Hospitals are one of the dynamic institutions used by general public without any distinction of age, sex, race, or religion (1). Health services eventually produce waste that can itself be harmful to environment and human health, while attending to health issues and treating patients (2). Any waste created during the diagnosis, treatment, or immunization process, or in research activities related thereto, or health camps are considered as Healthcare Waste (HW) or biomedical waste (3). Generation of enormous amounts of HW has been recognized as a major concern in many countries. The reckless and indiscriminate disposal of HW could lead to unpleasant odour, proliferation of insects and rodents, incidence of epidemics such as typhoid, cholera, and hepatitis (4–6).

Around 85% of HW is currently non-hazardous, while 10% is infectious and 5% is non-infectious but hazardous (7–9). Another study has reported that approximately 15 to 35% of HW generated in Bangladesh is infectious (9). Discarded blood, removed organs, surgical waste, sharps, undesired microbiological cultures, and expired medication etc. are examples for infectious waste (10). Therefore, storage, disposal and proper treatment of HW have become a major concern for both the medical and general communities (7). Therefore, Healthcare Professionals (HCP) with adequate knowledge, experience, and ability are required to handle HW and to ensure proper management of HW (11).

According to the World Health Organization (WHO), HW has been categorized into eight categories as, general waste, pathological waste, radioactive waste, chemical waste, infectious and possibly contagious waste, sharps, pharmaceuticals, and pressurized containers (12). Meanwhile, the Basel Convention has suggested five broad categories of HW as, non-hazardous HW, HW with special attention, infectious and highly infectious HW, radioactive HW and other hazardous waste (7, 13). Composition and generation rates of HW often vary between developed and developing nations. Generally developing countries denote lower HW generation rates than developed countries. However, HW generation rates are increasing significantly at the global level, mainly due to improved access to healthcare services and increasing aging population (14).

Even though, many countries are having different legislations and policies related to HW management, many developing nations are denoting poor HW handling practices. This directly reflects lack of adequate attention on HW management (15). At the hospital level, the effectiveness of HW management relies on a committed waste management team, good management practices, proper preparation, sound organization, robust legislation, sufficient support, and active participation of trained employees. National regulatory structure, internal management systems, training programmes, and the use of suitable disposal techniques, are crucial to ensure proper HW management (10, 16).

Health-care systems in Sri Lanka are progressing. However, the increasing population and their requirements have resulted HW management to become a complicated and demanding concern. The national strategy on HW management in Sri Lanka enacted in 2001, has demanded all healthcare providing facilities to develop specialized HW management plans under the supervision of the Provincial Department of Health Services (PDHS). Further, a colour code system for segregation of HW into seven categories was developed in 2006 (17). However, enormous quantities of HW generation, negligence and/or inadequate qualifications of personnel in charge of HW management have caused a poor performance of HW management in Sri Lanka (18). The absence of strategies and plans for correct and effective HW collection, transportation, and treatment, along with higher expenses associated with HW management, have further aggravated this issue (18, 19).

If handled improperly, HW may lead into numerous occupational hazards among HCP (10). According to Athapattu et al. (18), even though many government hospitals in Colombo are conscious of the dangers/health consequences of HW, environmental impacts or contaminations that may be caused by poor HW management remains neglected. Further, many gaps in HW management have been observed in Sri Lanka (18, 19). However, comprehensive studies that characterize the knowledge and practices of HCP on HW management in Sri Lanka are limited. Therefore, this study aimed to characterize the knowledge, perceptions and practices of HCP on the management of HW and to determine the risk factors associated with the occupational health hazards arising from poor HW management in government and private hospitals in the Colombo District of Sri Lanka.

Medical waste management has become a major problem for healthcare facilities worldwide due to increasing rates of HW generation, lack of adequate proper waste management utilities and limited knowledge and training among staff (22, 23). As a developing country, Sri Lanka also faces this challenge, while information available on current situation related to HW is limited. Around 76.9% of respondents were characterized with a high knowledge level on HW management, which is better than other neighboring countries in the region such as India (24, 25), Bangladesh (9) and Northwest Ethiopia (26). Although a notable fraction of the study population (57.2%) was having more than 5 years of experience in the health sector, only 65.4% of respondents were aware of HW management. Knowledge about HW management among the technically qualified HCP (Medical officers, nurses, and paramedical staff) was found to be satisfactory, in comparison to the attendants and labourers. This agrees with the findings of several previous studies (2, 27). Since poor knowledge and training on HW management may lead into serious health consequences and detrimental impacts on the environment (28), sufficient knowledge of all HCP on HW management is important. Therefore, addressing such issues is a timely requirement.

Knowledge regarding the classification system of HW and respective colour coding systems are highly important aspects in HW management. Present study revealed that the majority of respondents were familiar with the HW based colour coding system in Sri Lanka. A similar finding has been reported in Bangalore, where 96.1% of respondents had been aware of the colour coding system of HW (28). In addition, a higher fraction of respondents of this study were familiar with the biohazard symbol, which is also similar to the aforesaid study. Further, 72.2% of respondents were familiar with the maximum storage time of HW, which was significantly higher than in Ethiopia (26). Meanwhile, a notable faction of respondents (66.6%) had already received previous trainings on HW management, which could be the underlying reason behind the elevated awareness level. However, only a limited faction of respondents knew that body fluids, body parts and fecal matter are considered as pathological waste. Although, general knowledge regarding HW was found to be significantly high, several knowledge gaps in certain specific areas were found. Such knowledge gaps might lead into inappropriate practices among HCP (2). Therefore, organizing routine awareness programmes to enhance the knowledge and training of HCP on HW is essential.

Although, the majority of respondents in this study valued proper segregation and management of HW (91.1%), in Nepal only 6.0% of respondents have agreed with the importance of HW segregation (29). Around 50.8% of respondents were considering such practices as an additional work burden, which is common to many developing countries. Implementing a proper mechanism for HW collection, transportation and treatment remains difficult due to financial and human resource related challenges (28, 29). Few respondents perceived that government is entirely responsible for proper disposal of HW. A previous study in Bangalore has reported that only a limited faction of respondents considered government to be entirely responsible for proper disposal of HW (28). However, the attention of administrative staff on proper HW management was reported to be low (35.6%) at the institution level, while around 63.9% of respondents were satisfied with the adequacy of HW management practices. Effective management of HW is not only a legal necessity, but also a social responsibility (29). Findings of this study revealed that a higher fraction of the respondents have cultivated such attitudes in Sri Lanka.

Present study revealed that HW segregation was being practiced at a satisfactory level, while studied hospitals were having adequate facilities and procedures for HW treatment and disposal. But a study conducted in Nepal, has reported that HW storage facilities are not adequate (28). Incineration (82.6%), sterilization (54.8%) and chemical treatment (38.3%) were recognized as the major HW treatment strategies in studied hospitals. A previous study has reported open burning in a hole (54%), low-temperature incineration (52%) and open-air burning on the ground (18%) as the major HW treatment practices in Ethiopia (26, 30). Another study from Hawassa city has reported that low combustion incinerators and open burning methods are used to treat HW in Ethiopia (31).

The majority of respondents in the current study had been vaccinated for Hepatitis B and Tetanus. This contradicted with the findings from a previous study conducted in Ethiopia, where only 20 and 40% of HCP were vaccinated for HBV and tetanus toxoid, respectively (26). Owing to the occupational hazards associated with HW, use of adequate PPE is essential to avoid unnecessary health effects. Findings revealed that around a higher fraction of respondents were using PPE, such as gloves (98.5%), boots (84.3%) and aprons (74.6%), during handling of HW. However, several previous studies conducted in Northwest Ethiopia (26) and South Africa (32) have reported very lower rates of PPE usage. Moreover, in Southeast Nigeria and Tanzania, less than one-third (30%) of HCP had been provided with PPE and access to prophylaxis to avoid any health hazards arising from improper HW management (33, 34). Not being vaccinated for tetanus was also found as a significant risk factor. Being vaccinated for potential health effects such as tetanus, is a timely precaution, which could slim down the chances of facing severe health hazards associated with improper HW management. According to a study conducted in South Africa, a notable fraction of HCP was handling HW with their bare hands due to shortages in gloves, regardless of the provisions of the occupation Health and Safety Act in South Africa (32). This clearly suggests that despite the availability of regulations and national health policies concerning the HW management, a limited attention is placed on HW management in many countries (35).

A risk perception analysis conducted in Portugal has revealed that doctors and nurses in general show a higher risk perception than general staff (16). Better awareness levels on risks associated with HW among higher occupational categories has been identified as the major reasons for this (16). The limited access to information on proper HW management among lower occupational categories of HCP had further aggravated this. Respondents with higher working experience, knowledge and proper training on HW management were less susceptible for being influenced with HW related health hazards. Higher service period in the health sector empowers HCP to gain more experience and knowledge regarding HW management, thereby enabling them to handle HW with care based on standard guidelines (32, 34).

A study conducted in Jamaica (34) has revealed that the majority of HCP (98.1%), despite being doctors or nurses, had insufficient knowledge on HW management. A similar trend has been observed in India (36) and Bangladesh (37). However, 76.9% of respondents of this study were characterized with an appropriate knowledge on standard HW management, which is highly satisfactory compared with neighboring countries. A higher risk of infectious disease transmission is faced by HCP at the global level, especially in low-income countries, due to improper handling of HW (8, 38, 39). Meanwhile, Anozie et al. (40) has emphasized that the risk of occupational exposure to HW related hazards is worse in developing countries. In many developing countries, HW has not received the much-needed attention that it deserves (41–43), mostly due to inadequate resources and awareness, making it a low priority (44). However, in the present study, a notable level of respondents was satisfied with the contingency plans available for management of infectious HW during a sudden disaster (54.3%) and regular inspection and periodic maintenance programmes on HW management (57.5%).

Adequate level of awareness and training on HW management directly influence the perceptions and practices of HCP (34). Unsatisfactory HW management practices among HCP and limited availability of properly trained manpower to handle HW are major challenges faced by healthcare institutions in developing countries (45). Deficiencies in financial resources, required infrastructure and other facilities have further aggravated this situation. Therefore, implementing routine training programmes for HCP regarding the proper HW is critical to reduce occupational hazards. Further, strengthening the existing regulation framework, enhancing the motivation and commitment of administrators of healthcare institutions and provision of adequate level of financial and human resources are also important to increase the efficiency of HW management.

The current study focused only on a selected number of private and government hospitals in the Colombo District of Sri Lanka, which could be identified as a limitation. The restrictions in financial resources, time and acquiring administrative approval were behind this limitation. However, a satisfactory number of HCP were recruited from different occupational and healthcare institutional categories to compensate for the above limitation.

The majority of respondents were characterized with a high knowledge level (76.9%) and positive attitudes (53.8%) on HW management. Incineration was recognized as the most widely used HW treatment method. In addition, most of the respondents were using PPE at a satisfactory level and handling HW based on standard guidelines. However, limitations were reported in routine inspection of HW management process and treatment of liquid waste. Organizing of routine training programmes was also limited. Occupational designation, level of training received in HW management, professional experience, vaccination status for tetanus, degree of knowledge and attitudes on HW management were recognized as significant risk factors associated with HW related occupational hazards.

Compared to other developing countries in the region, treatment of HW in Sri Lanka was satisfactory. However, more attention should be placed on existing regulations on HW management. Strengthening the existing mechanisms for continuous monitoring of HW management and provision of more resources (financial, human and technological) are recommended to enhance the efficiency of HW management in Sri Lanka. In addition, administrative officers should be motivated to support the HW management processes at the institutional level and a proper framework should be developed to organize training and awareness programmes on HW management for HCP.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

Ethical approval was obtained from the Ethics Review Committee (ERC) of the National Institute of Health Science (NIHS), Kaluthara, Sri Lanka (ECR Clearance No: NIHS/ERC/21/05RR). Permission from Regional Director of Health Service, Colombo District and respective Director and Superintendents of each hospital was obtained, prior collection of data. The written informed consent was obtained from all the participants for participating prior to conducting the survey. The confidentiality of the acquired data was maintained throughout the study. The entire study was conducted adhering to regulations and guidelines of the ERC.

LU: conceptualization. LS and AP: data curation. LU: formal analysis. LU, AP, and LS: investigation, methodology. LU and KR: writing – original draft. TR: writing – review & editing. All authors contributed to the article and approved the submitted version.