Water, sanitation and hygiene at health care facilities in Afghanistan and Uganda: an analysis of access, quality, and predictors of disparity Público

Abstract

Background: Basic water, sanitation, and hygiene (WASH) in health care facilities (HCFs) are critical for infection prevention and control, containment of anti-microbial resistance, and provision of quality health care. Data on HCF WASH conditions remain scarce, and there is a need for field assessments and identifying determinants of WASH among HCFs in low-development/high-risk areas.

Methods: Primary survey, observation, and microbiological water quality data were collected from >250 HCFs in selected regions of Afghanistan and Uganda through the WASH Conditions (WASHCon) Assessment Tool. This report describes the WASH conditions and uses country-specific multivariable logistic regressions to identify determinants of 4 key outcomes: 1) basic water service; 2) hand hygiene facilities; 3) Six Cleans for safe delivery, and 4) microbiological water quality. 

Results and Conclusions:  Among HCFs assessed in Afghanistan and Uganda, respectively: 70% / 60% had basic water service; 86% / 74% had hand hygiene facilities at ≥1 point of care; 23% / 33% had all of the Six Cleans; and 21% in both countries had E. coli detected in ≥1 100mL water sample. Differences in coverage estimates emerged from small changes to indicator definitions, indicating need for careful consideration of these definitions. Private HCFs were more likely to have basic water service, access to hand hygiene facilities, and superior water quality compared to public HCFs in Uganda. Sub-national region was associated with hand hygiene access and water quality in both countries and Six Cleans access in Uganda. Higher levels of care were associated with basic water service in Uganda but poorer water quality in Afghanistan. Main water source type was the strongest predictor of E. coli detection in ≥ 1 water sample among HCFs in both countries. These analyses support development of evidence-based WASH interventions for HCFs and provide a roadmap for future research on the determinants of HCF WASH conditions.

Table of Contents

Chapter I.  Literature Review   1

1.   Introduction to WASH in HCFs 1

2.   Monitoring WASH in HCFs: Goals, Targets and Indicators 2

2.1.   UN Mandate: SDGs 6 and 3 2

2.2.   JMP Guidance: Five WASH Service Ladders 3

2.3.   WHO Guidance: Water Service and Water Quality 6

3.   Access to WASH Services in HCFs 7

3.1.   Access Rates 8

3.2.   Potential Drivers of Variation in Access to WASH Services 15

3.3.   Access vs. Safety in Practice 17

4.   Water Quality in HCFs 18

4.1.   Rates of Detection of Fecal Contamination in HCF Water Samples 19

4.2.   Potential Drivers of Variation 21

5.   Consequences of Unsafe WASH in HCFs 21

5.1.   Health Care-Associated Infections (HCAI) 21

5.2.   Disparities in HCAI Risk 24

5.3.   Anti-Microbial Resistance (AMR) 25

6.   Conclusion: Summary and Need for this Study 26

Chapter II. Thesis Objectives and Rationale 28

1.   Introduction 28

2.   Problem Statement 28

3.   Purpose Statement 29

4.   Research Questions 29

4.1.   Domain 1: HCF WASH Access (RQ 1.00, 1.01, 1.02, 1.03) 29

4.2.   Domain 2: HCF Water Quality (RQ 2.00, 2.01) 30

5.   Significance Statement 30

6.   Key Terms 31

Chapter III.    Manuscript 35

1.   Introduction 35

2.   Methods 40

2.1.   Data set and study design 40

2.2.   Data Collection and Sample Testing 44

2.2.1.   WASHCon Survey Methods 44

2.2.2.   WASHCon Water Quality Testing Methods 46

2.2.2.1.   Water Testing Methods in Afghanistan 46

2.2.2.2.   Water Testing Methods in Uganda 47

2.2.2.3.   Use of Water Quality Data Sets to Estimate Water Service Levels by Country 48

2.2.3.   WASHCon Deployment Differences 50

2.3.   Data Unification 51

2.4.   Data Analysis 51

2.4.1.   Outcomes 51

2.4.2.   Predictors 53

2.4.3.   Univariable Analyses 53

2.4.4.   Multivariable Analyses 54

2.5.   Reporting of Results 56

3.   Results 56

3.1.   Descriptive Results 56

3.1.1.   Access to HCF WASH (RQ 1.00) 56

3.1.2.   HCF Water Quality (RQ 2.00) 61

3.1.3.   Predictor Variables Tested in Analytic Modeling 65

3.2. Analytic Results 67

3.2.1.   Access to Basic Water Service (RQ 1.01) 67

3.2.1.1.   Predictors of basic water service in Afghanistan 68

3.2.1.2.   Predictors of basic water service in Uganda 69

3.2.2.   Access to a Functional Hand Hygiene Facility at ≥ 1 Point of Care (RQ 1.02) 73

3.2.2.1.   Predictors of access to a hand hygiene facility in Afghanistan 73

3.2.2.2.   Predictors of access to a hand hygiene facility in Uganda 74

3.2.3.   Access to the Six Cleans for Safe Delivery (RQ 1.03) 78

3.2.3.1.   Predictors of Six Cleans access in Afghanistan 78

3.2.3.2.   Predictors of Six Cleans access in Uganda 79

3.2.4.   Detection of E. coli in HCF Water Samples (RQ 2.01) 82

3.2.4.1.   Predictors of E. coli detection in HCF water samples in Afghanistan 82

3.2.4.2.   Predictors of E. coli detection in HCF water samples in Uganda 84

4.   Discussion and Implications 90

4.1.   Access to Basic Water Service (RQ 1.01) 91

4.2.   Access to a Functional Hand Hygiene Facility at ≥ 1 Point of Care (RQ 1.02) 96

4.3.   Access to the Six Cleans of Safe Delivery (RQ 1.03) 99

4.4.   Detection of E. coli in HCF Water Samples (RQ 2.01) and Other Water Quality Results 102

4.5.   Strengths and Limitations 106

5.   Conclusions 110

Chapter IV.    Conclusion and Recommendations 113

1.   Review of Key Descriptive Conclusions 113

2.   Review of Significant Analytic Conclusions 114

3.   General Conclusions and Recommendations for the Public Health Community 117

4.   Recommendations for the WASHCon Study Team  121

4.1.   Water (W) 121

4.2.   Hand Hygiene (HH) 125

4.3.   General/Administrative (GA) 127

5.   Conclusion 129

References 131

Appendix A. WASHCon Tool Executive Summary 136

Appendix B. WASHCon Enumerator’s Guide 137

Appendix C. WASHCon Survey Forms and Data Dictionary 141

1.   GPS Form and Added Demographic Variables 142

2.   Director Form 145

3.   Administrative Form 165

4.   Ward Form 167

5.   Water Quality Form 172

Appendix D. WASHCon Variable Inclusion Change Log 174

Appendix E. Data Sets and Data Cleaning Log 176

1.   Stage One Cleaning 177

1.1.   Overview  177

1.2.   Standardizing the linking variable (case_name) 179

1.2.1.   Afghanistan 180

1.2.2.   Uganda 183

1.3.   GPS data sets 188

1.4.   Director Data sets 189

1.5.   Administrative Data sets 191

1.6.   Ward Data sets 193

1.7.   Water Quality Data sets 196

2.   Stage Two Cleaning 196

Appendix F. Reference Table of Dependent, Independent, and Supplementary Variables 198

Appendix G. Pearson Correlation Coefficients for Pairs of Predictor Variables by Country 208

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Palabra Clave	Six Cleans E. coli Access Free chlorine Health care facilities Hand hygiene WASH Water Water quality
Committee Chair / Thesis Advisor	Moe, Christine L., Emory University

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