Article Research Waste management practices among dental surgery staff of major hospitals in Accra: a descriptive cross- sectional study Alex Ansah Owusu, Emma Edinam Kploanyi, Paa-Kwesi Blankson, Abu Manu, Ruby Yayra Goka, Richard Nii Armah, Patricia Akweongo Corresponding author: Alex Ansah, Owusu, Department of Oral Health, Pantang Hospital, Pantang, Ghana. aowusu@rt.gcps.edu.gh Received: 11 Oct 2022 - Accepted: 09 Mar 2023 - Published: 14 Mar 2023 Keywords: Clinic waste, dental surgery waste, oral health, hazardous waste, waste management practices Copyright: Alex Ansah Owusu et al. PAMJ - One Health (ISSN: 2707-2800). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Cite this article: Alex Ansah Owusu et al. Waste management practices among dental surgery staff of major hospitals in Accra: a descriptive cross-sectional study. PAMJ - One Health. 2023;10(5). 10.11604/pamj-oh.2023.10.5.37738 Available online at: https://www.one-health.panafrican-med-journal.com/content/article/10/5/full 4 Waste management practices among dental Accra, Ghana, Department of Population, Family surgery staff of major hospitals in Accra: a and Reproductive Health, School of Public Health, 5 descriptive cross-sectional study University of Ghana, Accra, Ghana, Department of Restorative Dentistry, Dental School, College of Alex Ansah Owusu1,&, Emma Edinam Kploanyi2, Health Sciences, University of Ghana, Accra, Paa-Kwesi Blankson3, Abu Manu4, Ruby Yayra Ghana, 6Department of Oral Health, St Andrew Goka5, Richard Nii Armah6, Patricia Akweongo7 Catholic Hospital, Shai-Osudoku, Ghana, 7Department of Health Policy Planning and 1Department of Oral Health, Pantang Hospital, Management, School of Public Health, University Pantang, Ghana, 2Department of Biological, of Ghana, Accra, Ghana Environmental and Occupational Health Sciences, School of Public Health, University of Ghana, Accra, Ghana, 3Department of Oral and Maxillofacial Surgery, Korle-Bu Teaching Hospital, Article &Corresponding author environmental problem [1]. Wastes may generally be classified as clinical, hazardous or domestic. Alex Ansah, Owusu, Department of Oral Health, Clinical waste refers to that which partly or Pantang Hospital, Pantang, Ghana entirely consists of human or animal tissue, blood or body fluid, excretions, pharmaceutical products, Abstract swabs or dressings, syringes, needles, or any sharp instruments [2]. Hazardous wastes on the other Introduction: the practice of dentistry in hand refer to those which cause harm to living contemporary times produces considerable waste organisms or the environment, either by that could be harmful to individuals and the themselves or through its component, while environment at large. In Ghana and many other domestic wastes describe those that are jurisdictions, there are guidelines that outline how generated in a dwelling [3]. Management of oral these wastes should be managed. This study was health conditions could potentially yield hazardous conducted to explore practices concerning dental wastes in the form of dental amalgam, etchants, waste management among dental surgery staff in used X-ray developers and fixers, lead foil packets, some public facilities in Accra, Ghana. Methods: a and disinfectants, among others [4]. Amalgam, for descriptive cross-sectional study involving dental example, contains mercury which makes it toxic to surgery staff of four major facilities in Accra was both humans and the environment, if not properly done. Overall, 124 staff from the selected facilities disposed of [5]. Although its use is gradually participated in the study, and 51 different dental waning, the effects of mercury on the entire surgeries were assessed. Data were collected using population and the environment have been a a structured questionnaire and an observation source of global concern [6]. checklist. The questionnaire included questions on socio-demographics, as well as knowledge and Similarly, improper disposal of sharps and other practices regarding dental waste management. dental waste may put clinical staff, patients and Results: there was unsatisfactory knowledge of their families at risk of infections such as hepatitis waste disposal, while practices did not generally B and C, and HIV [7]. A previous study showed that meet international recommendations and the general dental offices could produce 59 kg of Ministry of Health´s (MOH) guidelines. Though all waste per day, while specialist dental offices respondents stored their sharp waste in puncture- averagely produced 18 kg of waste per day. Of proof containers, 98.4% did not label their clinical these generated wastes, 34% were potentially waste, while 62.9% would dispose of used X-ray infectious, and 12% were toxic and chemical fixers by pouring them down the drain. None of the wastes [8]. In Africa, and Ghana in particular, it has 51 surgeries observed had more than one colour been noted in previous reports that medical waste code available. Conclusion: there is a palpable is poorly sorted, characterized and disposed of, need for education, monitoring, and further highlighting its pertinence in the health empowerment concerning waste management in system framework [9,10]. The challenges in the Ghana´s oral healthcare system. management of health facility waste are particularly more evident in developing Introduction countries [11]. Improper handling, storage, transportation and ultimately, disposal of clinical Globally, there are challenges in the management waste have led to a surge in health hazards and of health facility wastes. Efficient waste environmental pollution [12,13]. This has been management poses a significant challenge in many attributed to legislative challenges, unavailable parts of the world, while that of dental surgery specialized staff, and low awareness [14]. Limited waste is considered to be an important resources in developing countries make it even Alex Ansah Owusu et al. PAMJ-OH - 10(5). 14 Mar 2023. - Page numbers not for citation purposes. 2 Article more difficult to manage clinical waste by on knowledge explored colour coding of clinic accepted standards [12]. Dental surgery staff, waste, main content of used X-ray fixers, therefore, have the responsibility of ensuring that appropriate disposal of amalgam waste, disposal dental waste is managed according to of blood-soaked gauze and disposal of developed standard guidelines. This involves proper waste X-ray films.The observation checklist used to segregation, storage, transportation and final assess the dental surgery consisted of a ten-item disposal [6,15,16]. In exploring the challenge and specification which checked for color-coded bins, possible action areas, this study set out to explore matching of contents of the bins with the colour the practices of dental surgery staff in major code, appropriate disposal of infectious waste, facilities in Accra regarding dental waste presence of puncture-resistant sharps' container, management. waste container labelling, and presence of an amalgam separator. Methods Data management and analysis: data were Study design: this was a descriptive cross-sectional entered using Microsoft Excel 2010 and analysed study involving dental surgery staff of selected using Stata 14 software (StataCorp. College major hospitals in Accra. Station, TX). Socio-demographic characteristics were descriptively summarized, with report of Study setting: the study was conducted at the proportions. Responses on knowledge and dental units of Korle-Bu Teaching Hospital, 37 practices were coded as a dichotomous variable Military Hospital, Greater Accra Regional Hospital and scored for correct responses. A 95% and the Ghana Police Hospital. Data collection was confidence interval was used and a p-value of 0.05 done in June 2018. was accepted as statistically significant. Study participants and sampling: the study was a Ethical considerations: ethical approval was census of all the dental surgery staff in the sought from the Ghana Health Service Ethics selected facilities. Staff who were on leave were Review Committee (GHS- ERC: 133/12/17), the 37 not included in this study. The registered clinical Military Hospital Institutional Review Board staff of the hospital officially assigned to the (37MH-IRB IPN 211/2018), and the Korle Bu Dental department of the facilities were included. Teaching Hospital Institutional Review Board The participants were dentists, community oral (KBTH-IRB 00045/2018). Verbal consent was health officers, registered dental surgery obtained from participants. All identifiers that assistants, diploma nurses, and on-the-job trained would allow for the linking of data to an institution personnel who consented to be part of the study. or individuals were removed from the data. At each visit to a selected facility, workers meeting Electronic versions of the data were saved under a the inclusion criteria were selected consecutively password, and hard copies were stored in a lock to be part of the study. All the dental surgeries of that could be accessed by only the principal the various facilities were also assessed. investigator. Data collection: data were collected using a Results structured questionnaire, and an observation checklist. The observation checklist served as a A total of 124 respondents out of the estimated form of triangulation to minimize bias. The 155 dental surgery staff in the selected facilities questionnaire included questions on socio- were included in the study, the difference was demographics (age, sex, status, years of accounted for by staff who were on leave at the experience), as well as knowledge and practices time of the study. A total of 51 dental surgeries regarding dental waste management. Questions Alex Ansah Owusu et al. PAMJ-OH - 10(5). 14 Mar 2023. - Page numbers not for citation purposes. 3 Article (rooms where dental surgeries are done) were the observed bins was labelled. There were no assessed using an observation checklist. The missing data. median age of the respondents was 29 years (IQR: 27-35). The majority of the respondents 63 Discussion (50.8%) were within the age range of 20-29 years. A greater proportion of the respondents 79 This study set out to explore and describe the (63.7%) were females. Most of the participants 69 dental waste practices among dental surgery staff (55.7%) were Dentists. Other background in some major facilities in Accra. There was characteristics are shown in Table 1. About 95% of unsatisfactory knowledge of waste disposal, while the respondents knew how to dispose of used practices did not generally meet international sharps, while 23% responded accurately to the recommendations and the Ministry of Health´s colour-code for radioactive waste. Furthermore, (MOH) guidelines. Ghana´s Ministry of Health only 19% of the respondents knew the policy on clinical waste management states that recommended method of amalgam disposal (Table various waste categories need diverse ways of 2). handling, treatment, and disposal methods, hence waste should be segregated. The policy also states None of the respondents segregated their clinic that segregation of waste into appropriate colour- waste in colour-coded bins. Also, all the coded bins is the responsibility of the one who respondents store their sharp waste in puncture- produces the waste and must take place at the proof containers. Blood-soaked gauze was source of waste generation. The policy further disposed of with other clinic waste by all requires an instruction poster on the procedure respondents. Almost all participants 122 (98.4%) involved in waste separation to be posted at every did not label their clinical waste, while more than area of waste segregation [15]. This study found half 78 (62.9%) would dispose of used X-ray fixers that only 23% of the participants accurately by pouring them down the drain. According to responded to questions on colour coding of clinic 61.3% of this study´s respondents, regular waste waste. Comparatively, studies in India and the transporters are responsible for the final Philippines reported 48% and 4% respectively in transportation of dental surgery waste out of their this area [17,18]. We also found that none of the facilities. Furthermore, none of the 124 respondents segregated their dental surgery waste respondents knew of record-keeping in their into different colour-coded bins. Of the 51 dental facilities concerning clinical waste activities surgeries observed, 47 (92%) of them had only (Table 3). Less than 10% of the respondents 11 black colour-coded bins. Jumau-as et al. also (8.9%) had read the MOH policy on Clinical Waste reported that only four facilities out of 50 in a Management. Observation of the 51 surgeries in study in India practiced waste segregation [18]. the 4 referral facilities showed that all these surgeries stored their generated waste in colour- The MOH Policy on clinic waste management coded bins, however, none of the observed instructs that sharps be stored in puncture-proof surgeries had more than one colour-code available containers that are well-labelled and bear the (Table 4). All the observed surgeries had a biohazard symbol [15,19]. Sharps, when managed puncture-resistant sharp container, most of which according to recommended standards, protect 49 (96.1%) were labelled. The colour code dental surgery staff from puncture wounds that available in most of the surgeries 47, (92.2%) was could lead to cross infection [16]. This study black. It was also found that the content of the showed that all the respondents adhered to this bins did not match the colour code of the bins for guideline. A similar observation was made from all surgeries. All observed bins contained a mixture the checklist evaluation. When temporary of domestic and infectious waste, while none of amalgam storage materials are full, a registered Alex Ansah Owusu et al. PAMJ-OH - 10(5). 14 Mar 2023. - Page numbers not for citation purposes. 4 Article amalgam waste transporter should ideally be populace [22], peculiar attention is required for contacted to send the waste amalgam for dental waste generation, as they are a potential recycling or disposal. Waste amalgam should not source of environmental pollution [10]. Concerted be put in the garbage, washed into the drain or efforts must be made to implement recommended put in the container for sharps [16]. This study guidelines and standard practices in Ghana. Dental found an unsatisfactory practice with amalgam waste management and associated environmental disposal. A study in India reported that 79% of the pollution should be comprehensively taught respondents disposed of their generated amalgam during the training of the Dental surgeon, Nurse, waste together with general waste, while 13% of and all other allied professionals. Furthermore, them disposed of this waste in other inappropriate training and continuous professional development ways [17]. In a facility-based study in Iran, it was programs should regularly focus on waste found that 92% of the facilities disposed of management practices. As awareness and amalgam waste in toilets as well as the sewer knowledge are improved, a significant system [20]. A study done in Palestine found that responsibility might also befall administrators and over 80% of generated amalgam waste was managers to ensure an enabling working disposed of into either the clinic garbage or environment with the necessary materials. drain [3]. Lead foil packets are the waste products Healthcare leaders and Dentists must ensure that left behind after conventional X-rays are taken. training is provided to all employees at the This study found that they were disposed of with commencement of employment and to all the rest of the clinical waste in all the facilities that contract workers [23]. There could be a need for provided X-ray services. The lead could leach into the MOH to evaluate its methods of policy the soil and ground if disposed into landfills, dissemination considering the finding that less causing environmental pollution. Lead waste than 10% of respondents had read the MOH policy should be returned to manufacturers for recycling on Clinical Waste Management. In the future, or disposal [16]. Intake of high levels of lead can there will be the need to conduct a similar study predispose one to reproductive defects, nerve among dental surgery staff of private facilities. defects, cancers, hypertension, impairment in kidney function and immunological Limitations: the small sample size for sub- impairments [19]. Similarly, a study in Iran showed populations did not favour further analyses to that 78% of the facilities studied disposed of lead determine associations. The findings of this study foil packets with general waste [20]. are not widely generalisable. However, findings from this study would inform institutional Generators of medical/dental waste refer to those guidelines and practices concerning waste producing more than 23 kg of regulated management. medical/dental waste per month [21]. Generators who manage their waste by transporting it to Conclusion offsite disposal facilities are supposed to separate, package, label, mark, and track the waste There was a low level of knowledge on and according to stipulated regulations [10]. It is quite adherence to dental waste management evident from this exploratory study that there is a guidelines among the staff of the facilities studied. palpable need for education, monitoring, and There is a need to create an enabling environment empowerment concerning waste management in to promote adherence to dental waste Ghana´s oral healthcare delivery system. While management guidelines. unsatisfactory practices in waste management may be looked at in the broader scope of all healthcare personnel [9] and even the general Alex Ansah Owusu et al. PAMJ-OH - 10(5). 14 Mar 2023. - Page numbers not for citation purposes. 5 Article What is known about this topic Tables  There is evidence of the harmful effects of Table 1: background characteristics of certain dental waste on the environment. respondents Mercury from dental amalgam, lead from X-ray film packets are all known to be Table 2: the distribution of knowledge on dental hazardous to the environment. Some waste management among respondents researchers have described waste management practices in Ghanaian Table 3: the distribution of dental waste hospitals generally. management practices among respondents What this study adds Table 4: objective assessment of waste management in dental surgeries using observation  This study provides data on dental waste checklist management practices among dental surgery staff in some public health facilities References in Accra. 1. Muhamedagic B, Muhamedagic L, Masic I. 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SADJ. 2014 May;69(4): 178-81. medical solid waste at primary health care PubMed| Google Scholar centres in the Palestinian Territory and their remedial measures. Eastern Mediterranean Health Journal. 2013;19(SUPPL 3). Google Scholar Alex Ansah Owusu et al. PAMJ-OH - 10(5). 14 Mar 2023. - Page numbers not for citation purposes. 7 Article Table 1: background characteristics of respondents Background characteristics Frequency (n=124) Percentage (%) Sex Male 45 36.3 Female 79 63.7 Age of respondent 20-29 63 50.8 30-39 40 32.3 40-49 13 10.5 50-59 8 6.5 Qualification of respondent Dentists 69 55.7 Dental surgery assistants 35 28.2 Nurses 13 16.1 Others 8 9.9 Where respondent trained Ghana 114 91.9 African country other than Ghana 3 2.4 Outside Africa 7 5.7 Years of practice 0-5 75 60.5 6-10 27 21.8 11-15 9 7.3 16-20 6 4.8 21-25 3 2.4 26- 37 4 3.2 Alex Ansah Owusu et al. PAMJ-OH - 10(5). 14 Mar 2023. - Page numbers not for citation purposes. 8 Article Table 2: the distribution of knowledge on dental waste management among respondents Question on knowledge of respondents Frequency n=124 Percentage (%) What colour code should be used for radioactive waste? Correct response 29 23.4 Other responses 95 76.6 Used X-ray fixers have high concentration of…… Correct response 41 33.1 Other responses 83 66.9 How should amalgam waste be disposed of? Correct response 24 19.4 Other responses 100 80.6 How should blood-soaked gauze ideally be disposed of? Correct response 9 7.3 Other responses 115 92.7 How should sharps be disposed of? Correct response 118 95.2 Other responses 6 4.8 Developed X-ray films can be discarded with regular waste Correct response 42 33.9 Other responses 82 66.1 Alex Ansah Owusu et al. PAMJ-OH - 10(5). 14 Mar 2023. - Page numbers not for citation purposes. 9 Article Table 3: the distribution of dental waste management practices among respondents Practices of respondents Frequency (n= 124) Percentage (%) Is your surgery waste segregated into color-coded bins? No 124 100.0 Yes 0 0.00 How would you store waste amalgam? Stored under water in a closed container 102 82.3 Other responses 22 17.7 How do you dispose of sharps in your surgery? Stored in a puncture-proof container 124 100.0 How do you dispose of blood-soaked gauze in your surgery? Disposed of with other clinic waste 124 100.0 Do you label your clinic waste? No 122 98.4 Yes 2 1.6 How would you dispose of used X-ray fixers in your surgery? Pour down the drain 78 62.9 Other responses 46 37.1 How is your stored dental waste finally transported out of your facility? By regular waste transporter 76 61.3 By approved clinical waste transporters 6 4.8 Other responses 42 33.9 Do you have the contact of any of the manufacturers of the materials and chemical you use, such that you can send used or expired products back for recycling? No 121 97.6 Yes 3 2.4 When temporary storage of amalgam is full, how do you dispose of it? Disposed of with other clinical waste 43 34.7 Other responses 81 65.3 Do you keep records of waste management activities? No 124 100.0 Yes 0 0.0 Do you give detailed information on your clinical waste to the waste carriers? No 117 94.4 Yes 7 5.6 Does any of the facility administrators ever visit the surgery to monitor how the generated waste is managed? No 91 73.4 Yes 33 26.6 Alex Ansah Owusu et al. PAMJ-OH - 10(5). 14 Mar 2023. - Page numbers not for citation purposes. 10 Article Table 4: objective assessment of waste management in dental surgeries using observation checklist Observation Frequency (n=51) Percentage (%) Is waste stored in colour-coded bins? Yes 51 100.0 How many different colour codes are present? One (1) 51 100.0 What colour code(s) are available Black 47 92.2 Yellow 4 7.8 Do the contents of the bins match the colour code? No 51 100.0 Content of bins A mixture of domestic and infectious waste 51 100.0 Infectious waste only 0 0.0 Domestic waste only 0 0.0 Are bins labelled? No 51 100.0 Is a puncture resistant sharps container present? Yes 51 100.0 Is puncture resistant sharps container labelled? No 2 3.9 Yes 49 96.1 Does label contain all the required information? No 38 74.5 Yes 11 21.6 Not applicable 2 3.9 Is there an installed amalgam separator? No 51 100.0 Alex Ansah Owusu et al. PAMJ-OH - 10(5). 14 Mar 2023. - Page numbers not for citation purposes. 11