Staff Perceptions and Practice for Hospital Waste Management With Reference to Recycling in the UK versus Libya, a Comparative Study Yousef Eigitait A thesis submitted in partial fulfilment of the requirement of Liverpool John Moores University for the degree of Doctor of Philosophy June 2013 DECLARATION I hereby declare that the content of this document submitted by me is in fulfilment of the requirement for degree of Doctor of Philosophy and has not been previously submitted in support of an application for any degree or qualification of Liverpool John Moores University or any other University or Professional Institution. II DEDICATION This work is dedicated to my late parents and my little princess Nuria. They have given me support, advice and always stood by me during the stages of my life, and were particularly supportive in my education. III AKNOWLEDGEMENT I would like to express the deepest appreciation to my scientific supervisor Dr Ivan Gee who has shown the attitude and the substance of a genius: he continually and persuasively conveyed a spirit of adventure in regard to research and scholarship, and an excitement in regard to teaching. Without his supervision and constant help this dissertation would not have been accomplished. I would like also to thank my second and third supervisor Dr. Andy Ross, Matipa Wilfred, whose advice and recommendations demonstrated to me that concern for global affairs supported by an "engagement" in comparative literature and modem technology, should always transcend academia and provide a quest for our times. His comments and remarks on my work helped me catch up with the proper research mandates and methodologies. I also thank the ethical committee of the university who has evaluated my proposal from ethical point of view and provided the pennission to conduct the study in good time. In addition, a thank you to Professor Rafid M. Alkhaddar Chair of The faculty Committee, School of The Built Environment ,who introduced me to Linguistics, and whose passion for the underlying structures of my thesis aiming to fit with the university standards had a lasting effect. My sincere thanks extend to the admission office and all the university administrators who have supported me during the difficult times of my registration when my home country and particularly my home city of Misurata, where I had my own family faced daily threatens by the tyrant's Qaddafi. IV Last but not least, I thank the administrators of Wythenshawe hospital, Manchester Royal Infirmary, Alder Hey hospital, Tripoli Medical centre, Misurata Teaching Hospital and Benghazi Medical Centre for their help and cooperation during the collection of my data. v ABSTRACT Green hospitals with improved hospital waste recycling practices can be a key solution to the potential problems associated with hospital waste disposal and management. Recycling of household hospital waste could significantly impact on the overall waste disposal management systems and how hospital waste is segregated and eventually disposed. The involvement of hospital staff is of key importance in improving recycling performance, however, the perceptions of hospital workers towards recycling of hospital waste is still not clear and there is a lack of research in this area. The factors that determine the recycling behaviour are not adequately described in the medical literature, and differences between hospital workers perceptions of recycling in developing versus developed countries have not previously been extensively studied. This thesis was designed to examine the factors influencing the knowledge and attitudes of hospital workers towards toward recycling of hospital waste, using a novel questionnaire. A pilot study was first performed to test the efficiency of the questionnaire, conducted via sending the self-administered questionnaires to 12 experts. Their views were considered in the development of the final version of the questionnaires. These were distributed randomly in 2 pre-selected hospitals in the UK and 3 similar hospitals in Libya. A total of 453 questionnaires were returned. The response rates were generally low in both counties (less than 20%). Females and nurses responded significantly more frequently than men and physicians. In general there were relatively low levels of knowledge about waste management and recycling practice. In this study, none of the Libyan hospitals practiced any recycling and the VI hospital workers in Libya were significantly less enthusiastic towards recycling than their UK counterparts. Training in hospital waste management and education were found to be weak predictors of positive attitudes. Results showed that it is difficult to predict the recycling behaviours among hospital workers, however, waste management staff were more positive towards recycling than those without training in waste management. The study has shown similar results to previous studies, in that hospitals in developed countries generated much less waste compared to hospitals in developed countries. Unexpectedly, knowledge was weakly linked to attitudes in both UK and Libyan hospitals. This may be due to the fact that the attitudes of clinicians and hospital workers are not necessarily related to their knowledge but rather affected mostly by the hard working hours and busy atmosphere which makes recycling more challenging. The study opens doors for further studies to investigate factors influencing recycling attitudes, and encouraging hospitals in developing countries to commence recycling practice and provide whatever infrastructure is needed to make this possible. More education and training on hospital waste management should be encouraged in developing countries. Introducing new technologies in hospital waste management, particularly recycling of hospital house hold waste may change the future prospective of hospital waste disposal in developed and developing countries. More studies intervening with educating the hospital workers in waste management, particularly in recycling of hospital waste and it's relatively safety should be encouraged. Key words: Healthcare waste, hospital household recycling, knowledge, attitudes, hospitals, healthcare workers, waste management. VII ABBREVIATIONS Department of Health DH ECO-Management and Audit Scheme EMAS Electronic Health Records HER Environment General Authority EGA European Union EU First World War WWI Food and Drug Administration FDA Green Guide for Health Care GGHC Gross Domestic Product GDP Global Environment Outlook GEO Hazardous Waste HW Health Belief Model HBM HealthCare Waste HCW High Density Polyethylene HDPE Hospital Household Waste HHW Human Immunodeficiency Virus HIV Infection Control Risk Assessment ICRA International Geosphere Biosphere Programme IGBP International Council for Science ICSU VIII Leadership in Energy & Environmental Design LEED Municipal solid waste MSW National Health Service NHS Non Hazardous Waste NHW North West NW Organization for Economic Co-operation and Development OECD Poly vinyl chloride PVC Policy, Segregation, Recycling, Safety PSRS Reduce, Reuse and Recycle 3Rs Royal College of Nursing RCN Second World War WWII Single-Use Device SUD Statistical Package for Social Science SPSS Sustainability Recycling Model SRM The Health Expenditure THE United Nations environment programme UNEP United States of America USA United Kingdom UK Waste Generation Rate WGR Waste-to-energy WTE World Commission on Environment and Development WCED World Health Organization WHO IX CONTENTS Contents Staff Perceptions and Practice for Hospital Waste Management With Reference to Recycling in the UK. versus Libya, a Comparative Study I DECLARATION II DEDICATION III AKNOWLEDGEMENT N ABSTRACT VI ABBREVIATION VIII CONTENTS X LIST OF FIGURES XVI LIST OF TABLES XVII ~~I 1 I Introduction I 1.1 The history of recycling in general 5 1.2 The history of healthcare waste recycling 9 1.3 Attitudes and behaviours towards recycling hospital waste 12 1.4 Research motivation 17 1.5 General aims and specific objectives of the study 24 1.5.1 General aims 24 1.5.2 Specific objectives 25 1.6 Research expectations 25 Chapter 2 Sustainable development 27 2.1 Historical background 27 x 2.2 Sustainable hospitals 31 2.3 Building the basis for sustainability as a science 34 2.4 The concept of recycling for sustainability 37 Chapter 3 Hospital waste management 41 3.1 Definition of hospital waste 41 3.2 Methods of clinical waste disposal 45 a. Incinerators 46 b. Steam autoclaving 47 c. Chemical treatment 47 d. Microwave radiation 47 e. Other treatment systems 47 f. Disposal of Pathological Waste 48 3.3 Safety of recycling healthcare waste in developed and developing countries 48 3.4 Hospital waste in UK hospitals 50 3.5 Hospital waste in Libyan and North African hospitals 53 Chapter 4 Household waste 57 4.1 Definition of household waste 57 4.2 Household waste management in hospitals 58 1. Reduce 60 2. Reuse 62 3. Recycle 63 4.2.1 Advantages of recycling HHW: 64 4.3 Household waste in UK 65 4.4 Household waste in Libya 66 XI Chapter 5 Methodology 68 5.1 Study design 68 5.1.1 Quantitative methodology 70 I Questionnaire 1Date request from hospital waste managers 73 5.1.2 Data collection 72 II Questionnaire 2 Exploring knowledge and attitudes of hospital workers concerning Hew management and HHW recycling 74 5.2 Ethical approval 75 5.3 Hospital details 76 5.4 Questionnaires development 77 5.4.1. Pilot study 78 5.5 Questionnaire distribution 80 a 1. UK Hospital 1 82 a2. UK Hospital 2 82 a3. UK Hospital 3 82 b I. Libyan Hospital