healthcare waste dissertation

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Open Access

Peer-reviewed

Research Article

Assessment of healthcare waste management practices and associated factors in Addis Ababa City Administration Public Health Facilities

Roles Writing – original draft, Writing – review & editing

Affiliation Menelik II Medical and Health Science College, Addis Ababa, Ethiopia

Roles Methodology, Writing – review & editing

* E-mail: [email protected]

Affiliation University of South Africa, Pretoria, South Africa

• Menelik Legesse Tadesse, 
• Bethabile Lovely Dolamo

• Published: November 4, 2022
• https://doi.org/10.1371/journal.pone.0277209
• Peer Review
• Reader Comments

Healthcare waste management is very important due to its hazardous nature that can cause risk to human health and the environment. In developing countries, healthcare waste has not received much attention and has been disposed of together with municipal waste. The aim of the study was to assess the healthcare waste management practices in Addis Ababa City Administration Public Health Facilities.

An institutional-based cross-sectional design was used for the study at Addis Ababa city 15 Public health centres and 3 hospitals. Data were collected using self-administered questionnaires distributed to 636 randomly selected healthcare waste handlers and managers. Observational check list also used. The data were entered into the EPI- INFO version TM 7 and exported to IBM SPSS 20 for analysis. Both descriptive and analytic statistics were employed.

Among the respondents, 358 (90.86%) from health centres and 96.38% (133) from hospitals indicated that their facilities had separate containers for hazardous and non-hazardous waste however, 61 (15.48%) from health centres and 29 (21.01%) from hospitals indicated that healthcare waste containers were not clearly marked or labelled. The study found that the main forms of on-site treatment of healthcare waste for health centres and hospitals before disposal were burning. Manager respondents from the health centres 65 (92.86%), 64 (91.43%) and from hospitals 31 (91.18%), 30 (88.24%) indicated that healthcare waste handlers were used protective clothing when handling waste and were provided with protective clothing when handling healthcare waste respectively.

In this study healthcare waste management among healthcare waste handlers and healthcare facility managers were not getting full attention. Collection of healthcare waste were not done regularly, containers were not clearly marked and were not located in appropriate areas where they might be needed. Support healthcare waste handlers by training help to improve their knowledge, attitude and practice.

Citation: Tadesse ML, Dolamo BL (2022) Assessment of healthcare waste management practices and associated factors in Addis Ababa City Administration Public Health Facilities. PLoS ONE 17(11): e0277209. https://doi.org/10.1371/journal.pone.0277209

Editor: Nor Adilla Rashidi, Universiti Teknologi Petronas: Universiti Teknologi PETRONAS, MALAYSIA

Received: December 23, 2021; Accepted: October 22, 2022; Published: November 4, 2022

Copyright: © 2022 Tadesse, Dolamo. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All manuscript files are available from the UNISA database URI: http://hdl.handle.net/10500/26614 .

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Healthcare waste produced in the course of health care activities entails a higher risk of infection and injuries than municipal waste. In developing countries, healthcare waste has not received much attention and has been disposed of together with municipal waste [ 1 ]. In Ethiopia, improper healthcare waste management is alarming and poses a serious threat to public health [ 2 ].

The risk of healthcare waste and its management has become a global cause of concern. The majority of the problems are associated with an exponential growth in the health care sector together with low or non-compliance with guidelines and recommendations. The management of healthcare waste requires increased attention and diligence to avoid substantial disease burden associated with poor practice, including exposure to infectious agents and toxic substances [ 3 , 4 ]. According to the United Nations Environmental Program [ 5 ], healthcare waste is one of the most troublesome forms of waste and one of the most important environmental concerns for the global community. Healthcare waste production at hospitals and its management are important issues worldwide [ 6 ]. Since the mid-1990s the world has experienced a dramatic increase in the amount of hazardous waste generated, at the same time, a vigorous drive for sustainable development and increased environmental awareness and concern [ 7 ].

Poor waste management practices at the level of healthcare facilities, including failure to segregation of waste and errors in the colour coding of waste disposal, can result in hazardous waste being disposed of not only improperly, but also accessible to community members [ 8 ]. In Botswana, [ 9 ] found that due to a lack of understanding of the importance of colour coding and segregation in the management of healthcare waste, patients were given healthcare waste bags for their personal belongings and clothing after being discharged from the hospital. In Korea [ 10 ] found that policy on healthcare waste management was inadequate and required strengthening.

The poor management of healthcare waste (HCW) is associated with a lack of adequate training of healthcare workers and disposal practices, including disposal with municipal waste together with some autoclave treatment and incinerator use.

The studies conducted in Ethiopia health centres and hospitals focused on healthcare waste generation and did not consider its management and intervention [ 2 , 11 ]. The high generation of healthcare waste is due to the increasing population and the use of healthcare facilities that exceeds the ability of Addis Ababa City Administration to manage the increased amount of healthcare waste. This study wished to assess the management system The concern is about the lack of appropriate HCW segregation, selection, handling, storage, transport, treatment and final disposal. This motivated the researcher to conduct this study to assess the healthcare waste management in health facilities in Addis Ababa City Health Bureau. Between 2011 and 2016, the Addis Ababa City Administration Health Bureau built more than 60 health centres and one [ 1 ] referral hospital [ 12 ].

Materials and methods

Study setting and design.

The study setting was Addis Ababa, the capital city of Ethiopia. It is the largest and most populous city in the country [ 13 ]. The city has three layers of administration, the city administration at the top, 10 sub-cities administration in the middle and 116 Woredas (Districts) at the bottom [ 12 ]. There were 6 public referral hospitals and 95 functional public health centers during the study period. A facility based cross-sectional study was conducted among healthcare waste handlers and managers. The study assessed the healthcare waste management practices in 15 selected public health centres and 3 hospitals. Data was obtained from questionnaires distributed to 636 randomly selected healthcare professionals, ancillary staff and managers from January 24 to February 24, 2018.

Source population

All healthcare waste handlers and managers in Addis Ababa City Administration public health centres and hospitals.

Study population

Sampled healthcare waste handlers and managers from selected health centres and hospitals.

Inclusion and exclusion criteria

Healthcare waste handlers and managers (Doctors, Health Officers, Nurses, midwifes, pharmacists, laboratory technicians, Environmental health professionals, Biomedical engineers, ancillary staffs comprised cleaners, porters and operatives for handling waste selected by proportion.) in 15 health centres and 3 hospitals who were worked more than six months and agree to participate in the study were included. Healthcare waste handlers and managers who were absent at the time of data collection were excluded from the study.

Sample size and sampling techniques

The sample size determined for this study was determined by a single population proportion formula with the assumption of 50%, 95% confidence interval and 5% marginal error. The researcher used multistage sampling in this study and calculate the design effect of 2. Correction formula was also used because the number of healthcare workers were less than 10000. A total of 636 participants were selected out of which 532 were healthcare waste handlers and 104 were managers. Proportional allocation was performed 394 participant healthcare waste handlers were from 15 health centres and 138 were from 3 hospitals. Moreover 70 managers were from health centres and 34 were from hospitals. Simple random sampling method was used to select participants from both health centres and hospitals.

Data collection tool

Data was collected by means of questionnaires and observational check list. To reduce subjectivity (information bias), the principal investigator adopted a structured questionnaire from World Health Organization’s healthcare waste management rapid assessment tools [ 14 ] as a data collection tool in line with the research objective. The questionnaire included respondents’ demographic characteristics, knowledge and practice of HCW management. The questionnaire consisted of closed questions (requiring a ‘Yes’ or ‘No’ answer). The main questions covered segregation, collection, transportation, storage, treatment and disposal, waste recycling and re-use, occupational health and safety, internal policies, and administration and healthcare waste management. Data collectors distributed the questionnaires in the 15 health centres and 3 hospitals to the respondents. Observation was conducted by the data collectors and supervisors to see the waste management practice of healthcare waste handlers and the work site to health centres and hospitals. The data collectors used the prepared observational check list to follow the HCW management practice and captured supporting photographs.

Data quality control

Fifteen data collectors who graduated from a college with Grade 10+3 diploma in health science were used for data collection on healthcare waste management. Eight supervisors who were BSc graduates in Environmental Health or related fields assisted the principal investigator with the data collection. Training manual was prepared for two days of training. The principal investigator gave training to data collectors and supervisors, including data collection and fieldworkers practice in data collection and data-collection tools. Information sheet and consent form also attached with the data collection tool to share the information about the study. Data collection tools and observational check lists was pre-tested to two health centers and one hospital other than the study areas. Respondents who were not able to read, the English language questionnaires were the tool were translated to local language Amharic by professional translator and assisted by the data collectors. Daily onsite supervision was made by the supervisors and principal investigator during data collection assuring ethical issue and respondents assuring an animosity.

Data processing and analysis

Data was entered by EPI- INFO TM 7 after a manual check for completeness. The entered data were exported to IBM SPSS Version 20. Both descriptive and inferential statistics were used. Data analysis was performed separately for each of health centres and hospitals which were grouped by category. Tables and graphs were used to show frequencies, percentage, bivariate logistic regression analysis to identify candidate variables for multivariable logistic regression analysis. The multivariable analysis a significant association was found with a p-value of less than 0.05. the association were presented with an adjusted odds ratio (AOR) and corresponding 95% CI.

Ethical consideration

Ethical approval and clearance were obtained from the Higher Degrees Committee, Department of Health Studies, University of South Africa and Addis Ababa City Administration Health Bureau to conduct the study. The letter was submitted to both health centers and hospital administrators to begin the study. A written information sheet and consent form was provided to all participants. The participants were informed of the purpose of the study; that participation was voluntary, and that all information would be treated strictly confidentially. The participants signed informed consent and also informed to withdraw from the study at any time was clearly stated for the participants.

Sociodemographic characteristics of the respondents

A total of 636 healthcare waste handlers and managers, 370 (58.18%) and 266 (41.82%) were males and females participated respectively ( Table 1 ). In this study 15 health centres and 3 general hospitals were selected (Figs 1 and 2 ). The largest 251 (39%) participants were nurses 162 (64.5%) worked at health centres and 89 (35.5%) worked at hospitals, the least 2 (0.31%) participants were biomedical engineers worked at hospitals ( Fig 3 ).

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The respondents’ age ranged from 20 to 59 years. Of the respondents, 372 (58.49%) were aged between 20–29, 216 (33.96%) were aged between 30–39, and 5.03% (32) were aged between 40–49. The mean age of the respondents was 30.9 years ( Table 2 ).

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Of the respondents, 421 (66.19%), 158 (24.84%), 24 (3.77%) and 21 (3.3%) had work experience of, 1–5 years, 6–10 year, 11–15 years and 21 years and more experience respectively ( Table 3 ).

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Healthcare waste management practice

From this study healthcare waste handlers, 350 (88.83%) from health centres and 127 (92.03%) from hospitals indicated that the health facility they worked at had separate storage areas for HCW. With reference to storage, 358 (90.86%) from health centres and 133 (96.38%) from hospitals indicated that their facilities had separate containers for hazardous and non-hazardous waste. The respondent healthcare waste handlers, 61 (15.48%) from health centres and 29 (21.01%) from hospitals indicated that the healthcare waste containers were not clearly marked or labelled ( Table 4 ).

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Healthcare waste handlers, 339 (86.04%) from health centres and 106 (76.81%) from hospitals indicated that the HCW containers were located appropriate areas where they might be needed. Majority of respondent healthcare waste handlers, 325 (82.49%) and 83. 330 (76%) from health centres and 105 (76.09%) and 99 (71.74%) from hospitals indicated that the HCW containers in health facilities were made of leak-proof material and the HCW containers were easy to carry respectively ( Table 4 ).

Respondents from health centres343 (87.06%) and 119 (86.23%) from hospitals stated that the sharps containers were made of puncture-resistant material but 51 (12.94%) from health centres and 41 (22.71%) from hospitals indicated that sharps containers were not closed securely and disposed of whenever they were 3/4 full. Most of the respondents, 335 (85.02%) from health centres and 87 (63.04%) from hospitals stated that the HCW containers were emptied daily or whenever they were 3/4 full ( Table 4 ).

Healthcare waste handlers from health centres 96 (24.37%) and 41 (29.71%) from hospitals indicated that no formal or informal separation of waste took place at their health facilities. Respondents from health centres 209 (53.03%) and 87 (63.04%) from hospitals indicated that plastics and intravenous sets were not kept separately for recycling. Healthcare waste handlers, 126 (31.98%) and 310 (76.68%) from health centres and 49 (35.51%) and 93 (67.39%) from hospitals indicated that not all waste handlers wore heavy duty gloves and sturdy shoes when handling HCW and washed their hands and their hard duty gloves after handling waste respectively ( Table 4 ).

The respondent healthcare handlers 157 (39.85%), 260 (65.99%), 58.12% (229), 246 (62.44%) and 56 (14.21%) from health centres and 61 (44.2%), 97 (70.29%), 93 (67.39%), 90 (65.22%) and 38 (27.54%) from hospitals indicated cytotoxic, pathological, reagent, outdated pharmaceutical and radioactive waste was indicated their facility generated as waste of special concern ( Table 4 ).

None of the respondents who indicated that their facilities generated HCW of special concern indicated how the disposal thereof was handled. The respondents were asked to indicate how liquid waste was disposed of and to specify for cytotoxic and reagent processing liquids. Healthcare waste handlers, 20 (5.08%) from health centres and 10 (7.25%) from hospitals indicated that liquid waste was disposed of via sinks, and 23 (5.84%) from health centres and 4 (2.9%) from hospitals indicated via sewers. None of the respondents specified cytotoxic or reagent processing liquids ( Table 4 ).

Types of HCW generation

The types of HCW generated and observed in respective healthcare facilities in daily basis were asked to the study participants. Most respondents observed, 277 (70.30%), 261 (66.24%) and 265 (67.26%), 114 (82.61%) from health centres and hospitals indicated used gloves and sharps respectively were generated more in daily basis ( Table 5 ).

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The type of HCW least generated and observed from health centres and hospitals 80 (20.30%), 67 (48.55%) and 60 (15.23%), 59 (42.7%) were indicated human tissue and organ and excreta respectively ( Table 5 ).

The respondents were asked to indicate the on-site means of transportation observed of HCW in their healthcare facilities. The study found that health centres mainly used buckets followed by pedal bins and trolleys to transport HCW on site while hospitals used mainly pedal bins and sometimes buckets and trolleys ( Fig 4 ).

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Healthcare waste management and managers

Regarding HCW management issues, a total of 104 managers respondents, 70 from health centres and 34 from hospitals were participated. The type of professions to managers participated in the study were nurses, laboratory technicians and health officers accounted 37 (35.6%) and 15 (14.4%) each respectively ( Table 6 ).

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Manager respondents, 69 (98.57%) from health centres and 31 (91.18%) from hospitals indicated that HCW generated by their facilities was segregated. From health centres 47 (61.43%) and from hospitals 24 (70.59%) indicated that the HCW was securely stored before transportation to the incinerator. Healthcare manager from the health centres 65 (92.86%) and 31 (91.18%) from hospitals indicated that healthcare waste handlers used protective clothing when handling waste, and 64 (91.43%) from health centres and 30 (88.24%) from hospitals indicated that the waste handlers were provided with protective clothing when handling HCW ( Table 7 ).

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Managers from health centres 47(67.14%) and hospitals 21(61.76%) indicated that there were a current operational standard for HCW management in their health facilities. Forty-nine (70.0%) from health centres and 25(73.53%) from hospitals indicated they had applicable guideline for HCW in the health facilities, beside 57(81.43%) and 23(67.65%) from health centres and hospitals respectively indicated HCW management committee organized in healthcare facilities ( Table 7 ).

The respondent managers were asked to indicate the type of protective clothing used for handling HCW in health centres, 45 (64.29%) used gloves; 35 (50%) used gowns; 17 (24.29%) used aprons; 23 (32.86%) used sturdy shoes; 10 (14.29%) used goggles; 5 (7.14%) used capes, and 20 (28.57%) used masks. Of the respondents from hospitals, 21 (61.76%) used gloves; 9 (26.47%) used gowns; 11 (32.35%) used aprons; 9 (26.47%) used sturdy shoes; 12 (35.29%) used goggles; 3 (8.82%) used capes, and 8 (23.53%) used masks ( Table 8 ).

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The respondent managers were asked to rate their facilities’ handling and segregation of HCW in health centres, 37 (52.86%) rated the handling of HCW good; 20 (28.57%) rated it very good; 7 (10%) rated it excellent, and 6 (8.57%) rated it poor. The respondent managers in the hospitals, 16 (47.06%) rated the handling good; 13 (38.24%) very good; 5 (14.71%) poor, and none rated it excellent ( Fig 5A ).

Rate of handling (a) and segregation (b) of HCW in the study health facilities, Addis Ababa City Administration, February 2018.

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Respondent managers in health centres, 34 (48.57%) rated the segregation good; 23 (32.86%) very good; 8 (11.43%) poor, and 5 (7.14%) excellent. Manager respondents from hospitals, 18 (52.94%) rated the segregation good; 10 (29.41%) rated it very good; 5 (14.71%) rated it poor, and 1 (2.94%) rated it excellent ( Fig 5B ).

The manager respondents were asked to indicate the method and means of collection and off-site disposal of HCW, 14 (20%) from health centres and 7 (20.60%) from hospitals indicated that the municipality collected the HCW for off-site disposal. Of the respondents, 1 (1.43%) from the health centres and 1 (2.94%) from the hospitals indicated that a cooperative organisation was responsible for collection and off-site HCW disposal ( Table 9 ). Most of the respondents did not answer the question.

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The manager respondents were asked what was used to store hazardous HCW prior to disposal, from health centres, 34 (48.57%) indicated red plastic healthcare waste bags; 16 (22.86%) indicated yellow sharps containers; 11 (15.71%) indicated ‘other’ and specified large interim containers; 5 (7.14%) indicated black plastic refuse bags; 3 (4.29%) indicated pedal bins; 1 (1.43%) indicated standard metal dustbins. From hospitals, 58.82% [ 20 ] indicated red plastic healthcare waste bags; 6 (17.65%) yellow sharps containers; 4 (11.76%) pedal bins; 2 (5.88%) black plastic refuse bags; 1 (2.94%) indicated standard metal dustbins, and 1 (2.94%) indicated ‘other’ and specified large interim containers ( Fig 6 ).

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The respondent managers were asked how HCW was transported on-site for storage before collection for off-site disposal, from health centres, 24 (34.29%) indicated in pedal bins; 40 (57.14%) indicated buckets, and 6 (8.57%) indicated trolleys. Respondent managers from hospitals, 28 (82.35%) indicated pedal bins; 3 (8.82%) indicated buckets, and 3 (8.82%) indicated trolleys ( Table 11 ).

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Managers were asked who was responsible for HCW management in their facilities, in health centres, 28 (40%) indicated sanitarian/environmental health professionals were responsible for HCW management; 27 (38.57%) indicated safety officers, and 15 (21.43%) indicated ‘other’ and specified (laboratory technicians, midwifes, ancillary staffs) ( Fig 7 ).

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Managers from hospitals, 28 (82.35%) indicated sanitarian/environmental health professionals were responsible for HCW management; 5 (14.71%) indicated safety officers, and 1 (2.94%) indicated ‘other’ and specified ancillary staff ( Fig 7 ).

Risks of the current waste management system

The respondent managers were asked to indicate whether their health facilities had concerns about HCW management, 64 (91.43%) from health centres and 30 (88.24%) from hospitals indicated that management had concerns about HCW management. Managers from health centres 35 (50.0%) and from hospitals 21 (61.76%) indicated that the HCW posed risks to waste collectors; 19 (27.14%) from health centres and 24 (70.59%) from hospitals indicated that waste collectors (handlers) had been injured by needles. Respondent managers, 40 (57.14%) from health centres and 24 (70.59%) from the hospitals indicated that their facilities had a register for injury or HCW contamination to staff ( Table 12 ).

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The respondent managers were asked to indicate the number of HCW handlers (ancillary/janitors) working at their facilities, from health centres, 59 (84.29%) indicated 5 or more; 3 (4.29%) indicated 4; 5 (7.14%) indicated 3, and1 (1.43%) indicated 1. Manager respondents from hospitals, 29 (85.29%) indicated 5 or more; 3 (8.82%) indicated 2, and 2 (5.88%) indicated 1 ( Fig 8 ).

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The Manager respondents were asked to indicate the type of injuries sustained in their health facilities in the previous 12 months, from health centres, 8 (11.43%) indicated deep injuries; 10 (14.29%) indicated slight skin penetration; 5 (7.14%) indicated superficial, and 7 (10%) indicated splash injuries. From hospital managers, 12 (35.29%) indicated deep injuries; 15 (44.12%) indicated slight skin penetration; 14 (41.18%) indicated superficial, and 13 (38.24%) indicated splash injuries ( Table 13 ).

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Observation

The tide line of waste management with reference to waste minimisation, segregation, storage, handling, collection, and treatment was not properly and adequately practised by any of the surveyed health centres and hospitals. During the study 15 health centres and 3 hospitals selected were observed.

Interim storage

Of the health care facilities, 13 health centres and 1 hospital had interim storage sites and HCW disposal sites located in areas minimally accessible to their staff. Six health centres and 2 hospitals had interim storage containers that had no lids to prevent odour and escape of wastes and waste leakage. Open plastic buckets and safety boxes were used to transport waste manually to the disposal site. In 10 health centres and the 3 hospitals HCW stored on site remained on site for more than 48 hours before final disposal ( Table 14 ).

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Treatment and disposal of HCW

During the study period, almost all the health centres and hospitals did no use disinfection of HCW storage/collection utilities treatment (used chemical treatment or autoclaving) for HCW before disposal for on-site and off-site. Almost all the health centres and hospitals disposed of all HCW inside their compounds (on-site) as incineration considered the final treatment except placenta and surgically removed body parts. During observation, 1 health centre and 3 hospitals disposed of the HCW outside the compound (off-site) ( Table 15 ). The disposals of ash residues were seen to the field near by the incinerator during observation ( Fig 9 ). The burial site for placenta and surgical removals and were away from any water source at most of the health centres and hospitals. All the health facilities except 1 health centre had incinerators on the premises. In 3 of the health facilities, the incinerators were located downwind from the main service area. The incinerators of 11 health centres and 2 hospitals had sufficient air inlets on the side. At 12 of the health centres and all the 3 hospitals ash residues from the incinerators was disposed of inside the compound. The incinerators at 8 of the health centres and 2 of the hospitals were not surrounded by a fence or wall to limit access to scavengers ( Fig 10A and 10B ). Burial pits such as placenta pits and surgical removal pits were employed for final on-site waste disposal. The burial pits in most of the health centres and hospitals was 1–2 meters wide and 2–5 meters deep and the bottom of the pit was at least 1.8 meters above the water table ( Table 15 ).

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Incinerator (a) and placenta pit (b) with no fencing in one of the study health centres, Addis Ababa City Administration, February 2018.

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During observation all healthcare facilities used incineration for on-site HCW disposal except 1 health centre. The health centre that did not incinerate HCW disposed of it by open burning in the premises ( Table 16 ). All hospitals used municipality for off- site disposal moreover incineration for disposal of HCW. Most, 12 health centres had no off-site disposal for HCW some 3 of the health centres used cooperative organization for HCW off-site disposal beside incineration ( Table 16 ).

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Factors associated with healthcare waste handling practice

In the bivariate logistic regression analysis; Sex, age group, occupational category, work experience, type of health facility, separate container for HCW, located in appropriate place, leak proof materials used for HCW collection, labelling or marking of HCW container, easy to carry by the handlers, puncture- resistant material for sharps, HCW containers emptied daily or whenever ¾ full, formal or informal separation of HCW takes place, recycling of used plastic materials, HCW handlers wear heavy duty gloves and sturdy shoes, wash both hard heavy duty gloves and hands after handling HCW, means of transportation for HCW and generation of HCW of special concern (cytotoxic) showed statistically significant association with separate storage area for healthcare waste ( Table 17 ).

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The backward stepwise multivariate logistic regression analysis has shown that the odds of healthcare waste handling practice was found to increase by 5 times among using puncture resistant material for sharps [AOR = 4.82, 95% CI: (2.32, 10.02)]. The generation of cytotoxic waste had an association with the healthcare waste handling practice. Generation of cytotoxic waste [AOR = 8.37, 95% CI: (3.20, 21.88)] were 8.37 times more likely to health care waste handling practice ( Table 17 ).

From previous study done in Addis Ababa half of the health centers didn’t have separate containers for the collection of hazardous and non-hazardous wastes moreover the labeling of the waste containers didn’t see by seven of the study health centers [ 2 ]. In this study most respondents, 358 (90.86%) from the health centres and 133 (96.38%) from the hospitals indicated that their facilities had separate containers for hazardous and non-hazardous waste also some respondents 15.48% (61) from the health centres and 29 (21.01%) from the hospitals indicated that the healthcare waste containers were not clearly marked or labelled. Two hundred and forty-one, (67.3%) used the readily existing waste bins for placing of medical waste in South Omo Zone public health facilities [ 15 ]. The difference might be in organizing different management structure in the health care facilities.

In this study collection of HCW in the healthcare facilities was not regularly done, 55 (13.96%) from the health centres and 32 (23.19%) from the hospitals indicated that the HCW containers were not located in appropriate areas where they might be needed. The study from three hospitals of Addis Ababa indicated, HCW materials were collected daily basis while the collection program was irregular in the most hospitals [ 11 ]. The reason might be either there is a shortage of containers or negligence by the coordinators.

HCW containers in the health facilities were not made of leak-proof material it was indicated by the respondents, 69 (17.51%) from the health centres and 33 (24.26%) from the hospitals. It is also similar to the study done in Addis Ababa most of the HCW at the hospitals was found to be collected in perforated plastic bins that are intended for use in administrative areas only [ 11 ].

The study found that HCW containers were not easy to carry for transportation in the healthcare facilities, it was indicated by the respondents, 64 (16.24%) from the health centres and 39 (28.26%) from the hospitals. Most health centres mainly used buckets followed by pedal bins and trolleys to transport HCW on site while the hospitals used mainly pedal bins and sometimes buckets and trolleys. The study conducted in Addis Ababa private clinics showed 16 (5.8%) of the clinics had trolley/wheelbarrow and 2 (0.7%) of the clinics were linked with the sewerage lines [ 16 ]. The overall waste transporting practice was poor in 238 (85.6%) of the clinics [ 16 ]. The similarity might be the healthcare facilities consider to transporting HCW be the lower priority to manage.

In this study 310(76.65%) from health centres and 93(67.39%) from hospitals indicated that healthcare waste handlers washed their hands after handling wastes. Study done in Addis Ababa government hospitals, 57.6% professionals followed standard precaution practice after any direct contact to patients and their disposals [ 17 ]. This indicates most of the workers has a good practice to standard precaution practices.

Off-site disposal of HCW implemented in the healthcare facilities was assured by the respondents, 14 (20%) from the health centres and 7 (20.60%) from the hospitals and most of them indicated that the municipality collected the HCW for off-site disposal. Similarly, the study conducted in Addis Ababa hospitals showed that dispose their waste at off-site, the untreated hospital waste materials in the central storage area were finally loaded onto vehicles and transported to “koshe” unsanitary landfill site for open dumping [ 11 ]. This might be the healthcare facilities has a problem to treatment or disinfection of HCW which pose infection to human and the environment.

In this study application of operational standards and guidelines for HCW management in the healthcare facilities also limited, it was indicated by respondent managers from the health centres, 23 (32.86%) and from hospital 13 (38.23%) indicated there was no current operational standard for HCW management. In previous study conducted in Addis Ababa six out of ten studied health centers, Standard Operational Procedures, as well as any applicable local or regional guidelines about healthcare waste management were not found [ 2 ]. But another study done in Bahir Dar private and public hospitals 161(83.9%) and 179(79.2%) respectively indicated healthcare workers responded as there were rules and regulations regarding HCW management in the health facilities [ 18 ] also study done in South Omo Zone public health facilities indicated 41.3% of respondents apply medical waste management guidelines and policy to manage health-care waste correctly [ 15 ]. The reason might be either preparation of HCW management guideline by health facilities or the policy makers do consider HCW as an issue of priority.

In this study indicated most healthcare facilities had no HCW management committees 13 (18.57%) and 11 (32.35%) from the health centres and hospitals respectively also study done in Bahir Dar 59(30.7%) of private hospitals and 86(38.1%) of public hospitals health care workers indicated had no healthcare waste management committee in the health facilities [ 18 ].

Incineration was the most common method of treatment for HCW in studied healthcare facilities in Addis Ababa. Similar studies in Belo Horizonte, Brazil showed 60% of HCW treatment technology goes directly to incineration [ 19 ]. There is no centralized incineration for all HCFs in Addis Ababa and surrounding regions to destroy pharmaceutical wastes. Most of the study HCFs had incinerators on the premises; only a few incinerators were located downwind from the main service area burn all hazardous and non-hazardous waste together. Most incinerators had sufficient air inlets on the side in most cases ash from the incinerators was disposed of inside the compound. Many of the incinerators were not surrounded by a fence or wall to limit access to scavengers. The finding in line with other hospitals and private clinics study in Addis Ababa showed the main HCW disposal mechanism was incineration, incinerators incinerating all the solid HCWs together and used low combustion, single chamber, brick incinerators, and barrels in clinics incinerator as a treatment/final waste disposal method [ 11 , 16 ]. A systematic review done in Ethiopia waste treatment and disposal practice indicated low combustion incinerator was used to treat all the HCW types [ 20 ]. This might be due to lack of proper way of quantifying the types of waste management utility supply, poor financial allocation and rules and regulations.

Healthcare waste management system had been given very little attention in all health centers and hospitals. Pretreatment of infectious solid waste and liquid waste must be practiced before disposing helps to minimize the transmission of most pathogens to human and environment. Intervention measures are important point to fill the gap in knowledge, practice and attitude should be supported by training on healthcare waste management for waste handlers and managers bring greatest change on practice and management of HCWs. Healthcare facilities collaborate with private and non-government organization as partners or other stake holders also important strengthening Public Private Partnership is very important. The presence of applicable national, regional and local guidelines for HCW management practice is helpful for all healthcare facilities to guide all aspects in HCW management. The findings of the study should contribute to the achievement of the United Nations [ 21 ] sustainable development goals (SDGs) for 2016–2030, which are aimed at bringing about a sustainable world and protecting the planet.

Limitation of the study

This study has the following limitation: the study conducted was cross-sectional and couldn’t identify causality. The study was conducted in public healthcare facilities healthcare waste handlers and managers and couldn’t represent healthcare waste handlers and managers outside the public healthcare facilities (private HCF). The study is conducted on healthcare waste management issues other studies should also be conducted the generation rate is very important.

Acknowledgments

First, I would like to express my deepest gratitude to Professor Bethabile Lovely Dolamo for her unreserved support throughout the study period. I sincerely thank University of South Africa, Kotebe Education University Menelik II Medical and Health Science College, Addis Ababa City Government Health Bureau, head of the study health centers and hospital case teams and managers for their unreserved cooperation during data collection time. My deepest gratitude also goes to all data collectors and supervisor for their commitment during data collection. I would like to thank my beloved wife Alemnesh Mude, daughters Bezawit Menelik and Hermela Menelik for their patience during the study period.

• 1. Pichtel J. Waste management practices: municipal, hazardous, and industrial. 2nd edition ed. Boca Raton, FL: CRC Press.; 2014.
• View Article
• Google Scholar
• 3. Chartier Y, Emmanuel J, Pieper U, Prüss A, Rushbrook P, Stringer R, et al. Safe management of wastes from health-care activities. 2nd edition ed. Geneva: WHO; 2014.
• 4. Safe management of wastes from healthcare activities. Definition and characterization of healthcare waste [database on the Internet]. WHO. 2014 [cited January 2019]. Available from: https://who.int/water_sanitation_health/publications/wastemanag/en .
• 5. (UNEP) UNEP. Solid waste management. Nairobi: CaRecovery; 2005.
• PubMed/NCBI
• 8. Mohan B. Solid waste management in Kathmandu, Nepal: the anatomy of persistent failure. Doctoral dissertation. Baltimore, MD: Johns Hopkins University; 2009.
• 13. Agency CS. Population size by sex, area and density by region, zone and Wereda. Addis Ababa: Central statistic Agency, 2012.
• 21. UNDP. Sustainable Development Goals. New York, United States of America: United Nations Deveopment Programme, 2015.

Biomedical Waste Management: A Study on Assessment of Knowledge, Attitude and Practices Among Health Care Professionals in a Tertiary Care Teaching Hospital

Divya Rao 1 , M. R. Dhakshaini 2 , Ameet Kurthukoti 3 and Vidya G. Doddawad 4

1 Department of Health System Management Studies, JSS University, Mysuru.

2 Department of Prosthodontics, Vice Principal, JSS Dental College, JSS University, Mysuru.

3 Dental Health Officer, Department of Health and Family Welfare, Government of Karnataka.

4 Department of Oral Pathology and Microbiology, JSS Dental College, JSS University, Mysuru.

Corresponding Author E-mail:  [email protected]

DOI : https://dx.doi.org/10.13005/bpj/1543

Biomedical waste (BMW) generated in our nation on a day to day basis is immense and contains infectious and hazardous materials.  It is crucial on the part of the employees to know the hazards of the biomedical waste in the work environment and make its disposition effective and in a scientific manner. It is critical that the different professionals engaged in the healthcare sector have adequate Knowledge, Attitudes and Practices (KAP) with respect to biomedical waste management. Many studies across the country have shown that there are still deficiencies in the KAP of the employees in the organizations and hence it is necessary to make the appraisal of the same. To ascertain the levels of and the expanse of gaps in knowledge, attitudes and practices among doctors, post graduates, staff nurses, laboratory technicians and house-keeping staffs in a tertiary care teaching hospital in Mysuru, Karnataka. A cross sectional study was carried out using questionnaire as the study tool among the health care professionals in a tertiary care teaching hospital. The study demonstrated gaps in the knowledge amongst all the cadres of the study respondents. The knowledge in relation to BMW Management including the hospital BMW protocols was more desirable among doctors, but practical facets were better in nurses and the lab technicians. Knowledge, Attitude and Practice amongst the different cadres of staff members were found to be significant statistically.

Attitude; Biomedical Waste; Healthcare personnel;   Knowledge; Practice

Introduction

Health care waste is a unique category of waste by the quality of its composition, source of generation, its hazardous nature and the need for appropriate protection during handling, treatment and disposal. Mismanagement of the waste affects not only the generators, operators but also the common people too. 1

‘Bio-medical waste’ (BMW) means any solid and/or liquid waste including its container and any intermediate product, which is generated during the diagnosis, treatment or immunization of human beings or animals or in research pertaining thereto or in the production or testing thereof. 2

Due to the increase in the procedures that are carried out at the various health care setups, excessive amounts of waste have been generated at the centers of care.

India approximately  generates 2 kg/bed/ day 3 and this biomedical waste encompasses wastes like anatomical waste, cytotoxic wastes, sharps, which when inadequately segregated could cause different kinds of deadly infectious  diseases like Human immunodeficiency virus(HIV) hepatitis C and B infections, etc, 4   and also cause disruptions in the environment, and adverse impact on ecological balance. 5,6

Adequate knowledge amongst the health care employees about the biomedical waste management rules and regulations, and their understanding of segregation, will help in the competent disposal of the waste in their respective organizations. 7

Acceptable management of biomedical waste management begins from the initial stage of generation of waste, segregation at the source, storage at the site, disinfection, and transfer to the terminal disposal site plays a critical role in the disposal of waste. Hence adequate knowledge, attitudes and practices of the staff of the health care institutes play a very important role. 8,4,9

Teaching institutes play a critical role in the health care setup as it is from these places that the future health care professionals and all those persons involved in the care giving to the community are trained. 10

Studies documented from different parts of the country; still convey that there are gaps in the Knowledge, lacunae in the attitudinal component and inconsistency in the practice aspects which are matters of concern among the health care professionals. 8,11-15  With this background, the study was carried out to assess the current knowledge, attitude and practices of the health care workers like doctors, post graduates, interns, staff nurses, laboratory technicians and house-keeping staff in a tertiary care teaching hospital with regard to the management of BMW.

To assess the levels of knowledge, attitudes and practices among doctors, post graduates, interns, staff nurses, laboratory technicians and house-keeping staff in the different departments of a tertiary care teaching hospital.

To assess the gaps in knowledge, attitudes and practices among these health care workers in the different departments of a tertiary care teaching hospital.

Methodology

Study design

Cross-sectional study.

Study setting

Tertiary care teaching hospital

Study population

Staff working in the different departments of the hospital.

Eligibility Criteria

All consenting individuals amongst the different cadres of staff were included into the study. There were 2056 eligible participants, which was taken as the sampling frame.

Sample Size

Expecting that 50% of the study population had precise knowledge (considering the outcome variable) about the rules and legislation of biomedical waste management, 16  with an allowable error of 10%, at 95% confidence interval, and accounting for the finite population correction for 2,056 participants, a minimum sample size of 472 was calculated.

Sampling Strategy

The study population was classified according to the different strata based on their designation as doctors, postgraduates (junior residents), interns, staff nurses, laboratory technicians and house-keeping staff. Allocation of the population according to the strata.

Ethical Approval

The ethical clearance for the study was obtained from the Institutional Ethics Committee.

Materials and Methods

The tool used for the study was a pre-tested, semi-structured closed ended questionnaire which encompassed 42 questions on Knowledge, Attitudes and Practices.

The questions on knowledge appraised the participant’s knowledge on attributes related to the colour coding and their implications, identification of biomedical hazard symbol, waste categories, and hospital policies for biomedical waste management.

The questions on attitude were related to matters like, was biomedical waste hazardous, its management additional burden on their work or if their appropriate management burden on the finances of the hospital, and also on legislative measures for waste management.

The questions on practice appraised if the study respondents had received any training on biomedical waste management, if they were immunized against hepatitis B and if disinfection of sharps were carried out at the point of generation.

The literature review was done based on which the questionnaire was formulated according to the requirements of the study. The questionnaire was pretested and validated by a post-test and a pilot survey was conducted with a sample of 60 respondents, with representations from the various strata of the study respondents. The study tool consisted of 12 questions assessing the knowledge with yes/no/not sure responses, 10 questions assessing the attitude with agree/disagree/no comment as answers and 20 questions assessing the practices with yes/ no responses.

The participants filled up the self-administered questionnaires without scope for undue help.

The questionnaire was adapted from English to local language by an experienced professional who is involved in translating of health survey questionnaires to accommodate the housekeeping staff. The questionnaire was also back translated to English for checking of possible discrepancies and incorporating if any changes were required. The identity of the study respondents were maintained anonymous   at various stages of the study.

The results were evaluated across 3 domains for all the cadres of the study population.

The results are Displayed as Under

Statistical Methods

Data was analysed using MS-Excel and R version 3.4.3.  Percentages (with 95% confidence intervals) were calculated and the same are presented graphically. Chi-square test was performed to test the association between the different cadres related to their knowledge, attitude and practices towards BMW

Knowledge Score

The knowledge regarding general information about HCW was assessed, the mean score was highest in doctors (10) followed by nursing staff (9.3) and least in housekeeping staff (7.5). This is found to be statistically significant.

Table 1: The participant’s knowledge on biomedical waste management.

Overall, the study respondents showed satisfactory knowledge regarding biomedical waste management. The knowledge about BMW among doctors was the distinctively better, followed by that of nurses, technicians, post graduates, interns and housekeeping staff (in order). The gaps in knowledge were in the areas regarding the fate of the waste after it was segregated, and as well as who was the regulator for the safe transportation of biomedical waste from the hospital.

Table 2: The participant’s attitudes towards biomedical waste management.

The mean attitude score was 9.20 for the nurses and 9.18 out of 10 for the doctors. Favourable attitude was shown by most of the study respondents towards biomedical waste management. The best attitudes were displayed by the nurses showed, subsequently by doctors, interns, postgraduates, the laboratory technicians, and house keeping staff (in order). It was concerning that the lacuna in this domain was that biomedical waste management was considered as additional burden on work.

Table 3: The participant’s practices regarding biomedical waste management.

The mean practice score was 17.30 for the nurses and 16.50 for the housekeeping staff and 15.27out of 20 for the doctors, in the study. Though greater number of the study respondents displayed favourable biomedical waste management practices, it was noted that the nurses had the best practices, followed house keeping staff, doctors, technicians, interns and junior residents (in order). It was noted that the staff ware following the preventive measures of immunisation against Hepatitis B, and also routine health check-ups were conducted for the staff. Explicit training on BMW management was desired by most of the staff.

Chi-Square Test

The null hypothesis which was to be tested here was “The two attributes were independent”. Here three hypotheses were there to be tested:

Cadre and knowledge are independent.

(Chi-square = 160.8,  Degrees of freedom=10, p-value < 0.0001)

Cadre and attitudes are independent.

(Chi-square = 95.6, Degrees of freedom=10, p-value < 0.0001)

Cadre and practices are independent.

(Chi-square = 538.45, Degrees of freedom=15, p-value < 0.0001)

The present cross-sectional study recognized certain inadequacies in the knowledge component amongst the different cadres of health care workers, though greater than 50% of the study respondents, across cadres, demonstrated satisfactory or good knowledge, attitudes and practices. The knowledge component of the doctors was more desirable compared to their practices whereas visa versa was true for nurses and lab technicians. The knowledge component was low amongst the housekeeping staff; which was identical to the results from other similar studies conducted previously. 10,13,16 

The attitude towards BMW management of housekeeping staff was low. Low level of knowledge was mainly attributed to new staff coming on rotation to the hospital and also to comparably low educational levels of the housekeeping staff. Training of all cadres of staff will help in the analytical evaluations for suitable and applicable management of biomedical waste. 10,13,16 

The practice of recapping the needles was very low across cadres. Recapping of needles is one of the important risk factor for needle stick injuries; the prevalence was very low in the organization. This may be associated to the awareness of the staff and also due to the adequate number of needle cutters in the various patient care areas of the hospital.

Higher practice scores found in the house keeping staff and nursing staff in the present study may be due to higher responsibilities assigned to them in handling of BMW which was similar to findings of previous studies. 1,17 Overall 8.1 % of the study respondents attended the external training programmes on BMW management on their own accord, but others too (~ 59%) of them communicated their willingness to do the same if opportunities arose in the future. 10,13,16

Conclusions

Overall, the knowledge, attitudes and practices towards biomedical waste management among the study respondents was satisfactory.

Knowledge, attitudes and practices toward biomedical waste management were better among the nurses and doctors than the other cadre of staff.

Knowledge, Attitudes and Practices of the study respondents are dependent on the cadre that they belong too.

This study was a modest attempt to evaluate the KAP of the health care workers towards BMW. We recommend further studies on a larger stratum across hospitals to evaluate the awareness of health care workers towards BMW.

Recommendations

Training programs need to focus on empowering the healthcare professionals on biomedical waste management with broad scope and practical knowledge in all aspects. The ethical requirements and the institutional level policies form the directional pathway for the practical components in the organization. The right practices and other activities of BMW management and its ramifications in the form of avoiding of injuries, importance of vaccinations and following of universal precautions can be achieved when adequately supported by IEC (information, education and communication) strategies like handouts, stickers, charts, celebrations of various days like hand hygiene day and other days etc can help in bettering the practices of the employees of the organizations. Training the staff with checklists and regular inspections can bring about accountability in the staff.

All health care professionals regardless of their designation, experience and qualification , designation must be included in these interventions, so that it can avoid  cross infections among the professionals and patients in the health care sector.

Conflicts of Interest

There is no conflicts of interest.

•  Kumar P.V.A.G, Kapate R et al, Knowledge, Attitude, and Practices of Health Care Waste Management amongst Staff of Nursing Homes of Gulbarga City. Journal of Pharmaceutical and Biomedical Sciences. 2012;19(19)1-3.
• Sharma A.K. Biomedical Waste (Management and Handling) Rules. First edition. Bhopal. Suvidha Law House. 12.
• Patil A.D, Shekdar A.V.  Health-care waste management in India. J Environ Manage. 2001;63:211-20. CrossRef
• Nath P.A, Prashanthini V, Visvanathan C.  Healthcare waste management in Asia. Waste Management. 2010;30:154-61. CrossRef
• Lakshmikantha H.  Report on waste dump sites near Bangalore. Waste management . 2006;26(6):640-50. CrossRef
• Misra V, Pandey S.D. Hazardous waste, impact on health and environment for development of better waste management strategies in future in India. Environment International. 2005;31:417-31. CrossRef
• Kini B.S, Kumar , Kumar S, Reddy M, Nabar A.S, Kamath V.G, Kamath A, Eshwari K.  Knowledge, Attitudes and Practices regarding Biomedical Waste Management among staff of a tertiary healthcare centre in coastal Karnataka. J Pub Health Med Res . 2014;2(1):20-4.
• Pattnaik S, Reddy M.V. Assessment of Municipal Solid Waste management in Puducherry (Pondicherry).  India. Resources, Conservation and Recycling . 2010;54:512-20. CrossRef
• Mathur V, Dwivedi S, Hassan M.A, Misra R.P.  Knowledge, Attitude, and Practices about Biomedical Waste Management among Healthcare Personnel: A Cross-sectional Study. Indian J Community Med. 2011; 36:143-5. CrossRef
• Radha R.  Assessment of existing knowledge, attitude, and practices regarding biomedical waste management among the health care workers in a tertiary care rural hospital. Int J Health Sci Res . 2012;2(7):14-19.
• Verma L.K, Mani S, Sinha N, Rana S. Biomedical waste management in nursing homes and smaller hospitals around Delhi. Waste Management. 2008;28:2723-34. CrossRef
• Kumar S, Bhattacharyya J.K, Vaidya A.N, Chakrabarti T, Devotta S, Akolkar A.B.  Assessment of the status of solid waste management in metro cities, state capitals, class I cities, and class II towns in India: An insight. Waste Management. 2009;29:883-95. CrossRef
• Pandit N.B, Mehta H.K, Kartha G.P, Choudhary S.k.  Management of biomedical waste: Awareness and practices in a district of Gujarat. Indian J Public Health . 2005;49:245-7.
• Rao P.H. Report: Hospital waste management – awareness and practices: A study of three states in India. Waste Manage Res . 2008;26:297-303. CrossRef
• Kishore J, Goel P, Sagar B, Joshi T.K.  Awareness about biomedical waste management and infection control among dentists of a teaching hospital in New Delhi, India. Indian J Dent Res . 2000;11:157-61.
• Saini S, Nagarajan S.S, Sarma R.K. Knowledge, Attitude and Practices of Bio-Medical Waste Management Amongst Staff of a Tertiary Level Hospital in India. Journal of the Academy of Hospital Administration. 2005;17(2).
• Yadavannavar M.C, Berad A.S, Jagirdar P.B. Biomedical waste management: A study of knowledge, attitude, and practices in a tertiary health care institution in Bijapur. Indian Journal of Community Medicine. 2010;35(1):170-71. CrossRef

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• v.66(1); 2022 Jan

Dissertation writing in post graduate medical education

Department of Anaesthesiology, Dr. B R Ambedkar Medical College, Bengaluru, Karnataka, India

Mridul M Panditrao

1 Department of Anaesthesiology and Intensive Care, Adesh Institute of Medical Sciences and Research (AIMSR), Bathinda, Punjab, India

2 Department of Anaesthesiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India

Sukhminder Jit Singh Bajwa

3 Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Patiala, Punjab, India

Nishant Sahay

4 Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India

Thrivikrama Padur Tantry

5 Department of Anaesthesiology, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, Karnataka, India

Associated Data

A dissertation is a practical exercise that educates students about basics of research methodology, promotes scientific writing and encourages critical thinking. The National Medical Commission (India) regulations make assessment of a dissertation by a minimum of three examiners mandatory. The candidate can appear for the final examination only after acceptance of the dissertation. An important role in a dissertation is that of the guide who has to guide his protégés through the process. This manuscript aims to assist students and guides on the basics of conduct of a dissertation and writing the dissertation. For students who will ultimately become researchers, a dissertation serves as an early exercise. Even for people who may never do research after their degree, a dissertation will help them discern the merits of new treatment options available in literature for the benefit of their patients.

INTRODUCTION

The zenith of clinical residency is the completion of the Master's Dissertation, a document formulating the result of research conducted by the student under the guidance of a guide and presenting and publishing the research work. Writing a proper dissertation is most important to present the research findings in an acceptable format. It is also reviewed by the examiners to determine a part of the criteria for the candidate to pass the Masters’ Degree Examination.

The predominant role in a dissertation is that of the guide who has to mentor his protégés through the process by educating them on research methodology, by: (i) identifying a pertinent and topical research question, (ii) formulating the “type” of study and the study design, (iii) selecting the sample population, (iv) collecting and collating the research data accurately, (v) analysing the data, (vi) concluding the research by distilling the outcome, and last but not the least (vii) make the findings known by publication in an acceptable, peer-reviewed journal.[ 1 ] The co-guide could be a co-investigator from another department related to the study topic, and she/he will play an equivalent role in guiding the student.

Research is a creative and systematic work undertaken to increase the stock of knowledge.[ 2 ] This work, known as a study may be broadly classified into two groups in a clinical setting:

• Trials: Here the researcher intervenes to either prevent a disease or to treat it.
• Observational studies: Wherein the investigator makes no active intervention and merely observes the patients or subjects allocated the treatment based on clinical decisions.[ 3 ]

The research which is described in a dissertation needs to be presented under the following headings: Introduction, Aim of the Study, Description of devices if any or pharmacology of drugs, Review of Literature, Material and Methods, Observations and Results, Discussion, Conclusions, Limitations of the study, Bibliography, Proforma, Master chart. Some necessary certificates from the guide and the institute are a requirement in certain universities. The students often add an acknowledgement page before the details of their dissertation proper. It is their expression of gratitude to all of those who they feel have been directly or indirectly helpful in conduct of the study, data analysis, and finally construction of the dissertation.

Framing the research question (RQ)

It is the duty of the teacher to suggest suitable research topics to the residents, based on resources available, feasibility and ease of conduct at the centre. Using the FINER criteria, the acronym for feasibility, topical interest, novelty, ethicality and relevance would be an excellent way to create a correct RQ.[ 4 ]

The PICOT method which describes the patient, intervention, comparison, outcome and time, would help us narrow down to a specific and well-formulated RQ.[ 5 , 6 ] A good RQ leads to the derivation of a research hypothesis, which is an assumption or prediction of the outcome that will be tested by the research. The research topic could be chosen from among the routine clinical work regarding clinical management, use of drugs e.g., vasopressors to prevent hypotension or equipment such as high flow nasal oxygen to avoid ventilation.

Review of literature

To gather this information may be a difficult task for a fresh trainee however, a good review of the available literature is a tool to identify and narrow down a good RQ and generate a hypothesis. Literature sources could be primary (clinical trials, case reports), secondary (reviews, meta-analyses) or tertiary (e.g., reference books, compilations). Methods of searching literature could be manual (journals) or electronic (online databases), by looking up references or listed citations in existing articles. Electronic database searches are made through the various search engines available online e.g., scholar.google.com, National Library of Medicine (NLM) website, clinical key app and many more. Advanced searches options may help narrow down the search results to those that are relevant for the student. This could be based on synthesising keywords from the RQ, or by searching for phrases, Boolean operators, or utilising filters.

After choosing the topic, an apt and accurate title has to be chosen. This should be guided by the use of Medical Subject Headings (MeSH) terminology from the NLM, which is used for indexing, cataloguing, and searching of biomedical and health-related information.[ 7 ] The dissertation requires a detailed title which may include the objective of the study, key words and even the PICOT components. One may add the study design in the title e.g. “a randomised cross over study” or “an observational analytical study” etc.

Aim and the objectives

The Aims and the Objectives of the research study have to be listed clearly, before initiating the study.[ 8 ] “Gaps” or deficiencies in existing knowledge should be clearly cited. The Aim by definition is a statement of the expected outcome, while the Objectives (which might be further classed into primary and secondary based on importance) should be specific, measurable, achievable, realistic or relevant, time-bound and challenging; in short, “SMART!” To simplify, the aim is a statement of intent, in terms of what we hope to achieve at the end of the project. Objectives are specific, positive statements of measurable outcomes, and are a list of steps that will be taken to achieve the outcome.[ 9 ] Aim of a dissertation, for example, could be to know which of two nerve block techniques is better. To realise this aim, comparing the duration of postoperative analgesia after administration of the block by any measurable criteria, could be an objective, such as the time to use of first rescue analgesic drug. Similarly, total postoperative analgesic drug consumption may form a secondary outcome variable as it is also measurable. These will generate data that may be used for analysis to realise the main aim of the study.

Inclusion and exclusions

The important aspect to consider after detailing when and how the objectives will be measured is documenting the eligibility criteria for inclusion of participants. The exclusion criteria must be from among the included population/patients only. e.g., If only American Society of Anesthesiologists (ASA) I and II are included, then ASA III and IV cannot be considered as exclusion criteria, since they were never a part of the study. The protocol must also delineate the setting of the study, locations where data would be collected, and specify duration of conduct of the dissertation. A written informed consent after explaining the aim, objectives and methodology of the study is legally mandatory before embarking upon any human study. The study should explicitly clarify whether it is a retrospective or a prospective study, where the study is conducted and the duration of the study.

Sample size: The sample subjects in the study should be representative of the population upon whom the inference has to be drawn. Sampling is the process of selecting a group of representative people from a larger population and subjecting them for the research.[ 10 ] The sample size represents a number, beyond which the addition of population is unlikely to change the conclusion of the study. The sample size is calculated taking into consideration the primary outcome criteria, confidence interval (CI), power of the study, and the effect size the researcher wishes to observe in the primary objective of the study. Hence a typical sample size statement can be - “Assuming a duration of analgesia of 150 min and standard deviation (SD) of 15 min in first group, keeping power at 80% and CIs at 95% (alpha error at 0.05), a sample of 26 patients would be required to detect a minimum difference (effect size) of 30% in the duration of analgesia between the two groups. Information regarding the different sampling methods and sample size calculations may be found in the Supplementary file 1 .

Any one research question may be answered using a number of research designs.[ 11 ] Research designs are often described as either observational or experimental. The various research designs may be depicted graphically as shown in Figure 1 .

Graphical description of available research designs

The observational studies lack “the three cornerstones of experimentation” – controls, randomisation, and replication. In an experimental study on the other hand, in order to assess the effect of treatment intervention on a participant, it is important to compare it with subjects similar to each other but who have not been given the studied treatment. This group, also called the control group, may help distinguish the effect of the chosen intervention on outcomes from effects caused by other factors, such as the natural history of disease, placebo effects, or observer or patient expectations.

All the proposed dissertations must be submitted to the scientific committee for any suggestion regarding the correct methodology to be followed, before seeking ethical committee approval.

Ethical considerations

Ethical concerns are an important part of the research project, right from selection of the topic to the dissertation writing. It must be remembered, that the purpose of a dissertation given to a post-graduate student is to guide him/her through the process by educating them on the very basics of research methodology. It is therefore not imperative that the protégés undertake a complicated or risky project. If research involves human or animal subjects, drugs or procedures, research ethics guidelines as well as drug control approvals have to be obtained before tabling the proposal to the Institutional Ethics Committee (IEC). The roles, responsibilities and composition of the Ethics Committee has been specified by the Directorate General of Health Services, Government of India. Documented approval of the Ethics committee is mandatory before any subject can be enroled for any dissertation in India. Even retrospective studies require approval from the IEC. Details of this document is available at: https://cdsco.gov.in/opencms/resources/UploadCDSCOWeb/2018/UploadEthicsRegistration/Applmhrcrr.pdf .

The candidate and the guide are called to present their proposal before the committee. The ethical implications, risks and management, subjects’ rights and responsibilities, informed consent, monetary aspects, the research and analysis methods are all discussed. The patient safety is a topmost priority and any doubts of the ethical committee members should be explained in medically layman's terms. The dissertation topics should be listed as “Academic clinical trials” and must involve only those drugs which are already approved by the Drugs Controller General of India. More commonly, the Committee suggests rectifications, and then the researchers have to resubmit the modified proposal after incorporating the suggestions, at the next sitting of the committee or seek online approval, as required. At the conclusion of the research project, the ethics committee has to be updated with the findings and conclusions, as well as when it is submitted for publication. Any deviation from the approved timeline, as well as the research parameters has to be brought to the attention of the IEC immediately, and re-approval sought.

Clinical trial registration

Clinical Trial Registry of India (CTRI) is a free online searchable system for prospective registration of all clinical studies conducted in India. It is owned and managed by the National Institute of Medical Statistics, a division of Indian Council of Medical Research, Government of India. Registration of clinical trials will ensure transparency, accountability and accessibility of trials and their results to all potential beneficiaries.

After the dissertation proposal is passed by the scientific committee and IEC, it may be submitted for approval of trial registration to the CTRI. The student has to create a login at the CTRI website, and submit all the required data with the help of the guides. After submission, CTRI may ask for corrections, clarifications or changes. Subject enrolment and the actual trial should begin only after the CTRI approval.

Randomisation

In an experimental study design, the method of randomisation gives every subject an equal chance to get selected in any group by preventing bias. Primarily, three basic types employed in post-graduate medical dissertations are simple randomisation, block randomisation and stratified randomisation. Simple randomisation is based upon a single sequence of random assignments such as flipping a coin, rolling of dice (above 3 or below 3), shuffling of cards (odd or even) to allocate into two groups. Some students use a random number table found in books or use computer-generated random numbers. There are many random number generators, randomisation programs as well as randomisation services available online too. ( https://www-users.york.ac.uk/~mb55/guide/randsery.htm ).

There are many applications which generate random number sequences and a research student may use such computer-generated random numbers [ Figure 2 ]. Simple randomisation has higher chances of unequal distribution into the two groups, especially when sample sizes are low (<100) and thus block randomisation may be preferred. Details of how to do randomisation along with methods of allocation concealment may be found in Supplementary file 2 .

Figure depicting how to do block randomisation using online resources. (a) generation of a random list (b) transfer of the list to an MS excel file

Allocation concealment

If it is important in a study to generate a random sequence of intervention, it is also important for this sequence to be concealed from all stake-holders to prevent any scope of bias.[ 12 ] Allocation concealment refers to the technique used to implement a random sequence for allocation of intervention, and not to generate it.[ 13 ] In an Indian post-graduate dissertation, the sequentially numbered, opaque, sealed envelopes (SNOSE) technique is commonly used [ Supplementary file 2 ].

To minimise the chances of differential treatment allocation or assessments of outcomes, it is important to blind as many individuals as possible in the trial. Blinding is not an all-or-none phenomenon. Thus, it is very desirable to explicitly state in the dissertation, which individuals were blinded, how they achieved blinding and whether they tested the success of blinding.

Commonly used terms for blinding are

• Single blinding: Masks the participants from knowing which intervention has been given.
• Double blinding: Blinds both the participants as well as researchers to the treatment allocation.
• Triple blinding: By withholding allocation information from the subjects, researchers, as well as data analysts. The specific roles of researchers involved in randomisation, allocation concealment and blinding should be stated clearly in the dissertation.

Data which can be measured as numbers are called quantitative data [ Table 1 ]. Studies which emphasise objective measurements to generate numerical data and then apply statistical and mathematical analysis constitute quantitative research. Qualitative research on the other hand focuses on understanding people's beliefs, experiences, attitudes, behaviours and thus these generate non-numerical data called qualitative data, also known as categorical data, descriptive data or frequency counts. Importance of differentiating data into qualitative and quantitative lies in the fact that statistical analysis as well as the graphical representation may be very different.

Data collection types

In order to obtain data from the outcome variable for the purpose of analysis, we need to design a study which would give us the most valid information. A valid data or measurement tool, is the degree to which the tool measures what it claims to measure. For example, appearance of end tidal carbon dioxide waveform is a more valid measurement to assess correct endotracheal tube placement than auscultation of breath sounds on chest inflation.

The compilation of all data in a ‘Master Chart’ is a necessary step for planning, facilitating and appropriate preparation and processing of the data for analysis. It is a complete set of raw research data arranged in a systematic manner forming a well-structured and formatted, computable data matrix/database of the research to facilitate data analysis. The master chart is prepared as a Microsoft Excel sheet with the appropriate number of columns depicting the variable parameters for each individual subjects/respondents enlisted in the rows.

Statistical analysis

The detailed statistical methodology applied to analyse the data must be stated in the text under the subheading of statistical analysis in the Methods section. The statistician should be involved in the study during the initial planning stage itself. Following four steps have to be addressed while planning, performing and text writing of the statistical analysis part in this section.

Step 1. How many study groups are present? Whether analysis is for an unpaired or paired situation? Whether the recorded data contains repeated measurements? Unpaired or paired situations decide again on the choice of a test. The latter describes before and after situations for collected data (e.g. Heart rate data ‘before’ and ‘after’ spinal anaesthesia for a single group). Further, data should be checked to find out whether they are from repeated measurements (e.g., Mean blood pressure at 0, 1 st , 2 nd , 5 th , 10 th minutes and so on) for a group. Different types of data are commonly encountered in a dissertation [ Supplementary file 3A ].

Step 2. Does the data follow a normal distribution?[ 14 ]

Each study group as well as every parameter has to be checked for distribution analysis. This step will confirm whether the data of a particular group is normally distributed (parametric data) or does not follow the normal distribution (non-parametric data); subsequent statistical test selection mainly depends on the results of the distribution analysis. For example, one may choose the Student's’ test instead of the ‘Mann-Whitney U’ for non-parametric data, which may be incorrect. Each study group as well as every parameter has to be checked for distribution analysis [ Supplementary File 3B ].

Step 3. Calculation of measures of central tendency and measures of variability.

Measures of central tendency mainly include mean, median and mode whereas measures of variability include range, interquartile range (IQR), SD or variance not standard error of mean. Depending on Step 2 findings, one needs to make the appropriate choice. Mean and SD/variance are more often for normally distributed and median with IQR are the best measure for not normal (skewed) distribution. Proportions are used to describe the data whenever the sample size is ≥100. For a small sample size, especially when it is approximately 25-30, describe the data as 5/25 instead of 20%. Software used for statistical analysis automatically calculates the listed step 3 measures and thus makes the job easy.

Step 4. Which statistical test do I choose for necessary analysis?

Choosing a particular test [ Figure 3 ] is based on orderly placed questions which are addressed in the dissertation.[ 15 ]

Chosing a statistical test, (a). to find a difference between the groups of unpaired situations, (b). to find a difference between the groups of paired situations, (c). to find any association between the variables, (d). to find any agreement between the assessment techniques. ANOVA: Analysis of Variance. Reproduced with permission from Editor of Indian Journal of Ophthalmology, and the author, Dr Barun Nayak[ 15 ]

• Is there a difference between the groups of unpaired situations?
• Is there a difference between the groups of paired situations?
• Is there any association between the variables?
• Is there any agreement between the assessment techniques?

Perform necessary analysis using user-friendly software such as GraphPad Prism, Minitab or MedCalc,etc. Once the analysis is complete, appropriate writing in the text form is equally essential. Specific test names used to examine each part of the results have to be described. Simple listing of series of tests should not be done. A typical write-up can be seen in the subsequent sections of the supplementary files [Supplementary files 3C – E ]. One needs to state the level of significance and software details also.

Role of a statistician in dissertation and data analysis

Involving a statistician before planning a study design, prior to data collection, after data have been collected, and while data are analysed is desirable when conducting a dissertation. On the contrary, it is also true that self-learning of statistical analysis reduces the need for statisticians’ help and will improve the quality of research. A statistician is best compared to a mechanic of a car which we drive; he knows each element of the car, but it is we who have to drive it. Sometimes the statisticians may not be available for a student in an institute. Self-learning software tools, user-friendly statistical software for basic statistical analysis thus gain importance for students as well as guides. The statistician will design processes for data collection, gather numerical data, collect, analyse, and interpret data, identify the trends and relationships in data, perform statistical analysis and its interpretation, and finally assist in final conclusion writing.

Results are an important component of the dissertation and should follow clearly from the study objectives. Results (sometimes described as observations that are made by the researcher) should be presented after correct analysis of data, in an appropriate combination of text, charts, tables, graphs or diagrams. Decision has to be taken on each outcome; which outcome has to be presented in what format, at the beginning of writing itself. These should be statistically interpreted, but statistics should not surpass the dissertation results. The observations should always be described accurately and with factual or realistic values in results section, but should not be interpreted in the results section.

While writing, classification and reporting of the Results has to be done under five section paragraphs- population data, data distribution analysis, results of the primary outcome, results of secondary outcomes, any additional observations made such as a rare adverse event or a side effect (intended or unintended) or of any additional analysis that may have been done, such as subgroup analysis.

At each level, one may either encounter qualitative (n/N and %) or quantitative data (mean [SD], median [IQR] and so on.

In the first paragraph of Results while describing the population data, one has to write about included and excluded patients. One needs to cite the Consolidated Standards of Reporting Trials (CONSORT) flow chart to the text, at this stage. Subsequently, highlighting of age, sex, height, body mass index (BMI) and other study characteristics referring to the first table of ‘patients data’ should be considered. It is not desirable to detail all values and their comparison P values in the text again in population data as long as they are presented in a cited table. An example of this pattern can be seen in Supplementary file 3D .

In the second paragraph, one needs to explain how the data is distributed. It should be noted that, this is not a comparison between the study groups but represents data distribution for the individual study groups (Group A or Group B, separately)[ Supplementary file 3E ].

In the subsequent paragraph of Results , focused writing on results of the primary outcomes is very important. It should be attempted to mention most of the data outputs related to the primary outcomes as the study is concluded based on the results of this outcome analysis. The measures of central tendency and dispersion (Mean or median and SD or IQR etc., respectively), alongside the CIs, sample number and P values need to be mentioned. It should be noted that the CIs can be for the mean as well as for the mean difference and should not be interchanged. An example of this pattern can be seen in Supplementary file 3F .

A large number of the dissertations are guided for single primary outcome analysis, and also the results of multiple secondary outcomes are needed to be written. The primary outcome should be presented in detail, and secondary outcomes can be presented in tables or graphs only. This will help in avoiding a possible evaluator's fatigue. An example of this pattern can be seen in Supplementary file 3G .

In the last paragraph of the Results, mention any additional observations, such as a rare adverse event or side effect or describe the unexpected results. The results of any additional analysis (subgroup analysis) then need to be described too. An example of this pattern can be seen in Supplementary file 3H .

The most common error observed in the Results text is duplication of the data and analytical outputs. While using the text for summarising the results, at each level, it should not be forgotten to cite the table or graph but the information presented in a table should not be repeated in the text. Further, results should not be given to a greater degree of accuracy than that of the measurement. For example, mean (SD) age need to be presented as 34.5 (11.3) years instead of 34.5634 (11.349). The latter does not carry any additional information and is unnecessary. The actual P values need to be mentioned. The P value should not be simply stated as ‘ P < 0.05’; P value should be written with the actual numbers, such as ‘ P = 0.021’. The symbol ‘<’ should be used only when actual P value is <0.001 or <0.0001. One should try avoiding % calculations for a small sample especially when n < 100. The sample size calculation is a part of the methodology and should not be mentioned in the Results section.

The use of tables will help present actual data values especially when in large numbers. The data and their relationships can be easily understood by an appropriate table and one should avoid overwriting of results in the text format. All values of sample size, central tendency, dispersions, CIs and P value are to be presented in appropriate columns and rows. Preparing a dummy table for all outcomes on a rough paper before proceeding to Microsoft Excel may be contemplated. Appropriate title heading (e.g., Table 1 . Study Characteristics), Column Headings (e.g., Parameter studied, P values) should be presented. A footnote should be added whenever necessary. For outputs, where statistically significant P values are recorded, the same should be highlighted using an asterisk (*) symbol and the same *symbol should be cited in the footnote describing its value (e.g., * P < 0.001) which is self-explanatory for statistically significance. One should not use abbreviations such as ‘NS’ or ‘Sig’ for describing (non-) significance. Abbreviations should be described for all presented tables. A typical example of a table can be seen in Figure 4 .

Example of presenting a table

Graphical images

Similar to tables, the graphs and diagrams give a bird's-eye view of the entire data and therefore may easily be understood. bar diagrams (simple, multiple or component), pie charts, line diagrams, pictograms and spot maps suit qualitative data more whereas the histograms, frequency polygons, cumulative frequency, polygon scatter diagram, box and whisker plots and correlation diagrams are used to depict quantitative data. Too much presentation of graphs and images, selection of inappropriate or interchanging of graphs, unnecessary representation of three-dimensional graph for one-dimensional graphs, disproportionate sizes of length and width and incorrect scale and labelling of an axis should be avoided. All graphs should contain legends, abbreviation descriptions and a footnote. Appropriate labelling of the x - and the y -axis is also essential. Priori decided scale for axis data should be considered. The ‘error bar’ represents SDs or IQRs in the graphs and should be used irrespective of whether they are bar charts or line graphs. Not showing error bars in a graphical image is a gross mistake. An error bar can be shown on only one side of the line graph to keep it simple. A typical example of a graphical image can be seen in Figure 5 . The number of subjects (sample) is to be mentioned for each time point on the x -axis. An asterisk (*) needs to be put for data comparisons having statistically significant P value in the graph itself and they are self-explanatory with a ‘stand-alone’ graph.

Example of an incorrect (a) and correct (b) image

Once the results have been adequately analysed and described, the next step is to draw conclusions from the data and study. The main goal is to defend the work by staging a constructive debate with the literature.[ 16 ] Generally, the length of the ‘ Discussion ’ section should not exceed the sum of other sections (introduction, material and methods, and results).[ 17 ] Here the interpretation, importance/implications, relevance, limitations of the results are elaborated and should end in recommendations.

It is advisable to start by mentioning the RQ precisely, summarising the main findings without repeating the entire data or results again. The emphasis should be on how the results correlate with the RQ and the implications of these results, with the relevant review of literature (ROL). Do the results coincide with and add anything to the prevalent knowledge? If not, why not? It should justify the differences with plausible explanation. Ultimately it should be made clear, if the study has been successful in making some contribution to the existing evidence. The new results should not be introduced and any exaggerated deductions which cannot be corroborated by the outcomes should not be made.

The discussion should terminate with limitations of the study,[ 17 ] mentioned magnanimously. Indicating limitations of the study reflects objectivity of the authors. It should not enlist any errors, but should acknowledge the constraints and choices in designing, planning methodology or unanticipated challenges that may have cropped up during the actual conduct of the study. However, after listing the limitations, the validity of results pertaining to the RQ may be emphasised again.

This section should convey the precise and concise message as the take home message. The work carried out should be summarised and the answer found to the RQ should be succinctly highlighted. One should not start dwelling on the specific results but mention the overall gain or insights from the observations, especially, whether it fills the gap in the existing knowledge if any. The impact, it may have on the existing knowledge and practices needs to be reiterated.

What to do when we get a negative result?

Sometimes, despite the best research framework, the results obtained are inconclusive or may even challenge a few accepted assumptions.[ 18 ] These are frequently, but inappropriately, termed as negative results and the data as negative data. Students must believe that if the study design is robust and valid, if the confounders have been carefully neutralised and the outcome parameters measure what they are intended to, then no result is a negative result. In fact, such results force us to critically re-evaluate our current understanding of concepts and knowledge thereby helping in better decision making. Studies showing lack of prolongation of the apnoea desaturation safety periods at lower oxygen flows strengthened belief in the difficult airway guidelines which recommend nasal insufflations with at least 15 L/min oxygen.[ 19 , 20 , 21 ]

Publishing the dissertation work

There are many reporting guidelines based upon the design of research. These are a checklist, flow diagram, or structured text to guide authors in reporting a specific type of research, developed using explicit methodology. The CONSORT[ 22 ] and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiatives,[ 23 ] both included in the Enhancing the Quality and Transparency of Health Research (EQUATOR) international network, have elaborated appropriate suggestions to improve the transparency, clarity and completeness of scientific literature [ Figure 6 ].

Equator publishing tree

All authors are advised to follow the CONSORT/STROBE checklist attached as Supplementary file 4 , when writing and reporting their dissertation.

For most dissertations in Anaesthesiology, the CONSORT, STROBE, Standards for Reporting Diagnostic accuracy studies (STARD) or REporting recommendations for tumour MARKer prognostic studies (REMARK) guidelines would suffice.

Abstract and Summary

These two are the essential sections of a dissertation.

It should be at the beginning of the manuscript, after the title page and acknowledgments, but before the table of contents. The preparation varies as per the University guidelines, but generally ranges between 150 to 300 words. Although it comes at the very beginning of the thesis, it is the last part one writes. It must not be a ‘copy-paste job’ from the main manuscript, but well thought out miniaturisation, giving the overview of the entire text. As a rule, there should be no citation of references here.

Logically, it would have four components starting with aims, methods, results, and conclusion. One should begin the abstract with the research question/objectives precisely, avoiding excessive background information. Adjectives like, evaluate, investigate, test, compare raise the curiosity quotient of the reader. This is followed by a brief methodology highlighting only the core steps used. There is no need of mentioning the challenges, corrections, or modifications, if any. Finally, important results, which may be restricted to fulfilment (or not), of the primary objective should be mentioned. Abstracts end with the main conclusion stating whether a specific answer to the RQ was found/not found. Then recommendations as a policy statement or utility may be made taking care that it is implementable.

Keywords may be included in the abstract, as per the recommendations of the concerned university. The keywords are primarily useful as markers for future searches. Lastly, the random reader using any search engine may use these, and the identifiability is increased.

The summary most often, is either the last part of the Discussion or commonly, associated with the conclusions (Summary and Conclusions). Repetition of introduction, whole methodology, and all the results should be avoided. Summary, if individually written, should not be more than 150 to 300 words. It highlights the research question, methods used to investigate it, the outcomes/fallouts of these, and then the conclusion part may start.

References/bibliography

Writing References serves mainly two purposes. It is the tacit acknowledgement of the fact that someone else's written words or their ideas or their intellectual property (IP) are used, in part or in toto , to avoid any blame of plagiarism. It is to emphasise the circumspective and thorough literature search that has been carried out in preparation of the work.

Vancouver style for referencing is commonly used in biomedical dissertation writing. A reference list contains details of the works cited in the text of the document. (e.g. book, journal article, pamphlet, government reports, conference material, internet site). These details must include sufficient details so that others may locate and access those references.[ 24 ]

How much older the references can be cited, depends upon the university protocol. Conventionally accepted rule is anywhere between 5-10 years. About 85% of references should be dispersed in this time range. Remaining 15%, which may include older ones if they deal with theories, historical aspects, and any other factual content. Rather than citing an entire book, it is prudent to concentrate on the chapter or subsection of the text. There are subjective variations between universities on this matter. But, by and large, these are quoted as and when deemed necessary and with correct citation.

Bibliography is a separate list from the reference list and should be arranged alphabetically by writing name of the ‘author or title’ (where no author name is given) in the Vancouver style.

There are different aspects of writing the references.[ 24 ]

Citing the reference in the form of a number in the text. The work of other authors referred in the manuscript should be given a unique number and quoted. This is done in the order of their appearance in the text in chronological order by using Arabic numerals. The multiple publications of same author shall be written individually. If a reference article has more than six authors, all six names should be written, followed by “ et al .” to be used in lieu of other author names. It is desirable to write the names of the journals in abbreviations as per the NLM catalogue. Examples of writing references from the various sources may be found in the Supplementary file 5 .

Both the guide and the student have to work closely while searching the topic initially and also while finalising the submission of the dissertation. But the role of the guide in perusing the document in detail, and guiding the candidate through the required corrections by periodic updates and discussions cannot be over-emphasised.

Assessment of dissertations

Rarely, examiners might reject a dissertation for failure to choose a contemporary topic, a poor review of literature, defective methodology, biased analysis or incorrect conclusions. If these cannot be corrected satisfactorily, it will then be back to the drawing board for the researchers, who would have to start from scratch to redesign the study, keeping the deficiencies in mind this time.

Before submission, dissertation has to be run through “plagiarism detector” software, such as Turnitin or Grammarly to ensure that plagiarism does not happen even unwittingly. Informal guidelines state that the percentage plagiarism picked up by these tools should be <10%.

No work of art is devoid of mistakes/errors. Logically, a dissertation, being no exception, may also have errors. Our aim, is to minimise them.

The dissertation is an integral part in the professional journey of any medical post-graduate student. It is also an important responsibility for a guide to educate his protégé, the basics of research methodology through the process. Searching for a gap in literature and identification of a pertinent research question is the initial step. Careful planning of the study design is a vitally important aspect. After the conduct of study, writing the dissertation is an art for which the student often needs guidance. A good dissertation is a good description of a meticulously conducted study under the different headings described, utilising the various reporting guidelines. By avoiding some common errors as discussed in this manuscript, a good dissertation can result in a very fruitful addition to medical literature.

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The cost and quality of the U.S. healthcare system is one of the most prominent issues facing everyday Americans. It is a top policy concern for voters, a key indicator of economic efficiency, and a significant driver of the national debt. The recent release of the Organisation for Economic Co-operation and Development’s (OECD) 2024 Health Statistics — a comprehensive source of comparable statistics on healthcare systems across OECD member countries — provides policymakers and the public with some insight on how America’s healthcare system compares to others.

The United States Spends More on Healthcare per Person than Other Wealthy Countries

The amount of resources a country allocates for healthcare varies as each country has its own political, economic, and social attributes that help determine how much it will spend. Generally, wealthier countries — such as the United States — will spend more on healthcare than countries that are less affluent. As such, it helps to compare healthcare spending in the United States to spending in other comparatively wealthy countries — those with gross domestic product (GDP) and per capita GDP above the median, relative to all OECD countries.

In 2022, the United States spent an estimated $12,742 per person on healthcare — the highest healthcare costs per capita across similar countries. For comparison, Switzerland was the second highest-spending country with $9,044 in healthcare costs per capita, while the average for wealthy OECD countries, excluding the United States, was only $6,850 per person. Such comparisons indicate that the United States spends a disproportionate amount on healthcare.

Why Is the United States Spending More on Healthcare?

Healthcare spending is driven by utilization (the number of services used) and price (the amount charged per service). An increase in either of those factors can result in higher healthcare costs. Despite spending nearly twice as much on healthcare per capita, utilization rates in the United States do not differ significantly from other wealthy OECD countries. Prices, therefore, appear to be the main driver of the cost difference between the United States and other wealthy countries. In fact, prices in the United States tend to be higher regardless of utilization rates. For example, the Peterson-Kaiser Health System Tracker notes that the United States has shorter hospital stays, fewer angioplasty surgeries, and more knee replacements than comparable countries, yet the prices for each are higher in the United States.

There are many possible factors for why healthcare prices in the United States are higher than other countries, ranging from the consolidation of hospitals — leading to a lack of competition — to the inefficiencies and administrative waste that derive from the complexity of the U.S. healthcare system. In fact, the United States spends over $1,000 per person on administrative costs — almost five times more than the average of other wealthy countries and more than it spends on long-term healthcare.

Does this Higher Spending Lead to Better Outcomes?

Higher healthcare spending can be beneficial if it results in better health outcomes. However, despite higher healthcare spending, America’s health outcomes are not any better than those in other developed countries. The United States actually performs worse in some common health metrics like life expectancy, infant mortality, unmanaged diabetes, and safety during childbirth.

A healthcare system with high costs and poor outcomes undermines our economy and threatens our long-term fiscal and economic well-being. Fortunately, there are opportunities to transform the healthcare system into one that produces higher quality care at a lower cost. For more information on potential reforms, visit our solutions page and the Peterson Center on Healthcare .

Related: Healthcare Costs for Americans Projected to Grow at an Alarmingly High Rate

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