to say;
We burn the waste at a place close to the lagoon on a land which belongs to a certain man who wants to fill the place. It is known to everybody in the area that we burn our wastes every day at the place. Cleaner/security, NHSH
Final disposal of clinical solid waste
The study shows that averagely, respondents were acquainted with modern techniques of handling clinical waste because 57.4%, 65.7%, 61.5% and 46.7% from KSMH, CAH, NHSH, and SAMH respectively, mentioned that they have received training on clinical waste management (Table 33).
Table 33: Training on clinical waste management received by respondents
Received training on CWM Name of facility (%)
KSMH CAH NHSH SAMH
Yes 57.4 65.7 61.5 46.7
No 42.6 22.9 38.5 46.7
Don’t remember 0.0 11.4 0.0 6.7
Total 100 100 100 100
Source: Fieldwork, 2018
When asked about how clinical waste is finally disposed of, a sizeable proportion of the respondents from KSMH and CAH (47.1% and 48.6%) had no idea about the final disposal of wastes generated in their facilities (Table 34). SAMH and NHSH recorded the highest percentage of respondents (73.3% and 53.8% respectively) who mentioned open dumps as their means of final disposal of the clinical wastes in their facilities. Despite the large percentage of respondents having no idea about how clinical waste is finally disposed of, 31.4% of respondents from CAH indicated that Zoomlion Ltd is responsible for their final disposal of waste.

Table 34: Final disposal of clinical solid waste
Final disposal Name of facility (%)
KSMH CAH NHSH SAMH
Burying 11.8 11.4 7.7 0.0
Open dump 26.5 2.9 53.8 73.3
Burning 13.2 5.7 23.1 0.0
Zoomlion Ltd 1.5 31.4 7.7 6.7
Don’t know 47.1 48.6 7.7 20.0
Total 100 100 100 100
Source: Fieldwork, 2018
In answering a question on whether the clinical waste is disposed of together with the municipal waste, an official of the Municipal Health Directorate responded by saying;
“Yes, the non-hazardous ones are disposed together with the municipal waste but the hazardous ones (sharps, blood, body parts) are incinerated by us and the rests are disposed of with the municipal waste”. An official at MHD, Ketu South
The following Plates (11, 12 and 13) illustrate the final disposal site of the healthcare facilities as well as the presence of clinical waste at these dumps sites.

Plate 11: Final disposal site for NHSH
Source: Fieldwork, 2018

Plate 12: Final disposal site for the other healthcare facilities
Source: Fieldwork, 2018

Plate 13: Disposal of clinical waste together with the general waste at the final disposal site
Source: Fieldwork, 2018
Perceptions of health workers on the clinical solid waste problem
Perception involves actions of the senses (sight, touch, hearing, smell, and taste) in responding to external stimulation (Gibson, 2006). Ajzen (2002) further opined in his theory of planned behaviour that behavioural beliefs are the likely outcomes of a behaviour and the evaluation of the outcomes. The issue of what is a problem varies from person to person hence, respondents were asked to indicate the general problems in their health facility from a list of issues in their facility. Respondents were also asked to indicate the most serious environmental problem in the facility, whether they consider clinical waste as a serious problem in their facility as well as how concerned they are with the problem of clinical waste.
In the understanding of respondents’ perspectives on clinical waste, they were asked about the most serious environmental problem in their facility. In this regard, they were asked to select from a list of environmental issues that best suit their facility. It was evident from the study that clinical waste was considered as the most serious environmental problem in the four facilities followed by solid waste while water was considered as the least environmental problem in the Ketu South Municipality (Table 35).
Table 35: Most serious environmental problem
Most Serious Env. Problem KSMH (%) CAH (%) NHSP (%) SAMH (%)
Yes No Yes No Yes No Yes No
Sanitation 47.1 52.9 17.1 82.9 23.1 76.9 46.7 53.3
Water 36.8 63.2 8.6 91.4 61.5 38.5 20.0 80.0
Wastewater 48.5 51.5 14.3 85.7 30.8 69.2 53.3 46.7
Solid waste 47.1 52.9 48.6 51.4 7.7 92.3 46.7 53.3
Clinical waste 79.4 20.6 51.4 48.6 61.5 38.5 73.3 26.7
None 2.9 97.1 2.9 97.1 15.4 84.6 0.0 100
Source: Fieldwork, 2018
Specifically, respondents were asked if they considered clinical waste as a serious problem. In this regard, 55.9% and 53.3% respondents from KSMH and SAMH respectively considered clinical waste as a serious problem while CAH (54.3%) and NHSH (61.5%) do not consider clinical waste to be a serious problem in their facilities (Table 36).

Table 36: Clinical solid waste as a serious problem
CW as a serious problem Name of facility (%)
KSMH CAH NHSP SAMH
Yes 55.9 45.7 30.8 53.3
No 39.7 54.3 61.5 46.7
Don’t know 4.4 0.0 7.7 0.0
Total 100 100 100 100
Source: Fieldwork, 2018
On the degree of seriousness of the clinical waste, most respondents from KSMH (60.5%) and SAMH (62.5%) said it is extremely serious while 5.3% and 18.8% respondents from KSMH and CAH respectively expressed that it is slightly serious (Table 37).
Table 37: Seriousness of clinical solid waste management problem
How serious is CWM problem Name of facility (%)
KSMH CAH NHSP SAMH
Extremely serious 60.5 31.3 50.0 62.5
Quite serious 31.4 31.5 50.0 37.5
Slightly serious 5.3 18.8 0.0 0.0
Don’t know 2.6 18.8 0.0 0.0
Total 100 100 100 100
Source: Fieldwork, 2018
To probe more, respondents were asked about how they envisaged the clinical waste management problem to be in the next five (5) years. From Table 38, it can be seen that 50%, 37.1%, 46.2% and 53.3% respondents from KSMH, CAH, NHSH, and SAMH respectively said it will be less serious looking at their current approach to it. On the contrary, 20.6%, 14.3% and 7.7% respondents from KSMH, CAH and NHSH respectively envisaged that the problem of clinical waste management would be more serious in the next five (5) years.
Table 38: CSWM problem in the next 5 years
CWM problem in next 5 years Name of facility (%)
KSMH CAH NHSP SAMH
More serious 20.6 14.3 7.7 0.0
Quite serious 13.2 2.9 15.4 0.0
The same 13.2 0.0 30.8 13.3
Less serious 50.0 37.1 46.2 53.3
Don’t know 2.9 45.7 0.0 33.3
Total 100 100 100 100
Source: Fieldwork, 2018
In the same vein, respondents were questioned on how concerned they are towards the clinical waste management problem and it was evident that majority of them said that they were either concerned or very concerned (Table 39).
Table 39: Level of concern by respondents towards CSWM problem
Level of concern Name of facility (%)
KSMH CAH NHSP SAMH
Very concerned 47.1 45.7 61.5 53.3
Concerned 45.6 51.4 23.1 40.0
Not concerned 4.4 2.9 15.4 6.7
Not at all concerned 2.9 0.0 0.0 0.0
Total 100 100 100 100
Source: Fieldwork, 2018
Clinical solid waste-related risk perceptions and experiences
Respondents’ perception was also sought on the possible related risks associated with clinical waste management. In the same vein, respondents were asked about their risk of being infected while handling clinical waste. On a scale of “high”, “medium” and “low”, the majority of respondents expressed their risk of being infected to be low (Table 40).
In relation to the level of risk to other staff, 42.6% and 48.6% respondents from KSMH and CAH indicated a medium level of risk respectively. However, 53.8% and 53.3% of the respondents from NHSH and SAMH respectively maintained that there is a low risk of other staffs being infected through clinical waste management activities. Respondents maintained the same stand when asked about the risk of patients being infected due to the prevailing clinical waste management practices. The majority of them (61.8%, 65.7%, 76.9% and 66.7%) across all facilities said that there is a low risk of patients being infected and similarly, they did not consider the surrounding communities to be infected with any diseases due clinical waste management to pose risk to any community (Table 40).

Table 40: Levels of infection through CSWM
Risk of respondents being infected Name of facility (%)
KSMH CAH NHSP SAMH
High 10.3 5.7 23.1 6.7
Medium 29.4 45.7 0.0 26.7
Low 52.9 45.7 76.9 53.3
Don’t know 7.4 2.9 0.0 13.3
Total 100 100 100 100
Risk of other staff being infected
High 8.8 2.9 15.4 6.7
Medium 42.6 48.6 23.1 26.7
Low 41.2 40.0 53.8 53.3
Don’t know 7.4 8.6 7.7 13.3
Total 100 100 100 100
Risk of patients being infected
High 5.9 2.9 23.1 6.7
Medium 26.5 22.9 0.0 13.3
Low 61.8 65.7 76.9 66.7
Don’t know 5.9 8.6 0.0 13.3
Total 100 100 100 100
Risk of surrounding communities being infected
High 5.9 0.0 7.7 13.3
Medium 7.4 5.7 15.4 6.7
Low 67.6 82.9 69.2 60.0
Don’t know 19.1 11.4 7.7 20.0
Total 100 100 100 100
Source: Fieldwork, 2018
Subsequently, the majority of respondents (58.8%, 60%, 76.9% and 80%) expressed their view that there have never been cases or reports on clinical waste-related diseases in their facility. Only a few respondents (8.8%, 2.9%, and 15.4%) affirmed that there have been reported cases of clinical waste-related diseases (Table 41). Though the number of respondents who affirmed this was not substantial, it confirms the findings of ICRC (2011) and Pruss-Ustun, Rapiti and Hutin (2005) that in 2000, the WHO estimated at world level that accidents caused by sharps accounted for 87,000 cases of infection (hepatitis B virus, hepatitis C virus and HIV). ICRC (2011) also noticed that nursing staff are more prone to these viral infections through contaminated needles hence, sharps and pathogenic cultures are regarded as the most hazardous medical wastes.
Table 41: Reports on clinical solid waste-related diseases
Reports on CW related diseases Name of facility (%)
KSMH CAH NHSP SAMH
Yes 8.8 2.9 15.4 0.0
No 58.8 60.0 76.9 80.0
Don’t know 32.4 37.1 7.7 20.0
Total 100 100 100 100
Source: Fieldwork, 2018
Despite their previous responses on infection (Table 40 and 41), a significant percentage of the respondents (13.2%, 14.3%, 15.4% and 40%) maintained that they have ever sustained an injury in the past 6 months (Table 42). However, some respondents from KSMH, CH, NHSH, and SAMH with percentages of 32.4%, 20%, 7.7% and 46.7% respectively confirmed that there have been cases where other staffs sustained an injury (Table 42).
Table 42: Injuries in the past six (6) months
Injury in the past 6 months Name of facility (%)
KSMH CAH NHSP SAMH
Yes 13.2 14.3 15.4 40.0
No 82.4 82.9 76.9 53.3
Don’t know 4.4 2.9 7.7 6.7
Total 100 100 100 100
Staff sustaining an injury in the past 6 months
Yes 32.4 20.0 7.7 46.7
No 42.6 20.0 92.3 40.0
Don’t know 25.0 60.0 0.0 13.3
Total 100 100 100 100
Source: Fieldwork, 2018
Although most respondents reported low to medium clinical waste-related risks, respondents were asked to indicate possible risks that are associated with handling clinical waste. As illustrated in Table 43, the most outstanding risks selected from the options were needle pricks and injuries. Viral blood infections and disease outbreaks were the least identified risks of handling clinical waste.

Table 43: Possible risks of handling clinical solid waste
Possible risks KSMH (%) CAH (%) NHSP (%) SAMH (%)
Yes No Yes No Yes No Yes No
Injuries 52.9 47.1 62.9 37.1 15.4 84.6 73.3 26.7
Needle prick 88.2 11.8 77.1 22.9 92.3 7.7 86.7 13.3
Viral blood infection 17.6 82.4 11.4 85.7 0.0 100 33.3 66.7
Disease outbreak 17.6 82.4 5.7 91.4 53.3 46.7 17.6 81.7
Don’t know 5.9 94.1 17.1 82.9 0.0 100 6.7 93.3
Source: Fieldwork, 2018
Challenges in clinical solid waste management in the Ketu South Municipality
As stated by Riyaz, Asima, and Subhas (2010) that the management or handling of clinical waste is proving to be an overwhelming challenge for the government and the health sector, key issues were identified during this study. Respondents were presented with key challenges from which they were expected to select from on a scale of “Agree (A)”, “Disagree (D)” and “Don’t know (DK)”. Table 44 presents the various challenges identified with their respective frequencies per each facility.

Table 44: Challenges of clinical solid waste management
Challenges KSMH (%) CAH (%) NHSP (%) SAMH (%)
A D DK A D DK A D DK A D DK
Inadequate storage bins 45.6 45.6 8.8 45.7 54.3 0.0 15.4 61.5 23.1 40.0 60.0 0.0
Inadequate trained staff 47.1 39.7 13.2 77.1 20.0 2.9 15.4 61.5 23.1 33.3 60.0 6.7
Inadequate incinerators 61.8 19.1 19.1 20.0 65.7 14.3 23.1 53.8 23.1 53.3 33.3 13.3
Inadequate space for disposal 63.2 17.6 19.1 20.0 45.7 7.7 15.4 76.9 7.7 46.7 46.7 6.7
Poor attitude of patients 50.0 17.6 32.4 65.7 25.7 8.6 7.7 61.5 30.8 46.7 33.3 20.0
Poor attitude of staff 25.0 47.1 27.9 20.0 65.7 14.3 0.0 76.9 23.1 26.7 60.0 13.3
Ineffective regulation 27.9 39.7 32.4 57.1 22.9 20.0 0.0 76.9 23.1 13.3 73.3 13.3
Poor leadership 11.8 66.2 22.1 14.3 71.4 14.3 15.4 76.9 7.7 13.3 66.7 20.0
Financial constraints 73.5 19.1 7.4 77.1 11.4 11.4 23.1 76.9 0.0 60.0 33.3 6.7
Ineffective public education 77.9 16.2 5.9 82.9 11.4 5.7 15.4 76.9 7.7 66.7 33.3 0.0
Source: Fieldwork, 2018

The outstanding challenges identified were ineffective public education, financial constraints, and inadequately trained staff. The least challenges identified were poor leadership and poor attitude of the staff (Table 44).
These challenges confirm the findings of Abor and Bouwer (2008) and Tsakona (2007) that the problems associated with clinical waste management are related to inadequately trained staffs and poor attitudes of staff.
An official from the Municipal Environmental Health Office recounts some of the challenges in the Municipality;
The unavailability and inadequate distribution of personal protection equipment and other resources make it difficult for me to complain whenever I see indiscriminate disposal of waste by facilities. An official of MEHO, Ketu South
In light of these challenges, key solutions were sought from the respondents (Table 45). Majority of the respondents (85.3%, 94.3%, 76.9% and 86.7%) across all facilities accepted that improved storage of clinical wastes is one of the key solutions for solving the problem of clinical waste management in the Municipality. In the same vein, 70.6%, 88.6%, 76.9% and 93.3% respondents from KSMH, CAH, NHSH and SAMH respectively expressed that in-service training for healthcare workers is also a key solution while most of them also selected adequate provision of resources as well as segregation of clinical waste as some of the solutions. Staff motivation had a 100% response rate from KSMH only. In light of these, it was evident that these issues are key solutions to the menace of clinical waste management in the Ketu South Municipality (Table 45)
Table 45: Solutions to identified challenges
Solutions KSMH (%) CAH (%) NHSH (%) SAMH (%)
Yes No Yes No Yes No Yes No
Improved storage of clinical waste 85.3 14.7 94.3 5.7 76.9 23.1 86.7 13.3
Adequate segregation of clinical waste 63.2 36.8 74.4 25.7 30.8 69.2 73.3 26.7
Adequate provision of resources 76.5 23.5 71.4 28.6 61.5 38.5 80.0 20.0
In-service training for healthcare workers 70.6 29.4 88.6 11.4 76.9 23.1 93.3 6.7
Staff motivation 100 0.0 0.0 100 0.0 100 0.0 100
Source: Fieldwork, 2018
?
CHAPTER FIVE
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
Introduction
This chapter presents the summary and conclusions from the study as well as recommendations to help improve the clinical waste management situation in the Ketu South Municipality.
Summary of the study
The study sought to assess the clinical solid waste management practices adopted by healthcare facilities in the Ketu South Municipality. The study employed the concurrent triangulation approach and in line with this approach, the descriptive research design was also utilized. Census was used to select the sample size for the study. This consisted of 131 healthcare workers and 4 key informants. Observation, questionnaires and interview guide were used to collect the necessary data needed for the study. The data collected were edited to ensure consistency in responses, coded and analyzed using the Statistical Package for Social Sciences (SPSS, version 22.0) software. Presentation of data was done with the use of descriptive statistics (percentages, frequencies, and charts).
Summary of findings
With regard to, the background characteristics of the respondents, their age ranged from 20-59 and females constituted the majority (51.9%). In the same vein, the majority of the respondents (51.9%) worked at the Ketu South Municipal Hospital. Nurses were in majority with 63.2%, 28.6%, 38.5% and 33.3% from Ketu South Municipal Hospital, Central Aflao Hospital, New Hope Specialist Hospital and Sape Agbo Memorial Hospital respectively. The health facilities in the Municipal generate both infectious and non-hazardous clinical wastes.
The average daily generated clinical waste of the Municipal is 87.92Kg and averagely, 329 patients (clients) visit the health facilities in the municipal daily. Majority of respondents from NHSH (84.6%) and SAMH (60%) gather all wastes into one container for disposal without segregation. Out of the 131 respondents, only 35 (26.7%) know the right colour code for storing hazardous wastes in the Ketu South Municipal. Mostly, Zoomlion Ltd does the collection of clinical waste at KSMH (55.9%) CAH (85.7%) and SAMH (60%). The situation is different at NHSH where cleaners (84.6%) are responsible for the collection.
After collection, clinical waste is transported mostly in bins and wheelbarrows within the facility and are hauled on the same routes used by patients and other health workers during working hours. Majority of the respondents (92.6%, 88.6%, 100%, 80%) across all facilities use PPE provided by their facilities in handling clinical wastes. Two health care facilities (KSMH and CAH) have incinerators installed where sharps and other infectious clinical wastes are incinerated. All facilities in the Municipality resort to open dumping as their final disposal method for clinical wastes.
In terms of respondents’ perception of clinical solid waste problem, KSMH (55.9%) and SAMH (53.3%) considered clinical waste as a serious problem and on the degree of seriousness of the clinical waste, most respondents from KSMH (60.5%) and SAMH (62.5%) said it is extremely serious. Most respondents (KSMH 50%; CAH 37.1%; NHSH 46.2%; and SAMH 53.3%) indicated that the clinical waste problem will be less serious in the next five (5) years.
In relating the level of risk to respondents, other staffs, patients and surrounding communities, majority of respondents (52.9%, 45.7%, 76.9% and 53.3%) across all facilities expressed a low risk of being infected while 42.6% and 48.6% from KSMH and CAH indicated a medium level of risk respectively. Majority of respondents (61.8%, 65.7%, 76.9% and 66.7%) across all facilities said that there is a low risk of patients being infected and similarly, they did not consider the surrounding communities to be infected with any diseases due to risks posed by clinical waste management. A significant proportion of respondents (13.2%, 14.3%, 15.4% and 40%) reported that they had ever sustained injury in the past 6 months while some respondents from KSMH, CH, NHSH and SAMH (32.4%, 20%, 7.7% and 46.7% respectively) confirmed that there had been cases where other staff members sustained injury related to clinical waste, especially needle pricks.
Finally, challenges in clinical solid waste management in the Ketu South Municipality were also assessed and it was indicative that ineffective public education, financial constraints, and inadequately trained staffs were the main challenges hindering effective management of clinical waste in the Municipality.
Conclusions
The following conclusions could be drawn based on the findings of the study:
1. Segregation of clinical waste is not properly done by some health facilities in the Municipality hence, indiscriminate disposal of harmful portions of clinical waste in open spaces and nearby bushes.
2. The common mode of transporting clinical waste to the storage sites was through the use of bins and wheelbarrows. Healthcare workers are exposed to many risks as waste is hauled on the same routes used by patients and other health workers and also during working hours. The wastes are later disposed of through open dumping together with the infectious ones. This poses a great risk to the communities in which these pits are located.
3. The most common clinical waste treatment method in use by the Ketu South Municipality is the incinerator and only two (2) facilities have it installed and in good condition.
4. Clinical waste was considered as a serious problem by two (2) health facilities in the Ketu South Municipality (KSMH and SAMH) and on the degree of seriousness of clinical waste, these two (2) facilities said it is extremely serious. Meanwhile, most respondents indicated that the clinical waste problem will be less serious in the next five (5) years.
5. Healthcare workers do not consider themselves, patients and surrounding communities to be at risk from being infected with clinical wastes-related diseases. However, a significant proportion of them indicates that other healthcare workers had sustained injuries in the past 6 months, mostly from needle pricks.
6. The Ketu South Municipality faces clinical solid waste management problems due to ineffective public education, financial constraints, and inadequately trained staff. As a result, clinical waste management is not given the needed attention it deserves.
Recommendations
Based on the findings of the conclusions, the following measures are recommended for improved clinical waste management:
1. Clinical solid waste should be adequately segregated and colour coding applied to ease disposal of clinical waste in the Ketu South Municipality.
2. Transportation of clinical solid waste to storage sites should be done at odd times (early morning and evening) when routes are less busy.
3. Clinical solid wastes from all health facilities should be incinerated at the two facilities where incinerators are installed. This will reduce the rate of disposing infectious wastes into the environment.
4. There should be public education on the risks associated with ineffective disposal of clinical waste as well as possible risks that may be contacted through activities of waste scavenging at clinical waste disposal sites. This can be done through mediums such as radios, churches, mosques and other places of public gathering.
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APPENDICES
APPENDIX 1
UNIVERSITY OF CAPE COAST
FACULTY OF HUMANITIES AND LEGAL STUDIES
DEPARTMENT OF GEOGRAPHY AND REGIONAL PLANNING
QUESTIONNAIRE FOR HEALTH WORKERS
This research is aimed at examining clinical solid waste management practices in the Ketu South Municipality. I shall be grateful if you could participate in the research by answering the following questions, which will take about 50 minutes. Every information provided will be treated with utmost confidentiality. Thank you. Ali Mustapha. (MPhil. Geography and Regional Planning).
SECTION A (Demographic data)
TICK IN THE MOST APPROPRIATE BOX WHERE APPLICABLE.
1. Name of healthcare facility ………………………………..
2. What services do you provide? (a) General Hospital/ Clinical/ Health Centre (b) Special Hospital
3. Sex: (a) Male (b) Female
4. Age: (a) Below 20 (b) 20-29 (c) 30-39 (d) 40-49 (e) 50-59 (f) 60+
5. What unit of the hospital are you working in? (a) OPD (b) Wards (c) Pharmacy (d) Laboratory (e) Emergency (f) Injection/Dressing Room (g) Theatre (h) X-ray (i) Eye unit (j) Pathology unit (k) Renal (l) Other Specify.…………..…..
6. What is your job description? (a) Doctor (b) Nurse (c) Pharmacist (d) Lab Tech/Asst. (e) Health/Ward Asst. (f) cleaner (g) Radiographer (h) Other Specify………………………
7. How long have you been working in this health facility……………
SECTION B. (Characteristics of clinical solid waste generated).
8. What are the sources of clinical waste in your healthcare facility? Tick all that apply(a) Medical ward (b) Dental office (c) Laboratory (d) Radiology (e) Pharmacy store (f) Chemotherapy (g) Vaccination campaigns (h) Operating theatre (i) Others, Specify……
9. What type of wastes does your unit mostly generate at the facility? Tick all that apply(a) Infectious (b) Pathological (c) Sharps (d) Pharmaceuticals (e) Genotoxic (f) Chemicals (g) Waste with high metal content (h) Pressurized containers (i) Radioactive (j) Wastewater (k) Don’t know (l) Other, Specify…..…………
10. What is/are the nature of the wastes generated in this facility? Tick all that apply (a) Infectious (b) Hazardous/Toxic (c) Non-hazardous/non-toxic (d) General waste (e) Don’t know
11. On average, how much waste does the facility generate per day? (a) Less than 5kg (b)5kg – 10kg (c) 11kg – 15kg (d) 16kg – 20 kg (e) More than 20kg (f) Don’t know
SECTION C. (Methods of Clinical Solid Waste storage, treatment and disposal).
Storage
12. Is there waste storage bin at each unit of the facility? (a) Yes (b) No (c) Don’t Know
13. Do you gather all wastes into one container before final disposal or treatment? (a) Yes (b) No (c) Don’t Know
14. What type of waste bin(s) are/is used in storing wastes? Tick all that apply(a)Cardboard (b) Polythene bags (c) Plastic bin (d) Paper boxes (e)Paper bags (f)Metal bins (g)None (h)Don’t know
15. Are the bins labelled?(a) Yes (b) No (c) Don’t Know
16. If yes, how are they labelled? Tick all that apply (a) General waste (b) Infectious wastes (c) Sharps (d) Chemical and pharmaceutical wastes (e) Don’t know
17. Are the waste bins covered? (a) Not covered (b) Not always covered (c) Fully covered (d) Partially covered (e) Don’t know
18. How is hazardous clinical waste stored? (a) Black refuse plastic bag (b) Red clinical waste plastic bag (c) Standard metal dustbin (d) Pedal bin (e) Yellow Sharp container (f) Don’t know (f) Other, specify ……………………………………………..….
19. How do you rate the storage of clinical waste in your facility? (a) Excellent (b) Very Good (c) Good (d) Poor (e) Very Poor
Treatment
20. Do you separate clinical waste from other wastes (a) (b) (c) Don’t know
21. Do you segregate clinical waste based on their use? (a) Yes (b) No (c) Don’t know
22. If yes, how do you rate segregation of clinical waste in your facility? (a) Poor (b) Good (c) Very Good (d) Excellent (e) Don’t know
23. If yes, describe how the clinical waste segregation is done?
(a) Different containers (not labelled) (b) Different containers (labelled)
24. Do you use protective clothing when handling clinical waste? (a) Yes (b) No (c) Not applicable (d) Other (specify) …………..……
25. Does the facility provide you with protective clothing when handling clinical waste? (a) Yes (b) No (c) Not applicable (d) Other (specify) ………………..………………
26. If yes, state the protective clothing you use. Tick all that apply (a) Safety boots (b) Gloves (c) safety goggles/face shields/masks (d) coverall/jumpsuit/coats
27. Does the facility have an incinerator? (a) Yes (b) No (c) Don’t know
28. Does the facility incinerate clinical waste on site? (a) Yes (b) No (c) Don’t know
29. If no, where is clinical waste treated before final disposal? …………
30. How do you rate the treatment of clinical waste in your facility? (a) Excellent (b) Very Good (c) Good (d) Poor (e) Very Poor
Final Disposal
31. Have you received any training on clinical waste management?
(a) Yes (b) No (c) Don’t Know
32. Who collects clinical waste in your healthcare facility? (a) Ketu South Municipal Waste Management Department (b) Zoomlion Limited (c) cleaners/janitors (d) Other, (specify) ……………………..
33. How often is the collection done? (a) Daily (b) Once a week (c) Twice a week (d) Once a month (e) Other, specify………..
34. How is clinical waste transported within the facility? (Onsite)? (a) Basket (b) Bins (c) Wheelbarrow (d) Tricycle (e) Trolleys (f) Don’t know
35. How is clinical waste disposed in this health facility? (a) Burying (b) Open Dump Site (c) Don’t know (d) Other specify……………
36. How do you rate the disposal of clinical waste in your facility? (a) Excellent (b) Very Good (c) Good (d) Poor (e) Very Poor
37. Are there initiatives towards effective disposal of clinical waste? (a) Yes (b) No (c) Don’t Know
38. If yes, what are the initiatives? ………………………………………………………………………………………………………………………………………………………………
SECTION D. (Perceptions of healthcare workers towards clinical solid waste)
39. What are some of the general problems in your health facility? Tick all that apply (a) Financial constraints (b) Patients safety (c) Inadequate professional staff (d) Service provider shortage (e) Hospital security (f) Inadequate logistics (g) Water problem (h) Waste disposal (i) Structural deficiency (j) Other,(Specify) …………………………………………………………
40. Which is the most serious environmental problem in your facility? Tick all that apply (a) Sanitation (b) Water (c) Waste Water (d) Clinical Waste (e) Solid Waste (f) Other, (specify)………………..
41. Do you consider clinical waste as a serious problem in your facility?
(a) Yes (b) No (c) Don’t know
42. If yes, how serious is it? (a) Extremely serious (b) Quite serious (c) Slightly serious (d) Don’t know
43. In the next five (5) years, how do you expect clinical waste management problem to be for this facility? (a) More serious (b) Quite serious (c) The same (d) Less serious (e) Don’t know
44. How concerned are you in dealing with the clinical waste problem in this facility? (a) Very concerned (b) Concerned (c) Not concerned (d) Not at all concerned
45. Are there sanctions for facilities who dispose clinical waste indiscriminately in the municipality? (a) Yes (b) No (c) Don’t know
46. If yes, what are they? (a) Fine (b) Imprisonment (c) Both fine and imprisonment (d) Don’t know (e) Others specify…………………..
SECTION E: Clinical waste-related risk perceptions and experiences
47. Based on the storage and disposal of clinical waste in this facility, what is the risk of YOU being infected with clinically related diseases? (a) High (b) Medium (c) Low (d) Don’t know
48. Based on the storage and disposal of clinical waste in this facility, what is the risk of OTHER STAFF being infected with clinical waste-related diseases? (a) High (b) Medium (c) Low (d) Don’t know
49. Based on the storage and disposal of clinical waste in this facility, what is the risk of PATIENTS being infected with clinical waste-related diseases? (a) High (b) Medium (c) Low (d) Don’t know
50. Based on the storage and disposal of clinical waste in this facility, what is the risk of SURROUNDING COMMUNITY MEMBERS being infected with clinical waste-related diseases? (a) High (b) Medium (c) Low (d) Don’t know
51. Have there been reports on clinical waste-related diseases from your healthcare facility in the past 6 months? (a) Yes (b) No (c) Don’t know
52. If yes, State the diseases ………………………………………………………………………………………………………………………………………………………………
53. Have you ever sustained an injury during the handling of clinical waste in the past 6 months? (a)Yes (b) No (c) Don’t know
54. Has any staff ever sustained an injury during the handling of clinical waste in the past 6 months? (a) Yes (b) No (c) Don’t know
55. What are the possible risks of handling clinical waste in your facility? (a) Injuries (b) Needle prick (c) Viral blood infection (d) Disease outbreak (e) Don’t know (f) Other, specify ……………………………………………………………….……
SECTION F. (Challenges of clinical solid waste management)
56. To what extent do you agree with the following challenges in managing clinical waste in your healthcare facility? Tick at the appropriate box

Challenges Agree Don’t know Disagree
Inadequate storage bins
Inadequately trained staff
Inadequate incinerators
Inadequate space for disposal
Poor attitude of patients
Poor attitude of the staff
Ineffective regulations
Poor leadership
Financial constraints
Ineffective public education

57. What solutions can you suggest for effective management of clinical waste in the municipal? Tick all that apply (a) Improved storage of clinical waste (b) Adequate segregation of clinical waste (c) Adequate provision of resources (d) In-service training for healthcare workers (e) Other (Specify) ……………………………………………
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APPENDIX 2
INTERVIEW GUIDE FOR ZOOMLION LIMITED WASTE COMPANY
This research is aimed at examining clinical solid waste management practices in the Ketu South Municipality. I shall be grateful if you could participate in the research by answering the following questions, which will take about 60 minutes. Every information provided will be treated with utmost confidentiality. Thank you. Ali Mustapha. (MPhil. Geography and Regional Planning).
Date of interview …………………………………….
Place of interview ……………………………………
Gender of respondent ……….………………..………
Position/title of respondent……………………………
Characteristics of clinical waste generated
1. What is your view on the problem of clinical solid waste?
2. Which hospitals seek your services in the clinical solid waste collection?
3. Describe the types and quantity of clinical waste you collect daily from the health facilities?
Methods of clinical waste storage, treatment, and disposal
4. How will you describe the separation of clinical waste in the Municipality?
5. How do you store clinical wastes?
6. How do you treat clinical wastes?
7. How do you dispose of clinical waste?
8. Who oversees the treatment and disposal process?
9. What are your schedules for clinical waste collection from the various health facilities?
10. What equipment is at your disposal for clinical waste management?
Perception of healthcare workers towards clinical waste
11. How involved are you in the management of clinical waste?
12. How do you perceive the problem of clinical waste management in the municipality?
13. How do these perceptions affect your work?
14. Describe the training you give to your staff on clinical waste management?
Challenges of clinical waste management
15. How do the health facilities follow-up to check how you treat and dispose of waste collected from their facilities?
16. What are the challenges you face in managing clinical waste?
17. Would you like to make any other comments or ask questions with regards clinical waste management?

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INTERVIEW GUIDE FOR MUNICIPAL ENVIRONMENTAL HEALTH OFFICER AND MUNICIPAL HEALTH DIRECTOR OF KETU SOUTH
This research is aimed at examining clinical solid waste management practices in the Ketu South Municipality. I shall be grateful if you could participate in the research by answering the following questions, which will take about 60 minutes. Every information provided will be treated with utmost confidentiality. Thank you. Ali Mustapha. (MPhil. Geography and Regional Planning).
Date of interview …………………………………………..
Place of interview ………………………………………….
Gender of respondent ……….……………………………..
Position/title of respondent…………………………………
Methods of clinical waste storage, treatment, and disposal
1. Do the healthcare facilities in the municipality follow the following Guidelines for managing clinical waste?
a. WHO, 2014
b. International Solid Waste Association policy on clinical waste
c. National Environmental Sanitation Policy, 1999
d. Public Health Act, 2012
2. Have these documents been scrutinized to see whether they address all issues with clinical waste?
3. Does the MoH Guideline on clinical waste management commensurable with international standards?
4. Is clinical waste disposed of together with the municipal waste at disposal sites?
Perception of healthcare workers towards clinical waste
5. How do you perceive the problem of clinical waste management in the municipal?
6. How frequently do you visit healthcare facilities to assess their methods of clinical waste management?
Challenges of clinical waste management
7. What are the risks that inappropriate management of clinical waste poses to the environment and human?
8. Would you like to make any other comments or ask questions with regards clinical waste management?

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INTERVIEW GUIDE FOR INCINERATOR OPERATORS
This research is aimed at examining clinical solid waste management practices in the Ketu South Municipality. I shall be grateful if you could participate in the research by answering the following questions, which will take about 30 minutes. Every information provided will be treated with utmost confidentiality. Thank you. Ali Mustapha. (MPhil. Geography and Regional Planning).
Date of interview ……………………………………….
Place of interview ………………………………………
Gender of respondent ……….…………………..………
Position/title of respondent……………………………
Characteristics of clinical waste generated
1. What quantity of clinical waste is brought for incineration daily?
Methods of clinical solid waste storage, treatment, and disposal
2. Are the clinical wastes segregated at source?
3. Do you incinerate separately or together?
4. What procedures do you go through during incineration?
5. What other options are available for treating clinical waste?
6. What equipment is provided by your facility?
7. Are they adequate?
8. How do you store clinical wastes that could not be incinerated during the day?
Challenges of clinical waste management
9. Are you provided with adequate training on clinical waste handling?
10. How many injuries have you recorded in the past 6 months?
11. What challenges do you face?
12. Have you reported these challenges to the appropriate authorities?
13. What has been their response?
14. Would you like to make any other comments or ask questions with regards clinical waste management?

OBSERVATION CHECKLIST
DAY 1 2 3 4
DATE
The quantity of clinical waste per day
Number of patients who visited the healthcare facility per day
Sources of clinical waste
(a) Medical ward (b) Dental office
(c) Laboratory (d) Radiology
(e) Pharmacy store (f) Chemotherapy (g) Vaccination campaigns
(h) Operating theatre
Segregation of waste at source:
(a) Yes OR (b) No
Bag containing waste
(a) Secured fastened
(b) Not fastened securely
(c) Placed in the right place
(d)Left for too long
Supply of Receptacles ( A=Adequate, I=inadequate)
(a) Red plastic
(b) Sharps container
(c) Pedal Bins
Others (Specify)
Use of colour coded and labelled receptacles (a) Yes (b) No
Mode of transport to the storage place
(a) Use of hands (b) Pedal Bin
Other specify
Use of protective clothing when handling waste (a) Yes (b) No
Types of protective clothing used
Clinical waste storage room
(a) S=Secure, I=insecure (b)V=Ventilated, N=not ventilated (c) PS=Presents of scavengers (d) PWFA=Presents of worms, flies, animals (e) WP=Waste spilling.
State of waste. (a) R=Rotten (b) S=Smelling (c) D=Dry
Collection (Collected/ not collected)
Storage room, bins, trolleys cleaned after collection (a) Yes (b) No
Waste transportation off-site
(Use of designated vehicle)

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