Assessment of hazardous medical waste management at hospitals in yen bai city yen bai province

The objective of this study is to analyze the hazardous medical solid waste management of health-care facilities in Yen Bai city, to access to its current situation, investigate people's

THAI NGUYEN UNIVERSITY

UNIVERSITY OF AGRICULTURE AND FORESTRY

PHAM THI HUYEN

ASSESSMENT OF HAZARDOUS MEDICAL SOLID WASTE MANAGEMENT AT HOSPITALS IN YEN BAI CITY

YEN BAI PROVINCE

BACHELOR THESIS

Study mode : Full-time

Major : Environmental Science and Management Faculty : Advanced Education Program

Batch : 2014 – 2018

Thai Nguyen, 2018

Thai Nguyen University of Agriculture and Forestry

Degree Program Bachelor of Environmental Science and Management

Student name Pham Thi Huyen

Student ID DTN1453110069

Thesis Title Assessment of Hazardous Medical Waste Management at

hospitals in Yen Bai city - Yen Bai province Supervisor Dr Ho Ngoc Son

Abstract:

There has been an increase in public concern about the medical waste management

on a global basis and a significant effort has been directed toward proper and safe management of hazardous medical wastes in Yen Bai city The objective of this study is to analyze the hazardous medical solid waste management of health-care facilities in Yen Bai city, to access to its current situation, investigate people's awareness, and then propose solutions This study was carried out with the 8 member hospitals of Yen Bai's health-care facilities system Observation and questionnaire survey method was used to collect real data of the amount of medical solid waste and the status of medical solid waste management

Research showed some existing problems in the medical waste management in all hospitals due to lack of training and resources Moreover, the amount of medical solid waste has been increasing over the years, 8 surveyed hospitals discharged 212 tons in 2017 including 55 tons of hazardous medical solid waste Collection, separation, and transportation of medical waste have been implemented but there were still many limitations Besides, a lack of awareness of the people in Yen Bai city is an serious problem While nurse group and waste worker group shows higher knowledge about medical waste management with over 80%, the figure for doctor group only 57.1%, moreover, only 26.7% of the patient group were aware of the waste management regulations of the Ministry of Health and the Ministry of Natural Resources and Environment Among the major recommendations is that public education and awareness of participants should be developed to encourage sustainably medical solid waste management behavior, increasing construction of material facilities for the collection, separation, transportation and treatment of

hazardous medical solid waste; investing in non-burning technology is highly recommended

Key Words Yen Bai city, Health-care Facilities, Hazardous Medical

Solid Waste Management, Number of Pages 54 pages

Date of Submission September 25th, 2018

Supervisor’s

signature

I would also like to show gratitude to staff who are working at the Department

of Environmental protection of Yen Bai province for supporting me during the drafting process to completing this thesis

Most importantly, none of this could have happened without my family and my friends who always beside and support me, moreover, help me a lot during the investigation and data collection as well as to complete this thesis to the final step

TABLE OF CONTENT

ACKNOWLEDGMENT iii

TABLE OF CONTENT iv

LIST OF FIGURE vii

LIST OF TABLE viii

LIST OF ABBREVIATIONS ix

PART I: INTRODUCTION 1

1.1 Research rationable 1

1.2 Research’s objective 3

1.3 Research questions 3

1.4 Limitations 3

PART II: LITERATURE REVIEW 5

2.1 The definitions of medical waste 5

2.2 Generation and components of MSW 5

2.2.1 Generation of MSW 5

2.2.2 The components and characteristic of MSW 6

2.3 Classification of medical waste 9

2.3.1 Classification rules 9

2.3.2 Classification of medical waste 10

2.4 The impact of hazardous medical solid waste on the environment 10

2.4.1 Impact on soil environment 10

2.4.2 Impact on air environment 11

2.4.3 Impact on water environment 11

2.4.4 Impact on human health 12

2.5 Situation of medical waste management 12

2.5.1 Situation of medical waste management of some countries in the world 12

2.5.2 Situation of medical waste management in Viet Nam 13

2.5.3 Situation of medical waste management in Yen Bai city 15

2.6 Measures for hazardous medical waste treatment 17

2.6.1 Incinerator technology 17

2.6.2 Steam-oven technology 17

2.6.3 Sterilize by chemicals 18

2.6.4 Microwave technology 18

2.6.5 Biotechnology treatment 19

2.6.6 Radioactive treatment 19

PART III: METHODS 20

3.1 Material 20

3.2 Study design 20

3.3 Participants 20

3.4 Location and research background 21

3.5 Data collection 21

3.6 Data analysis and processing 22

PART IV: RESULTS AND DISCUSSIONS 23

4.1 The overview of health facilities in Yen Bai city 23

4.2 The situation of management of MSW in Health-care facilities in Yen Bai city 25

4.2.1 Collection, segregation, and storage 25

4.2.2 Transportation, treatment, and equipment 30

4.3 The awareness of healthcare workers, patients and patient’s family members about HMSWM 35

4.3.1 For medical staff 35

4.3.2 For patients and patient's family members 37

4.4 Solutions to improve hazardous medical waste management in Yen Bai city 38

4.4.1 Measures on environmental management 38

4.4.2 Measures to improve the collection, segregation, storage, transportation and treatment of HMSW 39

4.4.3 Alternative Treatment Technologies 41

PART V: CONCLUSIONS AND RECOMMENDATIONS 43

5.1 Conclusions 43

5.2 Recommendations 45

REFERENCES Error! Bookmark not defined APPENDIX 1 48

APPENDIX 2 53

APPENDIX 3 57

LIST OF FIGURE

Figure 1: Typical waste compositions in health-care facilities 7

Figure 2: The average components of medical waste in Yen Bai province 9

Figure 3: General scheme of waste classification in hospitals 28

Figure 4: Perception of color codes for waste containers 36

LIST OF TABLE

Table 1: Source of medical waste from health sector activities 6

Table 2: Physical and chemical properties of MSW in Yen Bai province 8

Table 3: Health-care waste generation according to national income level 13

Table 4: Volume of HMW in some localities in Viet Nam in 2014 14

Table 5: Situation of HMSW arising in medical establishments in Yen Bai province 15 Table 6: The overview of hospitals in Yen Bai city 24

Table 7: The amount of MSW arising in health-care facilities in Yen Bai city in 2017 26

Table 8: The amount of each type of HMSW in health-care facilities in Yen Bai City 27

Table 9: Compliance rates for HMSW bags at hospitals 28

Table 10: Situation of MSW treatment at hospitals in Yen Bai city 33

Table 11: The awareness of medical staffs about the medical waste management regulation 35

Table 12: Medical staff knowledge and awareness of hospital waste management 36

Table 13: The awareness of participant about medical solid waste management 37

LIST OF ABBREVIATIONS

HMSW Hazardous Medical Solid Waste

HMSWM Hazardous Medical Solid Waste Management MSW Medical Solid Waste

MSWM Medical Solid Waste Management

OMW Ordinary Medical Waste

WHO World Health Organization

YHF Yen Bai’s Health-care Facilities

PART I: INTRODUCTION 1.1 Research rationable

The environment plays an important role in human life as well as the economic development of each nation The environment is degrading and being pollution, and it becomes a global problem Thus, all government, department, socio-economic organizations and each citizens have responsibility for environmental protection to guard life (Vo Quy, 2011)

socio-Along with the development of socio-economic, the Vietnamese’ life has been improved coupled with the rised in number of population Health care needs are increasingly, for this reason, the system of medical facilities is focused on developing, expanding and improving the quality of services On the one hand, it brings a lot of benefits to humans (Minh Hoang, 2015) On the other hand, it creates a large amount

of medical solid waste, expecially hazardous medical waste

Hazardous medical solid waste are mainly infectious wastes, inflammables, explosives, corrosives, toxic wastes such as radioactive substances, cytotoxics and toxic chemicals arising in the Diagnosis and treatment of diseases, which are the risk factors for environmental pollution, spreading the disease from the hospital to the surrounding area It is therefore necessary to manage the hazardous waste generated from the health facility safely and appropriately

Yen Bai city is located in a mountainous province located in the northwest of Vietnam There are over 300 medical facilities in the city, including general hospitals and private clinics Yen Bai city is the political and economic center of Yen Bai province with the majority of provincial hospitals serving most of the needs of Yen

Bai people in general and Yen Bai city's citizens in particular (Do Viet Bach, 2018) Therefore, the volume of medical waste (including medical waste and medical wastewater) generated by hospitals in the city accounts for the majority of medical waste generated in the province The number of people who need to go to the hospital

is increasing, along with the fact that the amount of waste is increasing rapidly, most

of it are hazardous wastes At the same time, there are many shortcomings in the management of hazardous medical waste in these health-care facilities A number of public hospitals have been equipped with incinerators or autoclaves to meet environmental requirements, but there are still many health facilities using manual incinerators with low environmental safety and many private clinics are under the control of medical waste Moreover, the awareness about the danger of HMSW is not really popular as well as the importance of propaganda in the management of hazardous waste is undeniable which protects human health and the environment Therefore, the management of MSW, especially hazardous waste needs to be improved

to address both health care and environmental protection, also rise people awareness

Stemming from health-care waste problem in Yen Bai city, in order to find the management measures to contribute reducing the harm of medical waste, the study:

´´Assessment of hazardous medical waste management in Yen Bai city - Yen Bai

province`` is very important

1.2 Research’s objective

The general objective of the study is to assess HMSWM status in Yen Bai city, moreover, and to raise people awareness about the danger of HMSW and environmental protection

In particular, there are some specific objectives:

• To access the current situation of separation, collection, storage, transport and disposal of HMSW at YHF

• To investigate the awareness and attitude of medical staff and patients about the HMSWM

• To propose measures to manage HMSW to ensure safety and environmental sanitation in YHF

• To assess the effectiveness of measures to enhance understanding, awareness and actions of people about HMSWM

1.3 Research questions

1 What is the status of HMSW in Yen Bai city annually?

2 How is the HMSW managed in YHF?

3 What are the treatments of HMSW in YHF?

4 What is the level of awareness on HMWSM among respondents?

5 What are solutions to improve the HMWSM?

1.4 Limitations

The study can not survey all accurately HMSW data of all health-care facilities in the city, include all the status, management issues and treatment of HMSW There were some limitations throughout the study

• The first limitation is it impossible for the student to collect data in all YHF and conduct an interview for all waste management staff at each place because there are many medical facilities in the city

• The second constrant was the time limitation due to the student had a short time for this study

PART II: LITERATURE REVIEW 2.1 The definitions of medical waste

• Medical wastes are wastes generated during the operation of medical

establishments, including HMSW, ordinary medical wastes and medical wastewater (Ministry of Health and Ministry of Natural Resources and Environment, 2015)

• Hazardous medical solid wastes (HMSW) are medical wastes containing

infectious agents or other hazardous properties exceeding hazardous waste thresholds, including contagious wastes and non-contagious hazardous wastes (Ministry of Health and Ministry of Natural Resources and Environment, 2015)

• Medical waste management is the process of minimizing, classifying,

classifying, collecting, storing, transporting, recycling and disposing of medical waste and monitoring the implementation process (Ministry of Health and Ministry of Natural Resources and Environment, 2015)

2.2 Generation and components of MSW

2.2.1 Generation of MSW

MSW in general and hazardous solid medical waste in particular arise mainly from medical examination and treatment establishments (most of which are hospitals); Preventive health facilities; Training institutions and research facilities carry out medical tests In addition, HMSW can also be found in: home health clinics, traditional medicine clinics, cardiovascular services place, blood pressure measurement, home health care Besides, HMSW can be found in the services for the transportation of patients in the country and abroad, medicine service establishments, dental services establishments, clinics and health authorities

The source of medical waste from medical activity is shown in the following table:

Table 1: Source of medical waste from health sector activities

The types of waste more toxic than the waste above such

as radioactive substances, pharmaceutical chemicals, etc

It is from the department of examination, treatment, experimental activities, and pharmacy

(DONRE, 2014)

2.2.2 The components and characteristic of MSW

Most MSW are hazardous bio-waste and have a specific nature compared to other types of solid waste If these wastes are not carefully sorted before being disposed of together with household wastes will cause significant harm (Department of Natural Resources and Environment of Yen Bai province, 2015)

Figure 1: Typical waste compositions in health-care facilities

(Chartier et al, 2014)

Figure 1 shows that the main type of MSW is general waste which also knew as hazardous health-care waste while the figure for hazardous medical waste was total 15% including infectious and chemical/radioactive waste

The article 4 of the Joint Circular No 58/2015 / TTLT-BYT-BTNMT to delimit the MSW including:

 Infectious waste:

- Sharp waste (type A): Waste that can cause cuts or punctures, which can be infectious, including needle syringes, sharp ends of the surgical cord, scalpel, surgical spikes, saws, syringes, fragments of glass and other sharp objects used in medical activities;

- Infectious non-sharp waste (type B): Waste is infiltrated with blood, the body's bioavailability and the waste generated by the isolation chamber;

- Highly contagious waste (type C): Waste is generated in laboratories such as specimens and containers containing specimens; (Minister of Health 2007) Surgical waste (type D): Includes tissues, organs, organs of the human body; fetus, fetus and laboratory animals

 Noninfectious hazardous waste

- Disposal chemicals include or contain hazardous ingredients;

- Discharged drugs belong to the cytotoxic group or there is a hazard warning from the manufacturer;

- Broken, damaged, used medical equipment containing mercury;

- Other hazardous wastes prescribed in the Ministry of Natural Resources and Environment's Circular No 36/2015 / TT-BTNMT of June 30, 2015, on the management of hazardous wastes

 Ordinary medical waste includes:

- Daily-life solid waste arising in daily-life activities of people and external wastes in medical establishments;

- OMW arising from Health-care facilities not on the list of those subject to hazardous medical wastes or on the list but containing hazardous elements below the hazardous waste threshold

The composition, ratio, physical and chemical properties of MSW in Yen Bai province are shown in Tables 2 and Figure 2:

Table 2: Physical and chemical properties of MSW in Yen Bai province

Average emission factor of MSW 1.45kg/day/bed

Specific gravity 130kg/m3

The amount of ash content after burning 9.82%

Heat treatment 2.532 Kcal/kg

(DONRE,2010)

Figure 2: The average components of medical waste in Yen Bai province

(DONRE, 2015)

2.3 Classification of medical waste

The Article 6 of the Joint Circular No 58/2015 / TTLT-BYT-BTNMT stipulates principles for classification of medical wastes, including:

• When infection waste is mixed with other wastes or vice versa, the mixture must be collected, stored and treated as infection waste

2.3.2 Classification of medical waste

• Sharp infectious waste: Stored in a yellow barrel or carton;

• Non-sharp infectious waste: Store in a bag or lined-bag box and yellowed;

• High-risk infectious waste: Store in a bag or lined-bag box and yellowed;

• Surgical wastes: Stored in 2-layer bag or lined-bag box and yellowed;

• Non-infectious hazardous solid wastes: Stored in a bag or lined-bag box and

in black;

• Non-infectious hazardous liquid wastes: Stored in closed containers;

• OMW does not serve for recycling purposes: Store in a bag or lined-bag box and in blue;

• OMW serve for recycling purposes: Store in a bag or lined-bag box and in white

2.4 The impact of hazardous medical solid waste on the environment

2.4.1 Impact on soil environment

- If MSW are buried incorrectly, pathogenic microorganisms and toxic chemicals will penetrate the soil causing toxicity of the land, moreover, causing reuse

of burial sites in difficulty

- MSW have biological agents, microorganisms, bacteria, pathogenic fungus from patients The disease is released into the soil and then back to the people: Salmonella, Vibrio cholera, Amip, eggs, worms, etc

- Chemical and physical agents, heavy metal and radioactive substances can be deposited in the soil, causing pollution and accumulation People and animals will have to face with the disease when they eat contaminated vegetables and fruits grown

on that land

2.4.2 Impact on air environment

From the beginning to the end of the MSW's treatment process has a negative impact on the air environment (Salman Zafar, 2018):

- When MSW are sorting, collecting, transporting will spread the dust, microorganisms causing disease, solvent vapors and chemicals into the air

- At the stage of treatment (from MSW incinerator) generates toxic gases such

as dioxins, furan, etc In addition, heavy metals such as mercury can also be discharged by the incinerator exhaust gas

-From landfill generates toxic gases such as , etc

2.4.3 Impact on water environment

The MSW contain pathogenic microorganisms, heavy metals, mainly mercury from broken thermometers and silver from the X-ray film rinse which polluted the water environment In addition, some drugs that are disposed of without treatment may also contaminate the water supply (Van Huu Tap, 2016)

At the same time, the discharge of wastewater indiscriminate such as discharging infection wastewater into the conventional wastewater system can potentially cause the risk of polluting the water source due to the increase of organic BOD (biochemical oxygen demand)

2.4.4 Impact on human health

Exposure to hazardous medical waste can cause illness or injury All individuals those in the hospital or outside the hospital are at risk of exposure to hazardous medical waste Easily exposed people include health care workers such as doctors, nurses, midwives, technicians; patients, family members and patients visiting patients In addition, workers in the waste collection, transportation, laundry; Workers

in waste treatment and disposal facilities such as landfills or incinerators, including garbage pickers may be exposed to hazardous medical waste (Hysen Mankolli, 2013):

2.5 Situation of medical waste management

2.5.1 Situation of medical waste management of some countries in the world

Research on medical solid waste (MSW) has been conducted in many countries around the world, especially in developed countries such as the United Kingdom, the United States, Japan, and Canada, etc Which, referring to many areas such as MSW arising situation and classification; Medical solid waste management (measures to reduce waste, reuse of waste, treatment of waste, assessment of the effectiveness of waste treatment measures); Harms of health-care solid waste to the environment and human health (Le Minh Sang 2016) Moreover, the study proposes measures to reduce the harmful effects of MSW on public health; the threat of infectious waste to the community; the impact of medical wastewater on disease transmission; issues of the public health problem related with MSW (DONRE, 2016) Hospital waste generation has become a prime concern due to its multidimensional ramifications as a risk factor The generation of hospital wastes differs not only from country to country but also within a country In middle- and low-income countries, health-care waste generation

is usually lower than in high-income countries (Miller et al 2016) Developed countries face challenges with the sheer volume of waste from the use of disposable items On the other hand, developing countries, whose supplies are limited, are dealing with challenges of sorting and disposing of all types of medical waste in a sanitary manner (Sushma Rudraswamy, 2013)

Table 3: Health-care waste generation according to national income level

National income level Annual waste generation

(kg/head)

High income counties All health-care waste 1.1-12.0

Hazardous health-care waste 0.4-5.5 Middle-income

countries

All health-care waste 0.8-6.0 Hazardous health-care waste 0.3-0.4 Low-income countries All health-care waste 0.5-3.0

(DONRE, 2017)

2.5.2 Situation of medical waste management in Viet Nam

According to statistics of the Ministry of Health's Health Environment Management Agency in 2012, there are more than 1,000 hospitals in the country, 350-

500 tons of medical waste each day, of which about 47 tons of HMSW However, many hospitals do not have a dedicated burner system As a result, there are serious incidents of hospital hazardous waste incineration, which directly affect the patients as well as the citizens live nearby (Nguyen Hang, 2012) For solid waste generated from medical activities, along with the increase in hospital beds, the MSW volume tends to increase Currently, in the whole country, the average amount of solid waste discharged daily is 0.86 kg / bed, in which hazardous medical waste is 0.14 kg / bed The total amount of solid waste in hospitals across the country is up to 100 tons and 16

tons of medical waste need to be treated (Le Thi Tai, 2004) It is estimated that in

2015, the amount of medical discharge was 600 tons/day and in 2020 will be 800 tons/day However, there is not enough statistics on the number of hospitals where medical curing facilities are available to meet the required hygiene requirements

By 2015, the rate of collected medical MSW reached over 75%; The proportion

of hazardous waste collected and treated is about 65% Most hospitals collect and classify wastes but the collection vehicles are lacking and incomplete which most of them are not up to standards and there are no vehicles to ensure the transportation process is secure At present, technology for medical treatment of MSW is mainly by incinerators, however, some technologies for treatment of medical wastes by non-burning methods are encouraged and prioritized for development

Table 4: Volume of HMW in some localities in Viet Nam in 2014

2.5.3 Situation of medical waste management in Yen Bai city

2.5.3.1 Overview of medical facilities and the amount of HMSW arising in Yen Bai province

By the end of March 2016, the number of health facilities in Yen Bai province was 6 hospitals and 07 provincial preventive medicine centers, 09 district health centers, 19 multi-clinics 180 health clinics in the commune / ward / township, 01 training center, 01 private hospital, 105 general and private clinics and 01 branch hospital (Hospital of Transportation) located in the area

Table 5: Situation of HMSW arising in medical establishments in Yen Bai province

over each year In particular, in 2014, the total volume of MSW generated from all medical facilities in the province was 413.8 tons, of which MSW generated in 07 hospitals in Yen Bai City was 117.71 tons, accounting for nearly 30 % The HMSW volume arising from 07 hospitals in Yen Bai City is nearly 43 tons, accounting for 38% of the HMSW incurred in the province (112.4 tons) and accounting for 36.5% of the MSW generated from those hospitals

2.5.3.2 Status of management and capacity to handle HMSW in Yen Bai province

a HMSW collection, segregation, storage and transportation

Almost medical facilities have plastic bags, safety boxes and buckets to serve the collection and classification Basically, the collection and classification of medical solid waste, including solid hazardous medical waste have met requirements in accordance with the law However, the arrangement of plastic bags and safety boxes is not enough or they do not meet the requirements in accordance with the law In some establishments, there is the phenomenon of hazardous wastes are puted in wrong collection prescribed equipment or hazardous wastes and ordinary wastes and other hazardous wastes are stored together

Temporary waste storage facilities are built in almost health-care facilities in Yen Bai province basically to meet the requirements of the law

b HMSW processing capacity

At present, there are only five hospitals and one provincial-level health facility, and five district-level units under the management of the provincial Health Services have had hazardous medical waste incinerators with total designed

capacity approximately 1,690 kg / day and 01 hospital (transport hospital) with

a system of medical waste treatment by steam sterilization method which is Italian technology with a capacity of 7kg/hour (56kg / 8 hours) (People’s Committee of Yen Bai province 2016);

Moreover, some hazardous medical waste incinerators have deteriorated resulting in damage to efficiency handling (People’s Committee of Yen Bai province 2016)

2.6 Measures for hazardous medical waste treatment

2.6.2 Steam-oven technology

Steam-ovens are the most widely used in the medical industry to sterilize medical devices and treat medical waste that becomes ordinary waste This technology uses a combination of high temperature treatment, steam and pressure generation to remove germs, viruses and biological pathogens to turn hazardous medical waste into

ordinary waste which can be treated as a normal process such as buried in the ground Steam-oven technology has the highest levels of virus and pathogen destruction compared to other types of technology Owing to the above advantages, the technology

of the oven is widely used in hospitals to gradually replace the incinerator technology

2.6.3 Sterilize by chemicals

Disposaling medical waste by chemicals means use chemicals to eliminate the toxicity of medical waste and turn them into ordinary waste Chemicals are combined with hot water for disinfection The common chemicals are chlorine, ozone, formaldehyde, ethylene, oxide gas, propylene oxide gas and peracetic acid This technology allows for a thorough treatment of some types of waste but it still creates side effects for the waste after treatment Therefore, the use of chemical sterilization is rarely used in hospitals because of the various types of medical wastes which make it difficult to ensure that the waste is completely sterilized

2.6.4 Microwave technology

Microwave treatment technology is the process that waste is first milled and mixed with water, then using microwave processing The two combined action make the total volume of waste is reduced by 80% in the process of destroying toxic and sterilized substances However, microwave treatment is not well suited to certain types

of chemical waste resulting from the adverse effects that can affect the health of the person involved in the waste treatment process On the other hand, microwave technology is only suitable for medical centers with small scale waste treatment

2.6.5 Biotechnology treatment

This form of processing is gradually developing which process involves the use

of microorganisms to kill germs Basically this process is quite similar to chemical treatment because it takes advantage of the microbiological (chemical) properties to kill bacteria

2.6.6 Radioactive treatment

This treatment is only suitable for certain types of waste The principle is to use radioactive substances to kill bacteria, germs which requires that the treatment be quarantined to avoid radiation exposure The use of this method should be carefully studied to ensure the safety of users

In developed countries there are reliable medical waste treatment technologies such as microwave ovens, but these are not effective measures in developing countries Scientists in other Asian countries have come up with alternative methods of treating waste such as the Philippines has adopted a garbage treatment with lidded trash; Japan has tackled the problem of exhaust fumes escaping from closed garbage bins by attaching to containers with scouring equipment; Indonesia aims to raise awareness among hospitals about the hazards of the health system so that hospitals can make appropriate choices

PART III: METHODS 3.1 Material

Questionnaires were prepared for use to collect primary data by gathering information from respondents Books and many internet sources were used to find more information about the related topics Besides, the writer used notebooks and mobile-phone to recorded data as well as took photos The whole report is written in Word Software and collected data were analyzed in Exel Software by count and average function

3.2 Study design

The study was designed as survey on HMSW in 8 Health-care facilities which included 7 public hospitales and 1 specialised hospital in Yen Bai city – Yen Bai province

The literature was reviewed, the research framework was designed, the questionnaire was prepared and the fieldwork was completed from January 2018 to April 2018 The fieldwork was achieved after notices from the Yen Bai City Environmental Protection Department Permission was obtained from the hospitals prior to conducting the interviews with workers

3.3 Participants

Participants in this study were divided into two main categories:

- 45 staffs at health-care facilities were randomly investigated, including medical waste managers, doctors, and nurses

- 45 persons including patients and family members of patients at the departments of the surveyed health-care facilities were randomly asked

All participants were choosed randomly at 8 surveyed hospitals They were not admitted to the study if any of the following criteria were present: (1) They are not medical workers or patients and family members of patients at the health-care facilities; or (2) Residence outside the city of Yen Bai city or unwillingness to answer the question

3.4 Location and research background

The study was designed as a cross-sectional investigation, in which the setting was 8 health-care facilities in Yen Bai city – Yen Bai province They are City General Hospital; Provincial General Hospital; Traditional Medicine Hospital; Pediatric Hospital; Transportation Hospital; Endocrinology hospital; Mental hospital; Hospital for Tuberculosis and Lung Disease The city is located in the transition zone between the North West, Viet Bac and Northern Midlands, where located at 21,420B, 104,520 (Michelle, 2014)

3.5 Data collection

Primary data was mainly acquired through the questionnaires (Appendix 1, Appendix 2) This method helps to gather information through interviewing when the information needed does not exist in forms Face-to-face interview had been made and with the used of the survey questionnaire to assess the knowledge of participants These questionnaires have three parts: (1) Personal background; (2) Level of awareness; (3) Design propaganda form

Personal interview was done for other data outside the content of the questionnaires which is provided by waste managers in each Health-care facilities

Observation method was used to gather information through participation of respondents and observe the actual situation in the campus of survey facilities

Secondary data was initially collected through from different sources: the internet, books and other researches The Statistical Yearbook of Yen Bai in 2011-

2015 and reports on medical wastes from health-care facilities in 2017 Some data related to research have provided by Department of Environmental Protection Yen Bai

3.6 Data analysis and processing

Data collected about natural conditions, economy, and society in order to analyze advantages and disadvantages of the management of medical solid waste as well as hazardous medical solid waste in the area was synthesized analyzed

Data collected was analyzed, calculated and statistically processed with the aid

of computer software such as Microsoft Word, Excel Microsoft Excel was used to calculate the percentage of the level of awareness of the participants about hazardous medical solid waste management; Analysis to know the changes in amount of MSW during 4 first months in 2018 and the difference in the management of medical waste

at investigated health-care facilities Using software to draw graphs, interpret data already collected

PART IV: RESULTS AND DISCUSSIONS 4.1 The overview of health facilities in Yen Bai city

As of April 2018, there are 08 hospitals in Yen Bai which 07 are managed by the Yen Bai Provincial Health Department (including City General Hospital; Provincial General Hospital; Traditional Medicine Hospital; Pediatric Hospital; Endocrinology hospital; Mental hospital; Hospital for Tuberculosis and Lung Disease and a specialised hospital in the province (Transportation Hospital) In addition, three provincial Preventive Medicine Offices (Centers for Disease Control, Forensic Medicine Center, Drug Testing Center) and one district health center (Yen Bai City Medical Center); 17 medical clinics in the commune/ward, 01 private hospital (103 hospitals) and 82 private clinics

The hospitals in the area of Yen Bai City have the scale of 45-500 beds of which the largest is Provincial General Hospital and the capacity of used beds reached from 69.7% to 130% of which the highest in the City General Hospital Small and medium general and specialty clinics spread out over the city to serve the needs of most people in the province The overview of hospitals in Yen Bai city is shown in the following table:

Table 6: The overview of hospitals in Yen Bai city

capacity

of used beds (%)

Type of MSW treatment Plan Statistic

City General

Hospital

Tue Tinh street, Nguyen Thai Hoc ward, Yen Bai city, Yen Bai province

Hire ETC Nam Dinh company Traditional

Medicine

Hospital

Yen Ninh Street, Yen Bai

Pediatric Hospital

No 721, Yen Ninh Street, Minh Tan Ward, Yen Bai City, Yen Bai Province

Hire Nam Thanh company

Transportation

Hospital

Thanh Nien Street, Hong

Ha Ward, Yen Bai City, Yen Bai Province