ASSESSMENT OF LEVEL OF KNOWLEDGE IN HEALTH FACILITY WASTE

MANAGEMENT IN TUMAGA HEALTH CENTER

A Research Proposal
Presented to the Faculty of the College of Nursing
ATENEO DE ZAMBOANGA UNIVERSITY

In Partial Fulfillment of
The Requirements for the Course in Masters in Nursing Research

Cecil S. Resurreccion
Bryan FlorentinoM. Mortera IV

October 2020
 Chapter I

THE PROBLEM AND ITS BACKGROUND

[This chapter contains the following: Introduction; Review of literature; Statement of the
problem; Theoretical Framework; Scope and Limitation of the Study; Significance of the Study
and Definition of Terms.]

Introduction

The increasing population comes with the increase of healthcare facilities in the

Philippines has resulted in an increase in generation of healthcare waste. These healthcare

facilities include hospitals, clinics, medical laboratories and barangay health centers. The non-

hazardous waste consists of general domestic waste. The hazardous waste may include variety of

types, such as infectious, pathogenic, genotoxic, chemical, pharmaceutical, sharps, and waste

with heavy metals content, pressurized containers, and radioactive (Altin et al., 2003; Kuo et al.,

1999; WHO et al., 1999; WHO, 2006). According to the World Health Organization (WHO), the

hazardous waste fraction represents 10–25% of the total healthcare waste (WHO, 2006. Despite

the relatively lower quantity of hazardous waste generated the risk to cause adverse effects are

significant if it is not managed appropriately. Therefore, hazardous healthcare wastes should be

identified, quantified, segregated, handled, treated and disposed properly.

Apart from the risk to the patients and HCF workers, consideration must be given to the

adverse impacts of HCW to the general public and the environment. In particular, attention shall

be focused on the possible result of unmanaged waste to air, water and soil, including the

community. Minimizing the risk to public health and the environment will require actions to

1
deal with HCW within the HCF such as proper waste segregation and minimization so that it

does not enter the waste stream requiring further treatment before disposal. (Manual on Health

Care Waste Management 3rd edition)

Incineration is still widely used treatment method for most hazardous healthcare wastes

(Diaz et al., 2005; WHO, 2006; Iliopoulos et al., 2007). But due to changes in legislations In the

last few years, many researchers in developing countries have investigated the practices of

healthcare waste management at selected healthcare facilities within their countries (Da Sliva et

al., 2005; Bdour et al., 2007; Nemathaga et al., 2008; Marinkovic et al., 2008; Coker et al.,

2009). They concluded that management practices of such waste; especially the hazardous

portion represents a challenge in their countries due to deficiency in waste generation data and/or

gaps in the management framework. In addition, absence of healthcare waste management plan

at the country level and unavailability of suitable treatment and disposal options can further

hinder the waste management efforts.

The risk associated with healthcare waste and its management has gained attention across

the world in various events, local and international forums, and summits. However, the need for

proper healthcare waste management has been gaining recognition slowly due to the substantial

disease burdens associated with poor practices, including exposure to infectious agents and toxic

substances. Despite the magnitude of the problem, practices, capacities and policies in many

countries in dealing with healthcare waste disposal, especially developing nations, is inadequate

and requires intensification. (Cruz, et.al. 2014).

 Review of Related Literature

ENRIQUE T. ONA, MD. FPCS, FACS Secretary of Health from 2010 to 2014 cited his

message to the 3rd Edition of Manual Health Care Waste Management, and we quote; “Access to

affordable, quality and responsive healthcare services and facilities is the primary concern of all

healthcare facilities and is one of the key strategic thrusts of the Aquino Administration Health

Agenda: Achieving Universal Health Care for All Filipinos or KalusugangPangkalahatan, in

order to ensure better health for our countrymen. The Department of Health launched numerous

initiatives to implement this commitment, among which are our increased efforts towards patient

safety, “Malinis at MabangongOspital”, let us continue our cooperation to prevent the spread of

disease, occurrence of accidents and degradation of our environment.”(Manual on Health Care

Waste Management, 3rd Edition, December 2011).

Florence Nightingale known as Lady with the Lamp plays a vital role in establishing the

holistical approach in giving quality Healthcare to every individual. Her assumptions in her

Environmental Theory are as follows:“pure air, pure water, efficient drainage, cleanliness, and

light. She believed that these five points were vital in achieving anoptimal healing.

(https://nurselabs.com.>florence-nigthingale-environmental-theory).

Health Care Facilities provide vital care to people in order to promote well-being; they

are indispensable. However, because of the nature of their operational function in every facility,

they also inevitably generate large volume of some of the most hazardous waste. And if not

properly handled these waste posted dangerous effects to society from but not limited to

spreading of diseases, injuries and other waste related incidents to patients, families, hospital

staff, waste management workers, and society in general. (Case Studies on Healthcare Waste
Management Practices on Selected Public and Private Hospitals in Metro Manila by Enrico C.

Mina, Ateneo de Manila University, Philippines)

In South Africa, Community Health Workers provide nursing care activities to

patients many of whom were incontinent or bedridden, some of which are with HIV/AIDS/TB,

stroke, diabetes, asthma, arthritis and high blood pressure. These caregiving activities generate

sharps and infectious waste but CHWs and family members did not segregate health care waste

according to the risk posed as stipulated by the HCWM policy. In addition, this waste was left

with domestic waste. Major barriers to proper HCWM identified by CHWs include, lack of

assistance from family members in assisting patients to use the toilet or change diapers and

removing HCW from homes, irregular waste collection by waste collectors, inadequate water for

practicing hygiene and sanitation, long distance between the house and the toilets and poor

conditions of communal toilets and pit latrines. As a result of these barriers, HCW was illegally

dumped along roads or in the bush, burnt openly and buried within the yards. Liquid HCW such

as vomit, urine and sputum were disposed in open spaces near the homes. As a conclusion;

Current policies on primary health care (PHC) and HCWM in South Africa have not paid

attention to HCWM. Findings suggest the need for primary health care reform to develop the

competencies of CHWs in HCWM. In addition, PHC and HCWM policies should address the

infrastructure deficit in low resource communities. In order for low-and-middle-income-

countries (LMICs) to develop effective community health worker programmes, there is a need

for synergies in PHC and HCWM policies.(ncbi.nlm.nig.gov/pubmed/28506258, May 15, 2017)

Synthesis

The following literature obtained similarly would like to allow better consideration of
every health facility in their waste management program, and considering every health workers
has the major responsibility to adapt to the necessary guide as maybe stipulated in an
instructional manual. Every health workers have the important role to make sure to get hold of
the knowledge acquired related to waste management.

(Case Studies on Healthcare Waste Management Practices on Selected Public and Private
Hospitals in Metro Manila by Enrico C. Mina, Ateneo de Manila University, Philippines)
presented their studies focusing more on the Healthcare Waste Management Practices. The study
is trying to focus on the general effects it can provide to the patients, families, hospital staff,
waste management workers, and society in general especially when hazardous wastes are not
properly handled. The spread of diseases, injuries and other waste related incidents are huge
concern since this will involve the society in general. And accordingly because of the nature of
their operational function in every facility, the Health Care Facilities then must provide vital care
to people in order to promote well-being; and they are indispensable just like the necessity we
consider involving the health workers in our study.

(Manual on Health Care Waste Management, 3rd Edition, December 2011)The Secretary
of Health from 2010 to 2014 ENRIQUE T. ONA, MD. FPCS, FACS cited his message during
the 3rd Edition of Manual Health Care Waste Management, and we quote; “Access to affordable,
quality and responsive healthcare services and facilities is the primary concern of all healthcare
facilities and is one of the key strategic thrusts of the Aquino Administration Health Agenda:
Achieving Universal Health Care for All Filipinos or Kalusugang Pangkalahatan, in order to
ensure better health for our countrymen. There were numerous implementations that the
Department of Health had initiated and committed in aiming towards the safety in order to
continue to prevent the spread of disease, occurrence of accidents and degradation of our
environment. Among those programs implemented is “Malinis at Mabangong Ospital”, and
calling all in the health sectors for cooperation to address the need on this aspect. Indeed this is a
similar calling that we aim as well in our study.
 A study conducted in South Africa, Community Health Workers provide nursing care
activities to patients many of whom were incontinent or bedridden, some of which are with
HIV/AIDS/TB, stroke, diabetes, asthma, arthritis and high blood pressure. Accordingly in their
care giving activities generate sharps and infectious waste but CHWs and family members did
not segregate health care waste according to the risk posed as stipulated by the HCWM policy.
There were major barriers identified by CHWs to include, lack of assistance from family
members in assisting patients to use the toilet or change diapers and removing HCW from
homes, irregular waste collection by waste collectors, inadequate water for practicing hygiene
and sanitation, long distance between the house and the toilets and poor conditions of communal
toilets and pit latrines. As a result of these barriers, HCW was illegally dumped along roads or in
the bush, burnt openly and buried within the yards. Liquid HCW such as vomit, urine and
sputum were disposed in open spaces near the homes. In their conclusion; Current policies on
primary health care (PHC) and HCWM in South Africa have not paid attention to HCWM.
Findings suggest the need for primary health care reform to develop the competencies of CHWs
in HCWM. Likewise this is similar to our study aiming to develop and addressing its need
towards implementation using policy manual and the knowledge or competency of the health
workers in relation to the waste management.

Lastly according to Florence Nightingale known as Lady with the Lamp plays a vital role
in establishing the holistically approach in giving quality Healthcare to every individual. Her
Environmental Theory follows: “pure air, pure water, efficient drainage, cleanliness, and light.
She believed that these five points were vital in achieving an optimal healing. Indeed, the need to
achieve healing will always begin from every individual especially health workers on that aspect.
Healing the environment as how Florence Nightingale emphasized it would be similar to our
study emphasizing the need to assess environment and performance of health workers in terms of
sanitation.
 The conclusions of the study synthesized here are very much significant to our research
study, the comparison of variables among all the related studies includes the involvement of
health facilities, health workers and the society in general. To lay down our research apart, we
focus to include a district health facility, a district nurse, midwives and barangay health workers.
We plan to consider assessing their knowledge on how compliant they are in their health facility
waste management. With this, we can outline their participation following the standard in terms
of the health facility waste management.

Statement of the Problem

This is a study of assessing the level of knowledge of the health workers in health
facility waste management in Tumaga District Health Center. This will direct us towards
answering the following questions;

1. What is the level of knowledge of the HCWs in terms of waste management

standard?
2. How consistent the HCWs in the efficiency of correct practice of how the facility
utilize the proper waste handling and disposal.
3. What is their performance towards the standard of the health facility waste
management program.
4. How is the overall evaluation conducted by the district nurse to the HCWs in terms of
practices that is aligned to the standard program.
5. How is the support of the barangay officials in the proper collection and disposal of
waste?
 Theoretical Framework

The researcher would wish to determine the compliance level on the Health Care Waste

Management Manual of each Barangay Health Personnel in Tumaga District, Zamboanga City as

shown in the illustration below;

Health Care Waste Compliance Level

Management Manual of Health Care Personnel

Waste Management
Practices
 Directly Observed
 Questionnaire
Checklist

Illustration 1A: The Independent Variables represented by the Health Care Waste Management

Manual is expected to affect the Dependent Variables in terms of the Compliance level of every Health

Personnel on the given respondents which directly and indirectly determined by the Intervening Variable

represented by their actual waste management practices.

 Scope and Limitation

This study is focused on the assessment of level of knowledge of HCWs towards

the health facility waste management in Tumaga District Health Center. The respondents will be

the source of data to answer the problem in this study since the HCWs play a key role in the

proper waste disposal as they are involved in the entire waste management processes. The

appraisal of health worker’s knowledge and their skill in for proper waste management is vital to

quantify and minimize occupational associated risks for infection to the worker and to the

environment as well.

Limitation of this study was the visit made to other (3) Health Centers under Tumaga

District which the area of our study, an observation made that risk is a potential problem to the

patient and HCF workers, consideration must be given to the adverse impacts of HCW to the

general public and the environment. In particular, attention shall be focused on the possible result

of unmanaged waste to air, water and soil, including the community.

Significance of the Study

This study will be beneficial to the following:

Health Care Workers – will gain added information regarding waste management

program of which they play a very important key role within the health facility. They

will be provided the opportunity to enhance their knowledge and skills since there is a

wider basis now to enable them to practice following what is the standard.

District Nurse – the health care provider with the supervisory function to look into the

daily operation of the facility will be given the opportunity to give the impression in her

evaluation in terms of assessing the performance of her HCWs related to this waste

management process.

City Health Officer – the Health Officer who has the bigger involvement in terms

responsibility towards the environmental health needs of the entire region to include

health care facilities, HCWs and the community people general. This will provide her

the data in the management practices of her people of such waste.

Zamboanga City Health Office – the regional coordinating body of the city in the

monitoring and evaluating related programs of the Department of Health. Likewise this

will provide them data on how they can improve in order to address gaps in the

management framework in the city.

Researcher – this study hopes to serve as a tool and baseline information for future

researchers, developing strategies and advocacy in the health facility waste management

program.
Definition of Terms

The following terms were defined operationally based on their purpose on the study.

Assessment – a way of doing observation to evaluate a performance or a procedure.

Health – referring to the complete well being of every individual.

Waste – maybe referred to any substance or chemicals that maybe classified as

hazardous or not.

Environment – referring to the surroundings or location clean or not which can be

affected related to improper disposal of any substance.

Health Facility – can be classified as infirmary, health center and a hospital which may

be located in a urban or rural area.

Health Practices – referring to common habits or ways of an individual who can either

be a health practitioner or a common worker.

Knowledge – refers to the awareness of information regarding waste management

program.

Involvement – referring to the personal participation in the conduct of the waste

management program

Risk – referring to anything that is hazardous that may cause danger to anyone especially

to health workers.

Policy – a regulation or standard guide for every individual for a health worker to follow.

Health Workers – referring to health care providers who are in close contact with

patients and hazardous substance .

 Chapter II

Methodology

[This chapter presents the research design, population and sampling, participants of the

study, research instruments data gathering procedure and statistical tools employed in the

treatment and analysis of data]

Research Design

This study will utilize the mixed method of research. Mixed methods research involves

collecting and analyzing both quantitative and qualitative data. The quantitative data includes

closed-end information that undergoes statistical analysis and results in a numerical

representation. Qualitative data, on the other hand, is more subjective and open-ended. It allows

for the “voice” of the participants to be heard and interpretation of observations. Considering the

methods discussed in the quantitative and qualitative modules, following are a few examples of

how the methodologies may be mixed to provide a more thorough understanding of a research

problem.

In the micro perspective, this research will utilize a descriptive method in order to gather

information to determine nurses’ perception towards understaffing and relation to incidence of

nosocomial infection of patients. A descriptive method will be utilized to investigate current

conditions by collecting detailed and factual information to describe an existing phenomenon It

describes the nature of the phenomenon under investigation after a survey of trends,

perceptions, practices and conditions that relate to that phenomenon. It will allow the researcher

to carefully observe, describe and document aspects of situation as it naturally occurs. The
researcher will also utilize cross-sectional study to analyze data collected from the population, or

a representative subset, at a specific point in time. In this study the researcher will prepare

questionnaires and checklists to determine the perception of nurses towards understaffing and its

relation to incidences of nosocomial infections. Data collection will be through obtaining

records, questionnaires and direct observation. This research will also include data collection

using existing records.

Research Locale

The study will be conducted at Barangays Tumaga, Lumayang, Lumbangan and

Lumiyap. The location of the study was selected because it is suited and the concern for the

assessment of these barangays was requested by the City Health Director.

Respondents

The respondents of this study will comprise of Barangay Health workers including the

Midwives and trainedhilotof the respective health centerss. The inclusion criterion for

participation was to be employee of the Health Centers that are actively participating in the

provision of services health with any level of experience or education and should be capable of

verbally answering simple written and verbal questions.

This study will use the stratified random sampling method. The strata should be mutually

exclusive: every element in the population must be assigned to only one stratum. The strata

should also be collectively exhaustive: no population element can be excluded. Then simple

random sampling or systematic sampling is applied within each stratum. This often improves the

representativeness of the sample by reducing sampling error. It can produce a weighted

mean that has less variability than the arithmetic mean of a simple random sample of the

population.the number of respondents will be determined by Slovin’s formula. Slovin's formula

is a formula to get the ideal sample size for a given margin of error and populationsize.

n = N/ (1 + N˙e ²)

where n = sample size

N = population size

e = margin of error

Research Instruments

The survey will be a short, 30 item self-administered questionnaires consisting of three multiple-
choice questions, four open-ended questions, and eight questions offering a Likert response.
When a thorough review of the literature located no established tool to assess the level of
awareness and compliance of Barangay Health Centerson the Policiesof the HealthCare Waste
Management Manual

Validity test

The instrument that will be used in this research will be checked and reviewed by the

Chief Nurse of Brent hospital and two (2) clinical instructors from Brent College of nursing to

ensure the validity of the questionnaires. Comments, criticisms and recommendations from the
reviewers will further substantiate and improve the instrument that will be used by the researcher

in getting the information from the respondents.

Reliability test

The researcher will use test-retest reliability method. This approach assumes that there is

no substantial change in the construct being measured between the two occasions. The amount of

time allowed between measures is critical. We know that if we measure the same thing twice that

the correlation between the two observations will depend in part by how much time elapses

between the two measurement occasions. The shorter the time gap, the higher the correlation; the

longer the time gap, the lower the correlation. This is because the two observations are related

over time -- the closer in time we get the more similar the factors that contribute to error. Since

this correlation is the test-retest estimate of reliability, you can obtain considerably different

estimates depending on the interval.

Data Gathering Procedure

The data collection will start with the researcher sending a letter of permission to the City

Health administrator. The researcher will also send letter of approval to the midwife of each

barangay health center under Tumaga District. Upon approval, the researchers will put up

postersin the Barangay Health Centers describing the research project and the purpose of the

survey. The posters will include the researchers’ contact information in case of questions that

needed clarification before administration of the survey. Two days after the posting of

posters,the researcher will place surveys in the break room of each barangay health center. The

surveys will be kept in an envelope attached to a large poster to attract attention. Attached to the

front of each survey is an informational letter explaining the risks and benefits of participation in
the study. Completion of the survey implies that the nurse had read and reviewed the letter of

agreement and gave consent for participation.

Participants will be asked to place completed surveys in a sealed drop-box provided in

the break room of each nursing unit. In order to protect the identity and anonymity of the

participants no identifying or demographic information will be requested from participants and

the researcher will have sole access to the sealed box. Participants will be given two weeks to

complete surveys and place them in the sealed drop-box, after which the researcher will collect

the drop-boxes from each unit.

In order to protect privacy and confidentiality after collection of the data and analysis of

the results, all survey data and results will be stored in secured envelope, to which only the

researcher will have access. All data will be kept for a minimum of three weeks in this fashion,

after which all information will be destroyed appropriately

Plan of Analysis

After collection of the surveys from the nursing units, the researcher will review the

questionnaires and enter data into the Microsoft Excel for analysis of results. To maintain

confidentiality of the participants in the study, the researchers will input survey data using

random identification codes. The researcherswill thenanalyze the results of the study using basic

descriptive statistics available in Microsoft Excel.