RESEARCH ARTICLES

Healthservice waste: challenges and prospects in primary care

Luzibênia Leal de Oliveira^I; Patrício Marques de Souza^II; Francisco de Sales Clementino^III; Sérgio Cavalcanti de Paiva ^IV; Fátima Daniela Lúcio Jorge Rocha^V

^I Nurse. Master in Natural Resources, Federal University of Campina Grande. Professor at the Federal University of Campina Grande - Paraiba. Brazil. E-mail: luzibenia@hotmail.com
^II Veterinarian. PhD in Veterinary Clinic, University of Sao Paulo. Professor at the Federal University of Campina Grande - Paraiba. Brazil. E-mail: patriciomsouza@ig.com.br
^III Nurse. PhD in Nursing from the Federal University of Rio Grande do Norte. Professor at the Federal University of Campina Grande - Paraiba. Brazil. E-mail: clementinosales@ig.com.br
^IV Computer scientist. PhD in Computer Science from the Federal University of Campina Grande. Professor at Rural Federal University of Pernambuco. Email: scpaiva@yahoo.com.br
^V Physiotherapist. Master of Physiology, Federal University of Pernambuco. E-mail: daniela.lucio@gamil.com

ABSTRACT

This study examined solid waste management at family primary health care centers, from generation to disposition for external collection. This qualitative exploratory, descriptive study was conducted from August 2011 to January 2012 in Campina Grande, Paraíba. Data were collected through semi-structured interviews of 55 professionals from 36 family health teams, and analyzed within the framework of Bardin thematic content analysis. The results showed that most facilities have no suitable space for temporary waste storage, and no specific standards and laws have been published on waste. This evidences the need for a waste management plan that can be adjusted to health service realities in compliance with health and environmental standards.

Keywords: Management; waste; primary care; family health.

INTRODUCTION

This article is an excerpt of the dissertation entitled Study on health services waste management in primary care in Campina Grande - PB, which was defended in the Graduate Program in Natural Resources of the Federal University of Campina Grande - PB (UFCG).

Organic waste, if not managed properly, can be a source of transmission of numerous diseases, as they become habitat and food for many vectors. Another issue worth mentioning is leachate, that contaminates the soil and groundwater with organic substances, pathogenic microorganisms and many chemical contaminants present in various types of waste¹.

A percentage higher than 80% of the municipalities dispose their waste in open places, watercourses or environmentally protected areas. In these areas, people crowd in search of survival and many children live in these environments, a fact that highlights the social problems that poor waste management causes².

Proper management of waste generated by health facilities is crucial to the promotion of health, quality of life and preservation of the environment. To this end, it is necessary that managers - municipal, state and federal - seek to know deeply the subject and put in practice the existing legislation and norms.

In this context, it is possible to add that the issue of solid waste is even more difficult in small and medium-sized municipalities. Corroborating this reflection, it is stated that there is a need of more intensive action by the Government in regard to the implementation of public policies for this sector ³.

However, according to legal and technical guidelines of the Collegiate Board Resolution (RDC) of the National Health Surveillance Agency (ANVISA, in Portuguese) Number 306/04 and of the National Council on the Environment (CONAMA, in Portuguese) Number 358/05, all waste generators shall draw and implement the Management Plan of the Health Services Waste (PGRSS)^4,5.

PGRSS is the document that points and describes the actions relating to solid waste management, considering their characteristics and risks, in the scope of institutions, covering all aspects relating to the generation, segregation, storage, collection, transportation, treatment and final disposal and also the protective actions to health and the environment⁶.

As regards the city of Campina Grande-PB, locus of this study, similar to what happens in most municipalities, there is no proper management of municipal solid waste, including the health services waste (HSW). In this research, we highlight the waste produced in the establishments that make up the primary care, especially in basic family health units (BFHU).

This study had the following guiding question as a starting point: How can the problem of health services waste be better understood through situation analysis? In this perspective, we developed the following objective: to study the health services waste management produced by basic family health units, in the city of Campina Grande-PB, from generation to disposal for external collection.

LITERATURE REVIEW

The production of waste is inherent to life, since activities considered vital to the survival of any living generate them. But the increase in the generation of waste of all kinds, due to human action, has become of growing concern.

With the growth of the world population, and the concentration of this population in urban areas, as well as the way and the pace of the occupation of these spaces and the way of life based on increasingly faster production and consumption of goods, the problems caused by waste tend to become more apparent¹.

Waste is also called garbage, and can come from various sources, such as: industrial, residential, commercial, agricultural and sweeping services. The household waste is the result of daily activities, and Brazil produces between 200 and 500 grams of waste per day⁷.

The inner city areas contribute to the so-called commercial waste, mainly consisting of paper and cardboard discarded by stores, banks and offices. Other types of waste are those from the health services, discarded by hospitals, pharmacies, veterinary clinics, among other institutions.

The HSW are generally called medical waste, however, they may come from different places, such as: research centers, development or experimentation in the area of pharmacology and health, expired or deteriorated drugs and immunotherapy, those from morgues, funeral homes and forensic medicine services and those produced in sanitary barriers⁸.

In addition, part of the waste generated in homes can have characteristics from those produced by the health services, taking as an example those people with diabetes, who daily administer insulin and injected drug users that generate waste⁸.

All these waste, that is hazardous on human health, are despised along with common household waste to the point of impacting to the environment and consequently the health of people living with thereof⁸.

METHODOLOGY

This is a descriptive, cross-sectional, exploratory study, with a qualitative approach, with a view that goes beyond mere operationalization of variables, seeking to understand relationships, processes and events⁹.

Data collection was conducted in 36 primary family care units, located in the city of Campina Grande - PB, with the participation of 55 health professionals and 23 general helpers, from August 2011 to January 2012 by means of semi-structured interviews.

For the interviews, we used a script based on the Ministry of Health recommendations found in the Handbook for Health Services Waste Management, published in 2006. For the purpose of analysis on the responsibility of health professionals, we questioned the application of the concepts and rules adopted by the municipal administration, focusing on drawing up the HSW management plan in primary care of Campina Grande-PB.

We elected as inclusion criteria: professionals working in the Family Health Strategy of Campina Grande - PB, who had been working in the team for more six months and who was present at their workplace at the time of the data collection visit. The exclusion criteria included: those who do not meet the proposed inclusion criteria, as well as community health workers (CHWs), because their activities are conducted primarily outside the BFHUs, therefore, they hardly generate or handle waste in these establishments.

To preserve anonymity, participants were identified by the letters HP - representing the initial letters of the term Health Professional - followed by a number, for example, HP1, HP2, and so on. The recorded interviews were transcribed and analyzed using thematic content analysis of Bardin¹⁰.

This technique goes through three chronological poles: pre-analysis, exploration of the material and treatment of results, inference and interpretation. The pre-analysis consisted of listening and transcribing the interviews. Then, we observed the relationship between the content and objectives. We highlighted the most relevant fragments that composed the corpus of analysis. During the second chronological pole, the exploration of the material and the fragments of the corpus were grouped into four categories: Generation of Health Services Solid Waste; Packaging of HSW; Temporary Storage of HSW and Disposal of HSW.

This work was approved by the Research Ethics Committee (REC) of the State University of Paraíba (UEPB) under Protocol 0334.0.133.000-11 on August 1, 2011, according to the guidelines of Resolution No. 196/1996¹¹.

RESULTS AND DISCUSSION

From the analysis of the interviews it was possible to organize the themes in, basically, four thematic categories: Generation of health services solid waste; Packaging of HSW; Storage of HSW; Disposal of HSW.

Generation of health services solid waste

When asked about the relationship between places in the BFHU and the production of HSW, some professionals referred mainly to Vaccines Room, Dressing Room, Cytology Room, Pharmacy and Dental Office, though commonly there are other environments in the BFHU that are worth highlighting due to volume and dangerousness of waste they generate, like the bathrooms, screening room, nursing and physician offices.

This situation becomes evident in the later discursive manifestations:

[...] in each room that generates waste, there are trashcans. In medical offices there are common dumps; there are boxes of sharps in the screening room, in the vaccine room, in the dentist's room, in the doctor's room, because he likes to do blood glucose test in diabetic patients [...]( HP 13).

[...] there is the waste of the vaccine room, of the dressing room and of the cytology room. There is also the waste of the pharmacy, with packaging and expired medications; there is also excess mercury that is taken from the amalgam in the dentist's room [...] ( HP 34).

The generation of solid waste in a health service is determined by the complexity and by the frequency of services that an institution performs and by the efficiency that those responsible for services reach in the development of their tasks, as well as by the technology used¹².

In relation to activities undertaken in BFHUs and the potential thereof to the generation of waste, it is considered that the performance of immunization and dressings generates wastes listed in groups A and E. The pharmacy and the dental office stand out for the generation of chemical waste (group B), resulting from the storage of antimicrobial substances and amalgam, respectively. The medical and nursing offices can generate group A (infectious) waste, that are often stored together with the group D (common) waste.

Packaging of HSW

In this category it is evident that the units do not have plastic bags and containers suitable to make the correct packaging of waste, which is an essential procedure for the correct management of HSW. To portray this situation, the following statements were selected:

We have a separate trashcan for the contaminated material: gloves, gauze; other to cutting or sharp materials; and another for amalgam, which are the three types of waste we normally produce, and general waste ends up mixed in the contaminated waste, the one of the gloves, because it is a smaller quantity, since we do not use paper to dry hands, we dry hands on towels, so the common garbage is little generated [...] ( HP 02).

In this unit we don't have waste basket, actually, there is one in the dressing room, which was a donation. Generally, you can see that we use empty boxes of medication; they have never cared about this issue here, not at all [...] (HP 20).

The packaging of HSW concerns the act of packaging waste previously separated in bags or containers in adequate quantity and varieties, preventing segregation and favoring the correct packaging. Furthermore, the capacity of the containers used for packaging must be compatible with the daily generation of each type of waste⁶.

Inadequate or improvised containers, made of materials without proper protection, increase the risk of accidents at work⁶. This situation endangers the health of the community and workers who deal directly with HSW discarded in the environment improperly.

Health facilities must have suitable containers to package each type of waste, to ensure proper identification of the material, to facilitate transportation and cleaning operations; they need to be hermetic to avoid unnecessary exposure and be integrated to the physical and architectural conditions of the place. Such containers are supplemented with the use of specific plastic bags to make a proper packaging of waste¹².

In addition, we need to expand the investment of health departments in the supervision of health services, to strengthen the role of health managers and the institution itself with regard to guaranty and maintenance of salubrious work environments¹³.

Temporary storage of HSW

Reading the subsequent lines allows us to infer that most BFHU does not have a suitable place for temporary storage of HSW as health guidance require. These are usually improvised, and service areas, backyards, among others are chosen.

This unit lacks an adequate structure. We don't have place for storage. Lately the waste has been stored in the patients' bathroom, waiting for the staff to take it away [...] (HP 52).

There, at the end of the unit, in the service area, there is a trashcan where all contaminated material is stored there [...] (HP 12).

In general, we can see that the structures where the activities of primary care are developed in Campina Grande-PB are inadequate for internal storage of HSW, because they are mostly buildings initially thought to be houses and that were obtained to function as health services. So, they have been adapted for this purpose. This situation favors the emergence of harm to public health and to the environment, promoting soil contamination, visual pollution and proliferation of vectors.

According to the RDC No. 306/04 of ANVISA, there are two types of storage: the temporary storage and the external storage. The first may occur in cases where the distance between the point of generation and the external storage justifies this procedure. The latter is regard storing waste containers until the completion of the external collection step, in exclusive environment with easy access for collecting vehicles⁴.

A speech calls attention by the clarity that the health professional respondent has about the need for an organized and efficient management in the control of health services waste, in addition to inadequate working conditions, pointing out as a critical point in this dimension the scarcity of material resources.

By the way, the general helper told me that the waste basket where she put the white bags for the collection staff take them away is broken and that she is putting them in a corner of the unit. We had already complained that the waste basket was in a place where users have access, which should not have happened, and now we do not even have a waste basket anymore [...] (HP 02).

The previous speech shows how this problem affects workers' health. These unhealthy and dangerous conditions often become routine, and are not perceived by managers, nor by the health worker, that gets used to the situation or maintains self-control of the evidence, without seeking to clarify the real causes ¹⁴.

Ministerial regulation guides that external temporary storage of HSW should be done in protected and covered place, in suitable collector containers, in exclusive environment with easy access for collecting vehicles⁶. Also according to the Handbook for Health Services Waste Management⁶ , the external storage location must contain the following:

* Accessibility: the environment must be located and constructed so as it allows easy access to transport containers and collecting vehicles;

* Exclusivity: the environment should be used only for the storage of waste;

* Security: the environment must meet proper structural conditions, preventing the action of sun, rain, wind, among others. Unauthorized people or animals should not have access to the place;

* Hygiene and Sanitation: there must be place for cleaning the dustbins and containers; it should also have good lighting and ventilation and also floors and walls cladded with materials resistant to cleaning processes.

In that sense, authors guide on the need for conducting studies in order to identify new risks to which these professionals may be exposed, so as to design and implement management programs in the workplace, aimed at health, job satisfaction and consequently, improvement of quality of care directed to individuals, community and environment¹⁵.

Disposal of HSW

This category discusses the issue of HSW generated in family health units, showing the complete lack of knowledge of the respondents in relation to final destination of waste. This shows the lack of planning regarding HSW generated by primary care in the city of Campina Grande, PB.

The statements of the respondents indicate the complexity of this problem:

We know that they are collecting, but we do not know the final destination. We do our part, but regarding what happens after waste leaves the unit we do not know [...] (HP 02).

In the end, I think this waste goes to the landfill along with hospital waste, maternity, waste, our waste, waste from our houses. I believe, from what I see on television and radio, that waste leaves segregated, but in the final destination everything is mixed. (HP 13)

The city under study, similar to most Brazilian municipalities, does not dispose adequately their waste, a fact that deserves great concern. Besides, we notice, in the interviews, that this seems to be a problem relegated by health professionals, since they do not seem to be interested in knowing where the waste generated in their work environment has been allocated.

Providing a safe and efficient solution to HSW constitutes a major problem nowadays for both rich countries and for poor countries, as there is not a consensual scientific basis to ensure a better method of treatment and disposal, without causing damage to human health and the environment. Thus, it is necessary that this process is planned¹⁶.

The final disposal of HSW must be preceded by pretreatment of the waste, depending on their risk potential and this must be the generator's responsibility ¹⁶. According to Resolution No. 05/93 of CONAMA, group A waste - considered infectious - cannot be disposed in the environment without pretreatment, and its recycling is forbidden. After treatment, this type of waste is considered group D (common) waste and concerning it, it should be followed the recommendations of environmental organizations¹⁷.

For the RDC No. 33/03 ANVISA, groups A and B wastes must follow different types of treatment or decontamination in the very generating unit, before being forwarded to treatment and/or disposal. Group E waste must receive pretreatment or must be referred directly to landfill¹⁸.

According to RDC No. 306/04, ANVISA, the treatment for the group C waste is storage under suitable conditions for the decay of the radioactive element, until its activity reaches a level that enables releasing it as non-radioactive waste, whereas the group D (common) waste does not require pretreatment, and its disposal should be carried out in places licensed by the environmental organization in charge⁴.

The researcher recommends that the final disposal of HSW must be preceded by pretreatment, depending on their risk potential and that this is the generator's responsibility¹⁶. Thus, it is understood that each stage of the management process has its importance and therefore none can be missed.

CONCLUSION

In view of the challenge proposed by this research, in study the HSW produced by the family health units in the city of Campina Grande-PB, from its generation to the disposal for external collection, the findings indicate that visited health facilities lack of necessary infrastructure for proper management of waste. In addition, the units do not have a place for internal storage of waste that meets the required health standards, either. This favors the crossing of waste with medicines, foods and users.

Health facilities that compose primary care in Campina Grande-PB generate groups A, B, D and E waste, which is are not being properly segregated, since, according to reports from workers, besides the lack of training to prepare them for dealing with waste, there are not packagers available in quantity and quality necessary in their work units.

Thus, permanent education appears as an important tool for evaluation, regulation and monitoring in the health sector, as it stands as a possible strategy in restructuring health services, from the analysis of the social and economic determinants, especially of values and concepts developed by professionals. In this sense, we reinforce the need for intersectoral responses from strategies that contribute to improving the management of HSW and the public policies of environmental health.

We can cite as limitations of this study the lack of literature on the proposed theme, demonstrating greater incentive in disseminating scientific research in post-graduation courses and in Master's and Doctorate degrees, in order to disseminate, socialize and produce knowledge with a focus on environmental issues.

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