Strategies for the improvement of home medical waste management during the COVID-19 pandemic

ABSTRACT

Home care services (HCS) are important to assist patients with difficulties in accessing conventional health services. Nevertheless, in times of COVID-19 pandemic, the traditionally offered service needs to be restructured to protect health professionals, patients and their families. In this context, this article aims to identify the impacts resulting from the COVID-19 pandemic on home medical waste management (MWM), converting threats into opportunities, and weaknesses into management strengths. Three months before the pandemic (from October to December), a comprehensive survey was conducted on the practices of home care services and MWM with health professionals, caregivers and patients in Caruaru (Brazil). Quali-quantitative information was collected by structured and semi-structured interviews. For evaluation, the SWOT-TOWS analysis was applied to identify the threats and weaknesses of the practices of HCS and MWM, and to propose strategies to ensure the protection of public health and the environment. The results showed that the main weaknesses found were the lack of training of health professionals and the lack of guidance given by them to caregivers of patients, both related to MWM. Except for sharp waste, all other MWM practices have proved to be inadequate, posing threats, especially in a pandemic period. Four action strategies to improve HCS and MWM were identified: (i) providing MWM training to HCS personnel based on ISO standards; (ii) providing MWM information to caregivers and patients; (iii) planning actions to optimize the service during the pandemic; and (iv) sharing HCS management with municipal decision makers. Between December 2020 and January 2021, semi-structured interviews were performed only with health professionals, to verify the impacts and changes that have occurred in HCS in the COVID-19 pandemic. Comparing the results of the two surveys, improvements were achieved, including the incorporation during the pandemic of some strategies identified in the first phase of the research.

Implications: Home care service plays a fundamental role in the quality of life of patients and in the sustainability of the public health system in Brazil. In the pandemic period, HCS was impacted with routine changes and the adoption of new personal protective equipment. Our results showed the need to promote strategies to improve HCS to preserve the health of professionals and patients attended, in the pandemic and post-pandemic period. The strategies identified in the study contributed to improvements in the provision of the service and in the management of medical waste that is still inadequate. Such issues are of interest to municipal health management, which has adopted some of the suggested strategies. The thousands of HCS distributed in Brazilian municipalities can also adopt the strategic actions resulting from this research.

Introduction

Home care services (HCS) are recognized by health systems as a resource for assisting patients with difficulties in accessing health care. Prevention, rehabilitation and health care are increasingly provided by in-home professionals due to the aging population, the increase in chronic degenerative diseases and the number of people in need of continuous care (Olsen et al. 2019; Ritchie and Leff 2017). HCS reduces the congestion of hospitals, promotes greater turnover of occupied beds and improves patients’ quality of life (Di Mascolo, Espinouse, and El Hajri 2017). However, during the COVID-19 pandemic, the traditional provision of the service needs to be reformulated to protect health professionals, patients and their families.

The high transmissibility of COVID-19, especially at the onset of symptoms, suggests that generalized social distance measures are the most effective method of prevention (Cheng et al. 2020). However, one of the characteristics of the HCS is the placement of health teams in homes, following a route in which several families are visited in the same day. Even with the use of new personal protective equipment (PPE), the approach of teams and visiting routes must be rethought to avoid contagion between patients and teams, changing all the regular functions of HCS.

Home care services and COVID-19 pandemic

Literature has been increasingly documenting the concerns with the provision of home care services during the COVID-19 pandemic. Nilsson, Andersson, and Sjödahl (2021) showed the contribution of COVID-19 in the fatality of more fragile patients and patients with comorbidities, assisted in home care. Shang et al. (2020) and Sama et al. (2021) report that the professionals of home care services have verified the decline in the demand for home visits because of fear related to the risk of infection by COVID-19. Given the uncertainties imposed by the pandemic, home care health professionals, although being on the front line, expose difficulties in accessing training, supplies and technologies (Guerrero et al. 2020; Jones and Bowles 2020; Sterling et al. 2020). Furthermore, the search for strategies based on smart medical care as an encouragement to the use of telemedicine during and after the pandemic (Rosen et al. 2021; Zahoransky and Lape 2020) and the use of drones for the distribution of supplies (Euchi 2020) has been necessary to ensure the health care, eliminating contamination by the reduction of human contact.

In developing countries, changes and adaptations resulting from the COVID-19 pandemic will result in additional costs to already precarious HCS that suffer from a lack of medicines, materials and PPE, as well as inadequate waste management.

Home care services and waste management

Home medical care has been advancing worldwide (Ikeda, Fujiwara, and Sasaki 2021). Despite the undeniable benefit to the population’s health, the resulting generation of medical waste in households poses new challenges to municipal solid waste management systems, especially in developing countries. In countries such as South Africa, Ghana and Botswana, waste from HCS is discarded along with ordinary household waste, burned or buried (Hangulu and Akintola 2017; Kang’ethe 2008; Udofia, Gulis, and Fobil 2017; Zikhathile and Atagana 2018). Inadequate disposal of hazardous medical waste poses risks to the environment and public health (Ilyas, Srivastava, and Kim 2020).

The generation of medical waste in HCS is lower than that of hospitals, which are the main producers. In Turkey, more than 70% of HCS patients produce less than 0.5 kg/patient/day of medical waste (Sonmez, Nazik, and Andi 2018). However, HCS generate a quantity of potentially hazardous waste that, without proper management, can contribute to the risks of infections for family members and urban cleaning workers. With the recovery of COVID-19 patients in households, the chances of contamination of common waste with medical waste increase greatly (Capoor and Parida 2021), posing even more pressure on the already deficient services of collection of this type of waste in developing countries. Organisms such as the World Health Organization (WHO 2020a) and the Centers for Disease Control and Prevention (CDC 2020) recommend that waste potentially contaminated by COVID-19 convalescent patients should be treated as any other infectious waste. The home medical waste generated by COVID-19 convalescent patients should be stored in resistant bags closed before discarding and collection by the municipal waste services (WHO 2020a).

Some studies have highlighted the risks of accidents suffered by workers who regularly collect household waste, especially municipal workers concerned with accidents with needles during collection in Japan (Miyazaki, Imatoh, and Une 2007). In addition, the lack of publications on damage related to the disposal of household hazardous waste contributes to the neglect of the management of this waste (Udofia, Gulis, and Fobil 2017).

So far, there are few studies worldwide dealing with waste management of HCS. In Brazil, three studies found on that subject are those of Alves et al. (2012), Siqueira and Consoni (2008), both in Portuguese, and Cordeiro et al. (2019), in English. The present study is intended to minimize this gap by evaluating the situation in the municipality of Caruaru, Pernambuco State, since it represents a medium-sized city with an important regional medical-hospital hub. Caruaru has three HCS, which provide home medical care in urban and rural areas of the municipality and regional neighboring. The HCS addressed in this research is a public service provided by the Government and available in all Brazilian states, totaling 1,157 home care services and support teams (MS 2020a). In this context, this work is intended to identify ways and means of converting the possible threats presented by the pandemic into opportunities – transforming weaknesses into strengths – in relation to HCS practices. The practices considered in this work include home care services provided by municipal health teams and patient caregivers and the handling of waste resulting from home care services.

Methods

Before the COVID-19 pandemic, a survey on HCS waste management had been conducted between October and December 2019 in the municipality of Caruaru (Brazil). In addition to waste management, the researchers addressed the investigation of HCS work routines and procedures of the teams and patient caregivers by interviews and the application of structured questionnaires to all stakeholders. During the analysis of the results, amid the changes in habits imposed by the pandemic, the authors realized that the practices of health care and waste management identified in the field visits have been severely impacted, and modifications will be necessary.

Figure 1 summarizes the research design and methodology adopted for this work. The research was divided into four stages: (i) preliminary research assessment and literature gap identification, (ii) data collection, (iii) data analysis and (iv) conclusions.

Figure 1. Research design.

Description of the study area

The research was performed in the municipality of Caruaru, medium-sized city with a population estimated in 365,278 inhabitants for 2020, distributed over a territory of 923.150 km² (IBGE 2020). Caruaru is considered one of the largest manufacturing centers in Brazil, producing clothes sold for the national and international markets, and with total monthly billing superior to 144 million reais (around 28 million dollars) (Caruaru 2018).

Caruaru is also known as the medical reference center (SES 2018), with 517 public health units (general hospitals, specialized hospitals, clinics, basic health units, among others), reaching the position of the second largest medical center in the region, only behind the capital of the state of Pernambuco (CONDEPE/FIDEM 2017). HCS is one of the services provided by the basic health units and Caruaru has three HCS units, as shown in Figure 2. HCS are responsible for patient care in urban and rural areas and adjacent districts. Each HCS (HCS 1, HCS 2 and HCS 3) has a multiprofessional team formed by a doctor, a nurse, a physiotherapist and three nursing technicians. These teams perform weekly visits, attending four to six patients per day. The services provided include wound dressing, medication administration, collection of material for exams and palliative care. One of the criteria for the inclusion of patients in home care is the presence of a caregiver, who can be someone from the family or a friend. Thus, HCS ensures the continuity of care with health, by integrating caregivers in the activities to be performed daily.

Figure 2. Location of the municipality of Caruaru and distribution of HCS.

Sampling design

The research was performed in two distinct steps. The first step, with data collection in situ, occurred between October and December 2019, a little before the COVID-19 pandemic beginning. During this period, the HCS were assisting 49 patients, with teams composed of 18 health professionals (Table 1). The number of patients varied depending on the flow of people who are discharged or die. In this first step, all health professionals and caregivers/patients were interviewed personally, in other words, it was possible to interview 100% of the stakeholders.

Table 1. Sampling of research participants

Home Care System	BEFORE THE PANDEMIC				DURING THE PANDEMIC
	Health Professionals		Caregivers/Patients		Health Professionals		Caregivers/Patients
	Total	Total respondents	Total	Total respondents	Total	Total respondents	Total	Total respondents
HCS 1	6	6	15	15	6	4	N/A*	N/A*
HCS 2	6	6	16	16	5	3	N/A*	N/A*
HCS 3	6	6	18	18	6	5	N/A*	N/A*
Total	18	18	49	49	17	12	N/A*	N/A*

*N/A – Not allowed

The second step of the research, conducted between the months of December 2020 and January 2021, aimed at identifying the main alterations and challenges faced in the provision of HCS and in the management of home medical waste. In this second step, the interviews were semi-structured and performed by telephone and e-mail (electronic form). The in-person visits of the research team to assisted households have not been authorized, because of the pandemic. Among the 17 health professionals that belonged to the HCS teams, 12 (70.6%) answered to the remote survey.

Data collection

Interviews before the pandemic period

The descriptive and qualitative study was carried out using two types of questionnaires, one directed to the caregivers responsible for the patients and the other to the multiprofessional teams of the HCS. The questionnaires were developed based on a review of scientific literature and national legislation in force (ANVISA 2018; CONAMA 2005), in addition to conversations with health professionals. Structured and semi-structured questions were elaborated and selected, according to a degree of clarity and objectivity, in order to avoid doubts in the interviewees. The questionnaires were applied individually and personally. In the caregivers’ questionnaire, the questions were directed to the sociodemographic characterization (gender, age group, education, occupation) and to the main practices of handling the waste generated in daily care. The sociodemographic information of caregivers constitute important information for studies on medical home care (Guerrero et al. 2020; Sterling et al. 2020) and home medical waste management (Kang’ethe 2008; Udofia, Gulis, and Fobil 2017; Zikhathile and Atagana 2018). Caregivers are in direct contact with patients and need to learn how to correctly manage the waste generated from health care. In the health professionals’ questionnaire, the questions addressed professional qualifications, communication and training relationships between HCS teams and caregivers, in addition to the management and characterization practices of medical waste after home visits.

The interviews with the health professionals were conducted in each HCS and those with caregivers and patients, in the own patients’ residences during the visits with the health teams. On home visits, attitudes and practices were also observed in service provision and in medical waste management.

Interviews during the COVID-19 pandemic

Because of the pandemic, data collection to verify the changes in procedures was performed by phone calls and conversations with the professionals responsible for the HCS teams. From this first contact, a questionnaire was designed and applied remotely, by the submission of an electronic questionnaire by e-mail. The structured questions approached: (i) guidance given to professionals, caregivers and patients in relation to health and safety, during the COVID-19 pandemic; (ii) changes in the routine of home visits; (iii) access to personal protective equipment and disinfectant material; (iv) impacts and challenges in service provision during the pandemic; and (v) practices of medical waste management.

Data analysis

The collected data were analyzed using the statistical software R version 3.6.2 and are presented with the distribution of frequencies and averages. In addition to the questionnaires, the survey was conducted with on-site visits and checks.

With the information provided by the respondents, a SWOT analysis and TOWS matrix were employed in the analysis of home care practices. The SWOT analysis was performed based on direct observation and information obtained during the visits to the three HCS and to the households assisted in the research period. The use of the TOWS matrix allowed the identification of strategies to improve the health care and home medical waste management practices.

Results and discussion

General characterization of the interviewees

One of the criteria for inclusion of patients in HCS is the presence of caregivers in the patient’s daily activities. In this context, 77.6% of caregivers stated that they work exclusively at home. The majority of caregivers were female (79.6%) and aged over 50 years (55.1%). More than 60% of the caregivers did not attend or did not conclude high school. Table 2 shows a brief characterization of the caregivers.

Table 2. Brief characterization of the caregivers

Caregivers		%	Frequency
Gender	Female	79.6	39
	Male	20.4	10
Age of the caregivers	18–30	4.1	2
	31–40	14.3	7
	41–50	26.5	13
	>50	55.1	27
Occupation	Do not work outside home	77.6	38
	Work outside home	22.4	11
Level of schooling	Did not enter/conclude high school	63.3	31
	Complete high school	20.4	10
	Complete/incomplete higher education	16.3	8

Complementary training and working time for each HCS professional is described in Table 3. Each HCS team had three professionals with university degrees and three technical professionals. All professionals with degrees mentioned specializing in professional practice areas, except for one nurse (HCS 1). Regarding training in medical waste management, less than 25% of health professionals (nursing technicians and nurses) had received training within the past 5 years, even though they routinely deal with this type of waste.

Table 3. Complementary training and working time for HCS professionals

	Complementary training	Training in MWM^a (within the past 5 years)	Working time in HCS^b (months)
HCS 1
Doctor	Pediatrics	No	72
Nurse	-	No	60
Physiotherapist	Dermato-functional physiotherapy	No	72
Nursing technician 1	-	Yes	84
Nursing technician 2	-	No	36
Nursing technician 3	-	Yes	24
HCS 2
Doctor	Master’s degree in education	No	180
Nurse	Urgency and emergency	No	4
Physiotherapist	Manipulative physiotherapy and multiprofessional residency in public health	No	22
Nursing technician 1	-	Yes	96
Nursing technician 2	-	No	66
Nursing technician 3	-	No	6
HCS 3
Doctor	Occupational medicine, rheumatology and dermatology	No	2
Nurse	Adult and pediatric emergency, neonatal ICU	Yes	24
Physiotherapist	Osteopathy and manual/ intensive therapy	No	19
Nursing technician 1	-	No	96
Nursing technician 2	-	No	84
Nursing technician 3	-	No	72

Notes: ^aMedical waste management; ^bHome care services

Concerning experience in home care services, all professionals had more than 18 months of experience, except for a doctor, a nurse and a nursing technician. The information in Tables 2 and 3 was especially important in the formulation of the work strategies.

SWOT analysis

Strengths, weaknesses, opportunities and threats are abbreviated as SWOT. The SWOT analysis technique was used to identify the current internal and external environmental conditions in this context. According to (Eheliyagoda 2016), this technique or approach, which originated from the business management field, has been widely applied to a broad array of disciplines. A SWOT analysis of home medical waste management related to HCS with a focus on COVID-19 helps further our understanding of external and internal conditions these professionals face when developing strategies or action plans.

With the information obtained in the interviews, it was possible to identify four elements that make up the SWOT analysis, as follows:

(i) Strengths: Home care services are complementary to other approaches. In Brazil, HCS is an important channel of primary health care, the central axis of the public health system in Brazil. HCS consists of a set of actions to promote health, disease prevention and rehabilitation in households with guaranteed continuous care (MS 2020b). The service plays a strategic role in tackling the pandemic by reducing unnecessary hospitalizations and overcrowding in health facilities on an urgent and emergency basis. Although the maximum possible reduction in contact between people is a recommendation of the World Health Organization (WHO 2020b), decreasing home visits in this pandemic scenario can result in worsening health of existing users and the need for hospitalization (MS 2020c). Thus, the HCS, in addition to decreasing the demand for hospital beds for patients with severe symptoms, will also have the role of guiding users on the prevention of contagions, clinical manifestations and general care. Furthermore, HCS is an integrative service that encompasses multidisciplinary teams and caregivers, aiming for humanization of care and expansion of autonomy, inputs and medicines, and higher quality and resoluteness of care (MS 2020b).

(ii) Weaknesses: Among the factors that contribute to the malfunctioning of health services, lack of training is one of the most relevant. Insufficient knowledge can lead to inappropriate practices, increasing the risk of dangers and negative consequences in the short, medium and long terms (Ikeda 2014). Tabash et al. (2016) observed a statistically significant relationship between health professionals’ knowledge and practices in relation to waste management, and that educational programs can be considered an effective tool to change the practice of pharmaceutical waste management. Despite the legal obligation of training and capacity-building for teams providing health services (ANVISA 2018), more than 75% of HCS professionals reported that they had not received training on medical waste management in the last 5 years. In all HCS, only one nurse and just over half of the nursing technicians had received training in medical waste management within the past 5 years. About 40% of HCS professionals stated that they do not advise caregivers on the management of medical waste management. Regarding management practices, only sharp wastes (generated on the day of the visit) are segregated, packed in rigid collectors and taken by teams of health professionals for joint disposal with health waste from municipal health units. Other wastes produced in health procedures (gloves, gauze, probes, bandages, leftover medication etc.), during or after the visit of the health teams, are discarded together with ordinary household waste, stored in unmarked plastic bags or containers. Other sharp waste used in daily procedures, such as those of self-administration of insulin and self-monitoring of blood glucose, are also discarded together with ordinary household waste. Miyazaki, Imatoh, and Une (2007) highlighted the concern of people who work with urban cleaning in Japan when collecting or transporting medical waste, especially by reports of accidents with needles. Ikeda (2017) proposed that the sharp or infectious items should be collected by the HCS doctors or nurses, to avoid the storage of this type of waste in the houses of the patients and the discard together with common waste, in Japanese municipalities. In a study conducted in Turkey, Sonmez, Nazik, and Andi (2018) demonstrated that only the training of the caregivers for separating waste is not enough for proper management; the municipal collection of the medical waste is necessary.

In Brazil, the management of health service waste is a legal liability of the health unit that generates it (CONAMA 2005). The medical waste produced by HCS must be stored and collected by the service agents themselves or people trained for this purpose (ANVISA 2018). In Brazil, the practice of disposal of chemical and biological waste with household common waste was observed by Alves et al. (2012) in a HCS in Goiânia, Siqueira and Consoni (2008) in São Paulo, and Cordeiro et al. (2019) in Ribeirão Preto.

The lack of a specific management plan for home care contributes to non-standardization and nonconformity, such as those found in waste management, resulting from the misunderstanding of the roles and responsibilities of each person involved in the HCS.

(iii) Opportunities: In view of the evidence related to transmissibility and mortality caused by COVID-19, a set of surveillance, preparation, management and protection measures are being carried out with the intention of reducing the risk of contamination (Adams and Walls 2020). Proper management of waste potentially contaminated by the virus is an important step in minimizing risks. In Brazil, the handling and disposal of waste with the potential presence of biological agents that may present a risk of infection are regulated by National Health Surveillance Agency (ANVISA 2018) and National Environment Council (CONAMA 2005). The COVID-19 pandemic has presented an opportunity to discuss short- and long-term changes in waste management practices worldwide (Kalina and Tilley 2020; Shammi, Behal, and Tareq 2021), especially in developing countries, where waste management strategies are precarious. This opportunity can result in better management of the waste generated in home care services in current and future periods.

(iv) Threats: Most patients who receive HCS are elderly (over 68 years) and have chronic diseases; they are vulnerable to contamination or complications due to preexisting conditions, according to the pandemic risk groups (WHO 2020b). The transmission cycle of COVID-19 is short, and some studies suggest that transmission can happen even before the onset of symptoms (Bai et al. 2020; Cheng et al. 2020). Home care teams visit more than one residence per day, and caregiver-patient-health professional contact can be considered a route of transmission. Transmission may occur through direct contact between them, the continuous use of work instruments (medical record, thermometer, stethoscope) or contact with contaminated surfaces and residues, considering the time that the virus remains on surfaces which, according to (Ilyas, Srivastava, and Kim 2020), can be up to 72 hours on the surface of an individual protection equipment, such as a surgical mask.

TOWS matrix and strategies for improvement of home medical waste management

The TOWS (threat, opportunity, weakness and strength) matrix developed by (Weihrich 1982) is a commonly cited tool for structuring strategy generation (Jasiulewicz-Kaczmarek 2016). The TOWS analysis is a conceptual strategic planning model allowing for flexible formulation of an organization’s strategic directions by considering future opportunities and threats and seeking to optimize the use of the organization’s strengths to minimize its weaknesses. From the TOWS matrix, a comprehensive review on home care service provision was performed, based on the HCS that were the object of this study and other similar home care services that exist throughout the country.

As a result, it was possible to cover all strategic perspectives as follows (Figure 3): (i) offensive strategy (S * O) aims to increase and improve the strengths (S) to promote the appropriate use of opportunities (O), allowing competitive advantages; (ii) confrontation strategy (S * T) consists of developing confrontation strategies using strengths (S) to reduce threats (T); (iii) reinforcement strategy (W * O) aims to analyze and overcome weaknesses (W) to take advantage of opportunities (O); and (iv) defense strategy (W * T) aims to develop defensive actions to protect professionals and patients involved in the HCS, reducing the impact of threats (T).

Figure 3. SWOT analysis and the TOWS matrix.

Regarding home medical waste management, the following strategies are highlighted and detailed.

Offensive strategy (S * O)

As an offensive strategy, the implementation of periodic training programs to train professionals in the management of waste generated in the HCS will strengthen home care. As an accessory service to home health care, the teams of HCS will be able to better guide families regarding the dangerous characteristics and the need to separate medical waste. The specific collection of home medical waste, regardless of the HCS team visits, must be performed by the service provider (the municipality).

Two international standards (non-certifiable) can also better support this strategy, ISO 14063:2020 (Environmental management – Environmental communication – Guidelines and examples) (ISO 2020) and ISO 10015:2019 (ISO 2019) (Quality management – Guidelines for competence management and people development). The first document gives guidelines to organizations for general principles, policy, strategy and activities relating to both internal and external environmental communication. This standard can help share information, trust building, credibility and partnerships to raise awareness in those involved. The second document refers to what is necessary for an organization to establish, implement, maintain and improve systems for competence management and people development to positively affect outcomes.

Confrontation strategy (S * T)

As a confrontation strategy, the search for a guarantee of HCS service provision is highlighted, given the adversities imposed by the pandemic period. Many HCSs have been experiencing a reduction in the demand for home visits, because of the concern of users and health professionals regarding infection by COVID-19. In this sense, caregivers and patients must have access to guidelines and new procedures, which guarantee the safety and reliability in service provision, such as, for instance, the use of technologies based on smart medical care. In Brazil, the Brazilian Federal Council of Medicine (CFM) and the Brazilian Federal Council of Nursing (COFEN) have already standardized the use of telemedicine as a way to fight the COVID-19 pandemic (CFM 2020; COFEN 2020).

Reinforcement strategy (W * O)

As a reinforcement strategy, it is observed that the pandemic has brought the opportunity to discuss the management of infected waste produced in the home environment, by people recovering from COVID-19. Simultaneously, it is demonstrated that the generation of chemical and biological waste in the home environment is not exclusive from the pandemic. With the visibility of this type of waste, a window of opportunity is opened for the discussion of the weaknesses in the management of medical waste generated in the HCS. In this sense, an important step is a deeper involvement of the decision-makers, in order to provide financial and material resources. They are crucial for developing protocols, booklets and websites with information and guidelines to the caregivers and patients on the appropriate management of the medical waste. This is very important to control the transmission of diseases and environmental pollution. Municipal administration must contemplate the procedures related to appropriate storage, collection and disposal of home medical waste in the municipal solid waste management plan.

Defense strategy (W * T)

As a defense strategy, there is the aim of preventing the medical waste to be discarded inappropriately. Therefore, the establishment of micromanagement measures for the proper collection and disposal of home medical waste will be necessary, especially considering the logistical and practical challenges of the participation of public power. According to the WHO (2020c), where decontamination cannot be performed in the laboratory area or on site, the contaminated waste must be packaged properly, for transfer to another facility with decontamination capability. This same procedure could be recommended for infectious waste from patients in home treatment. When there are no routes established for collecting home medical waste, solutions to protect people who work with urban collection, public health and the environment must be presented. In other words, home medical waste must be stored in milky white bags, double when possible, and closed in order to isolate the material inside the bag, and identified with the symbol of infectious substance. The health service monitoring the patient’s home treatment can provide the materials for proper storage (kits with milky white plastic bags, seals and containers for the disposal of sharp material) and proceed with the collection of these materials on subsequent visits.

The strategies identified in this research are interrelated and require dedication of all stakeholders (heath care workers, caregivers, patients and authorities). Figure 4 summarizes the main strategic actions for improving the functioning of HCS.

Figure 4. Strategic actions to improve the home care services.

Actions to preserve the health and safety of professionals and patients are even more necessary during the pandemic. Care measures regarding transmission of COVID-19 were highlighted in this context, generating further potential actions in addition to those aimed at the care of waste generated through these services.

Changes adopted in the pandemic period

In March 2020, some HCS work routines have been modified by internal and external requirements: (i) new guidelines on personal and environmental hygiene practices were given to patients and caregivers; (ii) the number of families visited daily has been reduced to 3 families and telemedicine was adopted for patient care; (iii) new equipment and products (N95 masks, gloves, eye protection, apron and gel alcohol) were made available to HCS professionals during health care.

Those responsible for HCS also reported: (i) there was a drop (from 49 to 39 patients) in the demand for HCS for new patients after the start of the pandemic and much of the face-to-face assistance was replaced by telemedicine; (ii) 33.3% of HCS professionals and a still inaccurate number of patients became infected with the new coronavirus (SARS-CoV-2); (iii) the only medical waste management activity observed was the adequate collection of sharps.

Conclusion

This study illustrated the need to promote strategies to improve home care services, emphasizing strengths and opportunities and minimizing weaknesses and threats. Regarding home medical waste disposal, the sharp materials used by the HCS health teams are collected for proper disposal by the municipal medical waste management service. The other home medical waste generated during the visit, as well as those produced by the care to the patient in the subsequent days, are discarded together with common household waste. Since there is no regular home medical waste collection by the municipality, nor guidelines to avoid disposal together with household waste, the HCS teams do not guide caregivers about the danger of this waste and the need for separation and appropriate discard. Even with the COVID-19 pandemic, inappropriate practices of home medical care disposal have remained.

Knowing the role that HCS plays in people’s quality of life and the sustainability of the public health system in Brazil, especially in this pandemic period, new measures regarding medical waste management and practices must be taken to preserve the health and safety of professionals, families and patients. Strategies such as: (i) guidance and awareness of professionals and the community served about waste management and contagion prevention, (ii) use of technologies based on smart medical care; (iii) greater participation by the public authorities in waste management; and (iv) greater availability of financial and material resources for the services, were some of the strategies identified to improve the provision of health care services at home.

The lack of training and proper management of home medical waste reflects that the authorities were not yet sufficiently aware of the magnitude of the problem, even before the COVID-19 pandemic. Generally, home medical waste management requires awareness, commitment and skills of all stakeholders in their respective area of expertise.

The acquisition of reliable primary data in this study can subsidize the municipal administration in the management of home medical waste. This article also fills a gap in studies on home MWM in Brazil and contributes to the improvement and optimization of the functioning of HCS.

Limitations and recommendations

This work has the merit of bringing a contribution to the study of home medical waste management, specifically regarding the waste generated by the HCS, an important service offered by the Brazilian public health service. This study has two limitations: (i) because of the worsening of the COVID-19 pandemic in Brazil, it was not possible to visit the households and interview the caregivers and families, in the second step of the research; (ii) this study did not include the perspective of political authorities/decision makers. For future research, in addition to the inclusion of managers in the universe of respondents, it is also recommended that other consequences of the COVID-19 pandemic be investigated in public health services, besides HCS.

Acknowledgment

The authors would like to thank the government of Caruaru (Health Department), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Fundação de Amparo à Ciência e Tecnologia de Pernambuco (FACEPE) and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the CNPQ; FACEPE [IBPG-0531-3.01/21].

Notes on contributors

Thais Silva

Thais Silva is M.Sc. in Civil and Environmental Engineering, and Ph.D. student in Civil Engineering at Universidade Federal de Pernambuco, Recife PE, Brazil.

Renata Maciel

Renata Maciel is Ph.D. in Production Engineering, Associate Professor at Universidade Federal de Pernambuco, Caruaru PE, Brazil.

Lourdinha Florencio

Lourdinha Florencio is Ph.D. in Environmental Technology, Professor at Universidade Federal de Pernambuco, Recife PE, Brazil.

Simone Machado Santos

Simone Machado Santos is Ph.D. in Civil Engineering, Associate Professor at Universidade Federal de Pernambuco, Caruaru PE, Brazil.