Principal findings

This study represents a significant contribution as one of the few investigations to delve into the influence of training on Healthcare Waste Management (HCWM) practices within a university hospital setting in Tunisia. It is well-acknowledged that waste generated by healthcare institutions poses substantial health risks to hospital personnel, patients, and the environment. If these wastes are not managed through appropriate collection, storage, and disposal methods, they can evolve into severe environmental and public health concerns [19]. According to guidelines established by the World Health Organization (WHO), effective waste management necessitates regular and comprehensive training programs, along with the development of robust information systems [20]. One of the most efficacious strategies to curtail improper HCWM is the continuous education of healthcare workers at their respective workstations [21].

Since 1991, the Department of Prevention and Security of Care (DPSC) at Sahloul University Hospital has been overseeing hygiene indicators. Over the years, DPSC has conducted annual audits of HCWM practices and intermittently organized training sessions. However, these previous sessions were partial, non-continuous, and lacked evaluation of effectiveness. In contrast, our study adopts a comprehensive approach, particularly highlighted during the COVID-19 outbreak. Our findings illustrate that regular HCWM training sessions have significantly improved overall waste sorting practices.

Strength and limitations of the study

To the best of our knowledge, this study is among the few that have addressed the impact of training on HCWM practices within a university hospital in Tunisia. While the literature review uncovered several studies that have explored the influence of training on the knowledge, attitudes, and practical skills of healthcare professionals in relation to HCWM in Tunisia [12, 22] and globally only a limited number have evaluated daily HCWM practices within the workplace. [9, 11, 16, 19, 23] ,

In Sahloul University Hospital, we have embraced a waste segregation system at the source, employing color-coded high-density polyethylene bags and bins for easy identification and separation of infectious and non-infectious waste. Infectious waste is carefully packaged to mitigate potential injury and the transmission of diseases [24]. Standard color-coded plastic bags (black for general waste and yellow for infectious waste) and sharps containers are consistently distributed to various hospital departments. These bags and containers are appropriately labeled to specify the place of generation, collection date, and sample number. Wastes are collected daily and weighed using a scale. Over the years, we have made efforts to enhance our HCW resources. Between 2019 and 2021, there was an improvement in certain resource indicators such as the “Presence of sufficient numbers of yellow bags” (54.9% vs. 83.3%; p = 0.003), “Presence of sufficient numbers of black bags” (63.9% vs. 82.18%, p = 0.003), and “Presence of wheeled trolleys for HCW transport” (34.1% vs. 82%, p < 0.001). However, we observed a decline in the “Presence of a checklist for agent visits” indicator (12.5% vs. 7.2%, p < 0.001). Overall, the total units surveyed decreased from 160 in 2019 to 132 in 2021, primarily due to the exclusion of units hospitalizing COVID- 19 patients in 2021.

The overall compliance with recommended practices improved between 2019 and 2021 after the implementation of training sessions, This training sessions were conducted for all hospital healthcare workers, including nurses, physicians, and support staff. The comprehensive training program ensured participation across all departments to promote a unified approach to healthcare waste management (HCWM). New hires during the study period also received training to maintain consistency in practices. Given the continuous growth in hospital waste generation, it is imperative that all healthcare personnel receive “Hospital Medical Waste Plan” guidance and regular training on the appropriate disposal of each waste type [25]. Globally, an estimated 16 billion injections are administered annually, posing potential infection risks responsible for 30%, 1.8%, and 0.3% of HBV, HCV, and HIV infections, respectively. WHO guidelines recommend the disposal of used syringes/needles in safety boxes, which can then be disposed of through burial, incineration, autoclaving, or shredding, depending on the country’s scenario [26]. In our study, the overall compliance rate for sorting sharps increased from 60.3 to 77.6% (p < 0.001). Significant improvements were noted in two dimensions: “The sharp container is securely affixed in its support” and “Absence of non-sharp HCW in the containers.” A study in Pakistan also highlighted that regular training and monitoring of healthcare professionals substantially improved sharp waste management by nearly 80% [18].

Regarding the sorting of soft and solid waste, the overall score increased from 32.5% in 2019 to 72.4% in 2021 (p < 0.001), with significant improvements in all four dimensions. Notably, significant improvements were observed in the intra-service collection step, particularly in the indicators “Absence of non-sharp HCW apart from sharps containers and waste bags (benches, flower beds, etc.)” (Increased from 27 to 90.9%, p = 0.05) and “The wheeled trolley reserved for HCW is well labeled” (increased from 0 to 29.1%, p < 0.001).When reviewing the literature, many studies have stressed the importance of recurrent training sessions to enhance waste handling practices among healthcare staff and the necessity for consistent information and reinforcement concerning infectious waste management [10, 16]. Additionally, it is suggested that improving the performance of healthcare professionals might require comprehensive initial training, complemented by regular refresher training sessions [27].

Persistent inadequacies were noted in the labeling of containers and bags, as well as the traceability of HCW collection times. This labeling deficiency has been reported in multiple studies, including one conducted in Jordan [9]. The absence of labeling can be attributed to insufficient training for workers responsible for waste transportation or a shortage of supplies such as marker pens [28].

Similar to previous research, our findings indicate that nurses attend training sessions more frequently than physicians and exhibit higher compliance with HCWM recommendations compared to other professionals. Effecting changes in HCWM practices and addressing established routines can be challenging in our context. While HCWM involves relatively simple actions, it appears to be inadequately integrated into clinical practice, especially among physicians, who show limited interest in HCWM training. Therefore, it is imperative to understand the factors hindering physicians’ attendance at training sessions in order to enhance adherence to HCWM best practices.

Implications for policy, practice and research

In light of our findings, we recommend the following.

Continue and strengthen training programs targeting all healthcare professionals, regardless of their roles or grades.

Engage hospital managers in HCWM to ensure the sustained adherence to recommended practices.

Investigate the reasons behind resistance to employer adherence to recommendations related to dimensions with the lowest scores, such as labeling and traceability.

Enhance training efforts regarding indicators that continue to exhibit deficiencies.

Integrate and reinforce a culture of safety and risk management into basic training programs for paramedics and future doctors.

Addressing these recommendations will be crucial for advancing HCWM practices in our hospital and similar healthcare settings.