Evaluation of the Sustainability and Impact on Water Quality of Decentralized Water Treatment Systems Installed by the General Electric Foundation in Six Government-run Hospitals in Ghana Open Access

Abstract

Little is known about water availability, quality and use in health care facilities in developing countries. Decentralized water purification technology is increasingly available and is applied in low-resource settings to address the need for safe, affordable, and reliable access to clean drinking water in public settings such as schools, hospitals, and churches. In 2005, the General Electric Foundation donated and installed decentralized membrane filtration systems (DMFS) in six government-run district-level hospitals in Ghana. Research is needed to understand the feasibility, performance and sustainability of institution-based DMFS in low-resource settings.

Safe water in healthcare facilities is vital for positive health outcomes. Due to poor water source reliability and inadequate centralized treatment processes in Ghana, DMFS have the potential to improve water quality in health care settings. Therefore, it is essential to evaluate the ability of these water treatment systems to sustainably provide safe water for consumption, hygiene and medical purposes.

To evaluate the use, performance, and sustainability of DMFS in six government-run district hospitals in Ghana.

Surveys were conducted with hospital staff, patients, and visitors. To assess water quality, over 200 water samples were analyzed for E. coli, total coliforms and Pseudomonas aeruginosa using the IDEXX Quanti-Tray 2000 method. A sustainability metric was used to quantitatively evaluate four sustainability domains: accountability, technical feasibility, on-site capacity, and institutional engagement and support.

Of the 78 water samples collected at the point of use (POU) in all six study hospitals, 48% met WHO standards for total coliforms, 58% met the standards for E. coli and less than 10% met the CDC guidelines for free chlorine residual. Geometric mean E. coli concentrations in POU samples by hospital ranged from 0.5 to 20.6 MPN/100 mL. Geometric mean P. aeruginosa concentrations in POU samples by hospital ranged from 76.5 to 933.8 MPN/100 mL. Water samples collected from sink taps within the hospital were more likely to meet WHO standards for water quality than samples collected from storage bucket taps within the hospital. Overall, most hospitals did not meet the basic requirements for sustainability in all four sustainability domains.

Targeted solutions are needed to improve the sustainability of the water treatment systems and address unique challenges within each hospital.

Table of Contents

Table of Contents
Acknowledgements...i
List of Tables...v
Glossary of Terms...vi

1 INTRODUCTION...1

1.1 Problem Statement...2
1.2 Purpose..3
1.3 Significance...4
1.4 Scope of Research...5

1.4.1 Study sites...5
1.4.2 Site Overviews...5

1.5 Definitions...6

2 REVIEW OF THE LITERATURE...7

2.1 Global Perspective on Safe Water Access...7
2.2 Safe Water versus Improved Water...7
2.3 Water, Sanitation and Hygiene Disease Burden...8
2.4 Microbiological Water Quality...8
2.5 Pseudomonas aeruginosa in Water: Important in Hospitals...9
2.6 Drinking Water Guidelines...9
2.7 Water, Sanitation and Hygiene in Healthcare Facilities...10
2.8 Access to Improved Water in Ghana...11
2.9 Reliability of Water Sources and Quality in Ghana...11
2.10 Institutional Structure for Water Supply in Ghana...12
2.11 Ghana's Health Ministry Priorities...13
2.12 General Electric Foundation (GEF) Project Objectives and Goals...14
2.13 Decentralized Water Distribution Systems...15
2.14 Water Treatment Technologies...15

2.14.1 Advantages and Disadvantages of Membrane-based Systems...16
2.14.2 Previous Research on Homespring® Filters...16

2.15 Sustainability...17

2.15.1 Sustainability Definitions...17
2.15.2 Importance of Sustainability...18
2.15.3 Issues Impacting Sustainability of Water-related Interventions...19
2.15.4 Measuring and Assessing Sustainability...20

3 METHODS...23

3.1 Research design...23

3.1.1 Hospitals with GEF donated water treatment systems in Ghana...24

3.2 Study sites...24
3.3 Data collection tools...25

3.3.1 In-depth interviews...25
3.3.2 Knowledge, attitudes, and practices (KAP) surveys...26
3.3.3 Water-use survey...27
3.3.4 Facility inspection guide...27
3.3.5 Maintenance info graphic survey...28
3.3.6 Maintenance supply checklist...28

3.4 Sustainability metric...29

3.4.1 Domains...29
3.4.2 Sub-domains...29
3.4.3 Broad questions...31
3.4.4 Scoring...32

3.5 Data collection process...32

3.5.1 In-depth interviews...32
3.5.2 Knowledge, attitudes, and practice (KAP) surveys...33
3.5.3 Water-use surveys...33
3.5.4 Facility inspection guide...34
3.5.5 Maintenance supply checklist...34

3.6 Water quality testing procedures...34

3.6.1 Water sample site selection within each hospital...34
3.6.2 Sample collection...35
3.6.3 Sample processing...35

3.7 Data Analysis...38

3.7.1 Analysis of demographic data...38
3.7.2 Knowledge, attitudes and practices data...38
3.7.3 Water quality...38
3.7.4 Sustainability metric...39

3.8 Ethical considerations and confidentiality...39

4 RESULTS...40

4.1 Hospital demographic data...40
4.2 Key Maintenance Tasks and Hospital Infrastructure...41
4.3 Water Quality...44
4.4 Knowledge, Attitudes, and Practices Related to Hospital Water...48
4.5 Sample Collection Points and POU Water Quality...52
4.6 Sustainability Metric Scores...57

4.6.1 Accountability...58
4.6.2 Technical Feasibility...65
4.6.3 On-site Capacity...65
4.6.4 Institutional Engagement...66

5 DISCUSSION...68

5.1 Impact of the GEF- donated DMFS...68

5.1.1 Impact of DMFS on Water Quality and Hospital Infrastructure...68
5.1.2 Impact of DMFS on Staff's Knowledge, Attitudes and Practices...69
5.1.3 Impact of DMFS on Patients' Knowledge, Beliefs, and Practices...70

5.2 Sustainability Evaluation...71

5.2.1 Successes and Areas of Improvement...71

5.3 Strengths and Limitations of the Study...77

6 RECOMMENDATIONS AND NEXT STEPS...79

6.1 Recommendations...79

6.1.1 Recommendations for GEF and Study Hospitals...79

6.2 Next Steps...82

6.2.1 Next Steps for GEF and Study Hospitals...82

7 CONCLUSIONS...83

References...84
Appendix A: Interview Tools...87
Appendix B: Sustainability Metric Tool...142
Appendix C: Institutional Review Board Documentation...169

About this Master's Thesis

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• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Rollins School of Public Health
Department	Environmental Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	Sustainability Evaluation WASH in Hospitals Water Quality and Health Water Treatment Systems
Committee Chair / Thesis Advisor	Moe, Christine L, Emory University
Committee Members	Tolbert, Paige, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs Industrial or Commercial (for-profit) organization

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