Impact of an educational program on knowledge and practice of health care staff toward pharmaceutical waste management in Gaza, Palestine

ABSTRACT

In health care facilities, pharmaceutical waste is generally discharged down the drain or sent to landfill. Poor knowledge about their potential downstream impacts may be a primary factor for improper disposal behavior. The objective of this study was to determine the impact of an intervention program on knowledge and practice of health care staff regarding pharmaceutical waste management. The study was designed as a pre/posttest intervention study. Total sample size was 530 in the pre-intervention phase, and then a subsample of 69 individuals was selected for the intervention and the post-intervention phases. Paired-sample t test was used to assess the difference between pretest and follow-up test results. A statistically significant improvement in knowledge and practice was achieved (P < 0.001). Poor knowledge and poor practice levels (scores <50%) were found to improve to satisfactory levels (scores ≥75%). Therefore, educational programs could be considered as an effective tool for changing health care staff practice in pharmaceutical waste management.

Implications: In health care facilities, pharmaceutical waste is generally discharged down the drain or sent to landfill. A lack of knowledge about the potential impacts of this type of waste may be a leading factor in improper disposal behavior. Following an educational program, statistically significant improvement in knowledge and practice of health care staff as regards to pharmaceutical waste management (PWM) was achieved. It is thus recommended that authorities implement training-of-trainers (TOT) programs to educate health care staff on PWM and organize refreshment workshops regularly.

Introduction

In Gaza Strip, rapid population growth has been associated with expansion in public services, including health care services (Palestinian Central Bureau of Statistics, 2007). According to Palestine Ministry of Health, total pharmaceutical waste (PW) disposed of in 2011 was 317.6 m³ (Palestine Ministry of Health, 2012). PW consists of “expired, unused, spilt, and contaminated pharmaceutical products that are no longer required and need to be disposed of appropriately. This also includes discarded items used in the handling of pharmaceuticals, such as connecting tubing, and drug vials“ (Chartier et al., 2014). In a health care facility, PW is discharged down the drain or sent to landfill. This might take place due to poor knowledge about the potential negative impacts of pharmaceutical waste on human health and the environment (Smith, 2008).

Concerning the impacts on human health, many cytotoxic drugs have been recognized as being carcinogens, mutagens, or teratogens. Nurses, pharmacists, waste handlers, and laundry workers could be at risk of exposure to these hazardous drugs (Sunita et al., 2009). In 1979, a hospital-based study reported signs of mutagenicity in the urine of oncology nurses (Falck et al., 1979). Other side effects were also reported, such as increase in spontaneous abortion (Rillo, 2009). In another study conducted in German hospitals, 40% of pharmacists and oncology workers were found to have a certain concentration of some cytotoxic drugs in their urine, even though they had not handled these drugs. They could have been potentially exposed through contamination of work surfaces, clothing, or drug containers (Pethran et al., 2003).

As for the impacts on the environment, a variety of pharmaceuticals were discovered in surface, ground, and drinking waters in the United States of America (Sumpter and Johnson, 2005). A study carried out in 139 streams across 30 U.S. states reported the presence of coprostanol (fecal steroid), triclosan (antimicrobial disinfectant), and caffeine. Although some pollutants were in concentrations within drinking-water guidelines, and aquatic-life criteria, others, however, did not have such guidelines established. This study highlighted the importance of obtaining data on drug metabolites in order to have a comprehensive understanding of not only the fate and transport of pollutants in the hydrologic system but also their ultimate effect on human health and the environment (Kolpin et al., 2002). Further research detected other pharmaceuticals in aquatic ecosystems. Examples include chemotherapeutic agents, antibiotics, and hormones (McQuillan et al., 2002). Such aquatic pollution could be troublesome because aquatic organisms are captive to continuous, multigenerational exposure, and this could lead to undetectable effects until the cumulative level of these effects finally ends in irreversible changes in the exposed organisms (Daughton and Ternes, 1999)

In addition, chemical residues discharged into the sewerage system may have adverse effects on the operation of biological sewage treatment plants (Chartier et al., 2014). Similar problems may be caused by pharmaceutical residues (U.S. Environmental Protection Agency [EPA], 2006).

Pharmacists and nurses do not acquire information on pharmaceutical waste management (PWM) during their academic studies. In addition, safety personnel and heads of environmental services may not recognize the potential for occupational exposure to active ingredients present in pharmaceutical products (Smith, 2008). Hence, the objective of this study was to assess knowledge and practice of health care staff in some governmental hospitals in Gaza Strip concerning PWM and to determine the impact of an intervention program on these knowledge and practice.

Materials and methods

Study setting

The study was conducted in 2014 in Gaza Strip. It is a small piece of land located in the southern area of Palestine with 1,701,437 inhabitants in 365 km² (PASIA, 2009). It has 13 governmental hospitals distributed in five governorates: North Gaza, Gaza, Deir Albalah, Khan Younis, and Rafah. The study was carried out in five hospitals: European-Gaza, Nasser, Al-Aqsa, Al-Shifa, and Kamal Odwan. Selection of the hospitals was based upon being the largest hospitals serving the greatest number of patients. Table 1 shows the geographical location, the type, number of beds, number of employees, and their proportions in every hospital under study (Palestine Ministry of Health, 2013).

Table 1. Name, geographical location, type, number of beds, and number of employees of the hospitals under study.

Hospital	Geographic Location	Type	No. of Beds	No. of Employees
				Physicians	Nurses	Pharmacists	Waste Workers	Administrators, Technicians, Others	Total
Al-Shifa Medical Complex	Gaza	Internal medicine, surgery, maternity	619	635	394	23	152	283	1487
Nasser	Middle of Khan Younis	Internal medicine, surgery, maternity	322	330	295	18	77	49	769
EGH	East of Khan Younis	Internal medicine, surgery	246	164	221	11	50	335	781
Al-Aqsa	Deir-Elbalah	Internal medicine, surgery, maternity	129	116	94	4	42	306	562
Kamal Odwan	North Gaza	Internal medicine, surgery, maternity	119	99	75	4	40	92	310
Total			1435	1344	1079*	60*	361*	1065	3909

Notes. *Nurses, pharmacists, and waste workers constituted the study population with a total of 1500 individuals.

In these hospitals, PWM does not receive adequate consideration: there is neither policy nor practical guidelines to adhere to. There is no training on health care waste management. In addition, sharps are the only waste category found to be segregated and collected in puncture-proof containers. Otherwise, all pharmaceutical waste categories are collected in black plastic bags with domestic waste and transported on the same trolley to the incinerator. This latter is old and lacking air emission control devices. When the incinerator is out of service for maintenance reasons, pharmaceutical waste is transported to municipal landfill without any treatment. As for personal protective equipment (PPE), they were not always available in the hospitals under study; only pharmacists working in oncology departments were using them on a regular basis while preparing cytotoxic drug dosage forms.

Study sample

The study was a pre/posttest intervention study. It included three phases: pre-intervention phase, intervention phase, and post-intervention phase.

In the pre-intervention phase, the study population consisted of different health care staff (pharmacists, nurses, and waste workers) working in the five selected hospitals. Physicians were not included, as they have no responsibility regarding health care waste management as per their job description. The sample size was calculated using the Statcalc module of the Epi-Info program, version 7 (Centers for Disease Control and Prevention, USA), with a population size = 1500 (this is the total number of pharmacists, nurses, and waste workers working in the five selected hospitals), expected frequency of knowledge, attitude, and practice (KAP) score = 60% (Hakim et al., 2014) using a dominating effect = 1.8 and five clusters. This yielded a sample size of 530. Then, a proportional allocated sample (based on the size of the study population in every hospital) was taken as follows: 201, 138, 99, 50, and 42 staff members from Al-Shifa, Nasser, European-Gaza, Al-Aqsa, and Kamal Odwan Hospitals, respectively. These staff members were selected randomly inside every hospital.

Concerning the intervention and the post-intervention phases, they were done in only two of the five hospitals: Al-Shifa and European-Gaza. Selection of these two hospitals was based upon their being the ones offering chemotherapeutic treatment and therefore had the greatest potential occupational and environmental health exposures to pharmaceutical waste. Hence, the study sample of these phases was a subsample of the individuals involved in the pre-intervention phase. Using StatsDirect to calculate the subsample size, assuming starting with 60% KAP and ending with 80%, at confidence interval = 5% and power of the test = 80%, the sample size for corrected chi-square and Fisher’s exact test was 57 health care staff. This was increased to 72 in order to include all health care staff (100%) working in the oncology departments within Al-Shifa and European-Gaza Hospitals. Among the 72 individuals, 32 were working in European-Gaza Hospital and 40 were in Al-Shifa Hospital.

Data collection tool

A questionnaire was used to assess knowledge and practice of the study sample regarding PWM. The questionnaire included three main sections: the first was concerning the demographic data of the participants; the second and third sections were formulated to test their knowledge and practice, respectively, regarding PWM. Development of the questionnaire was based upon World Health Organization (WHO) guidelines for safe health care waste management (Chartier et al., 2014), and on EPA best management practices for unused pharmaceuticals (EPA, 2010), by transforming the theoretical contents in these handbooks into questions.

In the questionnaire, 15 questions were used to assess knowledge. Correct complete and incomplete answers were given scores of “2” and “1,” respectively. Wrong answers and “don’t know” were given a score of “0.” Practice was assessed using nine questions. Answers were either “Yes,” “Sometimes,” or “No.” They were given scores of “2,” “1,” or “0,” respectively.

A score was computed for every question. The maximum score for each one was 1060. In the “knowledge” section, this was representing the total number of participants (530) giving complete correct answers, whereas in the “practice” section, this was representing the total number of participants (530) answering “yes.” Hence, scores of 795–1060 (≥75%) were considered as satisfactory level of knowledge and/or practice; those of 530–794 (50% to <75%) were representing a fair degree of knowledge and/or practice; and scores less than 530 (<50%) were demonstrating a poor level of knowledge and/or practice, as regards to PWM.

In order to check the validity and reliability of the questionnaire, face and content validity were confirmed by presenting the questionnaire to the Review Board of the High Institute of Public Health, Alexandria University and obtaining their approval. Furthermore, in Gaza, the questionnaire was coupled with a covering letter containing the title and objectives of the study and was sent to 12 experts from different backgrounds, including researchers, environmental experts, pharmacists, nurses, and academicians. They were asked to estimate the relevance, clarity, and completeness of each item; some questions were modified accordingly. As for reliability, test-retest reliability was assessed for the knowledge section of the questionnaire and was found to be acceptable (α = 0.71). The internal consistency reliability for the practice section was also acceptable (α = 0.73).

The questionnaire was then pretested in a pilot study involving 30 persons of different job titles (administrators, pharmacists, nurses, and waste workers), and accordingly, it was decided to use it as an interviewing questionnaire rather than a self-administered one, since some respondents were found to leave some questions unanswered when they were administering the questionnaire by themselves.

Training program

It was designed as six educational sessions (90 min each) delivered over two weeks’ period in every hospital. Sessions had the following titles: “Definition, sources and categories of pharmaceutical waste,” “Public health impacts of improper pharmaceutical waste management,” “Regulations of pharmaceutical waste management,” “Operation of pharmaceutical waste management,” “Case studies,” and “Planning for pharmaceutical waste management.”

Various educational methods were used in the training program. Examples include PowerPoint presentation prepared and presented by the researcher, videos downloaded from Internet, besides group discussion.

Phases of the study

Pre-intervention phase

The questionnaire, predesigned by the researchers, validated, and pretested, was used to assess knowledge and practice of the study sample (530 health care staff) regarding PWM. Approval for conducting the study was obtained from the Ministry of Health as well as from all hospital managers. Every respondent was notified about the objective of the study and was informed that data collected would be confidential, by keeping all questionnaires anonymous.

Intervention phase

Based on the results of the pre-intervention test, the educational program was implemented in both Al-Shifa Hospital and European-Gaza Hospital. It started 2 weeks after the end of the pre-intervention phase. Participants were divided into groups of 5–20. A number of trainees attended morning sessions from 10:00 a.m. to 11:30 a.m., others attended afternoon sessions from 12:00 p.m. to 1:30 p.m., and a third session was organized in the evening from 5:00 p.m. to 6:30 p.m. for those failing to attend morning and afternoon sessions.

In addition to the training sessions, a written practical guide concerning safe management of pharmaceutical waste was developed based upon international standards (Chartier et al., 2014). This guide was reviewed and certified by the Ministry of Health in Gaza. Then it was distributed to health care staff in the selected hospitals. Signs were also placed near disposal areas to remind workers about safe disposal practices and improve their awareness. Finally, the resources required for the process of pharmaceutical waste collection such as labeled color-coded bags and containers were provided, and health care workers were trained on how to use them.

Post-intervention phase

After implementation of the educational program, knowledge and practice were reassessed for the program attendees using the same interviewing questionnaire, both immediately (posttest) and 6 months after the end of the program (follow-up test). Out of 72 participants, 3 (4.2%) were not able to go through the post-intervention phase due to personal reasons, thus making the sample size of the post-intervention phase 69 participants (30 in European-Gaza Hospital and 39 in Al-Shifa Hospital).

Statistical analysis

Data were cleaned, coded, and entered to the statistical software SPSS (Statistical Package for Social Sciences) version 16 (SPSS, Chicago, IL, USA; Fiddler et al., 2004). The parametric paired-sample t test was used to assess the difference between pretest and follow-up test results. Tests were two tailed. P value less than 0.05 was considered significant.

Results

Demographic data of the study sample

As shown in Table 2, the majority of respondents were male (56.2%) and were less than 40 years old, with a mean age of 32.4 ± 8. Regarding qualification, the majority of participants reported being college graduates (47.2%), followed by high school graduates (30.4%), secondary school (15.5%), and only a minority held a postgraduate degree (7%). As for the profession, 68.7% of study sample were nurses, 17.2% were waste workers, 8.7% were pharmacists, 4% were radiographers, and 1.5% had other specializations (physician, health manager, etc.). The total experience of nearly one-quarter of the respondents was reported to be less than 5 years (26.8%), whereas employees who had 5–10 years of experience presented 42.3%, and the rest had an experience of more than 10 years.

Table 2. Demographic characteristics of the intervention study sample (n = 69).

Variable	No.	%
Age
Less than 30	230	43.5
From 30 to 40	215	40.6
More than 40	84	15.9
Missing	1	.18
Gender
Male	298	56.2
Female	232	43.8
Qualification
Secondary school and less	82	15.5
High school diploma	161	30.4
Bachelor	250	47.2
Postgraduate	37	7.0
Profession
Pharmacist	46	8.7
Radiographer	21	4.0
Waste worker	91	17.2
Nurse	364	68.7
Others	8	1.5
Total experience
Less than 5 years	142	26.8
From 5 to 10 years	224	42.3
More than 10 years	164	30.9

Impact of the educational program on knowledge

As shown in Table 3, in the pre-intervention phase, participants were found to have a poor level of knowledge (score <50%) as regards to nearly 50% (7/15) of the questions. They were about steps of PWM, importance of waste segregation, waste types that should be segregated from each others, color-coded bags used for segregation, optimum collection frequency for generated waste, specifications of the vehicle used for pharmaceutical waste transport, and pharmaceutical waste treatment methods. A fair knowledge level (score 50% to <75%) was detected as regards to 25% (4/15) of the questions; they included definition of pharmaceutical waste, reasons of pharmaceutical waste generation in hospital pharmacies and in the nursing floor, and importance of the presence of a storage room especially designated for pharmaceutical waste. Finally, a satisfactory level (score ≥75%) was observed as regards to the remainder 25% (4/15) of the questions. They were concerned with mentioning any step in PWM, environmental and health hazards that might be caused by pharmaceutical waste, and the importance of wearing PPE.

Table 3. Knowledge of the pre-intervention study sample (n = 530) as regards to pharmaceutical waste management and impact of the educational program (n = 69).

	Pre-intervention Phase (n = 530)				Impact of Educational Program (n = 69)
	Answers (%)				Knowledge Score* as %
Question	Correct Complete	Correct Incomplete	Wrong/Don’t Know	Score* (%)	Pretest	Posttest	Follow-up	P value**
What is the definition of pharmaceutical waste?	5.3	91.6	3	51.1	52.1	66.6	81.1	<0.001
What are the reasons for pharmaceutical waste generation in pharmacies? n = 46	18.1	80.4	1.5	58.3	71.4	85.7	85.7	<0.001
What are the reasons for pharmaceutical waste generation at nursing floor? n = 364	6.7	91.8	1.5	52.6	53.8	71	77.3	<0.001
Does pharmaceutical waste cause any health hazards?	84.7	—	15.3	84.7	85.5	91.3	95.7	0.034
Does pharmaceutical waste cause any environmental hazards?	83	—	17	83	75.4	85.5	94.2	0.004
Is it important to wear PPE when handling pharmaceutical waste?	76.2	—	23.8	76.2	81.2	89.9	95.7	0.007
What are the steps of PWM? (one step at least)	75.5	—	24.5	75.5	75.4	81.2	92.8	0.006
What are the steps of PWM? (all steps)	21	53	26	47.5	42.7	60.8	71.9	<0.001
What is the importance of pharmaceutical waste segregation process?	24	34.7	41.3	41.4	33.3	50	75.3	<0.001
What are the pharmaceutical waste types that should be segregated from each other?	17.5	53.7	28.8	44.4	30.4	51.4	74.6	<0.001
What are the colors that should be used to segregate each type of pharmaceutical waste?	0.6	34.1	65.3	17.6	0	39.1	52.2	<0.001
Is it important to have a storage room for pharmaceutical waste in each hospital?	64	0	36	64	68.1	75.4	92.8	<0.001
What is the optimum collection frequency for generated pharmaceutical waste?	20.8	0	79.2	20.8	15.9	63.8	76.8	0.005
What are the specifications of the vehicle used for pharmaceutical waste transport?	0	8.8	91.2	4.9	7.9	51.4	73.2	<0.001
What are the treatment methods of pharmaceutical waste?	2.6	33	64.4	19.2	28.4	55.7	75.3	<0.001
Mean knowledge score	49.4 ± 25.2				48 ± 28	68 ± 17	81 ± 12	<0.001

Notes: *Scores ≥75% = satisfactory; scores 50% to <75% = fair; scores <50% = poor. **P value between pretest (n = 69) and follow-up test (n = 69).

In the posttest, the educational program was found to improve knowledge of the participants from a poor level to a fair one as regards to six items out of the seven poorly known ones. The exception was concerning the color codes that should be used for the waste collection bags, which remained as poorly known as it was in the pre-intervention phase. As for the four points that were fairly known in the pre-intervention phase, two of them (reasons of pharmaceutical waste generation in hospital pharmacies and the importance of pharmaceutical waste storage room) were found to improve to a satisfactory level of knowledge. With regards to the other two (definition of pharmaceutical waste and reasons of pharmaceutical waste generation in the nursing floor), they continued to be fairly known. Therefore, in the posttest, satisfactory and fair knowledge levels were noticed as regards to 50% (8/15) and 43% (6/15) of the questions, respectively, whereas a poor level was only identified as regards to one question (7%).

Six months later, in the follow-up phase, color codes for waste containers were found to be fairly known. Besides, five items among the eight fairly known ones in the posttest were found to increase from fair level of knowledge to a satisfactory one. They were about definition of pharmaceutical waste, reasons of pharmaceutical waste generation in the nursing floor, importance of pharmaceutical waste segregation, optimum waste collection frequency, and waste treatment methods. Accordingly, in the follow-up phase, a satisfactory level of knowledge was observed with regards to 73% of the questions (11/15) present in the questionnaire, and the remainders 27% (4/15) were found to be fairly known.

As for knowledge mean score, it was found to increase from 48 ± 28% (poor level) in the pre-intervention phase to 68 ± 17% (fair level) in the posttest conducted immediately after the end of the educational program, and to 81 ± 12% (satisfactory level) in the follow-up test conducted 6 months later. Such improvement was found to be statistically significant (P < 0.05).

Impact of the educational program on practice

As shown in Table 4, participants showed a poor level of practice in the pre-intervention phase (score <50%) as regards to nearly 78% (7/9) of the questions. These were about following a specific system for PWM, adherence to written guidelines, attending training workshops on waste management, waste segregation at generation point, regular waste collection, spill management, and pharmaceutical waste storage in especially designed rooms. A fair level of practice (score 50% to <75%) was observed as regards to 11% (1/9) of the questions; this was about the immediate replacement of full waste bags. Finally, a satisfactory level (score ≥75%) was noticed as regards to wearing PPE while handling PW, and this was representing 11% (1/9) of the questions.

Table 4. Practice of the pre-intervention study sample (n = 530) as regards to pharmaceutical waste management and impact of the educational program (n = 69).

	Pre-intervention Phase (n = 530)				Impact of Educational Program (n = 69)
	Answers (%)				Practice Score* as %
Practice	Yes	Sometimes	No	Score*	Pretest	Posttest	Follow-up	P value**
Following a specific system in PWM	19.6	29.2	51.1	34.2	23.1	22.4	78.2	<0.001
Adherence of PWM system to written guidelines	7.5	13	79.5	14	4.3	5.7	85.5	<0.001
Attending training workshops about PWM	17.5	0	82.5	17.5	17.5	100	100	<0.001
Pharmaceutical waste segregation at generation point	17.7	34.7	47.6	35.05	26	31.8	92	<0.001
Regular collection of PW	16.2	34	49.8	33.2	39.1	36.9	82.6	<0.001
Immediate replacement of full waste bags	60.2	27.7	12.1	74.05	72.4	69.5	90.5	0.001
Spill management	19.6	34.7	45.7	36.9	39.2	42	80.4	<0.001
In-site storage of PW in specially designed rooms	8.5	0	91.5	8.5	8.5	0	0
Using PPE while handling PW	60.6	36.8	2.6	79	79	89.8	95.6	0.001
Mean practice score	36.9 ± 24.7				34.3 ± 26	44.2 ± 35	78.3 ± 30

Notes: *Scores ≥75% = satisfactory; scores 50% to <75% = fair; scores <50% = poor. **P value between pretest (n = 69) and follow-up test (n = 69).

Immediately following the educational program, one poor practice was found to turn into a satisfactory one: this was related to attending training workshops about PWM. Other practices remained unchanged.

Six months later, in the follow-up test, all the practices regarding PWM were found to be satisfactory except the storage of pharmaceutical waste in specially designed rooms: it continued to be poorly done in the hospitals under study. Accordingly, a satisfactory level of practice was observed with regards to 89% (8/9) of the questions, and a poor one as regards to 11% (1/9).

As for the practice mean score, it was found to increase from a poor level in both pretest and posttest phases (scores of 34.3 ± 26 and 44.2 ± 35, respectively) to a satisfactory level (78 ± 30) in the follow-up phase 6 months later. Such increase was statistically significant (P < 0.05).

Discussion

Impact of the educational program on knowledge

As shown in Table 3, all participants had fair knowledge about definition of pharmaceutical waste and reasons of their generation. This confirms the necessity for a comprehensive training, since the first step in any waste prevention and minimization program is to identify reasons of waste generation (EPA, 2010).

When respondents were asked whether pharmaceutical waste could be hazardous to the environment or to human beings, their answers proved a satisfactory level of knowledge in all tests of the study. This was in agreement with results of a study conducted in Iran that showed that the majority of health care workers had appreciable knowledge about health risks associated with hospital waste (Lakbala et al., 2012).

A poor level of knowledge was identified during the pre-intervention phase regarding segregation and color codes of different pharmaceutical waste types. These results were in accordance with those of a study carried out in Yemen, which reported that only a few workers in governmental hospitals were acquainted with the necessity of segregation of medical waste into different categories for proper waste management (Al-Emad, 2011). Ideally, steps of PWM start with segregation (WHO, 1999), the objective of which is to separate waste pharmaceuticals into categories (infectious/hazardous/nonhazardous) that require different disposal methods and to reduce the budget required for disposal. Segregation is done using color-coded bags (WHO, 1999). These bags should then be packed into steel drums or into cardboard boxes, with the contents clearly written on the outside of the containers. After that, they should be transported into a dry secure separate room to avoid being confused with in-date pharmaceuticals, until treatment and/or disposal are carried out (WHO, 1999). Color-coding of waste containers facilitates the segregation process for health care staff and hospital employees and keeps different types of waste segregated during storage, transport, treatment, and disposal. In addition, color-coding can indicate the potential risk posed by each waste type. A single system of segregation should be applied throughout a country. Many countries have their national legislation that sets the waste segregation categories and the system of color-coding to be used. Where national legislation is absent, WHO scheme could be used: it consists of using yellow, brown, and black colors for infectious, hazardous, and general waste, respectively (Chartier et al., 2014).

Regarding the frequency of pharmaceutical waste collection, this should be done once daily. As for the vehicle, it should be secure, of suitable size, carrying international biohazard sign, marked with the name of transporter, easy-to-clean, and with a bulkhead between the driver’s cabin and the vehicle body so as to retain the waste load if the vehicle is involved in a collision (Chartier et al., 2014).

As concerns treatment methods of pharmaceutical waste, as a best management practice, they should not be treated with infectious waste (red bag waste). The latter is steam-sterilized (e.g., in an autoclave) before disposal in landfills. The temperature at which steam sterilization occurs is not sufficient to destroy the former (EPA, 2010). Moreover, following segregation of PW from infectious waste, antineoplastics should be segregated from other pharmaceuticals in order to be destroyed at a temperature not less than 1200 °C in a two-chamber incinerator equipped with air emission control system. In addition, pharmaceutical waste dosage forms should be taken in consideration while selecting the appropriate method of treatment. For example, ampoules (of antineoplastics and anti-infective drugs) should not be incinerated, as they will explode causing damage to incinerator and injury to workers. They should not be crushed and the content discharged to the sewerage system. They should be treated by encapsulation (WHO, 1999).

As for the score representing the overall knowledge of the study sample in the pre-intervention phase (48 ± 28%), it was in accordance with two studies conducted in India that detected a poor level of knowledge about health care waste management practices among health care personnel in both Jaipur Dental College (Sharma et al., 2013), and in a tertiary care hospital (Shivalli et al., 2014). In addition, the significant increase (P < 0.001) in this score to 81 ± 12% that was observed in the follow-up phase (Table 3) was consistent with a study carried out in Malaysia that revealed a significant increase in the knowledge score of nurses from 45.5 ± 10% to 73.4 ± 9% following an educational program on the hazardous effects of cytotoxic drugs and the necessity of applying proper waste handling measures (Keat et al., 2013).

The satisfactory level of knowledge that could be observed among study participants in the follow-up phase could be attributed to the fact that, although the program was finished, posters were put everywhere in the hospitals as reminder to staff members, besides brochures and booklets that were distributed in all departments.

Impact of the educational program on practice

In the pre-intervention phase, about half of the participants reported that they were not following any system for PWM. As for the presence of guidelines, 80% reported that they were not provided with any written guidelines. These results were in accordance with Kumar et al. (2013) who revealed that tertiary care hospitals in Pakistan were not following WHO guidelines for health care waste management (Kumar et al., 2013). In the follow-up phase, these two practices were found to improve, and this could be due to the guideline booklet, prepared by the researcher, approved by the Ministry of Health, and offered to the hospital administration. According to the WHO, technical guidelines constitute a complement to any health care waste management system in order to specify regulations and to set responsibilities and training requirements (Chartier et al., 2014).

As regards to staff training, our study revealed inadequate training practice for PWM in the pre-intervention phase. Only 17.5% of the respondents confirmed having received training. Similar results were obtained from a previous study conducted in Gaza (Sarsour et al., 2014). Immediately following the educational program, this poor practice was found to turn into a satisfactory one that got a score of 100%, since all interviewees were the trainees of the program.

Poor segregation practice of pharmaceutical waste was also identified during the pre-intervention phase of our study. This was in agreement with results of the Environmental Quality Authority (EQA) survey that was conducted in 2005 in the West Bank and Gaza Strip (EQA, 2005). Similar results were also reported in studies conducted in Egypt (Hussein and Selim, 2008), Portugal (Ferreira and Ribau-Teixeira, 2009), Nigeria (Abah and Ohimain, 2011), and Ghana (Sasu et al., 2011).

Concerning regular collection of generated PW during the pre-intervention phase, a negative answer was obtained from nearly half of respondents, who reported that waste was collected randomly. Six months after the educational program, waste collection (segregation in color-coded bags, regular frequency of bag collection, and immediate replacement of full bags) and spill management practices were found to have improved. This might be due to the availability of resources required (color-coded bags and spill kits offered by the researcher) and the application of the instructions given throughout the training program.

As for the absence of a storage room especially designated for pharmaceutical waste in the hospitals under study, this result was in consistence with a survey conducted by EQA that revealed that the majority of health care facilities had no storage rooms for neither general nor medical waste (EQA, 2005). On the contrary, a study conducted in Jordan (Aukour, 2008) and another one conducted in Nepal (Sapkota et al., 2014) revealed that all collected medical waste were stored in a central storage area within the hospital premises. Unfortunately, the educational program failed to cause a change in this aspect, as the management system in the hospitals under study did not specify a special room for pharmaceutical waste storage, and this could be attributed to the limited space of these hospitals.

Regarding regular use of PPE, a satisfactory level of practice was detected in the pretest and was found to continue in the posttest and the follow-up test. This could be attributed to the fact that the study was carried out in oncology departments where the use of PPE is done on a regular basis. On the other hand, in 2006, a study was conducted to assess the occupational safety among cleaning workers in Palestinian hospitals and its relation with the medical waste management, and the researcher observed that PPE were not always available for all workers (Al-Khatib, 2006). Furthermore, a recent study carried out in 2014 in Palestine indicated that only 66% of waste workers were using gloves during working time (Abu-Mohsen, 2014).

Concerning PWM practices mean scores, they demonstrated poor levels in both the pretest and the immediate posttest (table 4). This could be explained by the unavailability of guidelines, lack of training courses and programs, inadequate supplies, lack of supervision, and lack of incentive for proper waste management. This was in agreement with Mostafa et al. who assessed the knowledge and practice related to waste management among doctors, nurses, and housekeepers at Al-Mansoura University Hospital, Egypt, and revealed inadequate practices in most areas of waste management (Mostafa et al., 2009).

As for the significant increase in the overall practice mean score in the follow-up phase, it might be attributed to improvement in knowledge regarding PWM as well as the availability of resources needed for best management practice. This was consistent with Lewise et al. who reported that good practice is the result of theoretical understanding that helps health care staff to acquire new skills (Lewise et al., 2004).

Conclusion

A significant improvement in knowledge and practice of health care staff as regards to PWM was achieved in two governmental hospitals in Gaza Strip as a result of an intervention educational program.

Recommendations

It is recommended authorities organize refreshment workshops on PWM regularly in every hospital and provide the resources required for such management.

Study limitation

One limitation of the study is the lack of evidence on whether change in practice was a result of improvement in knowledge of health care staff, establishment of a system in the health care facility, or allocation of resources needed for proper PWM. This could be the subject of further research.

Additional information

Notes on contributors

Mohammed I. Tabash

Mohammed I. Tabash is a Ph.D. candidate in Department of Environmental Health, High Institute of Public Health, Alexandria University.

Rim A. Hussein

Rim A. Hussein is an associate professor of environmental chemistry and biology, Department of Environmental Health, High Institute of Public Health, Alexandria University.

Aleya H. Mahmoud

Aleya H. Mahmoud is a professor of environmental health, Department of Environmental Health, High Institute of Public Health, Alexandria University.

Mohamed D. El-Borgy

Mohamed D. El-Borgy is a professor of health education, Department of Health Administration and Behavioral Science, High Institute of Public Health, Alexandria University.

Bassam A. Abu-Hamad

Bassam A. Abu-Hamad is a lecturer of health management, Faculty of Public Health, Al-Quds University.