Journal of Hospital Infection 121 (2022) 49e56

Available online at www.sciencedirect.com

Journal of Hospital Infection

journal homepage: www.elsevier.com/locate/jhin

Effectiveness of a multi-modal capacity-building

initiative for upgrading biomedical waste management
practices at healthcare facilities in Bangladesh: a 21st
century challenge for developing countries
L. Ara*, W. Billah, F. Bashar, S. Mahmud, A. Amin, R. Iqbal, T. Rahman,
N.H. Alam, S.A. Sarker
Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh

A R T I C L E I N F O S U M M A R Y

Article history:
Received 12 August 2021
Accepted 12 November 2021
Available online 20 November
2021
Keywords:
Biomedical waste management
Multi-modal intervention
Infection control
Personal protective equipment
Introduction: Biomedical waste management (BMWM) has attracted attention across the
world as improper management can pose a serious threat for healthcare workers (HCWs),
the general population and the environment. This study aimed to analyse the effective-
ness of a multi-modal intervention (MMI) to upgrade BMWM practices at healthcare
facilities across Bangladesh.
Methods: This quasi-experimental study, with a pre- and post-test design, was undertaken
at nine healthcare facilities (five public, three private and one autonomous) over three
phases, and concluded in 2019. The MMI included various strategies including: (i) system
change; (ii) education and training; (iii) visual reminders; (iv) monitoring and feedback;
and (v) ensuring sustainability at the study hospitals. Data collected from 2726 HCWs and
waste handlers through direct observation were analysed using Statistical Package for
Social Sciences Version 24.
Results: Significant improvements were seen in waste segregation practices using colour-
coded bins (from 1% to 79%). The use of personal protective equipment during trans-
portation and final management/disposal increased from 3% to 55%. Compliance with the
use of standardized methods for collecting and transporting biomedical waste (BMW)
increased substantially from 0% to 78%, while compliance with standardized methods for
final management/disposal of BMW improved by 39%.
Conclusion: Compliance with BMWM practices is very poor in Bangladesh due to a lack of
knowledge, manpower and resources. Nevertheless, this MMI can be used as a tool to
significantly improve BMWM practices in healthcare facilities. Initiatives such as this MMI

* Corresponding author. Address: Clinical Governance and Systems, International Centre for Diarrhoeal Disease Research, Bangladesh, 68,
Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh. Tel.: þ880 1730320370.
E-mail address: lutfeara@icddrb.org (L. Ara).

https://doi.org/10.1016/j.jhin.2021.11.009
0195-6701/ª 2021 The Authors. Published by Elsevier Ltd on behalf of The Healthcare Infection Society. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
50 L. Ara et al. / Journal of Hospital Infection 121 (2022) 49e56
will help the Government of Bangladesh to achieve Sustainable Development Goal 3.3 and
universal health coverage by 2030.
ª 2021 The Authors. Published by Elsevier Ltd
on behalf of The Healthcare Infection Society. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction logistics and laboratory-based technology, poor infrastructure,

Biomedical waste management (BMWM) is a highly neglec-
ted public health issue, as two-thirds of countries around the
world lack adequate facilities for proper management of bio-
medical waste (BMW) [1,2]. BMW can pose severe health haz-
ards which may result in the acquisition of healthcare-
associated infections (HCAIs) or sharps injuries by patients,
healthcare workers (HCWs) and waste handlers (WHs) if not
segregated and treated properly [3]. The World Health
Organization (WHO) considers BMWM to be an important com-
ponent of standard infection control practices to prevent
HCAIs, so strategies to improve standardized BMWM practices
have received urgent global attention and are now a priority
[2,4,5].
Studies have revealed that even now, in the midst of the 21st
century, low- and middle-income countries (LMICs) are lagging
far behind in the implementation of effective BMWM policies
compared with developed countries [6,7]. In Bangladesh, the
negligence of HCWs and WHs regarding BMWM is particularly
evident in hospitals, as BMW is not segregated properly and is
buried in closed or open pits by WHs who do not use any per-
sonal protective equipment (PPE) [8e15]. Furthermore,
standardized methods for waste collection and transportation
are not followed, so scattered waste can be found in hospital
yards. This attracts insects and animals that act as vehicles for
transmission of infection [6,12,15]. Some hospitals in Bangla-
desh collect and dump BMW along with municipal waste in city
corporation bins, where scavengers collect certain disposed
medical waste (e.g. saline bags, syringe needles, blood bags,
etc.) to resell without being aware of their potential health
risks (e.g. hepatitis B virus, hepatitis C virus, human immuno-
deficiency virus) [6,15]. In addition to environmental hazards,
poor BMWM has an adverse effect on the economy of the
individual and the economy of the nation as a whole [16,17].
Despite the formulation of national waste management
guidelines in 2008 as well as an action plan for 2017e2022 by
the Government of Bangladesh, implementation of such
strategies is very challenging for Bangladesh as well as other
LMICs [18,19]. The lack of a trained workforce, inadequate
the absence of a dedicated infection control team, and low
administrative support have been identified as the main issues
[6]. In addition, recent multi-centre studies reported that
extremely poor knowledge of BMWM among physicians, nurses,
janitors and administrative personnel was also relevant
[20e22]. Some studies have highlighted isolated aspects of
BMWM in Bangladesh such as amount and type of waste gen-
erated, practices of WHs, and barriers to proper BMWM
[6e15,19e23]. However, to the authors’ knowledge, no proj-
ects have been undertaken in Bangladesh with the aim of
building the capacities of HCWs and WHs in relation to
improving BMWM practices. WHO and others have reported that
a multi-dimensional, integrated approach should give better
results than focusing on a single intervention [24e26]. As such,
this capacity-building study was undertaken to determine the
impact of a WHO-recommended multi-modal intervention
(MMI) to improve the compliance of HCWs and WHs with BMWM
practices at nine healthcare facilities in Bangladesh.
Methods
The effect of the MMI on BMWM was examined using a pre-
testepost-test study. The study was conducted at nine
healthcare facilities that had not received any previous inter-
ventions or training on BMWM. In order to obtain a diverse and
representative sample, facilities were chosen purposively and
varied in terms of level (primary, secondary and tertiary) as
well as type (public, private and autonomous). Primary facili-
ties are usually the smallest in terms of bed capacity, and
provide only the most basic healthcare services, while secon-
dary and tertiary facilities are typically larger and are able to
provide more specialized services. Public hospitals (250e500
beds) are fully funded and owned by the Government of Ban-
gladesh, and provide healthcare services for free or at minimal
cost, while autonomous hospitals (75e200 beds) are able to
provide more efficient services as they are free from the
structures associated with conventional bureaucracy. Private
hospitals (50e800 beds) are run by organizations or a group of
individuals where patients receive personalized treatment but

Table I
Methodology matrix
Facility (coded) Category of healthcare facilities District
Public-1 Public hospital, primary level Sunamganj
Public-2 Public hospital, secondary level Sirajganj
Public-3 Public hospital, primary level Sunamganj
Public-4 Public hospital, secondary level Sunamganj
Public-5 Public hospital, tertiary level Sylhet
Autonomous-1 Autonomous hospital, tertiary level Dhaka
Private-1 Private hospital, secondary level Sunamganj
Private-2 Private hospital, tertiary level Mymensingh
Private-3 Private hospital, tertiary level Sylhet
 L. Ara et al. / Journal of Hospital Infection 121 (2022) 49e56 51

Table II
Phases of the study
Phase
Pre-intervention phase
Intervention phase
Post-intervention phase
BMWM, biomedical waste management; HCW, healthcare worker; MMI, multi-modal intervention; PPE, personal protective equipment.
Description of activities Time frame
Prior to the intervention, baseline data were collected using a structured 3 months
checklist to gather data and evaluate the trends in current BMWM practices at
all study settings.
A multi-modal, multi-faceted intervention was implemented to educate and 6 months
increase the competency and compliance of HCWs regarding BMWM practices at
the study facilities. This MMI was field tested before implementation and
comprised the following elements:
 System change: colour-coded waste bins were placed at key waste col-
lection points and the availability of PPE was ensured.
 Educational training (classroom and hands-on): educational sessions on
proper BMWM and use of PPE were provided by utilizing both theoretical
and visual content (videos, demonstrations).
 Visual reminders: colourful posters with proper instructions on BMWM were
hung in vital areas at the study facilities.
 Continuous monitoring and performance feedback: compliance with BMWM
was monitored systematically by project physicians and nurses through a
structured checklist, and feedback was provided regularly to individual
participants. Feedback was also shared routinely with the administrative
head of the study sites.
 Establishment of a safety climate: an infection control committee
comprising doctors, nurses, support staff and administrative staff was
formed at each study site and acted as an institutional monitoring unit.
An end-line evaluation was carried out by the same observers using the same 3 months
baseline checklist to assess improvements and compare results.

services are more expensive. The methodology matrix is shown
in Table I.
The study was conducted in three phases as shown in
Table II. All HCWs and WHs (i.e. doctors, nurses, laboratory
technicians, phlebotomists, cleaning staff, etc.) were invited
to participate voluntarily in the study.
Data collection
Data on adherence to standardized BMWM practices were
collected by project research physicians and nurses through
direct observation using checklists. Efforts were made to
reduce the Hawthorne effect (observer bias) during data col-
lection as much as possible by having observers maintain a
certain minimum distance from HCWs and WHs.
Data analysis
Data were coded and examined using Statistical Package for
Social Sciences Version 24 (IBM Corp., Armonk, NY, USA). The
compliance rate was calculated by dividing the total number of
standardized practices observed by the total number of
opportunities observed. In addition, Chi-squared test was used
to compare adherence rates. Odds ratios (OR) for strength of
association were calculated using logistic regression. Overall
progress was calculated with 95% confidence intervals (CI)
where P<0.05 was considered to indicate statistical
significance.
Ethical considerations
Ethical approval was obtained from the Institutional Review
Board of International Centre for Diarrhoeal Disease Research,
Bangladesh for this study (PR# 17217). The director/head of
each study site gave institutional permission by signing a
memorandum of understanding. Moreover, verbal consent was
obtained from participants after explaining the objectives of
the study. The names of hospitals and participants have been
coded to maintain confidentiality.
Results
Table III shows significant (P<0.001) overall improvement in
waste management practices at all types of healthcare facili-
ties. In particular, waste segregation by colour-coded bins and
use of PPE at the nine healthcare facilities improved by 78% and
52%, respectively. Moreover, overall compliance with stand-
ardized methods for waste collection and transportation, and
final management/disposal of waste improved from 0% and 2%
pre-intervention to 78% and 41% post-intervention,
respectively.
Table IV shows that compliance with standardized BMWM
practices was low at all study facilities, regardless of facility
type or level, prior to the MMI. Following the MMI, compliance
with waste segregation increased to 77%, 82% and 82%, while
the use of PPE improved to 52%, 60% and 55% for public, private
and autonomous hospitals, respectively (P<0.0005). Likewise,
52 L. Ara et al. / Journal of Hospital Infection 121 (2022) 49e56

Table III
Overall biomedical waste management before and after the multi-modal intervention
Health facilities/variables Pre-intervention Post-intervention Improvement (%) P-value
N (%) N (%)
Waste segregation by colour-coded bins
Public-1 0 (0) 106 (88) 88 <0.001
Public-2 0 (0) 208 (95) 95 <0.001
Public-3 0 (0) 158 (84) 84 <0.001
Public-4 11 (9) 82 (66) 57 <0.001
Public-5 0 (0) 368 (68) 68 <0.001
Autonomous-1 6 (16) 31 (82) 66 <0.001
Private-1 0 (0) 181 (84) 84 <0.001
Private-2 0 (0) 45 (80) 80 <0.001
Private-3 0 (0) 185 (80) 80 <0.001
Total 17 (1) 1364 (79) 78 <0.001
Use of PPE during transportation and disposal of waste
Public-1 0 (0) 277 (78) 78 <0.001
Public-2 0 (0) 109 (19) 19 <0.001
Public-3 10 (2) 371 (65) 63 <0.001
Public-4 25 (7) 181 (49) 43 <0.001
Public-5 1 (0) 893 (55) 55 <0.001
Autonomous-1 21 (9) 122 (55) 45 <0.001
Private-1 0 (0) 420 (72) 72 <0.001
Private-2 0 (0) 57 (76) 76 <0.001
Private-3 99 (6) 339 (49) 43 <0.001
Total 156 (3) 2769 (55) 52 <0.001
Use of standardized method for collection and transportation of waste
Public-1 0 (0) 33 (61) 61 <0.001
Public-2 0 (0) 47 (60) 60 <0.001
Public-3 0 (0) 159 (83) 83 <0.001
Public-4 0 (0) 97 (78) 78 <0.001
Public-5 0 (0) 30 (65) 65 <0.001
Autonomous-1 0 (0) 55 (73) 73 <0.001
Private-1 0 (0) 166 (89) 89 <0.001
Private-2 0 (0) 19 (76) 76 <0.001
Private-3 0 (0) 27 (90) 90 <0.001
Total 0 (0) 633 (78) 78 <0.001
Proper method of final management/disposal
Public-1 0 (0) 111 (93) 93 <0.001
Public-2 37 (46) 100 (52) 6 <0.001
Public-3 0 (0) 78 (41) 41 <0.001
Public-4 0 (0) 45 (37) 37 <0.001
Public-5 0 (0) 36 (10) 10 <0.001
Autonomous-C 0 (0) 58 (79) 79 <0.001
Private-1 0 (0) 0 (0) 0 <0.001
Private-2 0 (0) 24 (96) 96 <0.001
Private-3 0 (0) 96 (41) 41 <0.001
Total 37 (2) 548 (41) 39 <0.001
PPE, personal protective equipment.

adherence to standardized methods for waste collection and
transportation increased by 74%, 88% and 73%, and adherence
to standardized methods for final management/disposal
increased by 34%, 43% and 79% in public, private and autono-
mous facilities, respectively.
In terms of facility level, significant (P<0.0005) compliance
with waste segregation increased to 92%, 80% and 73%, and the
use of PPE increased by 41%, 62% and 50% in primary, secondary
and tertiary level facilities, respectively, after the MMI. Sim-
ilarly, compliance with standardized practices for waste col-
lection increased by 66%, 84% and 74%, and adherence to
standardized methods for final management/disposal of waste
increased by 68%, 37% and 31% for primary, secondary and
tertiary level hospitals after the MMI.
Figure 1 shows that, before the MMI, usage rates for gloves
(5%) and masks (3%) were very low, and shoes were not used
(0%) at all. However, a significant increase was observed in
overall use of gloves (76%), masks (48%) and shoes (40%) at all
study hospitals after the MMI.
A logistic regression model (Table V) demonstrated that
compliance with standardized BMWM practices improved sig-
nificantly in all categories of healthcare setting after the MMI.
 L. Ara et al. / Journal of Hospital Infection 121 (2022) 49e56 53

Table IV
Biomedical waste management at healthcare facilities
Healthcare facility Pre-intervention Post-intervention Improvement (%) P-value
N (%) N (%)
Type of healthcare facility
Waste segregation by colour-coded bins
Public 11 (1) 922 (77) 76 0.00
Private 0 (0) 411 (82) 82 0.00
Autonomous 6 (16) 31 (82) 66 0.00
Total 17 (1) 1364 (79) 78 0.00
Use of PPE during transportation and disposal of waste
Public 36 (1) 1831 (52) 51 0.00
Private 99 (4) 816 (60) 56 0.00
Autonomous 21 (9) 122 (55) 45 0.00
Total 156 (3) 2769 (55) 52 0.00
Use of standardized method for collection and transportation of waste
Public 0 (0) 366 (74) 74 0.00
Private 0 (0) 212 (88) 88 0.00
Autonomous 0 (0) 55 (73) 73 0.00
Total 0 (0) 633 (78) 78 0.00
Proper method of final management/disposal
Public 37 (4) 370 (38) 34 0.00
Private 0 (0) 120 (42) 43 0.00
Autonomous 0 (0) 58 (79) 79 0.00
Total 37 (2) 548 (41) 39 0.00
Level of healthcare facility
Waste segregation by colour-coded bins
Primary 0 (0) 314 (92) 92 0.00
Secondary 11 (2) 421 (80) 78 0.00
Tertiary 6 (1) 629 (73) 72 0.00
Total 17 (1) 1364 (79) 78 0.00
Use of PPE during transportation and disposal of waste
Primary 0 (0) 386 (41) 41 0.00
Secondary 35 (2) 972 (64) 62 0.00
Tertiary 121 (4) 1411 (54) 50 0.00
Total 156 (3) 2769 (55) 52 0.00
Use of standardized method for collection and transportation of waste
Primary 0 (0) 137 (66) 66 0.00
Secondary 0 (0) 422 (84) 84 0.00
Tertiary 0 (0) 74 (74) 74 0.00
Total 0 (0) 633 (78) 78 0.00
Proper method of final management/disposal
Primary 37 (12) 211 (68) 56 0.00
Secondary 0 (0) 123 (37) 37 0.00
Tertiary 0 (0) 214 (31) 31 0.00
Total 37 (2) 548 (41) 39 0.00
PPE, personal protective equipment.

Improvements were significantly greater in private healthcare Discussion

facilities compared with public healthcare facilities. In terms
of facility level, primary level hospitals performed better than
secondary and tertiary level hospitals after the MMI. However,
in terms of the use of PPE, secondary and tertiary level hos-
pitals performed much better than primary level hospitals after
the MMI.
The study findings show that this WHO-recommended MMI
improved the knowledge and practices of HCWs on BMWM
(Table III). Previous studies conducted in LMICs assessed cur-
rent BMWM practices in healthcare settings, and found that the
lack of in-house training, suboptimal knowledge and poor
54 L. Ara et al. / Journal of Hospital Infection 121 (2022) 49e56
5%
3% 0%
Pre-intervention
Figure 1. Use of personal protective equipment. Dashed and dotted line, gloves; dotted line, masks; solid line, shoes.
adherence of nurses to standard operating procedures were
key reasons for poor compliance [20e22]. However, to the
authors’ knowledge, this is the first study to be undertaken in
Bangladesh that attempted to improve the BMWM capacity of
HCWs and WHs. In addition, this was the first study in Bangla-
desh to include a wide range of healthcare facilities (in terms
of type and level) as study sites for the MMI. As a result, this
study highlights the potential of the MMI as notable improve-
ments were achieved in overall BMWM at a wide range of study
facilities (Table IV). Furthermore, under this MMI, an infection
control committee was established in every study facility to
oversee educational activities, and continuously monitor and
provide feedback to the HCWs and WHs in order to ensure long-
term sustainability of the programme.
Pre-intervention, HCWs and WHs were unfamiliar with
waste segregation practices at the study locations due to a lack
of knowledge and proper training on BMWM procedures; this
has been reported in previous studies conducted in LMICs
[5e12,14,19e22]. The MMI helped to address these issues for
the first time in Bangladesh by educating HCWs and WHs about
waste segregation, and by introducing colour-coded waste bins
at key locations to aid HCWs in differentiating and segregating
various types of BMW. Table IV shows that this led to a 78%
improvement in overall compliance with waste segregation
practices at all of the study facilities, with primary level
facilities showing the greatest improvement (92%).
The pre-intervention data were in line with other studies
and indicated that WHs were not compliant with standardized
procedures, and were using their bare hands to gather, collect
and transport BMW (Table III) [5,6,15,19,23]. Other studies
have reported that negligent attitudes towards BMWM by the
concerned authorities resulted in WHs being forced to handle
waste in this way as they had no access to PPE [15,20]. Pre-
intervention observations from this study also revealed that
the use of PPE was poor in public and private facilities, while
autonomous hospitals had a compliance rate of 9% (Table IV).
Furthermore, medical waste was not collected in a timely
manner, with some waste left in open spaces for extended
periods, similar to other LMICs [27]. However, following the
MMI, compliance with standardized practices regarding col-
lection and transportation of waste increased by 78%. The
newly established infection control committees at the study
76%
48%
40%
Post-intervention
sites also ensured and monitored the supply of PPE and other
necessary resources for HCWs and WHs. Thus, this study was
able to bring about system change through a cohesive and
holistic approach by including and engaging all relevant
stakeholders. In this respect, this study was not only unique but
also played a major role in improving the knowledge and
practices of HCWs and WHs regarding the use of PPE.
Binary logistic regression (Table V) indicated that, following
the MMI, overall use of PPE at the nine study sites improved
dramatically from 3% to 52% (OR 61.14, 95% CI 48.16e77.63;
P<0.01). Post-intervention, Public-1 showed the highest com-
pliance with the use of PPE (78%; P<0.005) followed by Private-
2 (76%; P<0.005), and Public-2 demonstrated the lowest
compliance with the use of PPE (19%; P<0.005). This low
compliance rate was found to be associated with a lack of
prioritization by administrative authorities and unavailability
of PPE. Nevertheless, proper supply, accessibility and avail-
ability of PPE at all other study facilities were ensured through
this innovative MMI initiative.
Prior to the study, most of the study facilities did not have
any designated areas for waste disposal; instead, yards or
ponds within the hospital premises were used for this purpose.
Some study facilities even disposed of BMW with general waste,
all of which was collected together by the city corporation
which could lead to serious problems in the long term. Previous
studies conducted in LMICs presented a similar picture and
identified budget constraints, unskilled staff, absence of
proper logistics in the desired areas, and a lack of account-
ability from higher authorities as key reasons behind these
unethical practices [6,7,12,19,23]. Nevertheless, no previous
studies in Bangladesh have aimed to implement any inter-
ventions to improve the knowledge of hospital authorities,
HCWs and WHs in an effort to change their practices regarding
final management/disposal of waste.
This capacity-building MMI programme motivated some of
the study sites to upgrade their infrastructure for effective
final management/disposal of BMW. This included initiatives
such as resurfacing yards (that were previously used for final
management/disposal of waste) and investing in incinerators.
In terms of infrastructure, only Autonomous-1 had access to an
electrical incinerator, and Private-2 used a manual incinerator.
Regarding the leftover ash, the project teams educated the
 L. Ara et al. / Journal of Hospital Infection 121 (2022) 49e56 55

Proper method of final HCWs at the study facilities to ensure that ash was disposed of

30.04 (21.30e42.36)a
management/disposal safely by burying it in pits. At the remaining facilities, Public-3

0.54 (0.43e0.67)a

0.34 (0.26e0.44)a
0.23 (0.19e0.28)a
and Public-5 used pit burial, and Private-1, Private-3, Public-1

2.33 (1.65,3.30)a
and Public-4 used third-party organizations for waste disposal
purposes. No study facilities treated the BMW before disposal
Reference

Reference

Reference
as this was deemed too expensive by the hospital authorities.
Following the MMI, improvements in final management/dis-
posal of waste were seen at all nine facilities. Post-
intervention data also reveal that average compliance with
final management/disposal of waste improved by 39%
(Table III). Private-2 showed the highest rate of improvement
(96%) and Public-2 showed the lowest rate of improvement
(6%); despite the MMI, Public-2 failed to adapt to the stand-
61.14 (48.16e77.63)a

ardized waste management/disposal practices. All private

1.64 (1.33e2.03)a
1.74 (1.43e2.11)a
hospitals showed significant improvements in final manage-
0.91 (0.79e1.05)
1.02 (0.73e1.43)
Use of PPE

ment/disposal of waste practices apart from Private-1, which

Odds ratios (OR) for strength of association of different covariates for compliance with the standardized waste management system

continued to dispose of BMW with general waste even after

Reference

Reference

Reference

the MMI due to the ignorance of the administrative authority.

The findings indicate that successful implementation of the
MMI can play a vital role in improving final management/dis-
posal practices as shown by logistic regression (OR 29.91, 95%
CI 21.21e42.18; P<0.01) in Table V. As a result, communities,
HCWs, WHs and patients have benefited from improved final
management/disposal practices as this is expected to lead to
reduced transmission of diseases.
collection and transportation of waste

This is the first evidence-based study in Bangladesh to

Use of standardized method for

focus on the role of a WHO-recommended MMI to improve the

knowledge and practices of HCWs and WHs regarding BMWM.
0.36 (0.26e0.49)a
0.30 (0.20e0.46)a

The dismal state of BMWM practices before the MMI shows how
0.96 (0.76 1.20)a
0.71 (0.49 1.01)

BMWM is neglected within the health sector in Bangladesh,

and why changing the status quo will prove to be a challenging
Reference

Reference

endeavour. Furthermore, the lack of adequate knowledge and

poor awareness of proper BMWM practices are also key con-
tributing factors behind such poor compliance amongst HCWs
and WHs. This study also revealed that the parameters for
final management/disposal of waste showed limited
improvement, and this was primarily due to the fact that
At 1% level of significance, ORs were calculated using logistic regression.

improving this component will require large-scale investment

by the hospital authorities. Unfortunately, a major shift in the
mentality of hospital authorities will be required, as they are
currently unwilling to spend large sums of money to improve
their waste management infrastructure. The Government of
PPE, personal protective equipment; CI, confidence interval.
402.92 (246.54e658.50)a

Bangladesh could potentially step in to provide a solution by

Waste segregation by

establishing biomedical waste treatment/recycling plants at

colour-coded bins

the subdistrict level. This would not only reduce the financial
0.55 (0.48e0.64)a

0.69 (0.56e0.80)a
1.23 (0.78e1.95)

0.84 (0.70e1.02)

burden on hospital authorities, but would ensure that bio-

medical waste is treated/recycled safely. Nevertheless, this
Reference

Reference

Reference

capacity-building MMI initiative managed to induce positive

perceptual and behavioural changes amongst HCWs, WHs and
administrative authorities regarding BMWM. The MMI enabled
the study hospitals to strengthen their capacity, uphold
institutional supervision, and ensured that BMWM practices
were improved in a sustainable way. This study did have
certain limitations, such as the absence of a comparator group
Level of health facility
Type of health facility

and varying sample sizes at different study settings. However,

as the baseline values for most of the variables were close to
Post-intervention
Pre-intervention

zero, strong conclusions could still be drawn without the

Study period

Autonomous

presence of a control group. The significant improvements

OR (95% CI)

Secondary

made after the implementation of this capacity-building

Variables

Tertiary
Primary
Private
Table V

programme demonstrate that this MMI is a cost-effective

Public

and efficient way to upgrade the BMWM practices of HCWs

a

and WHs across Bangladesh, regardless of facility level or

56 L. Ara et al. / Journal of Hospital Infection 121 (2022) 49e56
type. The study outcomes should prove beneficial for the
Government of Bangladesh to achieve Sustainable Develop-
ment Goal 3 as well as universal health coverage by 2030 by
scaling up this innovative capacity-building programme to
cover more healthcare facilities to significantly improve com-
pliance of HCWs and WHs with proper BMWM practices across
the country. Finally, the MMI initiative should benefit not only
Bangladesh but also other LMICs by assisting them to develop
their own context-specific capacity-building programmes to
improve BMWM practices at their healthcare facilities.
Acknowledgements
The authors wish to thank GlaxoSmithKline (GSK) for helping
to strengthen the health system in Bangladesh. The authors
also wish to thank the hospital authorities at the study sites,
and are indebted to the Government of Bangladesh for their
unwavering support throughout the study.
Conflict of interest statement
None declared.
Funding source
This study was supported by GSK. However, they did not play
any role in study design, data collection, data analysis, data
interpretation or report/manuscript writing.
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