healthcare waste management in nigeria a case study

Health Care Waste Management and COVID 19 Pandemic pp 197–218 Cite as

Healthcare Waste Management Practices in Nigeria: A Review

• David O. Olukanni 3 ,
• Justin D. Lazarus 3 &
• Emmanuel Fagbenle 3  
• First Online: 13 November 2022

183 Accesses

In most low-income economies, healthcare waste (HCW) management, a major component of solid waste presents a serious concern. HCW being categorized as an hazardous or infectious solid wastes are unwanted products of healthcare activities that are generated during diagnosis or treatment of patients, immunization or vaccination of human beings or animals mostly during production or biological testing (Idowu et al., 2013; Olukanni et al., 2014; Chukwunonye, 2015; Awodele et al., 2016; Afolabi et al., 2018; Akpan & Olukanni, 2020). Hierarchical structure and complexity characterize HCW and healthcare facilities. The categories of HCW range from infectious, pathogenic, and sharp to genotoxic, chemical, and radioactive waste, each with a complement of various health risks. They include basically hazard prone materials such as blades, needles, and syringes, known as sharps, then non-sharps including bandages and swabs; body/tissue/organs or blood parts and various unfriendly chemicals and solvents such as mercury and disinfectants, radio-actives, and pharmaceuticals (Longe, 2012; Oyekale & Oyekale, 2017). Not only that, but some other major healthcare by-products also include unused and expired drugs, pharmaceutical products, and vaccines that need to be disposed of immediately and appropriately.

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Olukanni, D.O., Lazarus, J.D., Fagbenle, E. (2022). Healthcare Waste Management Practices in Nigeria: A Review. In: Ghosh, S.K., Agamuthu, P. (eds) Health Care Waste Management and COVID 19 Pandemic. Springer, Singapore. https://doi.org/10.1007/978-981-16-9336-6_9

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• Published: 25 September 2017

Healthcare waste management practices and safety indicators in Nigeria

• Abayomi Samuel Oyekale 1 &
• Tolulope Olayemi Oyekale 2  

BMC Public Health volume  17 , Article number:  740 ( 2017 ) Cite this article

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Adequate management of healthcare waste (HCW) is a prerequisite for efficient delivery of healthcare services. In Nigeria, there are several constraints militating against proper management of HCW. This is raising some environmental concerns among stakeholders in the health sector. In this study, we analyzed the practices of HCW management and determinants of risky/safe indices of HCW disposal.

The study used the 2013/2014 Service Delivery Indicator (SDI) data that were collected from 2480 healthcare facilities in Nigeria. Descriptive statistics, Principal Component Analysis (PCA) and Ordinary Least Square (OLS) regression were used to analyze the data.

The results showed that 52.20% and 38.21% of the sampled healthcare facilities from Cross River and Bauchi states possessed guidelines for HCW management, respectively. Trainings on management of HCW were attended by 67.18% and 53.19% of the healthcare facilities from Cross River and Imo states, respectively. Also, 32.32% and 29.50% of healthcare facilities from rural and urban areas previously sent some of their staff members for trainings on HCW management, respectively. Sharp and non-sharp HCW were burnt in protected pits in 45.40% and 45.36% of all the sampled healthcare facilities, respectively. Incinerators were reported to be functional in only 2.06% of the total healthcare facilities. In Bauchi and Kebbi states, 23.58% and 21.05% of the healthcare facilities respectively burnt sharp HCW without any protection. Using PCA, computed risky indices for disposal of sharp HCW were highest in Bayelsa state (0.3070) and Kebbi state (0.2172), while indices of risky disposal of non-sharp HCW were highest in Bayelsa state (0.2868) and Osun state (0.2652). The OLS results showed that at 5% level of significance, possession of medical waste disposal guidelines, staff trainings on HCW management, traveling hours from the facilities to local headquarters and being located in rural areas significantly influenced indices of risky/safe medical waste disposal ( p  < 0.05).

The study concluded that there was low compliance with standard HCW management. It was recommended that possession of HCW management guidelines, staff training on HCW disposal and provision of requisite equipment for proper treatment of HCW would promote environmental safety in HCW disposal.

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Solid waste management is one of the major challenges facing many developing countries. Although some institutional mechanisms for addressing waste accumulation and associated health hazards exist, peculiar implementation lapses due to some logistic and restrictive administrative bottlenecks sometimes make them ineffective. In some instances, illegal disposal of solid wastes poses serious environmental problems to the society. Given that the sixth target of the eleventh Sustainable Development Goal (SDG) emphasizes that countries should by “2030, reduce the adverse per capita environmental impact of cities, including by paying special attention to air quality and municipal and other waste management” [ 1 ], enhancement of environmental quality can no longer be left to the whims and wishes of few political clans.

In addition to domestic wastes, other waste products with significant environmental impacts are generated from construction and industrial production, agricultural activities and healthcare service delivery. More specifically, healthcare service delivery processes and their underlying activities often culminate into some waste products, which can constitute some environmental and health hazards to the society [ 2 , 3 ]. It had been noted that in general, about 85% of waste materials from healthcare facilities belongs to the general waste category [ 3 ], while the remaining 15% would comprise of highly infectious or toxic radioactive materials [ 4 , 5 ].

Therefore, health policy makers and professionals have come to a consensus that efficient management of HCW is an integral part of quality healthcare service delivery [ 6 ]. African policy makers cannot ignore this, given the urgent need for significant improvement in some major health indicators, in order to reposition the continent for significant economic growth and development. More importantly, the Health Professional Council of South Africa (HPCSA) [ 6 ] submitted that effective management of HCW is an integral component of acceptable healthcare professional practice. Therefore, in absence of some standard prescriptive guidelines for their timely disposal, HCW may pose serious health hazards to the society through their associated environmental pollution and their being channels of some diseases and epidemic outbreaks [ 7 , 8 ].

Furthermore, HCW management is a principal component of healthcare service delivery, which should be carefully evaluated by healthcare service providers. This is to ensure safety of medical personnel and other healthcare workers who are directly or indirectly involved in the whole processes of HCW generation, collection and disposal. It is sad to however realize that many healthcare facilities in Nigeria do not comply with the professional ethics of HCW management, thereby compromising some internationally acceptable standards. Similarly, absence of functioning platforms for monitoring compliance with ethical standards in HCW disposal, ignorance of assigned staff on some safety practices and deliberate violation of prescribed ethical procedures subject the environment to higher risk of pollution from HCW [ 9 ].

Generally, HCW of significant environmental hazards could be in the form of sharp objects, discarded human tissues in the course of surgical operations, blood tissues, patients’ vomits, chemical and pharmaceutical materials. Depending on the level of their associated hazard, HCW are meant to be disposed according to some approved international standards. It is perplexing to note that in many instances, HCW are disposed along with domestic wastes into landfills or municipal’s open waste dumpsites [ 2 ]. This increases the risk of human contacts with hazardous and highly infectious waste products and exposes the entire population to several form of environmental pollution [ 4 , 10 ] because some waste collectors could have access to landfill sites and open waste dumpsites. Therefore, the likelihood of human contact with highly infectious HCW increases when domestic wastes are disposed along with HCW. This calls for more research to study activities of healthcare facilities on the management of their waste products, in order to inform some cogent health and environmental policies.

It should be noted that although the Nigerian guidelines on disposal of HCW emphasize proper tracking in the course of waste disposal, little or no effort is put into effective implementation either by the designated monitoring body or the healthcare facilities [ 9 , 11 , 12 ]. Specifically, Longe and Williams [ 13 ] found that in four selected healthcare facilities in Lagos state, the responsibilities of medical waste management were contracted to Lagos State Waste Management Authority (LAWMA). However, majority of the healthcare facilities were involved in waste segregation using some form of colour codes. One fundamental problem is inability of some waste management authorities to ensure people’s safety in the course of waste disposal. This often results through failure to provide adequate covers for waste disposal vehicles, thereby resulting in littering and environmental pollution.

This study seeks to add to existing body of knowledge by analyzing healthcare facilities’ practices in HCW management and determinants of risky and safe disposal of HCW in Nigeria. The study is different from several previous studies by using Principal Component Analysis (PCA) to construct indices of risky and safe HCW management and analyzing these across healthcare facilities’ mode of operation, ownership type, rural/urban location and state of location. The study is also justified from the robustness and representativeness of the dataset.

Nigeria is the most populous country in Africa [ 14 ]. Some projections have indicated that the country’s population will increase from 140 million in 2006 [ 15 ] to 204 million by 2020 [ 14 ]. The country comprises of 36 states and the Federal Capital Territory (FCT). These states are sub-divided into six geopolitical zones which are the North West, North East, North Central, South West, South East and South South. The country is made up of several ethnic groups although the Hausas, the Yorubas and the Igbos are the predominant groups. Currently ranked as the second largest economy in Africa [ 16 ], Nigeria’s performance in achieving Millennium Development Goals (MDGs) was not that impressive. Therefore, conscientious efforts are required in making significant progress on the newly set Sustainable Development Goals (SDGs). This cannot be ignored given that Nigeria’s Human Development Indicator (HDI) increased from 0.467 in 2005 to 0.514 in 2014, with the country ranked 152nd among 188 countries [ 17 ].

Data and sampling procedures

This study used the data that were collected for health Service Delivery Indicator (SDI) in Nigeria [ 18 ]. The data were collected between July 2013 and January 2014 with well structured questionnaire comprising of four distinct modules. The first module contained information on selected healthcare facility, the second contained information on staff roster, the third was on patients’ case simulations in order to evaluate the knowledge of healthcare service providers, and the fourth contained facility’s profile of expenditures, resources and governance [ 19 ]. Data were collected from selected healthcare facilities using multi-stage cluster sampling with recognition of healthcare facilities’ geographic location (rural/urban) and the type. Sampling was implemented with random selection of two states from each of the six geopolitical zones in Nigeria. The selected states were Kebbi and Kaduna from North West, Bauchi and Taraba from North East, Kogi and Niger from North Central, Ekiti and Osun from South West, Anambra and Imo from South East, and Bayelsa and Cross River from South South. However, the sampling proceeded with stratification beginning at the local government areas. In all, a total of 2480 healthcare facilities were sampled. These comprised of 1480 rural healthcare facilities and 1000 urban healthcare facilities.

Table  1 presents the spatial distribution of healthcare facilities that were sampled. It shows that majority of the sampled healthcare facilities were in rural areas in Taraba, Niger, Kogi, Kaduna, Imo, Cross River, Bayelsa and Bauchi states. The states that were sampled in South West zone had majority of their healthcare facilities located in urban centers. The Table also shows the distribution of the sampled healthcare facilities based on their mode of operation. It reveals that Banchi and Kebbi states had the highest proportions being dispensaries with 45.28% and 47.37%, respectively. None of the selected healthcare facilities in Anambra, Bayelsa, Cross River, Ekiti, Kogi and Osun states was classified as dispensaries. Majority of the healthcare facilities that were sampled in Cross River (90.73%), Anambra (88.44%) and Niger (82.69%) states were classified as health centers. The table also shows the distribution of the sampled healthcare facilities based on type of ownership. It reveals that all the selected healthcare facilities from Anambra state were publicly owned. In the remaining states, healthcare facilities that were publicly owned constituted the highest proportions in Bauchi state (98.58%), Ekiti state (97.60%), Niger state (96.63%) and Cross River state (94.15%). However, the proportions of privately owned healthcare facilities were highest in Imo state (22.17%), Kaduna state (17.67%) and Bayelsa state (14.92%).

Principal component analysis (PCA) indicator computation

Principal Component Analysis (PCA) was used to aggregate some variables into composite indices, which were further subjected to some descriptive and inferential analyses. The use of PCA is justified given its ability to effectively generate some new uncorrelated variable(s) from a set of several highly correlated variables using orthogonal transformation [ 20 ]. PCA also affords elimination of multicollinearity in estimated variables given it unique data aggregation ability [ 21 ]. In this study, STATA 12 software was used for data analysis. The software is able to invoke “predict” command to generate new variable(s) after invoking the conventional “pca” command. Indices of risky and safe disposal of sharp and non-sharp HCW were computed as new variables. Specifically, risky indices of HCW disposal were computed from the answers that were provided by sampled healthcare facilities to those questions on disposal of HCW through open burning without protection, dumped without burning (no protection), dumped without burning in open pit without protection and removed off-site in unprotected area. However, safe indices of HCW disposal were computed with healthcare facilities’ responses to those questions on disposal of HCW in open burning pit or protected ground, dumped without burning in covered pit or pit latrine, dumped without burning in protected ground or pit, removed off-site and stored in covered containers, removed off-site and stored in other protected environment and removed off-site and burned with incinerators. Data for PCA analysis were presented with yes responses coded as one and no or missing responses coded as zero.

Ordinary Least Square (OLS) regression

The indices of safe and risky HCW disposal, which were computed with PCA were subjected to OLS regression analysis. Some standard econometric tests were carried out in order to determine the suitability of conventional OLS regression method for the estimated models [ 22 ]. More importantly, the independent variables were examined for multicollinearity using Variance Inflation Factor (VIF) [ 23 ]. The presence of heteroscedasticity was also examined with Breusch-Pagan/Cook-Weisberg test [ 24 ]. For the models where heteroscedasticity test showed statistical significance ( p  ≤ 0.05), the coefficients of the explanatory variables were computed with robust standard error. Given that Y ik represents the indices of risky/safe disposal of HCW, the following models were estimated for risky disposal of sharp HCW ( Y i 1 ), risky disposal of non-sharp HCW ( Y i 2 ), safe disposal of sharp HCW ( Y i 3 ) and safe disposal of non-sharp HCW ( Y i 4 ):

where π k , θ s , β s , μ s , and γ s are the vectors of estimated parameters. Also, Z ik  is a vector of the explanatory variables which are staff received training on waste management (yes = 1, 0 otherwise), healthcare facility located in southern states (yes = 1, 0 otherwise), rural health facility (yes = 1, 0 otherwise), public health facility (yes = 1, 0 otherwise), dispensaries/health center (yes = 1, 0 otherwise), traveling hours to headquarters, access to electricity (yes = 1, 0 otherwise), access to generators (yes = 1, 0 otherwise), batteries as second source of power (yes = 1, 0 otherwise), solar panel as second source of power (yes = 1, 0 otherwise), other source of power (yes = 1, 0 otherwise), access to improved water source (yes = 1, 0 otherwise), number of outpatient hours per day and possession of standard waste management guidelines (yes = 1, 0 otherwise). The stochastic error terms are denoted as h i , u i , v i and c i .

Possession of waste management guidelines and staff trainings

Table  2 shows the distribution of the sampled healthcare facilities based on possession of standard guidelines for medical waste management. It shows that healthcare facilities from Cross River state (52.20%) and Bauchi state (38.21%) reported the highest percentages, while the lowest percentages were from Osun state (12.62%) and Ekiti state (15.87%). In addition, urban healthcare facilities had higher proportion (26.20%) possessing standard waste management guidelines, when compared to their rural counterparts (24.39%). Also, public healthcare facilities had higher proportion (25.40%) having standard medical waste management guidelines, when compared to those that were privately owned (21.11%). Based on mode of operation, district hospitals reported highest percentage (40.36%) having waste management guidelines, while healthcare facilities that were classified as “others” reported the lowest percentage (18.63%).

Table 2 also shows the distribution of the healthcare facilities based on attendance of staff members at some trainings on HCW management. It reveals that Cross River state and Imo state reported the highest attendance by staff at trainings on HCW management with 67.18% and 53.19% respectively, while the lowest percentages were reported in Taraba state (20.21%) and Kaduna state (9.30%). However, 32.32% of rural healthcare facilities reported to have sent staff on HCW management trainings, as compared to 29.50% for urban facilities. Attendance of trainings on HCW management was also higher in public healthcare facilities (31.66%) than those that were privately owned (26.77%). In healthcare facilities that were classified as district hospitals and health centers, 38.18% and 32.05% respectively reported to have sent some staff members to HCW management trainings.

Distribution of HCW management practices

Table  3 shows the distribution of sampled healthcare facilities based on their waste management practices. The results indicated that some healthcare facilities were involved in open burning of sharp and non-sharp HCW wastes in some protected pits. However, in some instances, HCW were burnt without any form of protection. Specifically, the Table shows that healthcare facilities from Niger state reported the lowest practice of open unprotected burning of sharp HCW (6.25%). Other states that reported very low involvement in unprotected open burning of sharp HCW were Taraba (8.29%) and Kogi (8.74%). The states with healthcare facilities that had the highest involvement in burning sharp HCW without protection were Bauchi and Kebbi with 23.58% and 21.05%, respectively. Healthcare facilities from Kogi state (64.08%) and Anambra state (58.29%) reported the highest involvement in burning sharp HCW in protected pits.

Indices of risky and safe disposal of sharp and non-sharp HCW

Table  4 presents the results of safe and risky indices of HCW disposal as computed with Principal Component Analysis (PCA). It reveals that across the sampled states, indices of risky disposal of sharp HCW were highest in Bayelsa (0.3070) and Kebbi (0.2172), while it was lowest in Niger (−0.4086) and Taraba (−0.2381). In addition, indices of risky disposal of non-sharp HCW were highest in Bayelsa state (0.2868) and Osun state (0.2652), while they were lowest in Niger state (−0.4511) and Kaduna state (−0.3023). Bauchi state and Imo state had the highest average indices of safe disposal of sharp HCW with 0.6352 and 0.7346, respectively, while Kaduna state and Ekiti state had the lowest average values with −0.3080 and −0.3766, respectively. The results for indices of safe disposal of HCW show that Bauchi state and Kebbi state had the highest values with 0.6769 and 0.3852, respectively, while Osun state and Ekiti state had the lowest values with −0.3486 and −0.3418, respectively.

Table 4 also shows that healthcare facilities in rural areas had lower average risky index of sharp HCW disposal with −0.0034, when compared with their counterparts from urban areas with 0.0051. Urban healthcare facilities also had higher index of risky disposal of non-sharp HCW with 0.0044, as compared to −0.0029 for rural healthcare facilities. Similarly, rural healthcare facilities had higher indices of safe disposal of sharp and non-sharp HCW with 0.0560 and 0.0258, respectively. Urban healthcare facilities had average indices of safe disposal of sharp and non-sharp HCW being −0.0828 and −0.0383, respectively. The results revealed that public healthcare facilities reported lower average risky index for disposal of sharp HCW with −0.0025, while private healthcare facilities had lower average index for non-sharp HCW disposal with −0.0216. However, private healthcare facilities reported higher average safe indices for disposal of sharps and non-sharp HCW with 0.2676 and 0.2795, respectively.

Table 4 further shows that based on mode of operation, dispensaries had the highest indices of risky disposal of sharps and non-sharp HCW. In terms of safe HCW management practices, district hospitals reported the highest indices for safe sharp and non-sharp HCW disposal with 0.3359 and 0.4703, respectively. However, facilities that were classified as health centers had the lowest indices for safe sharp and non-sharp HCW disposal with −0.0866 and −0.1241, respectively.

Determinants of risky and safe indices HCW disposal

Table  5 shows the results of Ordinary Least Square regression of the determinants of risky indices of HCW disposal by healthcare facilities in Nigeria. Multicollinearity among the explanatory variables was not a problem given the very low value of computed average VIF (1.33). The last column of the Table presents the values of tolerance, which all show that multicollinearity was properly addressed as revealed by high tolerance levels. The Breusch-Pagan test statistics for heteroscedasticity were statistically insignificant ( p  > 0.05), implying that heteroscedasticity was not a problem in the estimated models. The computed F-test statistics also show statistical significance ( p  < 0.05), implying that estimated coefficients for the independent variables were not statistically jointly equal to zero. This test also confirms that estimated models produced good fits for the data.

Table  6 presents the results of the regression analyses for the factors explaining safe sharp and non-sharp indices of HCW disposal. The Breusch-Pagan tests for the two models showed statistical significance ( p  < 0.01). This implies that heteroscedasticity was a major problem in the models and there was the need to estimate the parameters with robust standard errors. Therefore, the t-statistics in Table 6 were computed with robust standard errors. The results of F-tests showed that the models were statistically significant ( p  < 0.01), implying that the estimated parameters were not statistically jointly equal to zero.

In Table 5 , the parameters of southern states show statistical significance ( p  < 0.01) in the two models. This implies that holding other variables constant, states in the southern part of Nigeria had their indices of risky sharp and non-sharp HCW disposal increased by 0.1851 and 0.2978 respectively, when compared with their counterparts in northern Nigeria. Similarly in Table 6 , the parameters of southern states show statistical significance in the two models ( p  < 0.05). Specifically, healthcare facilities that were located in southern states of Nigeria had their indices of safe sharp and non-sharp HCW disposal reduced by 0.1408 and 0.3251 respectively when compared with their counterparts in northern Nigeria.

Table 5 also shows that healthcare facilities that were using batteries as secondary source of power had their index of risky non-sharp HCW disposal being significantly lower ( p  < 0.10) by 0.5025 when compared with facilities without access to battery energy source. Similarly, in Table 6 , healthcare facilities with access to generator had indices of safe sharp and non-sharp HCW disposal being significantly higher ( p  < 0.10) by 0.1357 and 0.1577 respectively when compared to those without access to generators. The parameter of access to solar panel as second source of power shows statistical significance in the safe non-sharp HCW disposal model. This reveals that compared with those without access, healthcare facilities with access to solar power had their safe non-sharp HCW disposal indices increased by 0.3006.

Table 5 shows that the healthcare facilities with access to improved source of drinking water had their risky sharp HCW disposal indices being significantly reduced by 0.1254 when compared with those without access. The parameters of number of outpatient were statistically significant ( p  < 0.05) in the two estimated models. These imply that as outpatient hours increased by one unit, the indices of risky sharp and non-sharp HCW disposal decreased by 0.0080 and 0.0092, respectively.

In Table 6 , the parameter of staff attendance of training on HCW management shows statistical significance ( p  < 0.05) for the safe indices of non-sharp HCW disposal. This implies that healthcare facilities that reported training of some staff on HCW management had their safe non-sharp HCW disposal indices being higher by 0.1159, when compared to those healthcare facilities that did not send staff members for such trainings. Also, rural area parameter in the safe sharp HCW disposal model shows statistical significance ( p  < 0.01). This implies that healthcare facilities that were situated in rural areas had their indices of safe sharp disposal being higher by 0.2264, when compared with those in urban areas. The parameters of public healthcare facilities in the two models are statistically significant ( p  < 0.10). The results show that public healthcare facilities had safe sharp and non-sharp HCW disposal indices that were lower by 0.1510 and 0.1581 respectively when compared to those that were owned by private individuals. Similarly, the parameters of dispensaries or health centers show statistical significance ( p  < 0.01). These results show that indices of safe sharp and non-sharp HCW management reduced by 0.2095 and 0.2706 for healthcare facilities that were classified as dispensaries or health centers when compared with other healthcare facilities.

In Table 6 , the parameter of traveling hours to headquarters shows statistical significance ( p  < 0.05) in the model for safe sharp HCW disposal. This reveals that if travelling hour to local headquarters increases by one unit, indices of safe sharp HCW disposal will reduce by 0.0706. Finally, Table 6 shows that the parameters of possession of standard non-sharp HCW management guideline show statistical significance ( p  < 0.01) in the two models. These results show that indices of safe sharp and non-sharp HCW disposal increased by 0.3281 and 0.3844 respectively for healthcare facilities that had standard HCW management guidelines, when compared with those that did not have.

The need for proper management of HCW as a means of safeguarding health workers’ safety and preventing undue outbreak of diseases cannot be overemphasized [ 25 , 26 ]. This study found that majority of the sampled healthcare facilities did not have medical waste disposal guidelines. This is a reflection of poor attitudes by healthcare service providers to the management of their HCW. Several previous studies have indicated unethical conducts by healthcare facilities in their waste disposal activities [ 27 , 28 , 29 , 30 , 31 ]. Many researchers have similarly decried poor coordination and persistent dormancy of institutional frameworks for the management of HCW in Nigeria [ 32 , 33 , 34 ]. However, healthcare facilities are able to dismiss their duty of ensuring stringent diligence in HCW management and go scot-free as a result of inability of existing legal provisions to impose a mandatory “duty of care” on healthcare service providers and enforce some stringent penalties to serve as deterrent for defaulters [ 9 ]. Abah and Ohimain [ 35 ] reported that in a survey of a tertiary health facility in Nigeria, it was found that the hospital did not have waste management manuals. Possession of guidelines on HCW management was found to enhance safe indices of HCW disposal. This is expected since possession of HCW management guideline will assist designated staff members to understand the procedures for treating different components of waste products that are emanating from healthcare centers.

The results also indicated low training of staff on medical waste management. This is a pointer to inadequate attention being given to management of HCW by many healthcare facilities in Nigeria. This situation may be a perfect reflection of inadequacy of available funds which is a major problem confronting many healthcare facilities in Nigeria [ 36 ]. Precisely, in a situation where doctors are unable to procure basic medical equipment, funding may not be available for training those who manage HCW. Although the essentiality of trainings cannot be overemphasized in healthcare waste management, some previous studies have highlighted non-compliance on the part of designated institutions and other stakeholders [ 37 ].

Awodele et al. [ 8 ] found that in some selected healthcare facilities in Lagos, ability of hospital staff with substantial level of training to properly handle HCW was quite better than those with little or no training. Abah and Ohimain [ 35 ] also reported that in a tertiary hospital in Nigeria, only 11.5% of the respondents received some trainings that were related to management of HCW, while 46% understood the importance of having in place efficient waste management guidelines. Ogbonna et al. [ 38 ] found that in some healthcare facilities in Port Harcourt, inadequate training of designated staff was identified as a major constraint to proper management of HCW.

Other similar studies include Babatola [ 39 ], who conducted a study to analyze waste management practices of healthcare facilities in Akure city of Ondo state, Nigeria. Using a sample of twenty healthcare centers, it was found that only 2% of the staff that were handling HCW had undergone some form of trainings in HCW management. Oli et al. [ 40 ] also analyzed HCW management practices of healthcare facilities in Southeast Nigeria. The results showed that there was no significant difference in private and public healthcare participants’ knowledge about the risks posed by HCW. In addition, 7.0% and 16.2% of staff from private and public healthcare facilities respectively had previously attended some trainings on HCW disposal, while only 22.12% and 41.82% indicated that requisite logistics and materials for ensuring safety in HCW disposal were always available.

The results show that open burning of sharp HCW and other non-sharp HCW was reported by some healthcare facilities. It was also indicated that some healthcare facilities were burning sharp and HCW in protected pits. Generally, burning of HCW can constitute some form of air pollution as a result of release of some toxic substances into the atmosphere. Given this, drastic reduction in human exposure would still constitute some health hazards even at extremely low doses [ 41 ]. Similarly, HPCSA [ 6 ] noted that subjecting HCW to burning instead of incinerated will release some pollutants into the atmosphere, as a result of dioxins formation. In absence of burning, some health centers were disposing their wastes in open general places of dumping domestic wastes, while others dump them inside pits. Although land filling of HCW may be considered safe if properly done, contamination of ground water is equally possible in some exceptional cases [ 42 ].

Incinerators were used by few healthcare facilities, although the standard for protecting the environment from pollution thereof should be ensured. This is as a result of the likelihood of ashes from incinerating containing some pollutant because they could contain mercury and cadmium [ 43 ]. In some previous studies, it was reported that only 30% of the healthcare facilities in Akure were involved in waste segregation and majority were not sterilizing infectious wastes or using incinerators or autoclaves [ 39 ]. Similarly, Yelebe et al. [ 44 ] analyzed waste disposal behaviour of some healthcare facilities in Bayelsa state of Nigeria. It was found that majority of the healthcare facilities were grossly lacking in adoption of standard HCW management with absence of incinerators and any treatment of wastes before disposal. It was further noted that some healthcare facilities and municipal waste management authorities were burning waste in open pits, thereby compromising human safety as a result of associated environmental pollution. In a recent study, it was found that 1.98% of the healthcare facilities sampled in Ebonyi state followed standard procedures in medical waste management [ 45 ].

Healthcare facilities in Bayelsa state had high indices of risky disposal of sharps and ono-sharp HCW. Similarly, Ekiti and Osun states, both from south western part of Nigeria had lowest indices for safe disposal of sharps and non-sharp HCW disposal. The results for Bayelsa state are in line with the findings of Yelebe et al. [ 44 ]. Poor management of sharp HCW poses significant health risks to healthcare workers and those in charge of waste disposal. Precisely, World Health Organization [ 3 , 46 ] indicated that if a person is injured by an injection needle in the course of disposing HCW, the likelihood of being infected with Hepatitis B virus, Hepatitis C virus and HIV are 30%, 1.8% and 0.3% respectively. However, the implication of such injury becomes more alarming given that most of the healthcare facilities do not have insurance coverage for their staff, while functioning mechanisms for compensating victims of occupational health hazards may be completely absent [ 45 ].

The results indicated that healthcare facilities in northern Nigeria were performing better in HCW management than their counterparts in the southern parts of the country. One fundamental issue is that for efficient management of HCW, sufficient land space, equipment and well trained personnel cannot be compromised. The spate of urbanization, especially in southern Nigeria may constitute significant land constraint for treating HCW. More importantly, it should also be noted that majority of the sampled healthcare facilities in northern Nigeria were in rural areas. The volume of wastes that would be generated from many of such rural healthcare facilities would be low, thereby facilitating their safe management.

In addition, regular supply of electricity is required for processing HCW where incinerators are used for highly infectious wastes. The problem of power outage is a major issue in healthcare service delivery in Nigeria [ 47 , 48 ]. Availability of alternative sources of electricity through generator or batteries can facilitate healthcare service delivery. Waste disposal could as well become safer because healthcare facilities with such power sources may as well be able to procure necessary facilities for safe and effective handling of wastes. The results also indicated that access to safe drinking water reduced risky sharp disposal indices. This may also emphasize the role of regular supply of water in the whole process of HCW disposal. Similarly, the longer the time that healthcare facilities are opened for public use, the lower their indices of risky sharp and non-sharp HCW disposal. This may be directly linked to the size of the hospitals in terms of staff and available facilities for ensuring efficient healthcare service delivery. The need for staff training on handling of HCW was reemphasized by the results. This had been previously emphasized in several public health literature [ 6 , 49 ].

This study has provided some empirical analyses of factors explaining risky and safe disposal of HCW in Nigeria. The study has benefited from robust dataset that cuts across the six geopolitical zones in Nigeria. One major limitation of the study is inability to probe into different composition of HCW that were generated and their respective quantities due to data limitations. It can however be concluded that healthcare wastes are important component of healthcare service delivery. Without proper disposal, the healthcare system may become a source of environmental pollution, which could degenerate into disease outbreaks. In the light of the findings from this study, some recommendations are hereby made. First, there is the need for proper enforcement of medical guidelines in relation to safety and efficient service delivery. The current situation portends a perplexing neglect of responsibilities and failure of institutional mechanisms that are in place to ensure adequacy of medical service delivery and safety of healthcare workers. One of the fundamental requisites for managing HCW is training of staff members that are directly connected to the whole processes of waste sorting and disposal. This is also emphasizing the need for adequate budgeting in relation to training of staff on appropriate management of HCW. There should also be appropriate channels for educating hospital staff on the acceptable ways of handling and disposing HCW. These may include the use of posters and other audio visual materials. Precisely, adequate awareness should be created on associated health hazards to people as a result of unsafe disposal of HCW. The onerous task of handling HCW requires adequate logistic supports and provision of some essential equipment. In the light of declining funding to healthcare facilities in the public sector, the ordeal of inadequate disposal of HCW would further complicate the whole processes of economic development.

The results also highlight some significant differences between rural/urban and northern/ southern states’ healthcare facilities in handling of HCW. There is therefore the need for creation of more awareness and devotion of more resources to the management of HCW among healthcare facilities in southern Nigeria. Due to high volume of HCW that are daily generated, urban healthcare facilities and public healthcare facilities must have workable and sustainable means of managing their large spectrum of wastes in a way that ensures utmost environmental and human safety. Finally, ensuring adequate supply of power and water is critical for HCW management in Nigeria. Specifically, incinerators cannot be functionally utilized if electricity supply is erratic. Similarly, several processes that are associated with waste disposal would require regular supply of water.

Abbreviations

Healthcare Waste

Human Development Indicator

Human Immuno-Deficiency Virus

Health Professional Council of South Africa

International Household Survey Network

Lagos State Waste Management Authority

Millennium Development Goals

Ordinary Least Square

Principal Component Analysis

Sustainable Development Goal

Service Delivery Indicator

United Nations Development Programme

Variance inflation factor

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Oyekale, A.S., Oyekale, T.O. Healthcare waste management practices and safety indicators in Nigeria. BMC Public Health 17 , 740 (2017). https://doi.org/10.1186/s12889-017-4794-6

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Medical waste management at the primary healthcare centres in a north western Nigerian State: Findings from a low-resource setting

Semeeh akinwale omoleke.

a World Health Organization, Kebbi State Field Office, Birnin Kebbi, Kebbi State, Nigeria

b Department of Public Administration, Waziri Umaru Federal Polytechnic, Birnin Kebbi, Nigeria

Kehinde Kazeem Kanmodi

c Kebbi Medical Centre, Kalgo, Kebbi State, Nigeria

Mustapha Mohammed Ashiru

d Department of Veterinary Public Health, Kebbi State Ministry of Animal Health, Husbandry and Fisheries, Birnin Kebbi, Kebbi State, Nigeria

Associated Data

This study aims to examine medical waste management (MWM) practices and identify the challenges of optimal MWM at the primary healthcare (PHC) level in Kebbi State, Nigeria.

Study design

This study was a cross-sectional survey of 265 primary healthcare workers (PHCWs) and health facilities (HFs) in Kebbi State.

The study tool used was a questionnaire adapted from the WHO rapid assessment tool on MWM and water sanitation. Descriptive and inferential statistical analyses were conducted using SPSS version 20 software.

Data generated from 257 HWs were used in this study. Amidst other findings, only 65 (25%) HFs had MWM guideline or policy document; out of these 65HFs, only 19 (7%) of them had problem with its implementation. Only 42 (16%) HFs had a compensation package or a health insurance policy to take care of their health workers in case of MWM-associated hazards while 22 (9%) HFs had specific budgetary allocation for MWM. Only 105 (41%) HFs had trained staffers on MWM. Sharps, blood/body fluids and domestic wastes were the top three (3) wastes generated among the surveyed HFs. Medical waste treatment was on-site in 124 (48%) HFs and burn-and-bury method was the adopted method of medical waste disposal in 198 (77%) HFs. However, the majority (76%) of the surveyed HWs expressed dissatisfaction about the waste treatment practices adopted in their HFs.

Our study revealed a poor level of MWM practices in Kebbi State, Nigeria. The state government and partners need to urgently address the identified operational and policy gaps in MWM in Kebbi State, Nigeria. Furthermore, our study revealed the negative implication of fragmented governance and leadership structure at the PHC level on policy, practice and administration of medical waste management in the Kebbi State, Northwestern Nigeria. Addressing the gaps found in this study would contribute to the attainment of the United Nations Sustainable Development Goals in health and well-being, sustainable cities and communities and contribute to poverty eradication.

1. Introduction

Management of medical wastes has been challenging and critical in many developing countries, including Nigeria [ 1 ]. Medical wastes are potentially hazardous products of health care and related services rendered at health facilities, clinical research centres, biotechnology centres, and blood banks [ 2 ]. Medical wastes also include wastes originating from other variety of sources, such as wastes generated from healthcare undertakings at homes, self-administration of insulin, home dialysis, and recuperative care as well as rehabilitation care [ 2 ]. According to a WHO report in 2005 [ 2 ], 85% of the medical wastes are categorised as general (or non-hazardous) wastes. The general medical wastes often come from administrative, kitchen and house-keeping activities, packaging, hospital building, and facility maintenance at healthcare-related settings. The remaining 15% of medical wastes are categorised as infectious wastes (10%) and chemical/radioactive wastes (5%); these wastes are hazardous and may constitute a risk to health and the environment [ 2 ].

Medical wastes are generated at all levels of care, namely: primary, secondary and tertiary levels. Given the volume and potentially hazardous nature of these wastes, they are of high interest to public, occupational and environmental health [ 2 ]. Medical wastes are potentially harmful to health workers (HWs), patients, community inhabitants and the environment. Proper handling of medical wastes can minimize the hazards associated with improper waste management [ 3 , 4 ]. Furthermore, medical waste management (MWM) is an integral part of health care service delivery [ 5 ]. Good MWM can be an integral part of effective infection control procedures if properly implemented [ 2 ]. However, adequate attention has not been paid to MWM practices in many health institutions, especially in Nigeria [ 1 , 5 , 6 ]. Reports from the literature suggest no strict adherence to the professional ethics of MWM in Nigeria, showing a severe compromise of the internationally acceptable guidelines on MWM [ [4] , [5] , [6] ]. The situation appears worrisome at the primary health care (PHC) level. Some of the reasons attributed to the poor MWM are poor financing, weak institutional arrangement and governance [ 1 ], little or no capacity-building opportunity on MWM issues [ 1 , [6] , [7] , [8] ], and non-compliance to waste management guidelines or procedures [ [6] , [7] , [8] , [9] ]. In addition to the above, there is no mechanism in place to monitor adherence or compliance to best practices in MWM as the waste management policy in Nigeria appears to be infantile and barely operational at the health facilities [ 6 ].

Due to limited funding and paucity of literature in the northwestern region of Nigeria, our study focused on Kebbi State-a mostly rural State that has a population of about 4.7million inhabitants. A recent survey conducted in Kebbi State by Oyekale et al. [ 5 ], reported a high level of risky disposal of wastes, particularly sharps, in the State. This demonstrates the need to further investigate this observed challenge to provide a better understanding of the practices, knowledge and other waste management problems at the PHC level in Kebbi State. It is therefore imperative to examine the MWM system at this level of care (i.e., the PHC level) in Kebbi State, as this level of care remains the closest and most accessible source of orthodox healthcare services to the rural population. In an effort to better understand the practice(s) and challenges associated with the management of medical wastes at the PHC level, it is imperative to assess the role of governance and administrative system within the health sector as it affects MWM, using this rural Nigerian State as a case study. This study aims to examine the type of medical wastes and MWM practices at the PHC level in Kebbi State; assess the incidence and management of occupational injury at the PHC level in Kebbi State; assess the availability of waste management guideline, staff health insurance and compensation packages and funding as well as identify the challenges of optimal MWM at the PHC level in Kebbi State.

This study was a cross-sectional survey of PHC facilities in Kebbi State, Nigeria. Kebbi State is in the Northwestern region of Nigeria. The State is situated between latitudes 10° 8′ N – 13° 15′ N and longitudes 3° 30′ E − 6° 02′ E, and with an approximate surface area of 36,229 ​Km 2 [ 10 ]. Kebbi State has both local and international borders. Locally, it borders with Zamfara, Sokoto and Niger States while it has international borders with Niger and Benin Republics. There are 21 Local Government Areas in Kebbi State with 225 political wards [ 11 ]. The State is largely rural with a few semi-urban towns. Besides Birnin Kebbi, the State capital, other major towns include Argungu, Yauri, Zuru (all emirate headquarters) and Jega – the commercial capital of the state. Kebbi State is divided into four emirates – Gwandu, Argungu, Yauri and Zuru Emirates.

Kebbi State has a projected population of about 4,671,594 people (for 2018) based on the 2006 census population. Kebbi State enjoys a tropical climate characterized by annual rainfall ranging from 800 ​mm (northern part of the State) and 1000 ​mm (in the south) while temperature ranges from 21 to 40 degree Celsius (mean temperature: 26 degrees Celsius) [ 11 , 12 ]. The State has numerous ethno-linguistic groups with the Hausa/Fulani as the predominant. Other indigenous linguistic groups that can be found in Kebbi State are Dakarkari (Lelna), Zabarmawa, Kambari, Dukkawas and Gunganci. The major occupation of the people is farming and livestock rearing, essentially agrarian [ [11] , [12] , [13] ]. Islam is the predominant religion, although many communities in the Southern parts of the State practice other religions, mainly Christianity and traditional religions.

The instrument used for data collection was a paper questionnaire. The questionnaire was an adapted version of the WHO rapid assessment tool on MWM and water sanitation (the adapted tool can be found at http://www.who.int/water_sanitation_health/medicalwaste/ratupd05.pdf ).The questionnaire was validated by an expert (one of the authors: MMA) who ensured the words of the questionnaire are easily comprehensible, and suggestions made were effected in the finalized draft that was employed. A pilot study was conducted by giving the questionnaire to 50 conveniently selected PHC workers from two conveniently selected PHCs (note that the PHCs that were used for the pilot study were excluded from the main study in order to avoid bias) to go through for check of clarity and easy comprehension. All suggestions were noted, and corrections were effected. The final draft of the questionnaire had three sections, namely: section A, section B, and section C. Section A obtained information on the socio-demographic characteristic and basic information (such as age, ethnicity, designation, length of year in service, religion, marital status and education level) of each of the study participants. Section B obtained information from the study participants on staffing and available services at the surveyed HFs; training on MWM (any training done and time of the last training); medical waste generation (type of waste generated and quantity); waste storage (color-coding system and segregation methods); off-site transport of waste (system of transport, responsible person and frequency of transport); and final waste disposal/treatment (on-site or off-site treatment, method of waste disposal, ministry or agency responsible, number of incinerator in the State). Section C obtained information from the study participants on MWM regulations (waste management guideline/policy document, budgetary allocation and funding, structure of health system, functional waste management committee, extra-governmental collaboration, annual reporting on waste management and impediments to efficient and effective waste management system).

The sample size of the HFs to be surveyed in this study was determined from the Leslie formula stated below [ 14 ]:

In the above formula, n depicts the base sample; and Z ∝ / 2 (equal to 1.96) is the value of Z score obtained from the confidence level. P stands for prevalence rate of MWM. The value of p is usually estimated at 50% to reflect the assumption that impact is anticipated in 50% of the population, while q is the compliment of p (i.e. 1- p). “e” is the margin of error usually estimated at 0.05.

Given the total number (N ​= ​851) of functional health facilities (HFs) situated in all the LGAs in Kebbi State, an adjusted sample size was estimated as follows:

Thus, the study was based on a sample size of 265 HFs.

The HFs that were selected for the survey were randomly picked from a sampling frame which contains a total of 851 functional HFs in all the LGAs in Kebbi State. Having obtained the study’s sample size, proportionate stratified sampling technique was employed for the selection of the surveyed HFs in each LGA, hence eliminating selection bias and assuring wider coverage.

From March to April 2018, data on each of the selected HF was obtained from health workers within each facility, using the pre-tested self-administered questionnaire. Only one informant was recruited per HF. All informants interviewed in this study were HWs at each of the surveyed HFs. We used a table of random numbers in the selection of the HW serving as the study participants from the list of all HWs in each facility. Prior to data collection, each study participant was informed about the purpose and benefits of the study, and he/she was also informed that his/her participation is strictly voluntary and unanimous. Also, verbal informed consent was obtained from all the study participants before their participation. We also took some pictures of the waste disposal sites visited, for evidence (Supplementary file 2).

Data collected was cleaned, coded and entered in the SPSS version 20 software for analysis. The frequency distribution of all variables was determined. The test of association between variables was determined using a chi-square test, using a p-value of <0.005 to determine the level of statistical significance. Results from the data analysis were presented using tables.

A total of 265 study participants were recruited in this study. However, eight (8) workers dropped out of the study due to failure to return their filled questionnaires to the investigators during the study period. Hence, the response rate for the survey was 97% (257/265).

Out of the 257 successfully interviewed participants, only 89 were within the age bracket of 35–44 years, 193 were males, 215 had ordinary national diploma (OND), 77 had 1–10 years working experience, 212 were married, and 220 were Muslims ( Table 1 ).

Table 1

Socio-demographic profile of informants.

BD – Bachelor’s Degree; OND- Ordinary National Diploma; HND – Higher National Diploma; N – Total number of responses per category.

Not all the study participants responded to all the questions they were asked about their: HFs, knowledge of MWM practices; and opinion on MWM practices (see Tables 1–11 ). However, based on the data they provided, only 214 HFs had <10 health workers, 3 had no non-technical staffers, 108 operate 24-hour services, 64 had no bed, 172 render immunization services, and only 226 had a village/ward development committee ( Table 2 ).

Table 2

Information on staff strength, daily operational hours, bed availability, and kind of services rendered at the surveyed HFs.

N – Total number of facilities whose respondents responded to the variable; ANC – Antenatal care; ∗Multiple response variable.

Only 105 HFs were reported to have a positive history of staff training on MWM, and the training activity was conducted at only 55.2% (58/105) of these facilities ( Supplementary file 1 , Table S1 ).

Sharps, blood/body fluid, and domestic wastes were the top three wastes generated among the surveyed HFs ( Supplementary file 1 , Table S2 ).

Only 31 HFs had specific colour coding system ( Supplementary file 1 , Table S3 ).

Only 65 HFs adopted the use of motorcycle in transporting their wastes to the disposal sites; HF workers were the people that transported these wastes in most (224/257) of the surveyed HFs; and these wastes were often moved to disposal sites, on a daily basis, only at 128 HFs ( Supplementary file 1 , Table S4 ).

Medical waste treatment was on-site in 124 HFs while the burn-and-bury method was the adopted method of medical waste disposal in 198 HFs ( Supplementary file 1 , Table S5 ).

Furthermore, only 65 HFs had MWM guidelines or policy documents; out of these 65 HFs, only 19 of them had a problem with its implementation. There were cases of occupational hazards (such as needle prick, nosocomial infection, etc.) in 42 HFs. Only 42 HWs reported having a compensation package or health insurance policy to take care of them in case of occupational hazards. Only 78 HFs had functional waste management committees. Only 22 HFs had specific budgetary allocation for MWM. Only 50 HFs had reports on MWM practices in their facility ( Table 3 ).

Table 3

Information on medical waste management policy and regulations among the surveyed HFs.

Also, very vital information was provided by the health workers based on their own opinion (and knowledge) regarding MWM practices at their HFs and Kebbi State at-large. Based on the information provided, we noted that: (1) only 109 study participants knew the quantity of wastes generated, on daily basis, at their HFs ( Supplementary file 1 , Table S2 ), (2) only 48 study participants understood the colour coding system or waste segregation method ( Supplementary file 1 , Table S3 ), (3) only 196 study participants expressed dissatisfaction about the waste treatment options adopted in their HFs ( Supplementary file 1 , Table S5 ), (4) only 65 study participants reported that the Kebbi State Primary Health Care Development Agency was responsible for the treatment of medical wastes ( Supplementary file 1 , Table S5 ), (5) only 45 study participants reported that Kebbi State has only one or two functional incinerators ( Supplementary file 1 , Table S5 ), (6) only 15 study participants, out of the 22 study participants working in those HFs (N ​= ​22) having specific budgetary allocation for MWM, reported that the allocation was sufficient ( Table 3 ), (7) only 56 study participants reported that the government partners with external bodies in MWM ( Table 3 ), (8) “lack of training or awareness of proper handling and disposal of medical wastes”, “absence of waste regulatory policy or guideline”, and “inadequate waste treatment facilities” were the top three factors, as reported by the health workers, impeding efficient and effective MWM at the HF level ( Table 3 ).

Lastly, we performed bivariate analysis, comparing associations between the history of health workers’ training on MWM and characteristics of the surveyed health facilities, which yielded noteworthy results ( Table 4 , Table 5 , Table 6 ). Only statistically significant relationships (i.e., p-values <0.005) exist between operating hours, bed spaces, and the existence of a functional village/ward development committee, and history of MWM training at the surveyed HFs ( Table 4 ).

Table 4

Associations between history of health workers’ training on medical waste management and characteristics of the surveyed HFs.

Table 5

Associations between methods of medical waste disposal and characteristics of the surveyed HFs.

Table 6

Associations between existence of a functional waste management committee and characteristics of the surveyed HFs.

Also, no statistically significant relationship was recorded between methods of medical waste disposal and characteristics of the surveyed HFs ( Table 5 ).

Finally, amongst other comparisons, a statistically significant relationship exists between operating hours of the surveyed HFs and the existence of a functional waste management committee at the HF level ( Table 6 ).

4. Discussion

The majority of the study participants were Ordinary National Diploma holders and in the age range of 25–44 years. A similar finding on this socio-demographic profile was reported by Umar et al., who conducted a study at Fagge LGA, Kano State, Nigeria, involving PHCs [ 15 ]. This is, however, in contrast to a study conducted at PHCs at Zaria, Kaduna State, Nigeria, where nurses constituted the majority [ 16 ]. Other studies conducted at various or mixed levels of healthcare delivery had reported varying proportions of participants’ professional cadres [ 3 , [7] , [8] , [9] , 17 ].

In the HFs that were surveyed in this study, the types of waste generated there were sharps, domestic wastes, blood and body fluid, chemical and radioactive wastes. Roughly half of the wastes being generated were sharps, followed by domestic wastes, then blood and body fluids, while little chemical and radioactive wastes were also generated. This finding is similar to findings in a study conducted at the primary health care level at Fagge Local Government Area of Kano State [ 15 ] and selected hospitals in southeast Nigeria [ 8 ]. Other studies, particularly those that were conducted in secondary health care facilities, and bigger hospitals found domestic wastes constituting the highest proportion of wastes generated, followed by sharps [ 17 , 18 ]. These disparities in findings are essentially a reflection of the nature of services being rendered as it was found in this study that roughly one-third of the services rendered were immunisation activities. This was followed by ante-natal care/delivery services. Furthermore, the report of chemical and radioactive wastes generated among the study participants, though very minute, might result from an inadequate understanding of the question. Nevertheless, this is insignificant or too little to alter the overall outcome of the study. Based on responses from the study participants, a larger proportion of the surveyed HFs did not measure the daily wastes being generated, as shown in this study. This is an indication of the low standard of MWM practices in this setting. A similar finding had been documented in a study conducted in a South African Hospital where medical wastes were not quantified, and no reliable records were found [ 19 ].

The majority of the surveyed HFs did not segregate wastes by colour coding, and indeed the majority of the study participants did not understand the color-coding system in MWM. This is a clear indication of training deficit and poor MWM practices at this level. This finding agrees with several other studies conducted in Nigeria, where waste segregation was either non-existent or poorly observed [ 1 , [7] , [8] , [9] , 16 , 17 , 19 , 20 ]. Similarly, studies conducted in other developing countries had reported poor or incorrect segregation of medical wastes [ 4 , 18 , 19 , 21 , 22 ]. However, very few studies showed a high level of waste segregation in this environment [ 3 , 6 ]. These are essentially studies done in Lagos State, a State which seems to have a more organised and established MWM practice, involving the public waste management authority [ 3 , 6 ].

The treatment of wastes was mostly on-site, as mentioned by the study participants, and the majority indicated that burn-and-bury technique was the method of waste disposal being practised at their HFs. Also, incineration, which is the preferred method of MWM was infrequently used in Kebbi State. The use of incinerators in the final disposal of medical wastes in Nigeria was minimal and comparatively lower at the PHC level. Previous studies in Nigeria that have assessed the use of incinerators indicated very low use of incinerators [ 6 , 23 ]. At the primary health care level, incinerators are usually deployed to destroy massive medical wastes generated from vaccination campaigns (mass immunisation) where funds are earmarked for waste management.

In this study, the transport of medical wastes was mainly done by the PHCWs using motorcycles to a pre-defined site for onwards destruction. Kebbi State Primary Healthcare Development Agency rarely provides logistics support for the evacuation to the pre-defined site. Furthermore, the involvement of public waste management authority or the Ministry of Environment was significantly low in this study setting. This study’s finding is contrary to published studies from Lagos State, where there existed a partnership with Lagos State Waste Management Authority (LAWMA) in the final medical waste disposal [ 3 , 6 ]. A similar partnership or concession was also reported in a publication from Malaysia, where concession companies were involved in waste management [ 18 ]. However, this study finding corroborated older studies demonstrating poor waste transportation and disposal practices in Nigeria [ 1 , 7 , 8 , 17 , 23 ].

Furthermore, medical waste guidelines or policy documents were hardly available or known to the study participants. In the HFs where there are guidelines, the implementation levels were low amidst numerous challenges. This study data showed that few cases of occupational hazards had occurred in the sampled HFs. This study investigated the existence of insurance and compensation packages for victims of occupational hazards within the PHC services and found no insurance policy or compensation package in place to take care of injured or victims of occupational hazards. Similarly, in 2017, another study reported the non-availability of insurance and compensation packages for occupational hazards victims [ 7 ]. The finding calls for the protection of health workers’ rights to compensation and insurance packages in the event of injuries or deaths due to occupational hazards.

Regarding the existence of a functional waste management committee at the HF level, the majority of the HFs did not have a functional waste management committee. This finding corroborated a previous study conducted in Nigeria [ 8 ]. The waste management committee oversees the administration of waste management activities within the HF.

The governance of PHC services could affect the administration of MWM at the operational level (from the point of generation to final disposal) as most of the study participants indicated that the current structure affects the governance of MWM in Kebbi State. Regarding funding, most of the study participants indicated no funding allocation to the HFs for waste management. Further, nearly all the studies reported that was no funding allocation for MWM at the HF level [ 1 , 17 ].

This study also found that there was a minimal level of partners’ involvement in MWM in Kebbi State for routine PHC services. No previous study has investigated the involvement of development partners in medical waste management. Our field experience indicated that the development partners usually provide funds for MWM only during mass immunisation. This mitigated or prevented hazards the communities and environments would have been exposed to as a result of huge wastes (domestic and sharps) that were generated from such a large-scale immunisation exercise.

Bivariate analyses were conducted to explore the predictors of few outcomes such as training on waste management, waste disposal method and the existence of functional waste management committees.

Regarding the likelihood of training, the analysis showed that HFs with 24-hour services were more likely to conduct waste management training. Also, the presence of a functional village/ward development committee could be a predictor of the likelihood of implementation of waste management training. This study also found that the greater the number of beds in a facility, the more likely the health facility would have had medical waste management training. The variables or characteristics that predicted the likelihood of training are plausibly related to the functionality of the health facilities. For example, only health facilities that provided comprehensive primary health services operate 24hours’ services-such facilities often run in-patient services, have beddings, and more likely to be supported by a functional village/ward development committee (given the degree of functionality). The existence of functional VDC/WDCs reflects the strength of community linkage with PHCs. On the other hand, the number of health workers, the number of non-technical staff and the type of services rendered did not predict the likelihood of having medical waste management training.

The study tested the association between plausible potential predictors of waste management disposal method, i.e., number of health workers, number of non-technical workers, 24-hour operation, number of beds and functional village/ward development committee. However, there was no significant association between the test and outcome variables. This finding may be due to the extremely low use of acceptable disposal methods. Essentially, most PHC facilities use the burn-and-bury method while other methods, such as incineration and open dumping, were employed on a lesser scale. Similarly, the tested variables did not predict the likelihood of having a functional waste management committee at the health facilities.

Furthermore, this study investigated the possible impediments to effective and efficient waste management at the PHC level. The study revealed a lack of training or sensitisation on proper handling and disposal of medical wastes, inadequate treatment facilities, inadequate funding as well as governance and leadership problems. Previous studies had identified the above-listed challenges-local and international-in other developing countries [ 4 , 8 , 9 , [17] , [18] , [19] , [20] , [21] , [22] ], except the PHC system’s governance, as applied to the study area.

5. Conclusion

This study showed that medical waste management practices are grossly sub-optimal at the PHC facilities in Kebbi State, Nigeria. The study revealed the dire need for the government and partners to urgently address the operational and policy gaps in medical waste management in Kebbi State, Nigeria, given its public health and environmental implications. We recommend the speedy implementation of primary-health-care-under one-roof (PHCUOR) in Kebbi State to address the fragmented management system and weak governance that impeded optimal PHC activities, including medical waste management. Further, the Kebbi State Government should consider public-private partnerships in managing medical waste to improve efficiency and mitigate potential health and environmental hazards. Addressing the gaps found in this study would contribute to the attainment of the United Nations Sustainable Development Goals in health and well-being, sustainable cities and communities and contribute to poverty eradication.

6. What is already known on this topic

• • Good MWM can be an integral part of effective infectious control procedure, if properly implemented.
• • Adequate attention has not been paid to MWM practices in many health institutions in Kebbi State, Nigeria.
• • There is no strict adherence to professional ethics of MWM in Kebbi State, Nigeria.

7. What this study adds

• • Acceptable medical waste management practices are lacking at the PHC facilities in Kebbi State, Nigeria
• • There is a need for government and other relevant stakeholders to urgently address the identified operational and policy gaps in medical waste management in Kebbi State, Nigeria, given its public health and environmental implications
• • The fragmented governance and leadership structure of the PHC system has grave implications for the policy and practice of medical waste management in Kebbi State, Nigeria
• • Kebbi State Government should consider public-private partnerships in managing medical waste to improve efficiency and mitigate potential health and environmental hazards
• • Overall, addressing the gaps found in this study would contribute to attaining the United Nations Sustainable Development Goals in health and well-being, sustainable cities and communities, and contributing to poverty eradication.

The authors did not receive funding from a private or public organisation for the conduct of this study.

Authors’ contributions

SAO conceptualised, designed, managed and interpreted the study data and drafted the first version of the manuscript. NU contributed to the design, supervised and critically reviewed the manuscript drafts. KKK contributed to data management and reviewed the manuscript drafts while MMA reviewed the manuscript drafts. All authors read and approved the final draft before submission.

Ethical consideration

This study was conducted under the strict guidelines of the Helsinki Declaration of 1964. The study protocol was approved by the Kebbi State Research Ethics Committee, Kebbi State Ministry of Health, Kebbi State, Nigeria.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.puhip.2021.100092 .

Appendix A. Supplementary data

The following are the Supplementary data to this article:

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Healthcare waste management in Nigeria: A case study

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On-demand mobile hypertension training for primary health care workers in Nigeria: a pilot study

• Joseph Odu 1 ,
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BMC Health Services Research volume  24 , Article number:  444 ( 2024 ) Cite this article

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Metrics details

Only one out of every ten Nigerian adults with hypertension has their blood pressure controlled. Health worker training is essential to improve hypertension diagnosis and treatment. In-person training has limitations that mobile, on-demand training might address. This pilot study evaluated a self-paced, case-based, mobile-optimized online training to diagnose and manage hypertension for Nigerian health workers.

Twelve hypertension training modules were developed, based on World Health Organization and Nigerian guidelines. After review by local academic and government partners, the course was piloted by Nigerian health workers at government-owned primary health centers. Primary care physician, nurse, and community health worker participants completed the course on their own smartphones. Before and after the course, hypertension knowledge was evaluated with multiple-choice questions. Learners provided feedback by responding to questions on a Likert scale.

Out of 748 users who sampled the course, 574 enrolled, of whom 431 (75%) completed the course. The average pre-test score of completers was 65.4%, which increased to 78.2% on the post-test ( P <  0.001, paired t-test ). Health workers who were not part of existing hypertension control programs had lower pre-test scores and larger score gains. Most participants (96.1%) agreed that the training was applicable to their work, and nearly all (99.8%) agreed that they enjoyed the training.

Conclusions

An on-demand mobile digital hypertension training increases knowledge of hypertension management among Nigerian health workers. If offered at scale, such courses can be a tool to build health workforce capacity through initial and refresher training on current clinical guidelines in hypertension and other chronic diseases in Nigeria as well as other countries.

Peer Review reports

Hypertension in Nigeria

In Nigeria, cardiovascular disease accounts for 9% of all deaths each year [ 1 ]. Hypertension is a major driver of cardiovascular disease burden, with a prevalence between 32.5% and 38.1% among adults in Nigeria [ 2 , 3 ]. However, access to care and treatment for hypertension in Nigeria is inadequate, with only 12.0–33.6% of hypertensive individuals estimated to receive treatment [ 2 , 3 ]. Moreover, blood pressure control rates are extremely low, ranging from 2.8 to 12.4% [ 2 , 3 ]. Several factors contribute to this situation, including poor detection and management of hypertension at primary health centers (PHCs), a shortage of health workers (HWs), limited knowledge among some HWs, and inadequate equipment and supplies at health facilities [ 4 ].

The Nigerian Federal Ministry of Health (FMOH) has established national targets and developed a roadmap to address the rising burden of non-communicable diseases based on the World Health Organization (WHO) HEARTS hypertension control technical package [ 5 , 6 , 7 ]. In collaboration with the National Primary Healthcare Development Agency (NPHCDA), WHO, and Resolve to Save Lives, the FMOH launched the Nigerian Hypertension Control Initiative in 2020 [ 8 ]. The initiative aims to improve population-level blood pressure control by strengthening and scaling up screening, diagnosis, treatment, monitoring, and health education at the primary health care level.

Nigeria Hypertension Control Initiative strategies include standardizing hypertension treatment with a simple treatment protocol and implementing task shifting and task sharing of hypertension service delivery duties. This approach engages all cadres of PHC staff in hypertension management. The government is currently conducting in-person training of HWs in PHCs across the country using Nigeria-specific guidelines. However, traditional in-person training has several limitations.

Current gaps in health worker training

Low- and middle-income countries face significant challenges in establishing and maintaining a skilled health workforce to combat the growing burden of non-communicable diseases and other health challenges [ 9 ]. Conventional HW in-service training methods have not kept up with the rapid evolution of clinical guidelines and best practices [ 10 , 11 ]. Nigeria has over 30,000 PHCs that are staffed by hundreds of thousands of HWs [ 12 ]. Providing in-person training to upskill the entire PHC workforce on new hypertension guidelines would be a costly and logistically challenging endeavor. The system of pre-service HW training is also under strain. Meanwhile, developing countries continue to face severe shortages of HWs, particularly in rural and underserved areas [ 13 ].

The COVID-19 pandemic has further highlighted the need for innovative approaches to HW training. The pandemic significantly disrupted traditional training methods like in-person seminars and workshops [ 14 , 15 ]. Online training is emerging as a viable option to provide health professionals with the flexibility to study at their own pace and from any location while minimizing the risk of the spread of infection [ 14 ].

Present study

Our team previously piloted and evaluated a short, mobile-optimized online infection prevention and control course with HWs in Nigeria [ 15 ]. We found that the course had high completion rates and strong learning gains. Based on the success of the online infection prevention and control course, we applied a similar methodology to train HWs based in PHCs in Nigeria on new national hypertension diagnosis and management guidelines.

Program design informed by learning science

We expanded on the learning approach we developed in previous pilots of an infection prevention and control course in Nigeria [ 15 ]. We used insights from the learning sciences and our understanding of HWs’ learning and technology needs to develop a set of design principles. These include:

Structuring the learning around clinical cases that are directly relevant to HWs’ practice. This approach can boost HWs’ interest and motivation [ 16 ]. It also allows HWs to directly apply experiences and knowledge stored in long-term memory.

Engaging HWs through continuous low-stakes assessments (quiz questions) with constructive feedback. These assessments are intended to promote learning rather than merely evaluate learners [ 17 ]. Each question is accompanied by a brief explanation, which improves learners’ subjective experience [ 18 ].

Developing modules that repeat and expand upon key concepts, harnessing the benefits of spaced repetition to facilitate learning [ 19 ].

Focusing on essential content and eliminating nonessential material, which improves factual retention [ 20 ].

Teaching basic knowledge and skills, which may be more appropriate for online HW training than teaching advanced clinical practices [ 16 ].

Offering short courses, which increases course completion [ 21 ].

Implementing a user-friendly and well-organized learning experience, which reduces frustration and maintains learners’ self-efficacy [ 22 ].

Requiring learners to complete a short “sample” module to enroll in the full course. Some learners who sign up for free online courses do not intend to complete them [ 23 ], so this small commitment helps to ensure that those who enroll are invested in the learning.

Evaluation methodology

To assess short-term knowledge gains we used a pre-/post-test design. The 10-question multiple choice test was given once at the beginning of the course, with the same set of questions given again at the end of the course. Questions were presented in the same order each time, with the order of answers randomized. Although the pre-/post-test emphasized the content taught in the course, the pre-/post-test questions were not repeated in other modules of the course. Learners could only take each of these tests once and no minimum score was required on the test to advance in the course. Learners received minimal feedback (they could see the correct answers but there were no explanations given) after submitting their answers. To evaluate learners’ reactions, HWs answered a short survey at the beginning of the last module of the course. This survey included the net promoter score question, “How likely is it that you would recommend this course to a friend or colleague?” The survey also included two 5-point Likert scale questions assessing learners’ enjoyment of the course and its relevance to their work. Learners provided basic demographic data by answering a short survey at the end of the first (sample) module of the course. We based the survey questions (supplementary file 1 ) on questions we used in previous courses [ 15 ], with some additions and refinements to match the context of this course.

Collaborative course development

The development of the course was a collaborative and coordinated process that involved multiple government stakeholders, academic partners, and non-governmental organizations. These entities included the FMOH, NPHCDA, WHO-Nigeria Office, Johns Hopkins University, the University of Abuja Teaching Hospital’s Hypertension Treatment in Nigeria Project team, and Resolve to Save Lives.

The FMOH coordinated the co-creation of course materials aligned with the National Hypertension Treatment Guideline, developed in 2021. Prior to the pilot study, four hypertension program managers from WHO, NPHCDA, the Hypertension Treatment in Nigeria Project, and RTSL, three FMOH policymakers, and four clinical experts reviewed the course to ensure alignment with local guidelines and cultural context. An example module from the course is provided in supplementary file 2 . After the content was reviewed, the course was built on our learning management system and quality assurance was conducted by the team at Resolve to Save Lives.

Next, we conducted user testing at a PHC in Abuja to ensure the course’s usability and effectiveness. Four HWs from different cadres took part in the testing, including a medical doctor, a nurse/midwife, a community health extension worker (CHEW), and a pharmacy technician. HWs were selected who had a smartphone, an email account, and access to cellular data or Wi-Fi internet at the testing site. We carried out individual user testing sessions with each HW. Throughout these sessions, we offered an overview and context for the online hypertension course, secured consent from the participants, and clarified the procedure for accessing the course. The HW then received a text message with a link to the course and accessed selected modules on their mobile device. They were encouraged to provide feedback on their progress, including difficulties encountered, observations, and suggestions. The results of user acceptance testing were used to improve the course content and navigation for the subsequent pilot.

Course dissemination

Enrollment in the pilot online training was open from February 13 to April 20, 2023. Learners who enrolled had access through May 4, 2023 to ensure that they had enough time to complete the course. The FMOH, NPHCDA, the Hypertension Treatment in Nigeria Project manager, and state non-communicable disease coordinators distributed the link to the online course to HWs at Nigeria Hypertension Control Initiative facilities, hypertension treatment in Nigeria project facilities, and other facilities implementing hypertension control programs. The link was primarily shared via email and WhatsApp. The target audiences included doctors, nurses, and community health workers at PHCs who care for hypertensive patients. Due to task shifting and task sharing, all of these HW cadres contribute to hypertension diagnosis and management in PHCs in Nigeria.

Technologies used

The course was hosted on the LearnWorlds platform [ 24 ]. We optimized LearnWorlds settings to remove any unnecessary buttons or menus, simplify navigation, and maximize readability on mobile devices. Learners were required to answer all questions and move through the course in sequence. LearnWorlds was integrated with another tool, Zapier [ 25 ], to automatically enroll learners in the full hypertension course after they completed a sample module. Support requests were handled over email and learners used WhatsApp to support each other informally and contact program staff for support.

Data analyses

All data were downloaded from the LearnWorlds platform in.csv format. To calculate pre-/post-test scores, we gave each question equal weight. The net promoter score question was presented on an 11-point scale from 0 (not at all likely) to 10 (extremely likely). We calculated net promoter score by subtracting the percentage of detractors (6 and below) from the percentage of promoters (9 and 10) [ 26 ]. Likert scale questions were numerically coded to compute a mean. All data were analyzed in Microsoft Excel. Paired t tests were used to evaluate learning gains.

Enrollment, completion, and learner demographics

748 users entered the first “sample” module of the course. Of these, 574 completed the sample module to enroll in the full course. 75% of enrolled learners ( n  = 431) completed the course. The mean pre-test score was 65.4% among learners who completed the course, and 59.6% among learners who did not. Over 99% of enrolled learners reported living in Nigeria, and 75% of them were asked to take the course by a supervisor. 59% of learners reported working in a PHC that was part of an existing hypertension control program in Kano State, Ogun State, or the Federal Capital Territory. The vast majority of learners (89%) reported accessing the course on a smartphone or other mobile device. Almost all learners (98%) reported some work responsibilities related to hypertension diagnosis and management or the administration of hypertension programs (Table  1 ).

70% of learners reported completing training for at least one clinical role (Junior CHEW, CHEW, community health officer, Nurse, Midwife, or Doctor). 54% of learners reported completing some post-secondary schooling (but not a bachelor’s degree), and 34% reported completing a bachelor’s degree.

Learning gains and completion by health worker cadre and education level

Among the 431 learners who completed the course, the pre-test score was 65.4% and the post-test score was 78.2% ( P <  0.001). There was a wide range of scores on both tests (Fig.  1 ).

Pre- and post-test scores among learners who completed the course ( n  = 431)

There were differences in test scores and course completion by HW cadre (Table  2 ), but learning gains were significant in all cadres. Nurses, midwives, doctors, and those who completed a bachelor’s degree or above in microbiology or biomedical sciences had the largest learning gains. Doctors had the highest pre-test scores of any group, while community health officers had the lowest pre-test scores. CHEWs had the highest completion percentage and doctors had the lowest completion percentage.

Learning gains interact with study time and prior participation in hypertension control programs

Learners who completed all learning activities spent a median time of 160 min working in the course. Those who took longer to complete the course had greater learning gains than those who spent the median amount of time or less (Table  3 ). 59% of the 431 learners who completed the course reported working in a PHC that was part of an existing hypertension control program. These learners had higher pre-test scores and lower learning gains than those who were not working at such PHCs (Table  3 ).

Learner feedback

Of 434 responses to the net promoter score question, the average rating was 9.6/10, corresponding to a net promoter score of + 86. Learners also gave the course high ratings on two Likert-scale questions assessing their enjoyment of the course and its relevance to their work (Table  4 ).

We developed and piloted an online learning approach to train HWs in Nigeria on new national guidelines for hypertension management. The pilot had a high percentage of completion, positive learner feedback, and significant learning gains across different categories of PHC-based HWs. Most importantly, learners significantly gained clinically relevant knowledge regardless of their cadres. Along with our previous work [ 15 ], these results suggest that a mobile, digital, on-demand training approach is effective for training PHC-based HWs in Nigeria on best clinical practices in hypertension management. Future research, ideally randomized controlled trials, will be needed to determine the impact of such training on patient care and health outcomes.

This course had a high percentage of completion compared to industry norms, with 75% of enrolled learners completing the course, in contrast to massive open online courses, in which completion rarely exceeds 25% [ 27 , 28 , 29 , 30 ]. The high percentage of completion of this course is likely due to its endorsement by the FMOH and the encouragement HWs received to take the course from their supervisors. Factors that affect online course completion include endorsement and promotion by employers, the government, trusted sources, and professional networks [ 31 , 32 , 33 ]. Other factors reported to promote uptake of online courses include perceived usefulness and value relative to the effort required [ 29 , 34 , 35 ]. We hypothesize that the case-based nature of the training, its brevity, and its focus on only the most relevant material contributed to its effectiveness, as more than 95% of HWs said the course was relevant to their work, and almost all reported performing at least one work task related to hypertension management.

Learning gains were substantial and statistically significant, indicating that HWs’ knowledge of hypertension management improved upon completing the course in all relevant cadres. However, we observed some heterogeneity of learning gains, with HWs who had completed four or more years of post-secondary education (such as nurses, midwives, and medical doctors) having greater learning gains than cadres of HWs with two or three years of post-secondary schooling (CHEWs and community health officers). This association between level of formal schooling and preparedness to succeed in self-paced and self-directed online learning is in keeping with several previous studies, which reported the importance of self-efficacy, motivation, and digital skills to a participant’s success in online learning [ 33 , 36 , 37 , 38 , 39 ].

HWs who were not staff at PHCs taking part in existing hypertension treatment programs had lower pre-test scores and greater learning gains than those who were. This is at variance with other studies, which suggested that low prior knowledge is associated with poor outcomes in online courses [ 40 , 41 , 42 ]. It may be that those who were not in existing hypertension programs were more motivated to learn hypertension management, thereby leading to the large knowledge gains we observed in this group. Therefore, this mobile training approach might be useful for introducing HWs to new guidelines while also acting as “refresher training” for HWs who have already learned new guidelines.

Learner feedback was overall positive. Responses to two Likert-scale questions indicated that most learners found the course enjoyable and relevant to their work, with higher ratings than similar questions reported in other courses [ 43 , 44 , 45 ]. The net promoter score of this course (+ 86) was high, exceeding the “excellent” benchmark of + 50 and the reported net promoter score of other online courses [ 15 , 46 , 47 ].

On-demand, smartphone-based health worker training has the potential to fill the demand for clinical training efficiently and at lower cost compared with traditional, in-person training in Nigeria and other countries. The Nigeria hypertension training course can be deployed to meet several hypertension control program needs: (1) induction training of workers either en masse at facility activation, or when new workers join primary care teams that were previously trained, or (2) refresher training of workers who were already trained.

Online training for HWs is becoming more widespread globally due to higher demand (more HWs who can access digital training) and increasing supply (more options for those learners). The rapid rise in access to cellular internet and increasing smartphone ownership in Africa [ 48 ] could be a fulcrum that will promote online training in this part of the world. In Nigeria, an estimated 55% of the population is connected to the internet and over 97% of users access the internet with a mobile device [ 49 ]. Most HW cadres that work in PHCs in Nigeria have some post-secondary education, and many have completed bachelor’s degrees, so this group may be among early adopters of technology-enabled learning. It remains unclear whether mobile training applications are best used as an adjunct to traditional in-person group training, or a substitute for in-person training. Finally, rigorous educational and economic evaluations are needed to inform the optimal strategy for primary care health worker training.

Limitations

We only evaluated short-term knowledge gains, and we haven’t yet tested the impact of this training on clinical skills (such as proper blood pressure measurement) or clinical outcomes (such as control of hypertension). Without a comparator group, we can’t be certain that the observed knowledge gains are fully attributable to the online course. All data on learners’ demographics and education levels are self-reported and we did not independently verify the identity of course participants. Many HWs were asked to take the course by their supervisors and were encouraged to complete the course within 14 days, which may have led some HWs to rush through the course to complete it. There was also likely self-selection of HWs with high motivation, access to an internet-connected smartphone, and a certain level of digital literacy and familiarity with navigating through interactive websites.

We found that a simple-to-use, mobile-optimized, case-based online short course can effectively train PHC-based HWs on updated hypertension management guidelines. A high percentage of learners completed the course, learner feedback was very positive, and there were significant learning gains in all cadres of HWs. These results suggest that such training is a scalable way to build health workforce capacity on new clinical guidelines and to refresh knowledge of best clinical practices. Either on its own or in combination with traditional in-person group trainings, this approach could be applied to a variety of topics to improve HWs’ adherence to evidence-based practices in Nigeria and elsewhere.

Data availability

De-identified data are available from the corresponding author upon request.

Abbreviations

community health extension worker

Federal Ministry of Health

health worker

National Primary Health Care Development Agency

primary health center

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Acknowledgements

We would like to thank all of the health workers who participated in the course and shared their feedback.

This study was supported by Resolve to Save Lives. Resolve to Save Lives is funded by Bloomberg Philanthropies, the Bill and Melinda Gates Foundation, and Gates Philanthropy Partners, which is funded with support from the Chan Zuckerberg Foundation. This work was supported, in whole or in part, by the Bill & Melinda Gates Foundation grant award #OPP1175906. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission.

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Joseph Odu, Kufor Osi, Allison Goldstein, Andrew E. Moran, Emmanuel Agogo & Marshall P. Thomas

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Leander Nguyen & Andrew E. Moran

Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA

Lawrence J. Appel & Kunihiro Matsushita

Department of Internal Medicine, Faculty of Clinical Sciences, University of Abuja, Abuja, Nigeria

Cardiovascular Research Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria

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Federal Ministry of Health, Abuja, Nigeria

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Contributions

JO, KO, LJA, KM, AEM, EA, and MPT designed the project, contributed to course development, and wrote the paper. MPT and JO analyzed the data. LN, AG, DO, IAO, MA-O, DO, MMT, COE, SL, HB, MTD, and OC contributed to project design and course development. All authors reviewed this manuscript and provided critical feedback.

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Correspondence to Marshall P. Thomas .

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This work was reviewed and given expedited committee approval by the National Health Research Ethics Committee of Nigeria (NHREC/01/01/2007) and determined to be exempt human subjects research by the Resolve to Save Lives Research Committee. All participants provided informed consent to participate in the training. All methods were carried out in accordance with relevant institutional guidelines and regulations.

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Odu, J., Osi, K., Nguyen, L. et al. On-demand mobile hypertension training for primary health care workers in Nigeria: a pilot study. BMC Health Serv Res 24 , 444 (2024). https://doi.org/10.1186/s12913-024-10693-x

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Received : 26 September 2023

Accepted : 07 February 2024

Published : 09 April 2024

DOI : https://doi.org/10.1186/s12913-024-10693-x

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Healthcare waste management status in Lagos State, Nigeria: a case study from selected healthcare facilities in Ikorodu and Lagos metropolis

Affiliation.

• 1 Department of Civil and Environmental Engineering, University of Lagos, Lagos, Nigeria. [email protected]
• PMID: 21746754
• DOI: 10.1177/0734242X11412109

A survey of healthcare waste management practices and their implications for health and the environment was carried out. The study assessed waste management practices in 20 healthcare facilities ranging in capacity from 40 to 600 beds in Ikorodu and metropolitan Lagos, Lagos State, Nigeria. The prevailing healthcare waste management status was analysed. Management issues on quantities and proportion of different constituents of waste, segregation, collection, handling, transportation, treatment and disposal methods were assessed. The waste generation averaged 0.631 kg bed(-1) day(-1) over the survey area. The waste stream from the healthcare facilities consisted of general waste (59.0%), infectious waste (29.7%), sharps and pathological (8.9%), chemical (1.45%) and others (0.95%). Sharps/pathological waste includes disposable syringes. In general, the waste materials were collected in a mixed form, transported and disposed of along with municipal solid waste with attendant risks to health and safety. Most facilities lacked appropriate treatment systems for a variety of reasons that included inadequate funding and little or no priority for healthcare waste management as well as a lack of professionally competent waste managers among healthcare providers. Hazards associated with healthcare waste management and shortcomings in the existing system were identified.

• Health Facility Administration*
• Medical Waste Disposal*
• Medical Waste Disposal