Los sujetos activos (investigadores e inspectores)

There were a number of limitations in this research study related to site selection, data collection and data coding/analysis.

5.3.1 Site Selection

The three sites selected for this study were all large tertiary care hospitals located in Kathmandu. As the capital of Nepal, Kathmandu is the most developed city in the country and thus, recommendations from this study may not be applicable to hospitals in other parts of the country, particularly in rural areas where health facilities face a number of human, financial and material resource challenges that differ from those in Kathmandu. In addition, the type of HCWM system that was introduced in these hospitals—non- incineration with onsite treatment of high risk waste— may or may not be appropriate for smaller hospitals or health centers.

The non-incineration HCWM system that was assessed in this study relied on a robust system of recycling services available in the city. Although there are several other cities in Nepal that also offer recycling, these services are not available in most rural areas of the country. Future studies on HCWM in Nepal and South Asia should include a variety of health facilities in rural, urban and semi-urban areas, in towns and cities where recycling is a part of the local economy, as well as in places where it is not available, in order to better understand how critical this component is to the overall system.

Another limitation was the variation of implementation length of the HCWM system at the three sites. One hospital had been implementing the innovation more than twice as long as the other two sites. There were noticeable differences in implementation that respondents attributed to the longer

implementation period including task-related problems in the first 1-2 years of implementation that were resolved over time. This suggests that there is a potential period of improvement in implementation that the other two sites may have not yet gone through and that would possibly change the results. As discussed in Section 5.2.1, the variation in implementation length was also a strength of this study as it allowed for a more in-depth analysis of factors that differentiated the hospitals with different levels of implementation effectiveness.

Finally, the low number of sites included in this study was a limitation because the strength of the evidence to support the conceptual framework was dependent on replication across multiple sites.

Although the modified conceptual framework successfully explained the dynamics of introducing and implementing a non-incineration HCWM system in the sites that were studied, the question remains of whether the findings would be similar if hospitals were included in the study that were different sizes or from different geographic regions, and sites that either did not have partnerships or had different types of partners. A larger and more diverse number of sites would have further strengthened the conclusion that the conceptual framework is applicable in a low-income resource-constrained setting. This limitation is an inherent aspect of the case-study research design. It is worth noting that this design also has inherent strengths that other designs do not provide, such as the ability to study a current phenomenon in a real- world context (126). Rich descriptive data collected from multiple sources as part of the case study design can provide a holistic picture of a phenomenon and offer insights that might not be uncovered using other research designs.

5.3.2 Data Collection

Key informant and semi-structured interviews

This study relied heavily on qualitative research methods. Thus, the limitations that are inherent to these methods were also present.

All interviews for this study were conducted by the Principal Investigator and were therefore subject to personal bias. To minimize the bias, the Principal Investigator used a semi-structured questionnaire to guide the interviews and employed active listening skills and open probes to provide respondents the space to share additional information on any specific topic area. All interviews except one were recorded and therefore the Principal Investigator also had the opportunity to review the audiotapes multiple times to better understand the meaning behind the words of the informant.

There was also a potential bias in key informant reporting. The reporting could be dependent on the position that the respondent held in the hospital. For example, staff in low level positions—

housekeepers, waste management workers—may not have been as forthcoming due to perceived risks to their job security if they criticized the hospital. People in higher positions, such as Hospital Directors,

Matrons and Wards-in-Charge, may have reported more positively in order to present the hospital in the best possible light. The Principal Investigator was reasonably certain that the reporting was accurate given that 1) the Principal Investigator was not representing any organization and introduced as a university student (and therefore not a threat); 2) there was a balance of positive and negative comments in most interviews; 3) strict confidentiality was ensured at the beginning of each interview, 4) the discussions were held in a private room with nobody present except the respondent and Principal Investigator; and 5) information from interviews was, as much as possible, triangulated with data collected using other methods and data sources and shown to be accurate.

The type of people interviewed for this study was also a potential limitation. Although the Principal Investigator was able to interview a broad range of staff from each site, there may have been selection bias introduced into the process since most respondents were referred by the hospital

management. In addition, neither doctors nor patients/visitors were interviewed for this study. This was a limitation given that there were major findings related to these two groups. Respondents reported that both doctors and visitors of patients were not interested in waste segregation and not cooperative in using the system. The views of both groups would be important to understand in a follow up study, particularly for designing future approaches and systems for waste management.

5.3.3 Coding and Analysis

Given the time and resource constraints for this study, all of the data was collected, coded and analyzed by the Principal Investigator alone. This was a significant limitation. A second coder would have strengthened the reliability of the findings as some of the comments were open to interpretation. To minimize this limitation, a codebook was developed and utilized for this study with specific examples of when to and when not to employ a specific code. To prevent bias during analysis, the Principal