European Journal of Cardiovascular Medicine

Biomedical waste (BMW) refers to any waste generated during the diagnosis, treatment, or immunization of human beings or animals, or in related research activities or in the production or testing of biologicals [1]. The safe handling, segregation, transportation, and disposal of such waste are essential to prevent health hazards to healthcare personnel, patients, the general public, and the environment [2]. In India, with a rapidly growing healthcare sector, the burden of biomedical waste has increased significantly, making its proper management a public health priority [3].

Although the Biomedical Waste Management Rules, first enacted in 1998 and amended in 2016, provide a regulatory framework, these are often implemented inconsistently, especially in informal healthcare settings [4]. Informal health providers (IHPs), defined as individuals who deliver medical services without formal qualifications or licenses, play a vital yet often overlooked role in the Indian healthcare landscape, especially in rural and underserved areas [5]. Estimates suggest that in certain regions, more than 60% of initial healthcare contact is with informal providers [6].

Despite their pivotal role, IHPs often function outside regulatory scrutiny and lack access to formal training in biomedical waste management. Consequently, their practices may not align with prescribed guidelines, potentially resulting in hazardous exposure and environmental contamination [7]. Unsegregated and improperly treated waste such as sharps, contaminated materials, and pathological waste not only contribute to the transmission of infectious diseases but also increase the burden on municipal waste systems [8].

Existing literature highlights the challenges of enforcing biomedical waste management standards even within formal health institutions. However, there is a significant research gap concerning the knowledge, attitudes, and practices of IHPs, particularly in rural contexts where their services are often the only available option for many communities [9]. Studies that do exist are either geographically limited or fail to consider waste disposal behavior comprehensively across knowledge, practice, and behavioral domains [10].

Given the magnitude of informal healthcare provision in rural India and the growing environmental and health concerns posed by biomedical waste, it becomes imperative to investigate how IHPs understand and manage such waste. This understanding is essential for informing targeted interventions and for the formulation of inclusive waste management policies that account for all tiers of healthcare delivery.

This study, therefore, aims to assess the knowledge, practices, and biomedical waste disposal behavior among informal health providers in the rural field practice area of Kanyakumari Medical Mission Research Centre, Tamil Nadu.

Study Design and Setting: This cross-sectional, descriptive study was conducted in the rural field practice area of the Department of Community Medicine, Kanyakumari Medical Mission Research Centre, Muttum, Tamil Nadu. The study period extended from September 2023 to August 2024. The area comprises multiple rural and semi-urban localities where informal health providers (IHPs) operate without formal medical qualifications but offer various allopathic and traditional treatments to the population.

Study Population and Sampling: The target population included all self-identified informal health providers engaged in patient care within the study area, irrespective of the system of medicine practiced. Inclusion criteria were: age ≥18 years, active practice for at least one year, and willingness to participate. Those unwilling to consent or unable to respond to the questionnaire were excluded.

A sample size of 150 was calculated based on an expected 40% adequate knowledge level from prior regional estimates [1], with 7.5% absolute precision and 95% confidence level, accounting for a 10% non-response rate. Stratified random sampling was employed. The area was divided into five geographic strata, and equal samples were drawn from each to ensure representation.

Data Collection Tool and Procedure: Data were collected using a pre-tested, semi-structured questionnaire developed in English and translated into Tamil. The tool comprised four sections: (1) sociodemographic details, (2) knowledge of biomedical waste categories and color-coding, (3) waste handling and segregation practices, and (4) disposal behavior and barriers. The questionnaire included both closed and open-ended questions.

Face validity was established through expert review, and a pilot test was conducted among 15 IHPs in a neighboring locality (not included in the main study). Data were collected via face-to-face interviews by trained investigators using tablets with offline data-entry forms, later synchronized to a secure server.

Ethical clearance was obtained from the Institutional Ethics Committee Written informed consent was obtained from all participants. Confidentiality and anonymity were strictly maintained.

Data Analysis: Data were analyzed using IBM SPSS version 26. Descriptive statistics (frequencies, means, and standard deviations) were used for sociodemographic variables and practice patterns. Chi-square test was applied to assess associations between categorical variables (e.g., training vs proper segregation). Binary logistic regression was performed to identify predictors of correct waste disposal behavior, and odds ratios (OR) with 95% confidence intervals (CI) were calculated. A p-value of <0.05 was considered statistically significant.

Table 1: Demographic Characteristics of Informal Health Providers (n=150)

Table 2: Knowledge of Biomedical Waste (BMW) Management (n=150)

Table 3: Waste Handling Practices (n=150)

Table 4: Association Between Training and Correct Disposal Behavior

Table 5: Logistic Regression – Predictors of Correct BMW Disposal (n=150)

Fig 1: Disposal Behaviour

The study included 150 informal health providers (IHPs) with a mean age of 42.8 ± 9.5 years. The majority were male (67.3%), and more than half (52.7%) had been in practice for over five years. In terms of educational attainment, 45.3% had studied beyond the 10th standard, and 56.0% reported practicing allopathy.

Regarding knowledge of biomedical waste (BMW) management, only 42.0% were aware of the BMW Rules 2016, and just 31.3% could identify the correct color-coding system for waste segregation. Although 59.3% correctly identified infectious waste and 44.0% were aware of sharp disposal protocols, only 38.7% achieved an adequate knowledge score (defined as ≥3 correct responses out of 5).

Practice-related findings revealed concerning trends. Only 31.3% reported using color-coded bins, and 34.7% practiced proper waste segregation at the source. Moreover, 54.0% admitted to self-burning or open disposal of waste—posing significant health and environmental risks. Just 29.3% utilized municipal disposal services.

Table 4 highlights the strong association between formal training and correct disposal behavior. Among trained IHPs (n=46), 67.4% practiced proper waste disposal compared to only 27.9% of untrained providers. This association was statistically significant (p < 0.001).

Logistic regression analysis confirmed that formal training was a significant predictor of appropriate disposal behavior (Adjusted OR: 2.96, 95% CI: 1.72–5.08, p < 0.001). Similarly, having an adequate knowledge score was associated with improved disposal practices (Adjusted OR: 2.15, 95% CI: 1.21–3.81, p = 0.007). Although IHPs with ≥5 years of experience showed better behavior, this was not statistically significant (p = 0.074).

These findings emphasize the critical role of targeted training and knowledge enhancement in promoting safe BMW practices among IHPs.

Biomedical waste (BMW) poses a significant health and environmental hazard if not managed properly, particularly in settings with limited oversight. Informal health providers (IHPs), while indispensable in rural healthcare delivery, often remain excluded from formal waste management frameworks. This study was conducted to evaluate the knowledge, practices, and waste management behavior of IHPs in rural Tamil Nadu, with an aim to bridge this gap in the public health literature.

The rationale for this study stemmed from the lack of regulation and training among IHPs, who are often the first point of contact for rural populations. Our results confirm substantial deficiencies in BMW-related knowledge, with only 38.7% of providers demonstrating adequate understanding of critical components such as infectious waste categorization and the color-coding system. This aligns with findings by Bansal et al., who reported low awareness of BMW Rules 2016 among unregulated healthcare providers in similar rural settings [11].

Moreover, the practical application of BMW protocols was poor. Only 31.3% reported using color-coded bins, and a majority (54.0%) still relied on open burning or self-disposal of waste. Similar unsafe practices were also documented by Datta et al. in West Bengal, where informal providers lacked access to safe disposal infrastructure and training [12]. The current study, therefore, reinforces the broader concern that the informal sector remains a neglected node in BMW oversight.

Importantly, we identified formal training as a significant predictor of appropriate disposal behavior. Trained IHPs were nearly three times more likely to manage waste correctly (OR = 2.96, p < 0.001), echoing the results of Kumar and Aggarwal, who showed a 40% increase in compliance following short-term training interventions [13]. Adequate knowledge scores were also associated with better practices (OR = 2.15), suggesting that even basic orientation can lead to measurable improvement.

The implications are multifold. First, informal providers should be integrated into local biomedical waste management systems through training, certification, and regular monitoring. Second, waste collection infrastructure should be extended to include peripheral clinics, even if unregistered. Third, community awareness and legal enforcement should be leveraged to promote accountability across all care providers, not just those in the formal sector.

This study is not without limitations. It was geographically restricted to a single rural block in Tamil Nadu, and the findings may not be generalizable to urban or tribal settings. Self-reported data may have also introduced desirability bias. Additionally, observational validation of practices was not feasible due to logistical constraints.

This study highlights significant gaps in knowledge and unsafe practices related to biomedical waste (BMW) management among informal health providers (IHPs) in rural Tamil Nadu. Despite their critical role in grassroots healthcare delivery, the majority lacked awareness of BMW rules and failed to implement appropriate disposal methods. Formal training and adequate knowledge were independently associated with correct disposal behavior, underlining the need for inclusive and targeted interventions. Incorporating IHPs into local waste management systems through certification, infrastructure support, and community engagement is essential for ensuring safe and sustainable biomedical waste handling in rural settings.

Acknowledgement

The authors sincerely thank the Department of Community Medicine, Kanyakumari Medical Mission Research Centre, Muttum, Tamil Nadu, for academic and logistical support. We also acknowledge the cooperation of all informal health providers who participated in the study.

Conflicts of Interest

The authors declare no conflicts of interest.

1.      Government of India. Biomedical Waste Management Rules 2016. Ministry of Environment, Forest and Climate Change. 2016.

2. Chartier Y, Emmanuel J, Pieper U, et al. Safe management of wastes from health-care activities. 2nd ed. WHO; 2014.
3. Rao PH. Report: Hospital waste management—awareness and practices: A study of three states in India. Waste Manag Res. 2008;26(3):297–303.
4. Prüss A, Giroult E, Rushbrook P. Safe management of wastes from health-care activities. Geneva: WHO; 1999.
5. Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D. What is the role of informal healthcare providers in developing countries? A systematic review. PLoS One. 2013;8(2):e54978.
6. Gautham M, Binnendijk E, Koren R, Dror DM. 'First we go to the small doctor': First contact for curative health care sought by rural communities in Andhra Pradesh & Orissa, India. Indian J Med Res. 2014;139(3):420–429.
7. Reddy BS, Kumar MA. Biomedical waste management: A study of knowledge, attitude and practice among health care professionals. Indian J Community Health. 2013;25(4):465–471.
8. Gupta S, Boojh R. Report: Biomedical waste management practices in India—A review. Waste Manag Res. 2006;24(6):584–591.
9. Sharma S. Awareness about bio-medical waste management among health care personnel of some important medical centers in Agra. Int J Environ Sci Dev. 2010;1(3):251–255.
10. Patil AD, Shekdar AV. Health-care waste management in India. J Environ Manage. 2001;63(2):211–220.
11. Bansal M, Singh P, Garg S. Knowledge and practices related to biomedical waste management among unlicensed health practitioners in rural Haryana. J Health Res Rev. 2019;6(1):10–14.
12. Datta P, Mohi GK, Chander J. Biomedical waste management in India: Critical appraisal. J Lab Physicians. 2018;10(1):6–14.
13. Kumar R, Aggarwal AK. Impact of training on biomedical waste management in a tertiary care hospital in India. Indian J Med Microbiol. 2012;30(1):93–95.