Knowledge, Attitudes, and Practice Health Care Workers on Disposable Mask Waste Management in the Post-COVID-19 Pandemic

: Biomedical waste including disposable masks requires proper waste handling so it doesn’t pollute the environment and cause re-transmission of COVID-19 disease. The purpose of this study was to look at the relationship between the knowledge, attitudes and practices of the Public Health Centre in Pangandaran Regency. Methodology: Cross-sectional study approach to study assessed KAP. 91 participants were from 15 different public health centres in Pangandaran. Data analysis used chi-square statistical test. Presented with frequency distribution and the form of a tabulation. Result indicated knowledge of respondents was only 41.40% with high scores and practices with high scores were only 44.40% but attitudes towards disposable mask waste management with high scores reached 98.6%. There is a relationship between age and practice with a p-value of 0.009 and a relationship between knowledge and practice with a p-value below 0.05. Conclusion the participants had insufficient knowledge and practice scores but have good attitude scores. Our results conclude that the HCWs good attitude does not affect good practice but knowledge may lead to a proper practice. Findings of this study suggest that a regular training program for the HCWs on BMW specially on disposable mask management may lead to better practice.


Introduction
Covid-19 masks fall into the category especially medical Waste (BW) referring to waste generated by medical and laboratory activities during diagnosis, treatment or immunization of humans or animals.Hazardous waste is considered a major threat to health and the environment (Pieper et al., 2017).Improper management and exposure to infectious waste resulting from positive patients can easily infect health staff such as; doctors, nurses, waste collectors and visitors (Das et al., 2021).
The largest composition of Biomedical Waste from the manufacture of personal protective equipment (PPE), one of which is a mask, is a type of plastic.This composition was more or less the same before the pandemic and during the pandemic but due to very high demand, production increased significantly (Singh et al., 2020).In Indian hospitals, the number of Biomedical Waste increased from 25 tons pre-pandemic to 349 tons/day during May-July and is expected to double during August-October (Chand et al., 2021).The local government in Sydney reported a 35% increase in biomedical waste due to the COVID-19 pandemic (Scott et al., 2021).In Indonesia, in just one year (from March 2020 to February 2021) the amount of medical waste generated by healthcare facilities was 6,418 tons, this figure does not include medical waste from the Covid-19 vaccination process which began in January 2021 and is targeted to target 180 million Indonesian residents (Suryani, 2021).The massive production of Biomedical Waste during a pandemic is a new threat to public health and the environment (Haji et al., 2020).Managing Biomedical Waste during a pandemic needs special attention because this waste acts as a vector for COVID-19 and can increase the spread of the virus.The COVID-19 virus can survive for 72 hours outside the host organism on the surface of the mask used (Barcelo, 2020).
The satisfactory knowledge, attitudes and practices of health staff about the nature of the waste generated can be effective in the safe management of waste (World Health Organization, 2020).Sustainable management of medical waste management requires the existence of a waste treatment unit, allocating financial and labor resources, conducting regular training, monitoring, evaluating, and continuing to improve facilities and infrastructure (Das et al., 2021).Installation of biomedically marked waste disposal sites with trained administrators is the method used in many countries.For waste disinfection, using disinfectants and sort for 9 days if needed (Das et al., 2021).
In South Korea, the principles of managing the health and safety of health workers with a waste management approach, especially biomedical waste, are to reduce risk (Rhee, 2020).In Wuhan City it has improved its management processes by closing municipal waste dumps and investing more in disinfecting waste generated during the pandemic (Wang et al., 2021).Biomedical Waste is collected from specially marked containers, transported and disposed of by specially designed vehicles with trained workers (Sangkham, 2020).Healthcare staff must be sensitive to the environment; they must advocate for positive changes to manage the waste generated during the pandemic.In other words, maintaining the quality of patient care and worker safety must be considered in parallel with waste management.Producing exclusively educational or publicly available videos on proper waste management in COVID-19 and hosting webinars by environmental experts can help improve staff health knowledge, attitudes, and practices (Adam et al., 2019).
The focus of this research is the management of disposable mask waste in Pangandaran Regency, especially all Community Health Centers.The purpose of this study was to look at the relationship between the knowledge, attitudes and practices of the Public Health Centre (Puskesmas) staff towards the management of disposable mask waste at the Puskesmas.The choice of the Puskesmas as the study site was due to the fact that the incidence of COVID-19 among health workers working in Public Health Centre was higher (32.5%) compared to the incidence among health workers working in hospitals (17.9%).The study also found that health workers working in Public Health Centre tend to not use personal protective equipment (PPE) more often than health workers working in hospitals (Dhandapani et al., 2023).

Method
The type of research used is descriptive with a cross sectional study approach.The research sites were all puskesmas in Pangandaran Regency with the respondent population being puskesmas employees who were sampled using proportional random sampling (Riduwan, 2015).There are 1100 Puskesmas employees registered in 2021 in 15 Puskesmas.From this population, 91 samples were obtained which would become respondents with different proportions.Collecting data by interview using a questionnaire as well as observation with the observation sheet.Data collection was carried out from January -March 2023.Data analysis used univariate and bivariate with the chi square statistical test.Presentation of the results of the analysis in a descriptive manner with a frequency distribution and is presented in the form of a tabulation.

Relationship between Demographic and Practice
The practice of managing disposable masks is divided into 4 parts, namely: (1) Segregation of waste; (2) Collection and transportation of waste; (3) Waste management during the Covid-19 pandemic; (4) Waste management after the Covid-19 pandemic.
Table 3 show the results of the analysis of the demographic relationship with the practice of managing disposable mask waste turned out to only have one result that was significantly related, namely the relationship between age and the practice of collecting and transporting waste with a p-value of 0.009.Other results show no relationship between the demographics of respondents and the practice of managing disposable mask waste.

Relationship between Knowledge, Attitude and Practice
The results of the analysis can be seen in table 4, it turns out that there is a relationship between knowledge and all disposable mask waste management practices including knowledge and practice of waste sorting with a p-value of 0.003; Knowledge with the practice of collecting and transporting waste with a p-value of 0.026; Knowledge with waste management practices during the Covid-19 pandemic with a p-value of 0.002 and Knowledge with waste management during the post-Covid-19 pandemic with a p-value of 0.000.For Attitude, it turns out that there is no relationship with the practice of managing disposable mask waste.

Discussion
Medical waste generated especially mask waste at health care facilities may pose a serious threat to health care worker, common people and the surrounding environment if handling improper (World Health Organization, 2018).Since the health care worker play an important role in regulated biomedical waste disposal, it is important to have a high level of awareness.This emphasizes the importance of evaluating the knowledge, attitude, and practice of health care worker with respect to biomedical waste management and the factors that influence them.
Knowledge may lead to improper application of knowledge that may be detrimental to any healthcare organization, the value Knowledge is an essential resource in health science education (Karimi et al., 2014) (Shahmoradi et al., 2017).The present study results revealed that less than half (41.4%) of the participants had high knowledge of medical waste management generated at their work settings.Similar to our study findings, a recent survey conducted by Jalal SM in the Al-Hasa region of the KSA also found that only 41% of the healthcare professionals had excellent knowledge of biomedical waste disposal (Jalal et al., 2021).Other surveys conducted in some other countries also reported that a low proportion of the health care worker (HCWs) had favourable knowledge of healthcare handling and disposal (Deress et al., 2018) (Olaifa et al., 2018) (Woromogo et al., 2020)(Krithiga et al., 2021).Different from our study, a study conducted by (Reddy & Al Shammari, 2017) in the Hail region of the Kingdom of Saudi Arabia and (Akkajit et al., 2020) in Thailand stated that a higher proportion of healthcare professionals had good knowledge.The possible difference between our study and the latter studies could be the inclusion of healthcare facilities.The present study only from public health centre.
A positive attitude will guide the HCWs to follow the standards, protocols, and evidence-based practices this study found 98.8 5 have high score.Excellent attitude toward BMWs found in study conduct by (Dalui et al., 2023).Another study conducted in Cairo, Egypt, reported that the duration of work experience was not significantly associated with attitude (Hakim et al., 2014).These huge variations in the results among different studies could be due to the variations in data collection tools, survey settings, and cultural variations.
The results of the study show that there is a significant relationship with a p-value below 0.05 between age and one section of practice with p value 0.026, ither research have same result (Woromogo et al., 2020).The results of the relationship between knowledge and practice of the 4 sections of waste management showed all significant results (p-value <0.05) indicating that the knowledge of health workers about waste management is very important to improve proper waste management practices in health facilities.Therefore, it is necessary to make efforts to increase the knowledge of health workers about waste management and ensure that proper waste management practices are carried out in health facilities.Other research also states the same the knowledge of health workers and waste management practices similar according research by Tobin et al (Tobin et al., 2013) (Mathur et al., 2011).Different in other studies as said by N. Gupta (Dalui et al., 2023) that inadequate knowledge result low on precaution

Conclusion
The present study assessed knowledge, attitude and practice towards disposable mask management among public health center less than half of the participants had insufficient knowledge and practice scores but have good attitude scores.Furthermore, our results conclude that the health care worker (HCW's) good attitude does not affect to good practice but knowledge may lead to a proper practice.Findings of this study suggest that a regular training program for the HCWs on BMW specially on disposable mask management is necessary through symposiums, roleplay, interactive lectures, and other feasible training methods.These training programs can be focused and targeted oriented to the HCWs category with low and medium scores in knowledge may lead to good practice in the management of disposable mask waste.

Table 2 .
Attitude and Practice of Managing Disposable Mask WasteTable2presents the categorization (low/high) of knowledge, attitude and practice scores.From 70 respondents, knowledge scores with high scores were found at 41.4%, medium 50.0% and low 8.6%.Respondents who had a high attitude were 98.6%, while 1.4% and no one had a low score.Practices carried out by respondents with a high score were 44.3%, moderate 37.1% and 18.6% low.Distribution of Knowledge, Attitude and Practice of Among Respondent 9101Knowledge,

Table 3 .
Cross Tabulation between low/medium, high Practices Score and Demographic Characteristic

Table 4 .
Cross Tabulation between Knowledge, Attitude and Practice