Assessment of water, sanitation and hygiene service availability in healthcare facilities in the greater Kampala metropolitan area, Uganda

BMC Public Health, Volume 20, No. 1, Year 2020

Interpretation

Background: Improved Water, Sanitation and Hygiene (WASH) in Healthcare facilities (HCFs) is of significant public health importance. It is associated with a reduction in the transmission of healthcare acquired infections (HAIs), increased trust and uptake of healthcare services, cost saving from infections averted, increased efficiency and improved staff morale. Despite these benefits, there is limited evidence on availability of WASH services in HCFs in the Greater Kampala Metropolitan Area (GKMA). This study assessed the availability and status of WASH services within HCFs in the GKMA in order to inform policy and WASH programming. Methods: A cross-sectional study was conducted in 60 HCFs. Availability of WASH services in the study HCFs was assessed using a validated WASH Conditions (WASHCon) tool comprising of structured interviews, HCF observations and microbial water quality analysis. Data were analysed using Stata 14 software and R software. Results: Overall, 84.5% (49/58) and 12.1% (7/58) of HCFs had limited and basic WASH service respectively. About 48.3% (28/58) had limited water service, 84.5% (49/58) had limited sanitation service, 50.0% (29/58) had limited environmental cleanliness service, 56.9% (33/58) had limited hand hygiene service, and 51.7% (30/58) had limited waste management service. About 94.4% of public HCFs had limited WASH service compared to only 68.2% of private not for profit facilities. More health centre IIIs, 92.5% and health centre IVs (85.7%) had limited WASH service compared to hospitals (54.5%). Conclusions: Our findings indicate that provision of water, sanitation, hand hygiene, environmental cleanliness, and health care waste management services within HCFs is largely hindered by structural and performance limitations. In spite of these limitations, it is evident that environmental cleanliness and treatment of infectious waste can be attained with better oversight and dedicated personnel. Attaining universal WASH coverage in HCFs will require deliberate and strategic investments across the different domains. This cross sectional study utilised quantitative methods to collect data from selected public and private not for profit (PNFP) HCFs in the GKMA from January to March 2019. The GKMA includes the districts of Kampala, Wakiso and Mukono whose HCFs serve over 14% of Uganda’s population [6]. In this study, we considered HCFs at level III and above since these have a core mandate to deliver Maternal, New-born and Child Health (MNCH) services. In Uganda, the health care system is organised into a four-tier system (i.e., hospitals, health centres of levels IV, III and II) [7]. Level II health centres (HCs) have a catchment population of about 5000 people and only provide outpatient care and community outreach services. Level III HCs with a catchment population of about 20,000 people provide basic preventive, promotive, laboratory and curative services. They have limited inpatient capacity mainly maternity and general patient wards. Level IV HCs (catchment population 100,000) provide outpatient and inpatient services, maternity, children and adults’ wards, laboratory and blood transfusion services as well as an operating theatre. General hospitals (catchment population 500,000) provide preventive, promotive, curative, maternity, and inpatient health services and surgery, blood transfusion, laboratory, and medical imaging services. We sampled 60 out of 105 HCFs in the GKMA. In the sampling, we included all public and PNFP hospitals and HC IVs since these provide MNCH services to majority of the population in the GKMA. High volume PNFP hospitals and HC IVs were also purposively selected. We selected all the 8 PNFP hospitals, and 2 out of the 4 PNFP HC IVs. We purposively selected 28 out of 42 public, and 13 out of the 29 PNFP HC IIIs. HC IIIs with the largest catchment population were sampled. Data collection was conducted using the validated WASH Conditions (WASHCon) tool on the Commcare mobile data collection platform. The tool, developed by the Centre for Global Safe Water, Sanitation, and Hygiene (CGSW) at Emory University has been used to evaluate WASH conditions within HCFs in low- and middle-income countries including Uganda [8–10]. The WASHCon tool relies on data collected through surveys, observational checklists and water quality testing. Data collection was done using mobile devices. The data was then uploaded into pre-programmed dashboards via a cellular or wireless internet network (not required during data collection). For this study, the outcome of the WASHCon tool was WASH service which was categorized as basic, limited or unimproved/no service similar to the JMP WASH service ladders [8]. Based on WASHCon indicators, WASH service is a composite variable generated from five variables (water, sanitation, environmental cleanliness, hand hygiene and waste management services). In order to establish the water service, data was collected on source and accessibility, quantity and quality of water. Sanitation service was assessed by collecting data on accessibility to toilet facilities, number of toilets and existence of the infrastructure, while for hand hygiene services data was collected on availability of hand hygiene facilities and availability of associated supplies. Assessment of environmental cleanliness service was based on availability of cleaning supplies, cleaning practices and frequency, and facility hygiene. In order to establish the availability of waste management service, data were collected on segregation, treatment and disposal of healthcare waste. Using the WASHCon dashboard, evaluation scores were calculated on a scale of 1–3 for each of the WASH domains, as well as an overall score that is an average of all the domains. The scores were determined based on the responses to the survey questions, observation checklists, and water quality testing results (Additional file 1). These scores were further categorized into basic, limited or unimproved/ no service. HCFs that scored between 2.8 to 3.0 were classified as basic, and were considered to meet the minimum WASH in HCF requirements or were on track to meet them; HCFs that scored between 1.9 to 2.7 were classified as limited, and were considered to have made some progress towards meeting minimum requirements for WASH in HCFs but were not on track to meet them; while HCFs that scored between 1.0 to 1.8 were classified as having no service or unimproved (Additional file 1). Such facilities were considered to have made little or no progress towards achieving the minimum requirements for WASH in HCFs [8]. The independent variables included ownership (public vs. PNFP) and level of facility (HC III, HC IV and Hospital). Prior to data collection, study enumerators received training on the use of the WASHCon tool, quality control and research ethics. The observations and interviews were conducted by trained enumerators who had a minimum of a Bachelor’s degree in Environmental Health Science; Nursing; or Social Sciences. All the study enumerators were supervised to ensure quality control. In order to determine the availability of water services in HCFs, observations were done to establish the type of water source and availability of water, and this was followed by collection of duplicate water samples for microbial analysis. Water samples were collected from maternity wards, which were prioritised due to an elevated risk of transmission of HAIs compared to other patient care areas [11]. Water samples were collected using Whirl-Pak bags of 100 mls (with sodium thiosulfate to halt chlorine action in chlorinated supplies) and stored on ice until laboratory analysis. All samples were analysed within 4 hours from the time of collection. Water was tested for faecal coliform, i.e. E. coli using the membrane filtration method [12]. Chromocult agar was used for culturing E-Coli at 37 °C for 24 h. Colonies of E-coli (i.e. dark blue to violet in colour) were counted and results recorded per 100 ml of sample. The data obtained using the WASHCon Commcare app, preinstalled on a mobile device were uploaded onto a server managed by Makerere University School of Public Health and Emory University CGSW. Forms were synchronized daily by each enumerator. The investigators had access to preliminary results through a pre-programmed dashboard. Analysis was performed using Stata version 14 (StataCorp, Texas) and R 3.5.2. Descriptive statistics such as frequencies and proportions were used to summarize quantitative categorical data. Continuous data were expressed as means and standard deviations. Classification of WASH service and its five domains into basic, limited and unimproved/no service was guided by the scoring tool shown in additional file 1.

AI Digest

Study Justification:

– Improved Water, Sanitation, and Hygiene (WASH) in Healthcare facilities (HCFs) is crucial for public health.
– It reduces the transmission of healthcare-acquired infections (HAIs), increases trust and uptake of healthcare services, saves costs from infections averted, improves efficiency, and boosts staff morale.
– Limited evidence exists on the availability of WASH services in HCFs in the Greater Kampala Metropolitan Area (GKMA).
– This study aimed to assess the availability and status of WASH services in HCFs in the GKMA to inform policy and WASH programming.

Study Highlights:

– 84.5% of HCFs had limited WASH service, while 12.1% had basic WASH service.
– Limited water service was found in 48.3% of HCFs, limited sanitation service in 84.5%, limited environmental cleanliness service in 50.0%, limited hand hygiene service in 56.9%, and limited waste management service in 51.7%.
– Public HCFs had a higher percentage of limited WASH service (94.4%) compared to private not-for-profit facilities (68.2%).
– Health center IIIs (92.5%) and health center IVs (85.7%) had higher percentages of limited WASH service compared to hospitals (54.5%).

Recommendations for Lay Reader and Policy Maker:

– Increase investments in water, sanitation, hand hygiene, environmental cleanliness, and waste management services in HCFs.
– Improve oversight and dedicate personnel to ensure environmental cleanliness and proper treatment of infectious waste.
– Strive for universal WASH coverage in HCFs through deliberate and strategic investments across different domains.

Key Role Players Needed to Address Recommendations:

– Government health departments and ministries responsible for healthcare infrastructure and services.
– Healthcare facility administrators and managers.
– Public health organizations and NGOs working on WASH initiatives.
– Community leaders and stakeholders.

Cost Items to Include in Planning Recommendations:

– Infrastructure development and improvement costs (e.g., construction of water and sanitation facilities, installation of hand hygiene stations).
– Equipment and supply costs (e.g., water purification systems, toilets, cleaning supplies).
– Training and capacity-building costs for healthcare staff.
– Monitoring and evaluation costs to ensure sustained WASH service provision.
– Advocacy and awareness-raising costs to promote the importance of WASH in HCFs.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it provides detailed information about the study design, data collection methods, and analysis. The study utilized a validated tool and collected data from a sufficient number of healthcare facilities. The findings are presented clearly and include percentages and comparisons between different types of facilities. However, to improve the evidence, the abstract could include more information about the limitations of the study and potential biases. Additionally, it would be helpful to provide information about the generalizability of the findings and any implications for future research or policy.

Abstract

This cross sectional study utilised quantitative methods to collect data from selected public and private not for profit (PNFP) HCFs in the GKMA from January to March 2019. The GKMA includes the districts of Kampala, Wakiso and Mukono whose HCFs serve over 14% of Uganda’s population [6]. In this study, we considered HCFs at level III and above since these have a core mandate to deliver Maternal, New-born and Child Health (MNCH) services. In Uganda, the health care system is organised into a four-tier system (i.e., hospitals, health centres of levels IV, III and II) [7]. Level II health centres (HCs) have a catchment population of about 5000 people and only provide outpatient care and community outreach services. Level III HCs with a catchment population of about 20,000 people provide basic preventive, promotive, laboratory and curative services. They have limited inpatient capacity mainly maternity and general patient wards. Level IV HCs (catchment population 100,000) provide outpatient and inpatient services, maternity, children and adults’ wards, laboratory and blood transfusion services as well as an operating theatre. General hospitals (catchment population 500,000) provide preventive, promotive, curative, maternity, and inpatient health services and surgery, blood transfusion, laboratory, and medical imaging services. We sampled 60 out of 105 HCFs in the GKMA. In the sampling, we included all public and PNFP hospitals and HC IVs since these provide MNCH services to majority of the population in the GKMA. High volume PNFP hospitals and HC IVs were also purposively selected. We selected all the 8 PNFP hospitals, and 2 out of the 4 PNFP HC IVs. We purposively selected 28 out of 42 public, and 13 out of the 29 PNFP HC IIIs. HC IIIs with the largest catchment population were sampled. Data collection was conducted using the validated WASH Conditions (WASHCon) tool on the Commcare mobile data collection platform. The tool, developed by the Centre for Global Safe Water, Sanitation, and Hygiene (CGSW) at Emory University has been used to evaluate WASH conditions within HCFs in low- and middle-income countries including Uganda [8–10]. The WASHCon tool relies on data collected through surveys, observational checklists and water quality testing. Data collection was done using mobile devices. The data was then uploaded into pre-programmed dashboards via a cellular or wireless internet network (not required during data collection). For this study, the outcome of the WASHCon tool was WASH service which was categorized as basic, limited or unimproved/no service similar to the JMP WASH service ladders [8]. Based on WASHCon indicators, WASH service is a composite variable generated from five variables (water, sanitation, environmental cleanliness, hand hygiene and waste management services). In order to establish the water service, data was collected on source and accessibility, quantity and quality of water. Sanitation service was assessed by collecting data on accessibility to toilet facilities, number of toilets and existence of the infrastructure, while for hand hygiene services data was collected on availability of hand hygiene facilities and availability of associated supplies. Assessment of environmental cleanliness service was based on availability of cleaning supplies, cleaning practices and frequency, and facility hygiene. In order to establish the availability of waste management service, data were collected on segregation, treatment and disposal of healthcare waste. Using the WASHCon dashboard, evaluation scores were calculated on a scale of 1–3 for each of the WASH domains, as well as an overall score that is an average of all the domains. The scores were determined based on the responses to the survey questions, observation checklists, and water quality testing results (Additional file 1). These scores were further categorized into basic, limited or unimproved/ no service. HCFs that scored between 2.8 to 3.0 were classified as basic, and were considered to meet the minimum WASH in HCF requirements or were on track to meet them; HCFs that scored between 1.9 to 2.7 were classified as limited, and were considered to have made some progress towards meeting minimum requirements for WASH in HCFs but were not on track to meet them; while HCFs that scored between 1.0 to 1.8 were classified as having no service or unimproved (Additional file 1). Such facilities were considered to have made little or no progress towards achieving the minimum requirements for WASH in HCFs [8]. The independent variables included ownership (public vs. PNFP) and level of facility (HC III, HC IV and Hospital). Prior to data collection, study enumerators received training on the use of the WASHCon tool, quality control and research ethics. The observations and interviews were conducted by trained enumerators who had a minimum of a Bachelor’s degree in Environmental Health Science; Nursing; or Social Sciences. All the study enumerators were supervised to ensure quality control. In order to determine the availability of water services in HCFs, observations were done to establish the type of water source and availability of water, and this was followed by collection of duplicate water samples for microbial analysis. Water samples were collected from maternity wards, which were prioritised due to an elevated risk of transmission of HAIs compared to other patient care areas [11]. Water samples were collected using Whirl-Pak bags of 100 mls (with sodium thiosulfate to halt chlorine action in chlorinated supplies) and stored on ice until laboratory analysis. All samples were analysed within 4 hours from the time of collection. Water was tested for faecal coliform, i.e. E. coli using the membrane filtration method [12]. Chromocult agar was used for culturing E-Coli at 37 °C for 24 h. Colonies of E-coli (i.e. dark blue to violet in colour) were counted and results recorded per 100 ml of sample. The data obtained using the WASHCon Commcare app, preinstalled on a mobile device were uploaded onto a server managed by Makerere University School of Public Health and Emory University CGSW. Forms were synchronized daily by each enumerator. The investigators had access to preliminary results through a pre-programmed dashboard. Analysis was performed using Stata version 14 (StataCorp, Texas) and R 3.5.2. Descriptive statistics such as frequencies and proportions were used to summarize quantitative categorical data. Continuous data were expressed as means and standard deviations. Classification of WASH service and its five domains into basic, limited and unimproved/no service was guided by the scoring tool shown in additional file 1.

Materials

https://efashare.b-cdn.net/materials/1a22fab2b346939076edf724f676fd19e738a8d16d228b9ec8736c083c0c3b7c/12889_2020_9895_MOESM1_ESM.docx

Innovations

Based on the information provided, here are some potential innovations that can be used to improve access to maternal health:

1. Improved Water, Sanitation, and Hygiene (WASH) Infrastructure: Develop innovative solutions to ensure reliable access to clean water, proper sanitation facilities, and improved hygiene practices in healthcare facilities. This can include technologies for water purification, waste management systems, and hand hygiene solutions.

2. Mobile Data Collection and Monitoring: Utilize mobile devices and data collection platforms to assess and monitor the availability and status of WASH services in healthcare facilities. This can provide real-time data for decision-making and resource allocation.

3. Training and Capacity Building: Implement innovative training programs to enhance the knowledge and skills of healthcare workers in WASH practices. This can include interactive e-learning modules, simulation-based training, and mentorship programs.

4. Public-Private Partnerships: Foster collaborations between public and private sectors to improve access to maternal health services. This can involve innovative financing models, shared resources, and joint initiatives to address infrastructure and service gaps.

5. Community Engagement and Education: Develop innovative approaches to engage and educate communities on the importance of WASH practices for maternal health. This can include community-led initiatives, awareness campaigns, and behavior change communication strategies.

6. Data-driven Decision Making: Utilize data analytics and visualization tools to identify gaps and prioritize interventions for improving access to maternal health. This can help policymakers and healthcare providers make informed decisions based on evidence.

7. Innovative Financing Mechanisms: Explore innovative financing mechanisms, such as social impact bonds or results-based financing, to incentivize investments in WASH infrastructure and services in healthcare facilities.

8. Technology-enabled Solutions: Leverage technology, such as telemedicine and mobile health applications, to improve access to maternal health services in remote or underserved areas. This can include virtual consultations, remote monitoring, and health information systems.

9. Quality Assurance and Accreditation: Establish innovative quality assurance mechanisms and accreditation systems to ensure that healthcare facilities meet WASH standards for maternal health. This can involve third-party assessments, certification programs, and performance-based incentives.

10. Policy and Advocacy: Advocate for policy changes and investments in WASH infrastructure and services for maternal health at the national and international levels. This can involve innovative policy frameworks, partnerships with policymakers, and evidence-based advocacy campaigns.

AI Innovations Description

The study titled “Assessment of water, sanitation and hygiene service availability in healthcare facilities in the greater Kampala metropolitan area, Uganda” provides valuable insights into the current state of WASH services in healthcare facilities (HCFs) in the Greater Kampala Metropolitan Area (GKMA) and its impact on maternal health. Based on the findings of the study, the following recommendations can be developed into an innovation to improve access to maternal health:

1. Strengthen infrastructure: Invest in improving the infrastructure of healthcare facilities, particularly in terms of water supply, sanitation facilities, and waste management systems. This could involve upgrading existing facilities, ensuring reliable water sources, constructing adequate toilets, and implementing proper waste disposal mechanisms.

2. Enhance training and capacity building: Provide comprehensive training to healthcare staff on the importance of WASH in maternal health, as well as on proper hygiene practices and infection prevention measures. This could include training on hand hygiene, environmental cleanliness, and waste management. Additionally, capacity building programs can be implemented to empower healthcare workers to take ownership of maintaining WASH services within their facilities.

3. Increase monitoring and oversight: Establish robust monitoring systems to regularly assess the availability and functionality of WASH services in healthcare facilities. This could involve conducting regular inspections, implementing quality control measures, and ensuring compliance with national standards and guidelines. Additionally, mechanisms for reporting and addressing deficiencies should be put in place to ensure accountability and prompt action.

4. Promote public-private partnerships: Foster collaborations between public and private stakeholders to address the challenges related to WASH services in healthcare facilities. This could involve engaging private sector organizations, non-governmental organizations, and community-based groups to provide technical expertise, financial support, and resources for improving WASH infrastructure and services.

5. Raise awareness and community engagement: Conduct awareness campaigns to educate communities about the importance of WASH in maternal health and encourage active participation in maintaining clean and hygienic healthcare facilities. This could involve community meetings, radio programs, and the use of social media platforms to disseminate information and promote behavior change.

By implementing these recommendations, it is possible to develop an innovative approach that addresses the gaps in WASH services in healthcare facilities, ultimately improving access to maternal health services and reducing the risk of healthcare-acquired infections.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Improve water service: Address the limited water service in healthcare facilities by ensuring a consistent and reliable water supply. This can be achieved through infrastructure improvements, such as installing water storage tanks or connecting facilities to a reliable water source.

2. Enhance sanitation facilities: Address the limited sanitation service by improving the availability and accessibility of toilet facilities in healthcare facilities. This may involve constructing additional toilets, ensuring proper maintenance and cleanliness, and promoting proper waste disposal practices.

3. Strengthen hand hygiene practices: Increase the availability of hand hygiene facilities, such as handwashing stations with soap and water, in healthcare facilities. Promote proper hand hygiene practices among healthcare workers and patients to reduce the risk of healthcare-acquired infections.

4. Improve environmental cleanliness: Enhance the cleanliness of healthcare facilities by providing adequate cleaning supplies, implementing regular cleaning practices, and ensuring proper waste management. This can help create a safe and hygienic environment for patients and healthcare workers.

5. Increase oversight and dedicated personnel: Improve the overall management and oversight of WASH services in healthcare facilities. This may involve assigning dedicated personnel responsible for WASH services, conducting regular inspections and audits, and providing training and support to healthcare staff.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define indicators: Identify key indicators that reflect the access to maternal health services, such as the number of maternal deaths, maternal morbidity rates, or the percentage of pregnant women receiving prenatal care.

2. Collect baseline data: Gather data on the current status of access to maternal health services in the study area. This may involve conducting surveys, interviews, or reviewing existing data sources.

3. Implement interventions: Implement the recommended interventions to improve access to maternal health services in selected healthcare facilities. Ensure that the interventions are properly implemented and monitored.

4. Monitor and evaluate: Continuously monitor the progress and impact of the interventions on access to maternal health services. Collect data on the selected indicators at regular intervals to assess the changes over time.

5. Analyze data: Analyze the collected data using statistical methods to determine the impact of the interventions on access to maternal health services. Compare the baseline data with the data collected after the interventions to identify any improvements.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the effectiveness of the interventions in improving access to maternal health services. Make recommendations for further improvements or adjustments to the interventions based on the findings.

By following this methodology, it is possible to simulate the impact of the recommended interventions on improving access to maternal health services and inform policy and programming decisions.

Statistics:

Citations: 5

Authors: 21

Identifiers:

DOI: 10.1186/s12889-020-09895-9

Research Areas:

Community Interventions, Disparities, Environmental, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants

Study Countries:

Uganda

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative