p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e1 1

Available online at www.sciencedirect.com

Public Health

journal homepage: www.elsevier.com/puhe

Original Research

Impact of an intervention programme on

knowledge, attitude and practice of healthcare staff
regarding pharmaceutical waste management,
Gaza, Palestine

M.I. Tabash a, R.A. Hussein b,*, A.H. Mahmoud a, M.D. El-Borgy c,

B.A. Abu-Hamad d
a
Environmental Health Specialty, Environmental Health Department, High Institute of Public Health, Alexandria
University, Egypt
b
Environmental Chemistry and Biology Specialty, Environmental Health Department, High Institute of Public Health,
Alexandria University, Egypt
c
Health Education and Behavioural Sciences Specialty, Health Administration and Behavioural Sciences Department,
High Institute of Public Health, Alexandria University, Egypt
d
Department of Health Management, Faculty of Public Health, Al-Quds University, Palestine

article info abstract

Article history: Objectives: To assess knowledge, attitude and practice (KAP) of healthcare staff regarding
Received 5 June 2015 pharmaceutical waste management; and to determine the impact of an educational pro-
Received in revised form gramme on the KAP survey items.
10 December 2015 Design: Preepost-test intervention study.
Accepted 1 April 2016 Methods: The pre-intervention phase was performed using a sample of 530 out of 1500
Available online xxx healthcare workers. A predesigned interview questionnaire was used to assess KAP. Next,
an educational programme was designed and offered to a subsample of 69 healthcare
Keywords: workers. KAP were re-assessed for the programme attendees using the same interview
Public health questionnaire, both immediately (post-test) and six months after the end of the pro-
Environmental pollution gramme (follow-up test). The parametric paired sample t-test was used to assess the dif-
Waste product ference between pre-test and follow-up test results.
Medical waste Results: Poor knowledge and poor practice levels (scores 50%) detected in the pre-
Incineration intervention phase were found to improve to satisfactory levels (scores
75%) in the
follow-up phase. Attitude was found to be positive (score
75%) in all phases of the study.
Conclusion: The educational programme led to a significant improvement in KAP of
healthcare staff regarding pharmaceutical waste management (P < 0.001).
© 2016 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.

* Corresponding author. 165 Horreya Avenue, Alexandria, Egypt. Tel.: þ20 1002518599.
E-mail address: rimahamid@yahoo.com (R.A. Hussein).
http://dx.doi.org/10.1016/j.puhe.2016.04.001
0033-3506/© 2016 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.

Please cite this article in press as: Tabash MI, et al., Impact of an intervention programme on knowledge, attitude and practice of
healthcare staff regarding pharmaceutical waste management, Gaza, Palestine, Public Health (2016), http://dx.doi.org/10.1016/
j.puhe.2016.04.001
2 p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e1 1
Introduction
Pharmaceutical waste (PW) consists of expired, unused, spilt,
and contaminated pharmaceutical products, drugs, vaccines,
and sera that are no longer required and need to be disposed of
appropriately. This also includes discarded items used in the
handling of pharmaceuticals, such as bottles, boxes, gloves,
masks, connecting tubing, and drug vials’.1 In a healthcare
facility, PW is generated for various reasons including cessa-
tion of patient medication, spills/breakages and expiration of
drugs before use.2 Generally, PW is discharged down the drain
or sent to landfill. This may take place due to poor knowledge
about the potential negative impacts of PW on human health
and the environment. These impacts could occur directly
through contact with healthcare staff or indirectly through
contamination of soil, ground water and surface water.3
Concerning the impacts of PW on human health, many
cytotoxic drugs used in chemotherapy are known to be car-
cinogens, mutagens or teratogens. Nurses, pharmacists,
waste handlers, storehouse employees and laundry workers
could be at risk of exposure to these hazardous drugs.4,5 In
1979, a hospital-based study reported signs of mutagenicity in
the urine of oncology nurses.6 Other side-effects were also
reported, including an increase in spontaneous abortion, child
malformation and abnormal menstrual cycles.7 In a study
conducted in 14 German hospitals, the urinary concentrations
of certain cytotoxic drugs (cyclophosphamide, ifosfamide,
doxorubicin, epirubicin and platinum) were monitored. The
study results revealed that 40% of pharmacists and oncology
workers had one of the tested drugs in their urine. The same
study also documented the existence of drugs in the urine of
workers who did not handle these hazardous drugs but were
potentially exposed through contamination of work surfaces,
clothing or drug containers.8 Furthermore, platinum was
detected in the air of the antineoplastic drug preparation
room, and in the blood and urine of nursing staff who helped
patients to administer cisplatin.9
Regarding the impacts of PW on the environment, a variety
of pharmaceuticals have been discovered in surface, ground
and drinking waters in the USA.10 Pharmaceutical residues
detected included pain killers, cholesterol regulators, anti-
septics, chemotherapeutic agents, antibiotics and hor-
mones.11 Chemical residues discharged into the sewerage
system may have adverse effects on the operation of biolog-
ical sewage treatment plants, or toxic effects on the natural
ecosystems of receiving waters.1 Similar problems may be
caused by pharmaceutical residues.12
Knowledge, attitude and practice (KAP) studies aim to
collect information on what is known, believed and done by a
particular population in relation to a specific topic.13 Some
KAP studies have been undertaken on the management of
biomedical waste in general.14e18 Pharmacists and nurses do
not acquire information on hazardous waste management
during their academic studies. In addition, safety personnel
and heads of environmental services may not recognise the
active ingredients present in pharmaceutical products. It is
thus recommended that they should be given in-service ed-
ucation regarding proper handling of PW, especially that
resulting from chemotherapy.3
Please cite this article in press as: Tabash MI, et al., Impact of an intervention programme on knowledge, attitude and practice of
healthcare staff regarding pharmaceutical waste management, Gaza, Palestine, Public Health (2016), http://dx.doi.org/10.1016/
j.puhe.2016.04.001
In Gaza, rapid population growth (annual growth of 4.8%)
has been associated with public service expansion, including
healthcare services.19 According to the Ministry of Health,
317.6 m3 of PW was disposed of in 2011.20
This study had two objectives: (1) to assess the KAP of
healthcare staff in five major governmental hospitals in Gaza
with regard to PW management (PWM) using a KAP survey;
and (2) to determine the impact of an intervention programme
on the KAP survey items.
Methods
This preepost-test intervention study was conducted in 2014.
It consisted of three phases: pre-intervention phase; inter-
vention phase; and post-intervention phase.
Pre-intervention phase
The pre-intervention phase was conducted in five govern-
mental hospitals in Gaza: European-Gaza; Nasser; Al-Aqsa; Al-
Shifa and Kamal Adwan. These hospitals were selected as
they are the five largest hospitals in Gaza, and serve the
greatest number of patients. The study population consisted
of various healthcare staff working at the selected hospitals
(administrators, pharmacists, nurses and waste workers).
Doctors were not included as they are not involved in any
waste management steps. The sample size was calculated
using the StatCalc module of Epi-Info version 7, with a popu-
lation size of 1500, expected frequency of KAP score of 60%,15
using a dominating effect of 1.8 and five clusters. This yielded
a sample size of 530. Based on the proportion of healthcare
staff within each hospital, a proportional allocated sample
was taken as follows: 88; 107; 55; 227 and 53 staff members
from European-Gaza, Nasser, Al-Aqsa, Al-Shifa, and Kamal
Adwan Hospitals, respectively. These staff members were
selected randomly at each hospital.
A questionnaire, predesigned by the researchers, was used
to assess KAP of the study sample regarding PWM. The
questionnaire was developed based on the World Health Or-
ganisation's (WHO) guidelines for safe healthcare waste
management,1 and on the US Environmental Protection
Agency's best management practices for unused pharmaceu-
ticals2 by transforming theoretical content into questions/
statements. The questionnaire included four main sections:
the first concerned the demographic data of the participants;
and the second; third and fourth sections were formulated to
test their knowledge, attitude and practice regarding PWM,
respectively.
Twelve questions were used to assess knowledge, while
practice was assessed using nine questions. Attitude was
assessed through 21 statements, presented on a three-point
Likert type scale with ‘agree’, ‘neutral’ and ‘disagree’ re-
sponses. A score was computed for each question and state-
ment, and adjusted to a percentage. Scores <50%
demonstrated a poor level of knowledge or practice, or a
negative attitude. Scores between 50% and <75% represented
a fair level of knowledge or practice, or a neutral attitude.
Finally, scores
75% were considered satisfactory in terms of
knowledge and practice, and represented a positive attitude.
 p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e1 1 3

In order to validate the questionnaire (face and content),
approval was obtained from the Review Board of the High
Institute of Public Health, Alexandria University. Furthermore,
in Gaza, the questionnaire and a covering letter containing the
title and objectives of the study was sent to 12 experts from
different backgrounds including researchers, environmental
experts, pharmacists, nurses and academicians. They were
asked to estimate the relevance, clarity and completeness of
each item; some questions were modified accordingly.
Testeretest reliability was assessed for the knowledge section
of the questionnaire and was found to be acceptable (a ¼ 0.71).
Internal consistency reliability for the attitude and the practice
sections was also acceptable (a ¼ 0.71 and 0.73, respectively).
After checking the validity and reliability of the question-
naire, it was pretested in a pilot study involving 30 people with
different job titles (administrators, pharmacists, nurses and
waste workers). Following the pilot study, the decision was
made to use the questionnaire as an interview questionnaire
rather than a self-administered questionnaire.
Intervention phase
same interview questionnaire, both immediately (post-test)
and six months after the end of the programme (follow-up
test). A score was computed for each question and statement
in the same manner used in the pre-intervention phase.
Out of 72 participants, three (4.2%) were not able to
participate in the postintervention phase due to personal
reasons, thus reducing the sample size for the post-
intervention phase to 69 participants (30 in European-Gaza
hospital and 39 in Al-Shifa hospital).
Statistical analysis
Data were revised, coded and entered into Statistical Package
for the Social Sciences version 16.21 Assessment of the
normality of data was performed using Kolmogorov-Smirnov
test and a non-significant result was obtained (P > 0.05). The
parametric paired sample t-test was used to assess the dif-
ference between pre-test and follow-up test results to deter-
mine the impact of the intervention. Tests were two tailed.
P < 0.05 was considered to indicate significance.

An educational programme was designed based on the results Results

of the pre-intervention test. This was tailored according to the
needs of healthcare staff, and was offered in two hospitals: Al- Demographic data
Shifa and European-Gaza. These two hospitals were selected as
they were the only hospitals out of the five study hospitals that Age, sex, qualifications, profession and years of experience of
offered chemotherapy. Using StatsDirect to calculate the the participants in the pre-intervention phase are presented
sample size of the intervention phase, assuming a starting in Table 1. The majority of respondents were aged <40 years,
point of 60% KAP15 and ending at 80%, with 95% confidence with a mean age of 32.4 years (standard deviation [SD] eight
intervals and 80% power, the sample size for corrected chi- years). There were more male subjects than females (56.2%),
squared test and Fisher's exact test was 57 healthcare staff. probably due to the fact that the majority of administrators
This was increased to 72 in order to include all healthcare staff and waste workers in Gaza hospitals are males. In terms of
(100%) working in the oncology departments in the two hos- qualifications, 7% of employees were found to have
pitals (32 in European-Gaza hospital and 40 in Al-Shifa hospi-
tal). These healthcare staff were invited to attend the training
programme, which involved two sessions of approximately Table 1 e Demographic characteristics of the pre-
90 min each in two consecutive weeks (i.e. one session per intervention study sample (n ¼ 530).
week). Different training methods, such as posters and Pow- Variables n %
erpoint presentations, were used. In addition, daily meetings
Age (years)
for discussion with healthcare staff took place in the hospitals.
<30 230 43.5
A written practical guide concerning safe PWM was 30e40 215 40.6
developed based upon international standards.1,2 This guide >40 84 15.9
included the definition and classification of PW, as well as its Missing 1 0.18
impact on human health and the environment. In addition, it Sex
included procedures for safe PWM and occupational safety of Male 298 56.2
Female 232 43.8
healthcare workers. This guide was reviewed and certified by
Qualification
the Ministry of Health in Gaza, and was subsequently Secondary school or less 82 15.5
distributed to all pharmacists, nurses and waste workers in Diploma 161 30.4
the selected hospitals. Signs were also placed near disposal Bachelor 250 47.2
areas to remind working staff about safe disposal practices Postgraduate 37 7.0
and improve their awareness. Finally, the resources required Profession
Pharmacist 46 8.7
for PW collection, such as labelled colour-coded bags and
Radiographer 21 4.0
containers, were provided, and healthcare workers were
Waste worker 91 17.2
trained in their use. Nurse 364 68.7
Others 8 1.5
Postintervention phase Total experience (years)
<5 142 26.8
After implementation of the educational programme, KAP 5e10 224 42.3
>10 164 30.9
were re-assessed for the programme attendees using the

Please cite this article in press as: Tabash MI, et al., Impact of an intervention programme on knowledge, attitude and practice of
healthcare staff regarding pharmaceutical waste management, Gaza, Palestine, Public Health (2016), http://dx.doi.org/10.1016/
j.puhe.2016.04.001
4 p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e1 1

postgraduate degrees, 47.2% had bachelor degrees, 30.4% had Medicine rejected for non-
a diploma, and 15.5% had graduated from secondary school compliance to specificaƟons

or less. In terms of profession, 8.7% of study sample were

Vaccines and sera no longer used
pharmacists, 68.7% were nurses, 4% were radiographers,
17.2% were waste workers and 1.5% had other specialisations Items used in cleaning up spills
(public health specialist and health manager). The total
% of answers
experience of nearly one-quarter of the respondents was Spilled products

reported to be < 5 years (26.8%), while 42.3% of respondents

Products used in IV preparaƟons
had 5e10 years of experience and 31% of respondents had
>10 years of experience. Outdated drugs not returnable for
credit

Impact of the educational programme on knowledge 0 20 40 60 80 100

Fig. 1 e Percentage of incomplete correct answers obtained

Results of the pre-test (Table 2)
to the question ‘What is the definition of pharmaceutical
The first question in the knowledge section was about the
waste?’ IV, intravenous.
definition of ‘PW’. Answers revealed a fair level of knowledge
(score of 51%); 5.3% of the respondents provided a complete
correct answer; 91.6% gave an incomplete correct answer
(Fig. 1), not encompassing all types of waste stated in the WHO
definition1; and the remainder indicated that they did not
An error in doctor's prescripƟon
know.
The same fair level of knowledge (58%) was obtained
Mistake in the process of exchange
regarding the possible reasons for PW generation in hospital
pharmacies, where four-fifths of the pharmacists (80%) gave a
Damage as a result of poor
correct but incomplete answer (shown in Fig. 2). Only 18% of preservaƟon % of answers
respondents gave a complete correct answer including all
reasons. Spills

Regarding nurses' knowledge about the possible reasons

for PW generation at the nursing floor, 92% provided a correct ExpiraƟon prior to use

incomplete answer (presented in Fig. 3), indicating a fair level

0 20 40 60 80 100 120
of knowledge (score 52.6%).
When participants were asked to mention any steps in Fig. 2 e Percentage of incomplete correct answers obtained
PWM, the study results revealed a satisfactory level of to the question ‘What are the reasons for pharmaceutical
knowledge (score 75.7%). However, approximately 25% of the waste generation in hospital pharmacies?’
respondents failed to state even one step in this process
(Fig. 4).

Table 2 e Knowledge of the pre-intervention study sample (n ¼ 530) with regard to pharmaceutical waste management.
Questions Answers (%) Score (%)
Correct Correct Wrong/don't
complete incomplete know
What is the definition of pharmaceutical waste? 5.3 91.6 3 51.1
What are the reasons for pharmaceutical waste generation in pharmacies? 18.1 80.4 1.5 58.3
n ¼ 46
What are the reasons for pharmaceutical waste generation at nursing floor? 6.7 91.8 1.5 52.6
n ¼ 364
What are the steps of pharmaceutical waste management? (one step at least) 75.5 e 24.5 75.5
What are the steps of pharmaceutical waste management? (all steps) 21 53 26 47.5
What is the importance of pharmaceutical waste segregation? 24 34.7 41.3 41.4
What are the pharmaceutical waste types that should be segregated from each 17.5 53.7 28.8 44.4
other?
What are the colours that should be used to segregate each type of 0.6 34.1 65.3 17.6
pharmaceutical waste?
Is it important to have a storage room for pharmaceutical waste in each 64 0 36 64
hospital?
What is the optimum collection frequency for generated pharmaceutical waste? 20.8 0 79.2 20.8
What are the specifications of the vehicle used for pharmaceutical waste 0 8.8 91.2 4.9
transport?
What are the treatment methods for pharmaceutical waste? 2.6 33 64.4 19.2
Mean (standard deviation) knowledge score 41.4 (21.4)

Please cite this article in press as: Tabash MI, et al., Impact of an intervention programme on knowledge, attitude and practice of
healthcare staff regarding pharmaceutical waste management, Gaza, Palestine, Public Health (2016), http://dx.doi.org/10.1016/
j.puhe.2016.04.001

Use in IV preparaƟon
Mistake in the process of dispensing
PaƟent has an adverse reacƟon, or is
successfully treated, and stops…
PaƟent dies or is transferred
PaƟent refuses the medicaƟon
ExpiraƟon prior to use
0 20 40 60
Fig. 3 e Percentage of incomplete correct answers obtained
to the question ‘What are the reasons for pharmaceutical
waste generation at nursing floor?’ IV, intravenous.
Only 21% of participants provided a complete correct
answer about all steps of PWM, from the point of generation of
waste to its final treatment and disposal; 26% of participants
did not know how to answer this question. This showed a poor
level of knowledge in this aspect (score 47.5%).
Regarding the importance of using a colour coding system
for PW segregation, this study found a poor level of knowledge
among the interviewees, as only 24% were aware of the
importance. The same poor level of knowledge was detected
regarding the types of PW that should be segregated from each
other; only 17.5% of participants indicated all types correctly.
Meanwhile, approximately half of the respondents gave a
correct incomplete answer that included: unused pharma-
ceuticals (68.3%); chemotherapeutic drugs (55.4%); sharps
(80%) and domestic waste (70%).
Regarding the colour specified for each type of waste, only
0.6% of the study sample gave a correct answer, indicating a
poor level of knowledge (score 17.6%). The need for a specially
designed room for onsite storage of PW was fairly well known
(score 64%).
A poor level of knowledge concerning the frequency of PW
collection as well as the specifications of the vehicle used for
waste transport was illustrated (scores 20.8% and 4.9%,
respectively). Only 21% of interviewees correctly reported that
waste should be collected once daily, and 79% gave an incor-
rect answer. As for the vehicle, it should be secure, of suitable
Safe disposal
Treatment
Storage
CollecƟon and transport
SegregaƟon
0 10 20 30 40 50
Fig. 4 e Percentage of incomplete correct answers obtained
to the question ‘What are the steps of pharmaceutical
waste management?’
Please cite this article in press as: Tabash MI, et al., Impact of an intervention programme on knowledge, attitude and practice of
healthcare staff regarding pharmaceutical waste management, Gaza, Palestine, Public Health (2016), http://dx.doi.org/10.1016/
j.puhe.2016.04.001
p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e1 1 5
size, should carry the international biohazard sign, be marked
with the name of transporter, easy-to-clean, and with a
bulkhead between the driver's cabin and the vehicle body so
as to retain the waste load if the vehicle is involved in a
collision.1 As listed in Table 2, most respondents (91%) did not
know any of these features, and 8.8% of respondents only
% of answers
indicated two or three features.
When study participants were asked about various PW
treatment methods, only 2.6% provided a complete correct
answer. Thirty-three percent of respondents gave an incom-
plete correct answer. The remainder (64.4%) reported that
80 100 they did not know any treatment methods, or specified
treatment methods that could not be used for PW treatment
such as steam sterilisation and microwave heating.
Participants' responses were computed in order to provide
an overall score representing their overall knowledge. The
overall mean knowledge score was 41.4% (SD 21.4), indicating
a poor level of knowledge about PWM practices.
Results of the post-test and follow-up test (Table 3)
Immediately after completion of the educational programme,
the level of knowledge was found to have risen from poor to
fair in terms of all steps of PWM, importance of PW segrega-
tion, types of PW that should be segregated from each other,
collection frequency, specifications of transport vehicle, and
treatment methods. In addition, knowledge improved from
fair to satisfactory for reasons for PW generation in hospital
pharmacies. Knowledge about the definition of PW remained
fair as in the pre-intervention phase, and knowledge about
colour codes used for each type of PW remained poor.
Six months later, knowledge of healthcare staff was found
to be satisfactory (
75%) for eight of the 12 questions. Answers
to the remaining four questions e which concerned all steps
of PWM, types of PW that should be segregated from each
other, colour codes used for each type of PW, and specifica-
tions of the waste transport vehicle e showed a fair level of
knowledge. This improvement to either a fair or a satisfactory
level of knowledge was found to be significant (P < 0.05).
The mean knowledge score was found to increase from
41.4% (SD 21%) (poor level) in the pre-intervention phase to
63% (SD 14%) (fair level) in the post-test conducted immedi-
ately after the end of the educational programme, and to 77%
(SD 11%) (satisfactory level) in the follow-up test conducted six
months later. This significant increase (P < 0.001) could be
attributed to the fact that, although the programme was
finished, posters were placed throughout the hospitals to
remind staff members, and brochures and booklets were
distributed in all departments.
Impact of the educational programme on attitude
% of answers
Results of the pre-test (Table 4)
Among the 21 statements, interviewees had positive attitudes
towards 17 and neutral attitudes towards four. This led to a
mean score for attitude of 84.3% (SD 13%), demonstrating that
the healthcare staff had a positive attitude regarding PWM.
60 70
Results of the post-test and follow-up test (Table 5)
Immediately after the educational programme, a neutral
attitude improved to a positive attitude for three statements:
6 p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e1 1

Table 3 e Impact of the educational programme on knowledge of healthcare staff (n ¼ 69) with regard to pharmaceutical
waste management.
Questions Knowledge score (%) P-valuea
Pre-test Post-test Follow-up
What is the definition of pharmaceutical waste? 52.1 66.6 81.1 <0.001
What are the reasons for pharmaceutical waste 71.4 85.7 85.7 <0.001
generation in pharmacies? n ¼ 7
What are the reasons for pharmaceutical waste 53.8 71 77.3 <0.001
generation at nursing floor? n ¼ 53
What are the steps of pharmaceutical waste 75.4 81.2 92.8 0.006
management? (one step at least)
What are the steps of pharmaceutical waste 42.7 60.8 71.9 <0.001
management? (all steps)
What is the importance of pharmaceutical waste 33.3 50 75.3 <0.001
segregation?
What are the pharmaceutical waste types that should 30.4 51.4 74.6 <0.001
be segregated from each other?
What are the colours that should be used to segregate 0 39.1 52.2 <0.001
each type of pharmaceutical waste?
Is it important to have a storage room for 68.1 75.4 92.8 <0.001
pharmaceutical waste in each hospital?
What is the optimum collection frequency for 15.9 63.8 76.8 0.005
generated pharmaceutical waste?
What are the specifications of the vehicle used for 7.9 51.4 73.2 <0.001
pharmaceutical waste transport?
What are the treatment methods for pharmaceutical 28.4 55.7 75.3 <0.001
waste?
Mean (standard deviation) knowledge score 41 (21) 63 (14) 77 (11) <0.001
a
P-value for paired samples t-test comparing pre-test and follow-up test scores.

current methods used for PWM; training given to healthcare
staff; and legislation dealing with the safe disposal of PW in
Palestine. These sentences were written using a negative
status, and an increase in the ‘disagree’ response and/or a
decrease in the ‘agree’ response was considered to indicate an
improvement in attitude. However, regarding incinerators,
interviewees kept their neutral attitude towards the in-
cinerators currently used in their hospitals. The remaining
statements that displayed a positive attitude in the pre-
intervention phase remained as such.
Six months later, when the interview questionnaire was
administered to re-assess the attitude of healthcare staff, the
positive attitude observed in the pre-intervention phase vis-
 -vis 17 statements was found to be significantly improved
a Immediately after the educational programme, poor practice
(P < 0.05) for 11 statements (Table 5). The study participants
still had a positive attitude towards the remaining six state-
ments, but the difference from the pre-intervention phase
was not significant. In addition, a positive attitude was re-
ported for satisfaction with incinerators (P < 0.05).
The mean attitude score was found to increase from 84% in
the pre-intervention phase to 90.5% and 90% in the post-test
and follow-up test, respectively.
Impact of the educational programme on practice
Results of the pre-test (Table 6)
A poor level of practice was detected among the study sample
regarding following any system for PWM, adherence to certain
guidelines, staff training, segregation of PW in colour-coded
bags at the generation point, regular collection of generated
PW, managing spills resulting from damaged containers and/
or bags, and on-site storage of PW in specially designed rooms.
Sixty percent of the study participants reported immediate
replacement of full waste bags with new ones for healthcare
waste collection, thus revealing a fair level of practice in this
concern. In addition, 60% of the respondents reported using
personal protective equipment (PPE) regularly when handling
PW, and 37% reported that they used PPE sometimes, thus
revealing one practice performed in a satisfactory manner.
The mean practice score was 36.9% (SD 24.7%), demon-
strating a poor level of PWM practice.
Results of the post-test and follow-up test (Table 7)
related to attending training workshops about PWM was re-
ported to be satisfactory (score 100% as all interviewees were
programme trainees). However, six practices remained poor,
as in the pre-intervention phase. Immediate replacement of
full waste bags remained fair, as in the pre-intervention
phase. Use of PPE remained satisfactory, as in the pre-
intervention phase.
Six months later, six practices were found to change from
poor or fair levels to satisfactory levels with a significant dif-
ference in their scores (P < 0.001). These included presence of
PWM system, adherence to written guidelines, PW segrega-
tion at the generation point, PW collection on a regular basis,
immediate replacement of full waste bags, and spill man-
agement. Improvement in the first two practices could be due
to the guideline booklet, prepared by the researchers,
approved by the Ministry of Health and offered to the hospital

Please cite this article in press as: Tabash MI, et al., Impact of an intervention programme on knowledge, attitude and practice of
healthcare staff regarding pharmaceutical waste management, Gaza, Palestine, Public Health (2016), http://dx.doi.org/10.1016/
j.puhe.2016.04.001
 p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e1 1 7

Table 4 e Attitude of the pre-intervention study sample (n ¼ 530) with regard to pharmaceutical waste management.
Statements Response (%) Score
Agree Neutral Disagree
Pharmaceutical waste management is an important issue 97 1.5 1.5 97.7
Palestine has adequate legislation dealing with the safe disposal of hazardous 17.7 44.7 37.6 59.95
pharmaceutical waste
Healthcare professionals should be more aware of environmental issues 90 7.4 2.7 93.7
Formal training in pharmaceutical waste management should be provided by 93 4.7 2.3 95.3
the hospital for all healthcare staff
Hospital staff involved with waste management receive adequate training 21.3 31.9 46.8 62.7
The presence of a manual for pharmaceutical waste management is important 79.4 10.9 9.6 84.8
Clear defined procedures for waste collection from different departments in the 88.5 9.1 2.5 93
hospital are important
Each department or ward should keep records of pharmaceutical waste 71.7 19.2 9.1 81.3
generated
Waste management responsibility should be included in the job description of 82.1 15.1 2.9 89.6
healthcare professionals
A responsible person should supervise the process of pharmaceutical waste 88 8.9 3.2 92.4
management
Hospital staff should be protected when handling pharmaceutical waste 89.8 6.4 3.8 93
Pharmaceutical waste has a negative impact on human health 83.4 10.9 5.6 88.8
Mishandling of pharmaceutical waste may be hazardous to human health 87.6 6.8 5.6 91
Healthcare waste has no negative impact on the environment 13 9.8 77.2 82
Pharmaceutical waste generated by hospitals has no adverse impact on the 15.8 9.6 74.5 79.3
environment
Presence of special tools is essential for proper pharmaceutical waste 91.9 5.8 2.3 94.8
management
Incinerator staff should hold certificates of competency or should have received 89.1 8.3 2.7 93.2
adequate training
Incinerators must be certified 90.4 7.5 2.1 94.1
Current methods of pharmaceutical waste management are appropriate 18.9 34.5 46.6 63.85
You are satisfied with your incinerator system 22.2 51.3 26.4 52
You are willing to cooperate with healthcare waste specialised committees 84.8 10.9 4.4 90.2
Mean (standard deviation) attitude score 84 (13)

administration. Improvement in collection (segregation in
colour-coded bags, regular frequency of waste collection, and
immediate replacement of full bags) in spill management
practices may have been due to the availability of resources
required (colour-coded bags and spill kits offered by the re-
searchers) and the application of instructions given
throughout the training programme.
Besides these six practices, attendance of training work-
shops and use of PPE remained satisfactory, as in the imme-
diate post-test. On-site storage of PW in specially designed
rooms remained poor (score 0) in the follow-up test.
The mean practice score was found to increase from a poor
level in both pre-test and post-test phases (scores 34.3% [SD
26%] and 44.2% [SD 35%], respectively) to a satisfactory level
(78% [SD 30%]) in the follow-up phase six months later.
Discussion
To the best of the authors' knowledge, this is the first study to
tackle KAP regarding PW.
Knowledge
As listed in Table 2, all participants had fair knowledge about
the definition of PW and reasons for its generation. This
confirms the need for comprehensive training, as the first step
in any waste prevention and minimisation programme is to
identify reasons for waste generation.2
A poor level of knowledge was identified regarding segre-
gation and colour codes of different types of PW. These results
supported those of a study undertaken in Yemen, which re-
ported that only a few workers in governmental hospitals
were aware of the need to segregate medical waste into
different categories for proper waste management.22 Ideally,
PWM steps start with segregation, the objective of which is to
separate PW into categories (infectious/hazardous/non-haz-
ardous) that require different disposal methods and to reduce
the budget required for disposal. Segregation is performed
using colour-coded bags. These bags should be packed into
steel drums or cardboard boxes, with the contents clearly
written on the outside of the containers. Subsequently, they
should be transported to a dry secure separate room to avoid
being confused with in-date pharmaceuticals, until treatment
and/or disposal.23 According to WHO, colour coding of waste
containers facilitates the segregation process for healthcare
staff and hospital employees, and keeps different types of
waste segregated during storage, transport, treatment and
disposal. In addition, colour coding can indicate the potential
risk posed by each type of waste. A single system of segrega-
tion should be applied throughout a country. Many countries
have national legislation that sets the waste segregation cat-
egories and the system of colour coding to be used. Where
national legislation is absent, the WHO scheme could be used:

Please cite this article in press as: Tabash MI, et al., Impact of an intervention programme on knowledge, attitude and practice of
healthcare staff regarding pharmaceutical waste management, Gaza, Palestine, Public Health (2016), http://dx.doi.org/10.1016/
j.puhe.2016.04.001
8 p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e1 1

Table 5 e Impact of the educational programme on attitude of healthcare staff (n ¼ 69) with regard to pharmaceutical waste
management.
Statements Attitude score (%) P-valuea
Pre-test Post-test Follow-up
Pharmaceutical waste management is an important issue 91.3 95.6 97.8 0.001
Palestine has adequate legislation dealing with the safe disposal of hazardous 67.5 76.2 73.3 0.778
pharmaceutical waste
Healthcare professionals should be more aware of environmental issues 94.2 96.4 95.6 0.066
Formal training in pharmaceutical waste management should be provided by 93.4 94.8 96.4 0.038
the hospital for all healthcare staff
Hospital staff involved with waste management receive adequate training 73 76 54.5 0.005
The presence of a manual for pharmaceutical waste management is important 83.3 94.9 95.6 <0.001
Clear defined procedures for waste collection from different departments in the 95.6 97 95.6 0.005
hospital are important
Each department or ward should keep records of pharmaceutical waste 93.4 95.7 94.8 0.001
generated
Waste management responsibility should be included in the job description of 84.1 92.8 94.9 <0.001
healthcare professionals
A responsible person should supervise the process of pharmaceutical waste 87.6 94.8 96 0.010
management
Hospital staff should be protected when handling pharmaceutical waste 82.6 91.3 90.5 0.132
Pharmaceutical waste has a negative impact on human health 90.6 92.7 92 0.160
Mishandling of pharmaceutical waste may be hazardous to human health 91.3 93.4 95.6 0.074
Healthcare waste has no negative impact on the environment 90.6 91.35 92.8 0.321
Pharmaceutical waste generated by hospitals has no adverse impact on the 90.6 95.6 95.6 0.040
environment
Presence of special tools is essential for proper pharmaceutical waste 81.8 91.3 92 0.099
management
Incinerator staff should hold certificates of competency or should have received 92 94.2 94.9 0.030
adequate training
Incinerators must be certified 87.6 93.4 92.7 0.028
Current methods of pharmaceutical waste management are appropriate 66 80.4 78.9 <0.001
You are satisfied with your incinerator system 58.7 71.8 76.2 0.002
You are willing to cooperate with healthcare waste specialised committees 88.4 92 92.8 0.001
Mean attitude score 83.89 90.54 89.93
a
P-value for paired samples t-test comparing pre-test and follow-up test scores.

this uses yellow; brown and black for infectious; hazardous
and general waste, respectively.1
A poor level of knowledge was observed concerning
treatment methods of PW. As a best management practice,
PW should not be treated with infectious waste (red bag
waste). Infectious waste is steam-sterilised (e.g. in an auto-
clave) before disposal in landfills. The temperature at which
steam sterilisation occurs is not sufficient to destroy PW. In
addition, wastewater containing residual pharmaceuticals
may be generated from the autoclave, and discharged to the
sewer and receiving water bodies.2 Following segregation of
PW from infectious waste, antineoplastics should be segre-
gated from other pharmaceuticals in order to be destroyed at
a temperature not less than 1200  C in a two-chamber
incinerator equipped with an air emission control system.
Anti-infective agents and controlled drugs such as narcotics
could be treated in a single-chamber incinerator followed by
encapsulation and discharge to landfill. In addition to the
active ingredient, PW dosage forms should be taken into
consideration when selecting the appropriate treatment
method. For example, ampoules (of antineoplastics and anti-
infective drugs) should not be incinerated as they will
explode, causing damage to the incinerator and injury to
workers. They should not be crushed and the content
discharged to the sewerage system, but should be treated by
encapsulation.23
The mean knowledge score for the pre-intervention phase
(41.4% [SD 21.4%]) was in accordance with two studies con-
ducted in India that detected a poor level of knowledge
regarding healthcare waste management practices among
healthcare personnel in Jaipur Dental College and in a tertiary
care hospital.24,25 In addition, the significant increase in this
score to 77% (SD 11%) in the follow-up phase (Table 3) was
consistent with a study undertaken in Malaysia that revealed
a significant increase in the knowledge score of nurses from
45.5% (SD 10%) to 73.4% (SD 9%) following an educational
programme on the hazardous effects of cytotoxic drugs, and
the need to apply proper waste handling measures.26
Attitude
The positive attitude towards 17 statements regarding PWM
(Table 4) was in accordance with results reported by Sattar,27
Elkhalifa,28 Al-Khatib29 and Sarsour et al.30 who studied the
attitude of healthcare staff towards medical waste manage-
ment in general. With regard to the neutral attitude towards
PWM, this was also consistent with the results of a previous
study conducted in Gaza in 2000 that revealed a neutral

Please cite this article in press as: Tabash MI, et al., Impact of an intervention programme on knowledge, attitude and practice of
healthcare staff regarding pharmaceutical waste management, Gaza, Palestine, Public Health (2016), http://dx.doi.org/10.1016/
j.puhe.2016.04.001
 p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e1 1 9

the pre-test, and scores increased significantly in the post-test

Table 6 e Practice of the pre-intervention study sample
and follow-up test to 99.3% and 96.2%, respectively.32
(n ¼ 530) with regard to pharmaceutical waste
management (PWM).
Practice Answers (%) Score Practice
Yes Some- No
times As concerns practice, technical guidelines constitute a com-
Following a specific system in PWM 19.6 29.2 51.1 34.2 plement to any healthcare waste management system in
Adherence of PWM system to written 7.5 13 79.5 14 order to specify regulations for segregation, collection, stor-
guidelines age, handling, transportation, treatment and disposal of
Attending training workshops about 17.5 0 82.5 17.5 different waste categories, and to set responsibilities and
PWM
training requirements.1 Absence of guidelines for PWM e as
Pharmaceutical waste segregation at 17.7 34.7 47.6 35.05
revealed in this study e was in accordance with Kumar et al.
generation point
Regular collection of PW 16.2 34 49.8 33.2 who revealed that tertiary care hospitals in Pakistan were not
Immediate replacement of full waste 60.2 27.7 12.1 74.05 following any guidelines for healthcare waste management.33
bags Poor segregation practice of PW was also identified in the
Spill management 19.6 34.7 45.7 36.9 present study. This was in agreement with the results of the
On-site storage of PW in specially 8.5 0 91.5 8.5 Environmental Quality Authority (EQA) survey that was con-
designed rooms
ducted in 2005 in the West Bank and Gaza Strip.30,34 Similar
Use personal protective equipment 60.6 36.8 2.6 79
when handling PW
results were also reported in studies conducted in Nigeria,35
Mean (standard deviation) practice 36.9 (24.7) Ghana,36 Egypt37 and Portugal.38 All of these studies were in
score accordance with Smith, who stated that chemotherapeutic
waste should be managed as infectious waste (i.e. micro-
waved or autoclaved then shredded and landfilled), although
attitude of healthcare staff, especially nurses, towards medi- none of these processes ensure the destruction of the organic
cal waste management.31 molecules and their proper final disposal.39
Regarding the neutral attitude towards incinerators, this Regarding the absence of a storage room designated spe-
improved to a positive attitude in the follow-up phase of this cifically for PW, this result was in agreement with a survey
study (Table 5). This may be attributed to improvement in conducted by EQA which revealed that the majority of
participants' knowledge about the negative impacts of inap- healthcare facilities had no storage rooms for general or
propriate incineration and the health hazards resulting from medical waste.34 In contrast, studies conducted in Jordan and
products of incomplete combustion emitted from the incin- Nepal found that all collected medical waste was stored in a
erator stack, especially as the incinerators used in the hospi- central storage area within the hospital premises.40,41
tals under study were found to be old, poorly maintained, and The mean practice score was 36.9% (SD 24.7%) (Table 6),
lacked an air emission control system. demonstrating a poor level of PWM practice. This could be
The mean attitude score increased from 84% in the pre- explained by the lack of guidelines, lack of training courses
intervention phase to 90.5% and 90% in the post-test and and programmes, inadequate supplies, lack of supervision,
follow-up test, respectively. These results were in accordance and lack of incentive for proper waste management. This was
with Elkhalifa, who showed an improvement in attitude in agreement with Mostafa et al. who assessed the knowledge
regarding healthcare waste management from 76% in pre-test and practice related to waste management among doctors,
results to 90% in post-test results.28 In addition, a similar nurses and housekeepers at Al-Mansoura University Hospital,
study conducted in El-Mansoura, Egypt found that nurses had Egypt, and revealed inadequate practice in most areas of
a negative attitude towards healthcare waste management in waste management.16

Table 7 e Impact of the educational programme on practice of healthcare staff (n ¼ 69) with regard to pharmaceutical waste
management.
Practice Practice score (%) P-valuea
Pre-test Post-test Follow-up
Following a specific system in PWM 23.1 22.4 78.2 <0.001
Adherence of PWM system to written guidelines 4.3 5.7 85.5 <0.001
Attending training workshops about PWM 17.5 100 100 <0.001
Pharmaceutical waste segregation at generation point 26 31.8 92 <0.001
Regular collection of PW 39.1 36.9 82.6 <0.001
Immediate replacement of full waste bags 72.4 69.5 90.5 0.010
Spill management 39.2 42 80.4 <0.001
On-site storage of PW in specially designed rooms 8.5 0 0
Using PPE while handling PW 79 89.8 95.6 0.001
Mean (standard deviation) practice score 34.3 (26) 44.2 (35) 78.3 (30)
a
P-value for paired samples t-test comparing pre-test and follow-up test scores.

Please cite this article in press as: Tabash MI, et al., Impact of an intervention programme on knowledge, attitude and practice of
healthcare staff regarding pharmaceutical waste management, Gaza, Palestine, Public Health (2016), http://dx.doi.org/10.1016/
j.puhe.2016.04.001
10 p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e1 1
The significant increase in the mean practice score in the
follow-up phase (Table 7) may be attributed to improvement
in knowledge and attitude regarding PWM, as well as avail-
ability of resources needed for best management practice.
This is consistent with Lewise et al. who reported that good
practice is the result of theoretical understanding that helps
healthcare staff to acquire new skills.42
Conclusion and recommendations
A significant improvement in KAP of healthcare staff
regarding PWM was achieved in two governmental hospitals
in Gaza as a result of an educational programme. A poor
knowledge level (mean score 41.4% [SD 21%]) was detected in
the pre-intervention phase; this improved to a fair level (mean
score 63% [SD 14%]) in the post-intervention phase and to a
satisfactory level (mean score 77% [SD 11%]) in the follow-up
phase six months later. The difference in mean score was
significant (P < 0.001). Attitude towards PWM was found to be
positive in the pre-intervention phase (mean score 83% [SD
13%]), and scores increased significantly to 90.5% and 90% in
the post-test and follow-up test, respectively. The mean
practice score increased from a poor level in both pre-test and
post-test phases (scores 34.3% [SD 26%] and 44.2% [SD 35%],
respectively) to a satisfactory level (score 78% [SD 30%]) in the
follow-up phase six months later, which was a significant
difference (P < 0.001). This could be attributed to the
improvement in knowledge and attitude of healthcare staff
regarding PWM, as well as the availability of resources needed
for best management practice.
Based on previous results, educational programmes could
be considered as an effective tool for protecting human health
and the environment from the adverse impacts of PW. As
such, it is recommended that training-of-trainee programmes
of PWM should be implemented for healthcare staff in every
hospital at the beginning of their employment, with regular
refresher workshops. In addition, the provision of required
resources for proper PWM is highly recommended. These
include, but are not limited to, PPE for waste workers, colour-
coded bags and containers, waste storage room, a special
transport vehicle, and a two-chamber incinerator equipped
with an air emission control system.
A limitation of this study is the lack of evidence regarding
whether or not the change in practice was a result of
improvement of knowledge of healthcare staff, establishment
of a system in the healthcare facility, or allocation of resources
needed for proper PWM. This could be the subject of further
research.
Author statements
Ethical approval
This study was approved by the Ethics Committee, High
Institute of Public Health, Alexandria University. Approval for
conducting the study was also obtained from the Ministry of
Health in Gaza, as well as from all hospital managers. Before
data collection, each respondent was notified about the
objective of the study, and was informed that collected data
Please cite this article in press as: Tabash MI, et al., Impact of an intervention programme on knowledge, attitude and practice of
healthcare staff regarding pharmaceutical waste management, Gaza, Palestine, Public Health (2016), http://dx.doi.org/10.1016/
j.puhe.2016.04.001
would be confidential as all questionnaires would remain
anonymous.
Funding
None.
Competing interests
None declared.
references
1. Chartier Y, Emmanuel J, Pieper U, et al. Safe management of
wastes from health-care activities. 2nd edn. Geneva: WHO; 2014.
2. US Environmental Protection Agency. Guidance document. Best
management practices for unused pharmaceuticals at health care
facilities. EPA-821-R-10-006. Washington, DC: EPA Office of
Water; 2010.
3. Smith C. Managing pharmaceutical waste: a 10-step blueprint for
health care facilities in the United States. Practice Green Health.
Available at, http://www.hercenter.org/hazmat/
tenstepblueprint.pdf; 2008 (last accessed 7 May 2015).
4. Department of Justice and Attorney-General. Workplace Health
and Safety Queensland. Guide for handling cytotoxic drugs and
related waste. Available at, https://www.worksafe.qld.gov.
au/__data/assets/pdf_file/0006/88710/guide-handling-cytoxic-
drugs-related-waste.pdf; 2014 (last accessed 7 May 2015).
5. Sunita K, Kaur S, Patel K. Cytotoxic drug spillages among
nursing personnel working in the chemotherapy
administration areas. Nurs Midwif Res J 2009;5:116e23.
6. Falck K, Grohn P, Sorsa M, Vainio H, Heinonen E, Holsti L.
Mutagenicity in urine of nurses handling cytostatic drugs.
Lancet:1250e1. In: Centers for Disease Control and Prevention.
Occupational exposure to antineoplastic agents and other
hazardous drugs. Available at, http://www.cdc.gov/niosh/
topics/antineoplastic/monitoring.html, 1979;1 (last accessed
7 May 2015).
7. Rillo R. Health issues related to the management of antineoplastic
drugs. Thesis. Toledo: University of Toledo; 2009.
8. Pethran A, Schierl R, Hauff K, Grimm CH, Boos KS, Nowak D.
Uptake of antineoplastic agents in pharmacy and hospital
personnel. Part I: monitoring of urinary concentrations. Int
Arch Occup Environ Health 2003;76:5e10.
9. Nygren O, Lundgren C. Determination of platinum in
workroom air and in blood and urine from nursing staff
attending patients receiving cisplatin chemotherapy. Int Arch
Occup Environ Health 1997;70:209e14.
10. Sumpter JP, Johnson AC. Lessons from endocrine disruption
and their application to other issues concerning trace
organics in the aquatic environment: critical review. Environ
Sci Technol 2005;39:1e12.
11. McQuillan D, Hopkins S, Chapman T, Sherrell K, Mills D. Drug
residues in ambient water: initial surveillance in New Mexico, USA;
2002. Presented at the 7th Annual New Mexico Environmental
Health Conference, Albuquerque, New Mexico.
12. Environmental Protection Agency. Impact of residual
pharmaceutical agents and their metabolites in wastewater
effluents on downstream drinking water treatment facilities: final
report. Washington, DC: EPA; 20061e10.
13. World Health Organization. A guide to developing knowledge,
attitude and practice surveys. Geneva: WHO; 2008.
14. Ajai S, Nath S. Knowledge, attitude and practices of
biomedical waste management amongst staff of institutional
trauma center level II. Int J Res Health Sci 2013;1:62e8.
 p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e1 1
15. Hakim S, Mohsen A, Bakr I. Knowledge, attitudes and
practices of health care personnel towards waste disposal
management at Ain-Shams University Hospitals, Cairo. EMHJ
2014;20:347e54.
16. Mostafa G, Shazly M, Sherief W. Development of a waste
management protocol based on assessment of knowledge
and practices of healthcare personnel in surgical
departments. Waste Manag 2009;29:430e9.
17. Nkonge A, Mayabi A, Kithinji J, Mazambo J. Knowledge,
attitude and practice of health care waste management and
associated health risks in the two teaching and referral
hospital in Kenya. J Community Health 2012;37:1172e7.
18. Tenglikar P, Kumar G, Kapate R, Reddy S, Vijayanath V.
Knowledge, attitude and practice of health care waste
management amongst staff of nursing homes of Gulbarga
city. JPBMS 2012;19:1e3.
19. Palestinian Central Bureau of Statistics. Substantial changes in
the size, structure, growth rate, and type of housing in the Gaza
Strip between 1997 and 2007 Censuses. Ramallah: PCBS; 2007.
20. Ministry of Health. Hospitals annual report. Gaza: MoH; 2011.
21. Fiddler L, Hecht L, Nelson EE, Nelson EN, Ross J. SPSS for
Windows 16.0: a basic tutorial. Social Science Research and
Instruction Center, California State University. Available at:
http://www.ssric.org/trd/spss16 (last accessed 7 May 2015).
22. Al-Emad A. Assessment of medical waste management in the
main hospitals in Yemen. EMHJ 2011;17:730e7.
23. World Health Organization. Guidelines for safe disposal of
unwanted pharmaceuticals in and after emergencies. Geneva:
WHO; 1999.
24. Sharma A, Sharma V, Sharma S, Singh P. Awareness of
biomedical waste management among health care personnel
in Jaipur, India. Oral Health Dent Manag 2013;12:32e40.
25. Shivalli S, Sanklapur V. Healthcare waste management:
qualitative and quantitative appraisal of nurses in a tertiary
care hospital of India. Sci World J; 2014.
26. Keat CH, Sooaid NS, Yun CY, Sriraman M. Improving safety-
related knowledge, attitude and practices of nurses handling
cytotoxic anticancer drug: pharmacists' experience in a
general hospital, Malaysia. Asian Pac J Cancer Prev
2013;14:69e73.
27. Sattar S. An environmental impact perspective of the management,
treatment, and disposal of hazardous pharmaceutical compounds
generated as medical waste at selected hospitals in Cape Town,
South Africa. Thesis. Cape Peninsula University of Technology;
2011.
28. Elkhalifa A. Environmental sanitation assessment and
development of an integrated plan for healthcare waste
Please cite this article in press as: Tabash MI, et al., Impact of an intervention programme on knowledge, attitude and practice of
healthcare staff regarding pharmaceutical waste management, Gaza, Palestine, Public Health (2016), http://dx.doi.org/10.1016/
j.puhe.2016.04.001
11
management at the main hospitals in White Nile State, Sudan.
Thesis. Alexandria: Alexandria University; 2014.
29. Al-Khatib IA. Problems of management of medical solid waste
at primary health care centers in the Palestinian Territory and
their remedial measures. East Medit Health J 2013;19:152e8.
30. Sarsour A, Ayoub A, Lubbad I, Omran A, Shahrour I.
Assessment of medical waste management within selected
hospitals in Gaza Strip, Palestine: a pilot study. Int J Sci Res
Environ Sci 2014;2:164e73.
31. Shushaa S, Abu Safiah Y. Medical waste management among
health workers in Gaza governorates. Thesis. Gaza: Al-Quds
University; 2000.
32. El-Sayed S, Zakaria A, Gheith N. Intervention program for
nurses about health care waste management. Res J Med Med
Sci 2012;7:25e37.
33. Kumar R, Samrongthong R, Shaikh BT. Knowledge, attitude
and practices of health staff regarding infectious waste
handling of tertiary care health facilities at metropolitan city
of Pakistan. J Ayub Med Coll 2013;25:109.
34. Environmental Quality Authority. Master plan for healthcare
waste management. West Bank/Gaza Strip: Regional Solid
Waste Management Project; 2005.
35. Abah SO, Ohimain EI. Healthcare waste management in
Nigeria: a case study. J Public Health Epidemiol 2011;3:99e110.
36. Sasu S, Klaus K, Martin K. Assessment of pharmaceutical
waste management at selected hospitals and homes in
Ghana. Waste Manag Res 2011;30:625e30.
37. Hussein RA, Selim DH. Management of hazardous
pharmaceutical waste generated from health care facilities.
Bull High Inst Public Health 2008;38:49e65.
38. Ferreira V, Ribau Teixeira M. Assessing the medical waste
management practices and associated risk perceptions in
Algarve hospitals, Portugal, 2009. Available at: https://
sapientia.ualg.pt/bitstream/10400.1/1124/1/1-356paper_long.
pdf (last accessed 7 May 2015).
39. Smith CA. Managing pharmaceutical waste, what
pharmacists should know. J Pharm Soc Wiscon; 2002::17e22.
40. Aukour FJ. Healthcare waste management in Jordan King
Abdullah University Hospital. Case study. J Sci Med Eng
2008;20:61e77.
41. Sapkota B, Gupta GK, Mainali D. Impact of intervention on
healthcare waste management practices in a tertiary care
governmental hospital of Nepal. BMC Public Health
2014;14:1005.
42. Lewise S, Heitkemper M, Dirksen S. Medical surgical nursing:
assessment and management of clinical problems. 6th ed. Mexico:
Mosby; 2004.