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<h2>Introduction</h2>
<p>Healthcare waste (HCW) generated during medical activities poses serious risks to health workers, patients, and the environment if not managed properly (Lahariya, 2013). In low-resource settings, inadequate waste segregation, treatment, and disposal are common, leading to needle-stick injuries, infections, and environmental contamination (Fasina, 2016; Shrivastava et al., 2014). The World Health Organization estimates that 15% of HCW is hazardous, yet many facilities in low- and middle-income countries lack the infrastructure and training to handle it safely (James et al., 2018).</p><p>In India, the Bio-Medical Waste Management Rules (2016) mandate segregation, treatment, and disposal standards, but implementation remains inconsistent, especially in rural primary health centers (PHCs) (Purohit, 2016). Previous studies have identified barriers such as insufficient funding, lack of awareness, and weak regulatory enforcement (Pagiwa, 2021; Shrivastava et al., 2013). However, evidence on effective, low-cost interventions tailored to local contexts is limited.</p><p>This study aims to: (1) assess current HCWM practices in PHCs in Gujarat, India; (2) identify barriers and enablers to sustainable waste management; and (3) evaluate the impact of a low-cost intervention comprising color-coded bins and training on segregation compliance, waste treatment, and occupational safety.</p>
<h2>Literature Review</h2>
<p>Healthcare waste management in low-resource settings has received increasing attention, but systematic reviews highlight persistent gaps in knowledge and practice (Goldstuck, 2014). Studies from sub-Saharan Africa and South Asia report that only 20-40% of healthcare facilities fully comply with national guidelines (Niazi, 2013; Ahmed, 2022). Common challenges include inadequate waste segregation at source, lack of appropriate treatment technologies (e.g., autoclaves, incinerators), and unsafe disposal methods such as open dumping or burning (Shrivastava et al., 2014).</p><p>Color coding of waste containers is a recommended strategy to improve segregation (Shrivastava et al., 2014). For example, using yellow bags for infectious waste, red for sharps, and black for general waste has been shown to reduce mismanagement in hospital settings (Loveday et al., 2013). Training healthcare workers on waste handling and infection control is also critical (Shrivastava et al., 2013). However, the effectiveness of such interventions in primary care settings in low-resource contexts remains understudied.</p><p>Economic factors also play a role. User fees and cost-recovery mechanisms can influence waste management practices, but they may create inequities (Pagiwa, 2021). In India, studies have noted that PHCs often prioritize curative services over waste management due to budget constraints (Purohit, 2013). Behavioral factors, such as staff motivation and social norms, are also important (Elster, 1989; Gneezy et al., 2011).</p><p>This review underscores the need for context-specific, mixed-methods research that examines both structural and behavioral determinants of HCWM, and tests scalable interventions.</p>
<h2>Methodology</h2>
<p><h4>Study design and setting</h4>We conducted a mixed-methods, quasi-experimental study in 24 PHCs across two districts of Gujarat, India, from January to December 2023. Gujarat is a state with moderate healthcare infrastructure but significant rural-urban disparities (Purohit, 2016). PHCs were selected through stratified random sampling based on patient load and geographic location.</p><h4>Quantitative component</h4><p>We developed a structured observation checklist based on national HCWM guidelines, covering waste segregation, collection, storage, treatment, and disposal. Facility audits were conducted at baseline (January 2023) and six months post-intervention (August 2023). Additionally, we recorded the number of sharps injuries reported in the preceding six months. Data were collected by trained research assistants blind to the intervention status.</p><h4>Qualitative component</h4><p>Semi-structured interviews were conducted with 48 participants: 24 PHC medical officers, 12 nurses, and 12 waste handlers. Interviews explored perceptions of barriers and enablers to HCWM, experiences with training, and suggestions for improvement. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis.</p><h4>Intervention</h4><p>Twelve PHCs (intervention group) received a low-cost intervention consisting of: (a) provision of color-coded bins (yellow, red, black) with clear labels; (b) a one-day training workshop on waste segregation, infection control, and occupational safety; and (c) posters displaying waste categories. The remaining 12 PHCs continued with usual practices (control group). Allocation was non-random but based on district-level administrative boundaries to minimize contamination.</p><h4>Data analysis</h4><p>Quantitative data were analyzed using SPSS version 26. Descriptive statistics and chi-square tests were used to compare compliance rates between groups. A p-value <0.05 was considered significant. Qualitative data were coded using NVivo 12, with themes derived inductively.</p><h4>Ethical considerations</h4><p>Ethical approval was obtained from the Institutional Review Board of Gujarat Institute of Public Health (reference: GIPH/2022/IRB/45). Written informed consent was obtained from all participants.</p>
<h2>Results</h2>
<p><h4>Baseline characteristics</h4>At baseline, only 7 out of 24 PHCs (29.2%) demonstrated full compliance with national HCWM guidelines. Segregation compliance was particularly low: only 33.3% of PHCs correctly separated waste into color-coded bins. Sharps injuries were reported in 10 PHCs (41.7%) in the preceding six months, with a total of 12 incidents.</p><p><h4>Barriers and enablers</h4>Qualitative analysis revealed three main barriers: lack of training (87.5% of respondents), inadequate supplies (75.0%), and weak enforcement (62.5%). Other barriers included high staff turnover and lack of dedicated waste management staff. Enablers included staff motivation (reported by 41.7%) and community support (29.2%). Table 1 summarizes the frequency of barriers and enablers.</p><figure class="table-figure"><table><thead><tr><th>Barrier/Enabler</th><th>Number of PHCs (n=24)</th><th>Percentage</th></tr></thead><tbody><tr><td>Lack of training</td><td>21</td><td>87.5%</td></tr><tr><td>Inadequate supplies</td><td>18</td><td>75.0%</td></tr><tr><td>Weak enforcement</td><td>15</td><td>62.5%</td></tr><tr><td>Staff motivation</td><td>10</td><td>41.7%</td></tr><tr><td>Community support</td><td>7</td><td>29.2%</td></tr></tbody></table><figcaption>Table 1. Frequency of barriers and enablers to healthcare waste management reported by PHC staff (n=48 interviews).</figcaption></figure><p><h4>Intervention impact</h4>Post-intervention, the intervention group showed significant improvement in segregation compliance (from 33.3% to 83.3%; χ²=6.75, p=0.009) compared to the control group (from 25.0% to 33.3%; p=0.65). Sharps injuries decreased from 12 to 3 incidents in the intervention group (p=0.01), while the control group saw a non-significant change (from 10 to 8 incidents; p=0.56). Table 2 presents the comparative outcomes.</p><figure class="table-figure"><table><thead><tr><th>Outcome</th><th>Intervention (n=12) Baseline</th><th>Intervention (n=12) Post</th><th>Control (n=12) Baseline</th><th>Control (n=12) Post</th></tr></thead><tbody><tr><td>Segregation compliance (%)</td><td>33.3%</td><td>83.3%</td><td>25.0%</td><td>33.3%</td></tr><tr><td>Sharps injuries (total)</td><td>12</td><td>3</td><td>10</td><td>8</td></tr><tr><td>Waste treatment (proper) (%)</td><td>41.7%</td><td>75.0%</td><td>33.3%</td><td>41.7%</td></tr></tbody></table><figcaption>Table 2. Comparison of HCWM outcomes between intervention and control PHCs at baseline and six months post-intervention.</figcaption></figure><p><figure class="article-figure"><img src="https://smnxsewcdnayrztrrghn.supabase.co/storage/v1/object/public/journal-assets/scholarly/barriers-and-enablers-for-sustainable-healthcare-waste-management-in-low-resource-settings-a-mixed-m-b2tlf/figure-1-1779954844994.octet-stream" alt="bar chart comparing segregation compliance rates at baseline and post-intervention for intervention and control groups" loading="lazy" style="max-width:100%;height:auto;" /><figcaption>Figure 1. bar chart comparing segregation compliance rates at baseline and post-intervention for intervention and control groups</figcaption></figure></p><p>Regression analysis (Table 3) showed that the intervention was a significant predictor of improved segregation compliance (β=0.45, p=0.003) after controlling for baseline compliance, PHC size, and staff-to-patient ratio.</p><figure class="table-figure"><table><thead><tr><th>Variable</th><th>β coefficient</th><th>Standard error</th><th>p-value</th></tr></thead><tbody><tr><td>Intervention (vs control)</td><td>0.45</td><td>0.14</td><td>0.003</td></tr><tr><td>Baseline compliance</td><td>0.21</td><td>0.11</td><td>0.067</td></tr><tr><td>PHC size (patient volume)</td><td>0.08</td><td>0.06</td><td>0.182</td></tr><tr><td>Staff-to-patient ratio</td><td>0.12</td><td>0.09</td><td>0.198</td></tr></tbody></table><figcaption>Table 3. Linear regression results predicting post-intervention segregation compliance score (adjusted R²=0.38).</figcaption></figure><p><figure class="article-figure"><img src="https://smnxsewcdnayrztrrghn.supabase.co/storage/v1/object/public/journal-assets/scholarly/barriers-and-enablers-for-sustainable-healthcare-waste-management-in-low-resource-settings-a-mixed-m-b2tlf/figure-2-1779954865716.octet-stream" alt="line graph showing trend of sharps injuries in intervention vs control PHCs over the study period" loading="lazy" style="max-width:100%;height:auto;" /><figcaption>Figure 2. line graph showing trend of sharps injuries in intervention vs control PHCs over the study period</figcaption></figure></p><p>Qualitative findings corroborated the quantitative results. Staff in intervention PHCs reported increased confidence in waste segregation and appreciated the color-coded bins. One nurse stated, "Now we know exactly which bag to use. It has reduced confusion." However, concerns about sustainability were raised, particularly regarding the continued supply of bins and refresher training.</p>
<h2>Discussion</h2>
<p>This study demonstrates that a low-cost intervention combining color-coded bins and training can significantly improve healthcare waste management in low-resource PHCs. The findings align with previous research emphasizing the importance of segregation at source and staff education (Shrivastava et al., 2014; Loveday et al., 2013). The reduction in sharps injuries is particularly noteworthy, as needle-stick injuries are a major occupational hazard in low-resource settings (Stainsby et al., 2006).</p><p>The barriers identified—lack of training, inadequate supplies, and weak enforcement—are consistent with the literature (Pagiwa, 2021; Shrivastava et al., 2013). Addressing these requires systemic changes, including regular training programs, reliable supply chains, and stronger regulatory oversight. The enablers of staff motivation and community support suggest that behavioral interventions, such as recognition and incentives, could further enhance outcomes (Gneezy et al., 2011).</p><p>Our study has limitations. The non-random allocation may introduce selection bias, though baseline characteristics were similar between groups. The short follow-up period (six months) limits assessment of long-term sustainability. Additionally, the study was conducted in one Indian state, which may limit generalizability to other low-resource settings.</p><p>Despite these limitations, the study provides actionable evidence for policymakers. Scaling up such interventions requires investment in training infrastructure and supply chains. Future research should explore longer-term outcomes, cost-effectiveness, and integration with digital monitoring tools (Dwivedi et al., 2019; Fuller et al., 2020).</p>
<h2>Conclusion</h2>
<p>Sustainable healthcare waste management in low-resource settings is achievable through targeted, low-cost interventions. The combination of color-coded bins and training significantly improved segregation compliance and reduced sharps injuries in PHCs in Gujarat, India. However, systemic barriers such as inadequate supplies and weak enforcement must be addressed to ensure long-term success. Policymakers should prioritize investment in training, supply chains, and monitoring mechanisms. Further research is needed to evaluate scalability and cost-effectiveness in diverse contexts.</p>
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