European Journal of Cardiovascular Medicine

Hospitals, besides being centers of healing, are major generators of biomedical waste (BMW), which, if not managed properly, can pose significant risks to public health and the environment.(1) Biomedical waste includes all waste generated during medical procedures, research activities, or biological testing (Bio-Medical Waste Management Rules, 2016).(2) According to the World Health Organization (WHO), 85% of BMW is non-hazardous, while the remaining 15% is considered hazardous, with 10% being infectious and 5% consisting of toxic chemicals or radioactive materials (WHO, 2022).(3) Proper BMW management is crucial to prevent hospital-acquired infections, reduce environmental contamination, and ensure occupational safety. However, improper waste handling contributes to vector-borne diseases, pollution, and needle-stick injuries, which affect approximately 2 million healthcare workers worldwide each year, increasing their risk of contracting infections such as HIV and hepatitis B and C.(4)

The annual growth rate of BMW in India is estimated at 7%, with a projected increase to 775.5 tonnes per day by 2022.(5) The Bio-Medical Waste Management Rules, 2016, and their amendments in 2019 mandate strict segregation, handling, and disposal of medical waste. While legislation exists, the effectiveness of these regulations depends largely on the competence and adherence of healthcare personnel to best practices.(6) However, research suggests that gaps in knowledge among healthcare professionals, particularly undergraduate medical students, contribute to unsafe waste disposal practices.(7) Given that medical students represent the future workforce of the healthcare system, equipping them with comprehensive training on biomedical waste management is crucial for ensuring sustainable waste handling practices in hospital settings.

West Bengal, with its extensive network of tertiary care hospitals, faces similar challenges in BMW management. A preliminary assessment in select medical institutions of the region revealed that a significant proportion of students lacked adequate knowledge of the color-coded segregation system, safe disposal methods, and regulatory policies governing BMW management.(8) Moreover, inconsistencies in training programs and the absence of standardized educational interventions have exacerbated this problem. While sporadic sensitization sessions are conducted, they are often insufficient to instill long-term behavioral changes. Addressing these gaps necessitates structured training programs that focus on biomedical waste segregation, risk assessment, and adherence to national guidelines.

This study aimed to assess the impact of a structured training program on the knowledge and awareness of biomedical waste management among undergraduate medical students in a tertiary care hospital in West Bengal. By implementing targeted educational interventions, this study sought to evaluate the effectiveness of training in improving students' comprehension of biomedical waste segregation, disposal practices, and regulatory compliance. The findings will help inform institutional policies on medical waste management training, bridge existing knowledge gaps, and foster responsible waste disposal behaviors among future healthcare professionals.

Study setting

This study was conducted at Burdwan Medical College, a tertiary care teaching hospital in Purba Bardhaman, West Bengal. Serving a large catchment population from both rural and urban areas, the institution provides undergraduate medical education and comprehensive healthcare services. The study setting reflects the real-world context of biomedical waste generation and handling in a resource-constrained, yet functionally active public health facility. The local implementation of national biomedical waste management guidelines, combined with variable baseline awareness among medical students, provides a relevant environment for assessing the impact of structured training interventions on knowledge enhancement.

Study design

This cross-sectional study was conducted over three weeks in the Department of Microbiology, Burdwan Medical College and Hospital, West Bengal.

Study population

The study included 200 Professional MBBS candidates (4th semester), who were selected using a purposive sampling method. Written informed consent was obtained from all participants.

Sample size

This cross-sectional study, conducted over three weeks period, considered 200 Professional MBBS candidates (4th semester) who were willing to participate in the study.

Study procedure

A pre-validated, self-administered questionnaire was used to assess knowledge of biomedical waste management before and after the structured training intervention. Training sessions were conducted to increase participants' awareness and improve their knowledge of biomedical waste segregation. The sessions included three lectures focused on biomedical waste management rules, steps of the BMWM including segregation protocols, waste treatment, and disposal methods. The training spanned over three weeks and was organized in the general lecture theatre.

Data collection

Data collection was conducted using a pre-validated, structured, self-administered questionnaire designed to assess medical students’ knowledge of biomedical waste management. The questionnaire included multiple-choice questions covering key domains such as categorization of biomedical waste, color coding, segregation practices, handling protocols, and regulatory guidelines. The tool was validated through an expert review of content relevance, clarity, and alignment with the national biomedical waste management guidelines. Prior to administration, the students were briefed about the purpose of the study and assured of their confidentiality and voluntary participation.

The questionnaire was shared in Google form before and after a structured training session conducted by the faculty members of the Department of Microbiology. The training module focused on national guidelines, standard operating procedures, and infection control measures related to biomedical waste handling. Post-training responses were collected within 48 hours to assess immediate knowledge gain.

The collected data were manually entered into Microsoft Excel 2010 by two independent data entry personnel to minimize transcription errors. Data validation was ensured through cross-verification of the entries. Inconsistencies or missing data were identified and rectified by rechecking the original questionnaire. Range and logical consistency checks were applied to enhance data accuracy. Each questionnaire was assigned a unique code to maintain participant anonymity and to enable matched pre- and post-training analyses.

Data analysis

The data were analyzed using SPSS version 16 (SPSS for Windows; SPSS Inc., Chicago, IL, USA). Descriptive statistics, including frequency, percentage, mean, and standard deviation, were used to summarize the knowledge scores. To assess the impact of training, pre- and post-training knowledge scores were compared using paired t-tests. Statistical significance was set at p < 0.05.

Human participant protection

Informed consent was obtained from all participating students and confidentiality was maintained throughout the study. Ethical approval was granted by the Institutional Human Ethics Committee of Burdwan Medical College, Purba Bardhaman, West Bengal. No deviation from the approved study protocol was observed during the study period.

Knowledge about biomedical waste management in medical students before and after training

A total of 146 undergraduate medical students participated in the pre-training assessment, and 126 students completed the post-training evaluation using a structured, pre-validated questionnaire designed to assess their knowledge of biomedical waste (BMW) management. The findings demonstrated a general improvement in knowledge following the training intervention, although the degree of change varied across specific domains.

For the item assessing recognition of non-biomedical waste, 126 out of 146 students (86.3%) responded correctly before training, compared to 115 out of 126 students (91.3%) after training. Although an improvement was noted, the difference was not statistically significant (p > 0.05). In contrast, knowledge regarding the biohazard symbol showed a significant increase; 87 of 146 students (59.6%) could identify the symbol pre-training, while this increased to 99 out of 126 students (78.6%) post-training (p < 0.05), indicating a statistically significant improvement in hazard symbol recognition.

Awareness of the initial formulation year of the BMW Rules (1998) was moderately high at baseline, with 103 of 146 students (70.5%) answering correctly, which increased to 98 of 126 students (77.8%) post-training. However, this difference was not statistically significant (p > 0.05). Conversely, knowledge regarding the updated BMW Rules of 2016 showed a notable and statistically significant improvement from 99 out of 146 (67.8%) before training to 105 out of 126 students (83.3%) after training (p < 0.05).

The question identifying all potential hazards associated with infectious waste showed a high correct response rate at both time points: 128/146 (87.7%) pre-training and 116/126 (92.1%) post-training, with no statistically significant difference (p > 0.05). The understanding of color-coded bag segregation also improved significantly: 97 students (66.4%) correctly identified purple as not a standard BMW bag color before training, compared to 107 students (84.9%) after training (p < 0.05).

Regarding the legal duration for safe storage of biomedical waste (48 hours), 69 out of 146 students (47.3%) answered correctly before training, increasing to 74 out of 126 students (58.7%) post-training, a difference that was not statistically significant (p > 0.05). Similarly, the understanding of the correct procedural sequence in BMW management—segregation, pretreatment, transport, and treatment—was low at baseline (61/146, 41.8%) and showed minimal change post-training (55/126, 43.7%), with no significant improvement (p > 0.05).

Students' ability to correctly match color-coded containers with specific categories of BMW was suboptimal in both assessments. For red bins (used for syringes without fixed needles), correct responses increased from 29 of 146 (19.9%) to 37 of 126 (29.4%). For yellow bins (discarded disinfectants), responses improved from 30 (20.5%) to 35 (27.8%). For white bins (syringes with fixed needles), the number of correct responses increased from 33 (22.6%) to 41 (32.5%). However, for blue bins (medicine vials), correct identification decreased slightly from 41 (28.1%) to 35 (27.8%). None of these changes reached statistical significance (p > 0.05 in all cases).

Questions regarding regulatory aspects, such as record-keeping duration (5 years) and incident reporting (within 24 hours), showed limited changes and remained statistically insignificant. For example, only 31 of 146 students (21.2%) initially knew the correct record retention period, compared to 25 of 126 (19.8%) after training. Similarly, the recognition of the mandated accident reporting time marginally improved from 32 (21.9%) to 34 (27%). Finally, the awareness of the institutional infrastructure, such as the absence of an incinerator, remained largely unchanged; 22 students responded correctly both before (15.1%) and after (17.5%) the training (p > 0.05). (Table 1)

Table 1:  Comparison of knowledge about biomedical waste management among medical students before and after training using a self-administered pre-validated questionnaire.

A comparative analysis of pre- and post-test scores among medical students showed a significant improvement in their knowledge of biomedical waste (BMW) management after training. The mean pre-test score was 6.8 (n=146), which increased to 7.9 (n=126) post-training, with a statistically significant p-value of < 0.0001. This 1.1-point gain indicates the effectiveness of the educational intervention. Although the post-test scores showed slightly greater variability, the overall improvement confirmed the positive impact of training.

Table 2: Comparison of knowledge scores regarding biomedical waste management among medical students before and after training using a self-administered, pre-validated questionnaire.

This study evaluated the effectiveness of a structured training program in enhancing knowledge of biomedical waste (BMW) management among undergraduate medical students in a tertiary care teaching hospital in West Bengal. The results demonstrated an overall improvement in knowledge following the intervention, with a statistically significant increase in mean scores. This discussion highlights the key areas of improvement, persistent knowledge gaps, and implications for curriculum integration and policy reinforcement.

Knowledge about biomedical waste management in medical students before and after training

In our study, structured training yielded a general uplift in biomedical waste management (BMWM) knowledge, mirroring prior interventions in both the student and healthcare‐worker cohorts. For instance, Mlouki et al. demonstrated that student‐centred training significantly improved mean BMWM scores among Tunisian medical students (post‐test 25 ± 3.3 vs. 23.6 ± 5.5; p < 0.05), while a Bengaluru study reported similar pre–post gains following targeted BMWM workshops (pre 4.7 ± 1.7 vs. post 8.8 ± 1.3; p < 0.001).(9,10)

Knowledge of non-BMW items (kitchen waste) improved modestly but non-significantly (86.3%→91.3%; p > 0.05), contrasting findings among Egyptian waste handlers, where general and clinical waste identification showed significant gains after training (p > 0.05). (11) This suggests that familiarity with household waste has an increasing trend after training, but it may vary, indicating a need to emphasize contextual distinctions in future modules.

Biohazard symbol recognition rose markedly (59.6%→78.6%; p < 0.05), consistent with reports that visual aids and symbol‐focused sessions substantially boost hazard symbol literacy (from 79% to 95%; p < 0.05) among healthcare workers in tertiary hospitals.(10) Enhanced symbol awareness likely reduces sharps‐related incidents, underscoring its importance in infection control curricula.

Awareness of the original 1998 BMW Rules was high at baseline (70.5%), with a non-significant post-training increase to 77.8% (p > 0.05), whereas knowledge of the updated 2016 rules improved significantly (67.8%→83.3%; p < 0.05). Similar patterns have appeared in Indian studies: pre-and post-training on regulatory updates showed greater gains for recent amendments than foundational regulations, suggesting that recency and relevance drive learner engagement. This highlights the need for regular refresher sessions aligned with evolving legislation.(12,13)

High baseline comprehension of infectious‐waste hazards (87.7%→92.1%; p > 0.05) resembled the findings from the Tunisian study group to some extent, where medical students already exhibited good hazard‐recognition skills pre-intervention (mean > 60%). (9)Limited statistical change implies a ceiling effect, indicating that advanced topics may be better suited for differentiated learning strategies.

Color-coded bag knowledge, particularly the exclusion of purple bags, improved significantly (66.4%→84.9%; p < 0.05), yet matching specific colors to waste types remained uniformly poor (<35% correct; p > 0.05). This reflects literature noting that while broad segregation principles are grasped post‐training, improvement of knowledge regarding detailed color‐coding systems even after training was insignificant indicating more focused hands‐on drills are necessary.(10)

Knowledge of safe storage duration (48 hours) and procedural sequence in waste management showed modest, non-significant gains (47.3%→58.7% and 41.8%→43.7%, respectively; p > 0.05). However, Shivashankarappa et al. reported significant change in procedural and retention‐time knowledge among nurses and housekeepers (p < 0.05), suggesting these operational details require simulation‐based or on‐site training to translate into measurable learning.(10)

Finally, regulatory record-keeping (five years) and incident-reporting timelines (24 hours) regarding biomedical waste management, as well as awareness of institutional incinerator absence, remained static (<20% correct; p > 0.05). This finding indicates that legal knowledge may be poorly retained without continuous reinforcement or practical applications. Healthcare facilities often struggle with proper biomedical waste management practices, including record keeping and incident reporting. Studies had shown a lack of compliance with standard operating procedures and inadequate training on medical waste management and occupational safety.(14)

Overall, while the training program effectively improved knowledge in certain areas, the limited progress in others and unexpected decline in specific knowledge domains underscore the need for a comprehensive review of training methodologies. More structured training programs, nuanced operational details, and less prominent categories require iterative experiential learning approaches. Incorporating interactive elements, practical demonstrations, and regular assessments may enhance knowledge retention and application, leading to more effective BMW management practices among medical students.

Implications of the findings

However, the slight increase in the variability of post-test scores suggests that while the training was effective overall, it may not have uniformly benefited all participants. This variability could be attributed to differences in baseline knowledge, learning styles, and engagement levels during training sessions. Such disparities underscore the need for tailored educational approaches that address diverse learners’ needs.

An unexpected finding was the minimal improvement in certain domains, such as understanding the correct procedural sequence of BMW management. This stagnation may indicate that traditional lecture-based methods are insufficient to effectively convey procedural knowledge. Incorporating interactive elements such as simulations or problem-based learning can enhance comprehension in these areas.

These insights highlight the importance of not only implementing training programs, but also continuously evaluating and refining them to ensure a comprehensive understanding of all facets of BMW management. Future research should explore the efficacy of various pedagogical strategies to optimize learning outcomes in this critical area.

Strengths of the study

This study has several strengths, which enhance its feasibility and relevance. The use of a structured, pre-validated questionnaire ensures methodological rigor, while the focus on undergraduate medical students addresses a critical gap in early professional education on biomedical waste (BMW) management. The integration of training into the existing academic framework underscores its practical applicability and ethical soundness. Moreover, the study's emphasis on BMW management is particularly pertinent, given the ongoing challenges in healthcare waste handling, especially in regions such as West Bengal.

Limitations of the study

However, certain limitations of this study warrant consideration. The study's confinement to a single tertiary care hospital may limit the generalizability of its findings to diverse healthcare settings. Additionally, reliance on self-reported data could introduce response bias, potentially affecting the accuracy of the assessed knowledge levels. The absence of a long-term follow-up also precludes the assessment of knowledge retention over time.

These limitations suggest avenues for future studies. Expanding this study to include multiple institutions across different regions could enhance the representativeness of the findings. Incorporating objective assessments such as practical evaluations or observational studies may provide a more accurate measure of knowledge application. Longitudinal studies can also assess the durability of training effects, informing the development of ongoing educational interventions. Furthermore, exploring the integration of interactive and simulation-based training methods may address the gaps identified in procedural knowledge and enhance the overall effectiveness of BMW management education.

This study demonstrated that structured training significantly enhances medical students' knowledge of biomedical waste management, aligning with the study's objective. The findings underscore the importance of integrating regular, targeted educational interventions into medical curricula to promote safe and compliant waste-handling practices among future healthcare professionals. To enhance biomedical waste (BMW) management knowledge among medical students, we recommend integrating structured training into the medical curriculum complemented by periodic refresher sessions. Implementing regular assessments and practical evaluations can help to monitor the effectiveness of these interventions. Future studies should explore long-term knowledge retention and the impacts of diverse educational methodologies.

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgement

I express my heartfelt thanks and gratitude to the administration, faculty members, and staff of the Department of Microbiology, Burdwan Medical College and Hospital, for allowing me to conduct the study.

Funding

Funding: This study was supported by the authors. 

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