University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA ASSESSING THE AVAILABILITY OF WATER, SANITATION AND HYGIENE (WASH) SERVICES AND PATIENT SATISFACTION IN HEALTH FACILITIES IN GA WEST MUNICIPALITY OF GREATER ACCRA REGION BY AKOSUA TAKYIWA KWAKYE (10806858) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF THE MASTER OF PUBLIC HEALTH DEGREE NOVEMBER, 2020 University of Ghana http://ugspace.ug.edu.gh DECLARATION I AKOSUA TAKYIWA KWAKYE declare that this is the result of my original research under the supervision of Dr. Prudence Tettey. Where other works, ideas and views have been cited they have been duly acknowledged. This research has not been submitted to any other institution for an award of any degree. 8th September, 2021 ______________________________________ _________________________ Akosua Takyiwa Kwakye Date (Student) ________________________________________ ____8th September, 2021____ Dr. Prudence Tettey Date (Supervisor) i University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this thesis to my father Professor Kofi Oduro Asante who led the way for me to follow in his footsteps and to my dear husband Mr. Kojo Kwakye and my wonderful daughters Ivana and Elisa, my greatest cheerleaders for inspiring me to succeed. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENTS I would like to express my gratitude to my supervisor, Dr. Prudence Tettey for his advice, guidance and support throughout the study. I acknowledge the contribution of my research assistants and team-leader, Madam Esther Zu for supporting me to collect my data, amidst the COVID-19 pandemic. I am grateful to the administrators, staff and patients of all health facilities in Ga West Municipal who participated in the study for sharing their knowledge and views. I am equally thankful to Mr. Isaac Tegbe of Ga South Municipal Hospital for insights and support for the field work. I would also like to thank Dr. James Antwi for mentoring and supporting me throughout this journey. Special thanks go to my sister Afua Oduro Asante my rock for all her support and for urging me onto the finish line. I would sincerely like to thank Madam Juliana Akua Boatemaa for keeping up the home front throughout the entire course, I could not have done it without her. Lastly, I would like to thank my course mates, especially Josephine Asante for their friendship, assistance, and support in diverse ways. iii University of Ghana http://ugspace.ug.edu.gh Table of Contents DECLARATION ........................................................................................................................ i DEDICATION ........................................................................................................................... ii AKNOWLEDGEMENTS........................................................................................................ iii LIST OF TABLES ................................................................................................................... vii LIST OF FIGURES ............................................................................................................... viii LIST OF ABBREVIATIONS ................................................................................................... ix ABSTRACT ............................................................................................................................... x CHAPTER ONE ........................................................................................................................ 1 INTRODUCTION ..................................................................................................................... 1 1.1 Background to the Study .................................................................................................. 1 1.2 Problem Statement ........................................................................................................... 2 1.3 Conceptual Framework .................................................................................................... 4 1.4 Objectives of the study ..................................................................................................... 6 1.4.1 Main Objective .......................................................................................................... 6 1.4.2 Specific Objectives .................................................................................................... 6 1.4.3 Research Questions.................................................................................................... 6 1.5 Justification ...................................................................................................................... 6 1.6 Organization of the study ............................................... 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CHAPTER TWO ....................................................................................................................... 8 LITERATURE REVIEW .......................................................................................................... 8 2.1 Introduction ...................................................................................................................... 8 2.2 Review process and literature search ............................................................................... 8 2.3 Theoretical framework ..................................................................................................... 9 2.4 Empirical literature ........................................................................................................... 9 2.4.1 Patient satisfaction on overall healthcare services .................................................... 9 2.4.2 Patient satisfaction with WASH services ................................................................ 11 2.4.3 Water, Sanitation and Hygiene (WASH) and Health Services --Provision ............ 13 2.5 The conceptual framework variables ............................. 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CHAPTER THREE ................................................................................................................. 18 METHODS .............................................................................................................................. 18 3.1 Introduction .................................................................................................................... 18 3.2 Study Design .................................................................................................................. 18 3.3 Study Areas .................................................................................................................... 18 3.4 Study Population ............................................................................................................ 19 iv University of Ghana http://ugspace.ug.edu.gh 3.4.1 Inclusion Criteria ..................................................................................................... 19 3.4.2 Exclusion Criteria .................................................................................................... 19 3.5 Sampling Technique ....................................................................................................... 19 3.5.1 Selection of health facilities .................................................................................... 19 3.5.2 Selection of Participants within the Selected Facilities ........................................... 21 3.5.3 Sampling Size Determination .................................................................................. 21 3.6 Study Variables .............................................................................................................. 24 3.7 Data Collection Methods and Instruments ..................................................................... 24 3.8 Training of Data Collectors and Supervision ................................................................. 25 3.9 Pretesting and Data Collection ....................................................................................... 26 3.10 Data Analysis ............................................................................................................... 26 3.11 Ethical Consideration ................................................................................................... 27 CHAPTER FOUR .................................................................................................................... 29 RESULTS ................................................................................................................................ 29 4.1 Introduction .................................................................................................................... 29 4.2 Socio-demographic characteristics of respondents ........................................................ 29 4.3 Health Facility Assessment of WASH Facilities ........................................................... 32 4.4 Patient Satisfaction with WASH Services ..................................................................... 35 Statistically significant (p ≤ 0.05) ............................................................................................ 39 4.5 Patient satisfaction with WASH services in health care facilities ................................. 40 4.6 Bivariate analysis of Socio-demographic factors associated with patient satisfaction with WASH Services ........................................................................................................... 40 4.7 Factors associated with patient satisfaction with WASH Services ................................ 43 4.8 Expectations and Considerations of Patients ................................................................. 46 CHAPTER FIVE ..................................................................................................................... 48 DISCUSSION OF FINDINGS ................................................................................................ 48 5.1 Introduction .................................................................................................................... 48 5.2 Discussions ..................................................................................................................... 48 5.2.1 Availability and level of water, sanitation and hygiene (WASH) services in health facilities in the municipality ............................................................................................. 48 5.2.2 The level of patients’ satisfaction with the WASH services in health facilities in the Municipal .......................................................................................................................... 50 5.2.3 The influence of socio-demographic factors on patient’s satisfaction with WASH services ............................................................................................................................. 52 CHAPTER SIX ........................................................................................................................ 54 CONCLUSION AND RECOMMENDATION ....................................................................... 54 v University of Ghana http://ugspace.ug.edu.gh 6.1 Introduction .................................................................................................................... 54 6.2 Conclusion ...................................................................................................................... 54 6.3 Recommendation ............................................................................................................ 54 References ................................................................................................................................ 56 APPENDICES ......................................................................................................................... 62 APPENDIX 1 RESPONDENT INFORMATION SHEET AND CONSENT FORM ............ 62 APPENDIX II INFORMED CONSENT ................................................................................. 65 APPENDIX III: QUESTIONNAIRES .................................................................................... 65 APPENDIX IV ETHICAL APPROVAL LETTER ............................................................... 85 vi University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 3.1: List of health facilities surveyed ............................................................................. 20 Table 4.1: Socio-demographic characteristics of respondents (n = 428) ................................. 30 Table 4.1 Continued: Socio-demographic characteristics of respondents (n = 428) ............... 31 Table 4.2: Health Facility Assessment of WASH Facilities .................................................... 32 Table 4.3 Patient Satisfaction with WASH Services ............................................................... 38 Table 4.4 Socio-demographic factors associated with Patient Satisfaction with WASH Services .................................................................................................................................................. 41 Table 4.4 continued Socio-demographic factors associated with Patient Satisfaction with WASH Services ....................................................................................................................... 42 Table 4.5 Factors associated with patient satisfaction with WASH Services.......................... 44 Table 4.5 continued Factors associated with patient satisfaction with WASH Services ......... 45 Table 4.6 Expectations and Considerations ............................................................................. 46 Table 4.6 Continuation Expectations and Considerations ....................................................... 46 vii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1.1: Conceptual Framework- Water Sanitation and Hygiene facilities and Patient Satisfaction ................................................................................................................................. 5 Figure 3 1: JMP Service Ladders for Monitoring WASH in HCF .......................................... 16 Figure 4. 1 Level of WASH Services according to the JMP WASH Service ladders ............ 35 Figure 4.2 Mean score for items used to assess satisfaction with WASH services ................. 37 Figure 4.3 Proportion of patients satisfied with WASH services in health care facilities ....... 40 viii University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS CHPS Community Health Planning Services DHIMS District Health Information Management System DHMT District Health Management Team GHS Ghana Health Service HACI Hospital Acquired Infections HCF Healthcare Facilities JMP Joint Monitoring Programme LMICS Lower and Middle-Income Countries MOH Ministry of Health NGOs Non-Governmental Organizations UNICEF United Nations Children’s Fund WASH-FIT Water and Sanitation for Health Facility Improvement Tool WASH Water, Sanitation and Hygiene WATSAN Water and Sanitation WHO World Health Organization ix University of Ghana http://ugspace.ug.edu.gh ABSTRACT Introduction: There is a paucity of research on the level of patient satisfaction with water, sanitation and hygiene (WASH) services in Ghanaian health facilities. Objectives: This study aimed to assess WASH facilities in selected health facilities in the Ga West Municipality of the Greater Accra region and to ascertain patient satisfaction with these services. Methods: An analytical cross-sectional design was used to collect data from patients aged 18 years and above accessing healthcare in 8 selected health facilities in the Ga West Municipal of the Greater Accra Region. The 428 patients were selected via consecutive sampling from all selected facilities simultaneously to meet the facility-specific sample sizes. Administrators in each of the surveyed health facilities also provided general information about the facility. A checklist was used to assess the WASH services in the selected health facilities. Data was managed and analyzed using STATA version 16 using mean gap sore between patients expectation and what they perceived to measure patients satisfaction. Multiple logistic regression was used to determine factors associated with patients’ satisfaction. Results: The level of WASH services in health facilities in the municipality vary with higher level of services for water and hand hygiene than sanitation and waste management services. On the other hand, the level of patients’ satisfaction with the WASH services in health facilities in the municipal was low (percentage = 21.7%; 95% CI = 17.9% - 25.9%). The place of residence patients, rural areas (aOR = 5.13; 95% CI = 1.83 – 14.39; p = 0.002), patients who visit private health facilities (aOR = 0.003; 95% CI = 0.0004 – 0.02; p < 0.001) and level of health facilities; level 2 (aOR = 228.32; 95% CI = 62.03 – 840.40; p < 0.001) and level 3 (aOR = 4.31; 95% CI = 1.70 – 10.94; p = 0.002) health facilities were factors significantly associated with patient satisfaction with WASH services in the health facilities. Conclusion: The level of WASH services in the health facilities surveyed ranged from limited x University of Ghana http://ugspace.ug.edu.gh to basic services when compared to the JMP WASH service ladder. Overall patient satisfaction with WASH services in health facilities in the municipality was low. The WASH in HCF Technical Guidelines developed by the Ghana Health Services should be implemented particularly for new upcoming facilities and old facilities should be renovated to meet the said WASH standards. Keywords: Water, Sanitation, Hygiene, WASH Services, Patient Satisfaction, Healthcare Facilities xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background Adequate and safe water, sanitation and hygiene (WASH) services in health facilities are essential for the prevention of the spread of diseases, provision of quality of care and promotion of patient safety. In 2010 the United Nations General Assembly adopted the human right to water and sanitation under UN Resolution 64/292 (UN, 2010). This resolution called on member states to scale up efforts to provide safe, clean, accessible and affordable drinking water and sanitation for all citizens. The human rights to water and sanitation was further endorsed by the United Nations in 2015 through the UN Sustainable Development Goal (SDG 6) with target 6.2 aimed at achieving access to adequate and equitable sanitation and hygiene for all. In spite of the crucial role of WASH in infection prevention and the patient‘s right to safe healthcare. Healthcare-associated infections acquired during hospital visits and hospitalization affect hundreds of millions of patients every year. According to the World Health Organization (WHO, 2011), about 7% of estimated patients in high-income countries contract hospital-acquired infections during their stay in hospital. The proportion of hospital acquired infections is likely to be higher in low-income countries where the population groups at higher risk of acquiring hospital infections include, pregnant women, neonates and children under five years. Studies have however shown that in health facilities, adequate and improved WASH services can reduce the risk of infections for patients, their care givers and health workers (WHO, 2011). The provision of adequate WASH services and practices can result in increased demand and trust in the health services and improved patients' experience with the care they receive from 1 University of Ghana http://ugspace.ug.edu.gh healthcare providers. The positive effects of WASH practices and behaviours such as hand washing with soap can be passed on to friends and relatives of the patients, enhance staff motivation and improve performance and retention of health workers (Russo et al., 2012: Bouzid et al., 2017). In recent times, there is increasing concern of the need to monitor WASH services in settings like workplaces, schools and health facilities (Cronk et al., 2015). However, WASH services in healthcare facilities (HCF) have not been adequately researched in low- income countries, neither have the links between WASH services and patient satisfaction been sufficiently explored in Ghana to inform policy and practice discussions. Client satisfaction for services and goods is an important measure for quality and adequate provision of services and products. There is enough evidence to show the importance clients attach to service quality in both production and service organizations, particularly in high- customer oriented industries such as healthcare and financial services (Taheri et al. 2013). In the healthcare industry, Tirsit and colleagues (2015) have defined patient satisfaction as ‘an attitude resulting from a person’s general orientation towards a total experience of healthcare’. The need for patient satisfaction with health care services has been advocated at many levels. Yet, in low-income countries studies on patient satisfaction have focused on technical and functional areas accessing clinical care, with little attention to patient satisfaction for supporting services such as WASH (Tirsit et al., 2015). 1.2 Problem Statement The main focus of the assessment of WASH services has been in communities and less on the impact of WASH services on patients in healthcare facilities in low-income countries (Bouzid, et al. 2018). In 2015 an assessment conducted by WHO and UNICEF in 66 health facilities in 54 lower and middle-income countries showed that 38% of facilities lacked access to safe water, 19% had no improved sanitation and 35% had no soap for hand washing (WHO & UNICEF, 2015). According to the World Health Organization, (WHO, 2015) inadequate 2 University of Ghana http://ugspace.ug.edu.gh WASH services contribute to Hospital Acquired Infections (HAI). In Lower and Middle- Income Countries (LMICs) HAI is estimated at 15.5% and affects vulnerable groups such as pregnant women, neonates and children under five years (Allegranzi et al., 2011; WHO, 2011). Inadequate WASH services in healthcare facilities has resulted in several disease outbreaks. Such occurrences may increase patient dissatisfaction and limit healthcare-seeking behaviour (Bouzid et al., 2018). In Ghana, access to improved water is 86% and access to improved sanitation at the household is 20% (UNICEF, 2018). The low coverage of sanitation predisposes the population to infectious diseases. In 2019, the WHO/UNICEF Joint Monitoring Programme for WASH (JMP) published the baseline report for WASH in Healthcare Facilities. The Ghana estimates for basic water services defined as improved water supply, available and on-premises of the health facility was 85% (World Health Organization & United Nations International Children's Emergency Fund, 2019). However, there were no estimates for basic services for sanitation and hand hygiene due to lack of data. Although the WHO/UNICEF estimates for basic water services appears high this is not the case for all health facilities. There are disparities in the availability of WASH services by level of health facilities, tertiary or health centre, services provided and between location rural or urban areas. A WASH in HCF assessment conducted by Ghana Health Service (GHS) in Tatale Sangule District and Kpandai district in Northern Ghana found 16% had no toilet facilities, 12% of toilets were in very bad condition, 33% had improved water supply on the health facility premises, 41% improved water far from the premises and 20% did not have an improved water source. This illustrates the inadequacy of WASH services in some health facilities and thus the importance of targeted and needs-based interventions (GHS, 2016). 3 University of Ghana http://ugspace.ug.edu.gh In recent years the Ghana Health Service has integrated WASH in Infection Prevention Control and Quality of Care of Maternal and Child Health Programmes. WASH indicators have also been integrated into the District Health Information Management System, the second phase (DHIMS2). However, the database is in the initial stages and there is a lack of comprehensive data on the status of WASH services in Healthcare Facilities. There is also limited research on the level of patient satisfaction with WASH services in health facilities, especially in the Greater Accra region. This information is important as it will influence health-seeking behaviour and ultimately reduce adverse health outcomes (Bouzid et al., 2018) 1.3 Narrative of Conceptual Framework The conceptual framework below (Figure 1.1) explains the correlation and contribution of factors that influence patient satisfaction. It has been established that simple measures such as improving water supply, cleanliness of toilets and installing low-cost hand washing facilities at healthcare facilities improve quality of care. Adequate water, sanitation and hygiene (WASH) are essential components of providing basic health services. The provision of WASH in healthcare facilities serves to prevent infections and spread of disease, protect staff and patients, and uphold the dignity of vulnerable populations including pregnant women and the disabled. The adequacy of WASH facilities in health facilities from the patient's perspective is influenced by socioeconomic status. Low-income users in a Nigerian study reported better quality of services including clean toilets than high-income users (Mohammed et. al, 2013). The living conditions of the patient and previous experience in the use of WASH facilities also influence patients’ perception and level of satisfaction with services (Woldeyohanes et al., 2015). The framework illustrates how socio-economic factors and patients’ perception of the adequacy of WASH service i.e. availability of improved water, functionality and cleanliness of toilets, 4 University of Ghana http://ugspace.ug.edu.gh hand washing facilities at advantage points influence patient satisfaction. There are also interactions between the various WASH components, the availability of water supply is essential for both adequate sanitation and good hand hygiene. 1.4 Conceptual Framework Assessing the availability of WASH services in health facilities and the effect on patient satisfaction in selected hospitals will contribute to the knowledge and evidence for strategic planning. Figure 1.1: Conceptual Framework- Water Sanitation and Hygiene facilities and Patient Satisfaction 5 University of Ghana http://ugspace.ug.edu.gh 1.4 Objectives of the study 1.4.1 Main Objective The main objective of the study is to assess the availability of WASH services in health facilities and determine factors that influence patient satisfaction with these services. 1.4.2 Specific Objectives • To assess the availability and level of water, sanitation and hygiene (WASH) services in health facilities in the municipality; • To determine the level of patients’ satisfaction with the WASH services in health facilities in the municipality; and • To determine the association between socio-demographic factors on patients’ satisfaction with WASH services. 1.4.3 Research Questions ● What is the state and level of availability of water, sanitation and hygiene (WASH) services available in the healthcare facilities? ● Are patients satisfied with the WASH services in health facilities? ● Is patient satisfaction with WASH services influenced by socio-demographic factors? 1.5 Justification The aim of this study is to fill the literature gap in the water, sanitation and hygiene services in Ghana since studies in this area are limited. This study will also assess patient satisfaction on the three dimensions (3Es) of environmental factors (water, sanitation and hygiene) that might influence service delivery and patient safety in health facilities. Results attained from this current study can be generalized and applied to similar settings due to the quantitative methods proposed. The study results will also help shape policy and practice discussions on water, 6 University of Ghana http://ugspace.ug.edu.gh sanitation and hygiene services in health facilities. It will also help policymakers of the Ministry of Water and Sanitation, NGOs and other entities to plan for effective measures on water, sanitation and hygiene interventions in health facilities in the country as a whole. Finally, the study aims to contribute to the literature on water, sanitation and hygiene services in health facilities in the country. 7 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter provides a detailed review of existing literature that is appropriate to develop an understanding of water, sanitation and hygiene issues in health facilities. It examines the debate on water, sanitation, and hygiene in general with a focus on clients that visit health facilities. The review is on both empirical literature and theories on the subject and explores the various aspects of water, sanitation and hygiene (meanings and components). It also describes the framework to the study and how it connects with best practices and appropriate actions employed by health facilities to improve WASH practices. The chapter begins by describing the review process and literature search. It examines the dominant theories on patient satisfaction in healthcare facilities. It then proceeds to review empirical literature based on the various aspects of the conceptual framework (water, sanitation and hygiene) and examines best practices and challenges from other countries to serve as a guide for interpretation of results of the study. 2.2 Review process and literature search A comprehensive literature review was conducted to understand the theoretical foundation of the study. Initial search using the words or phrases; 'water', 'sanitation', 'hygiene', 'patient satisfaction', 'health facilities' were entered into Google Scholar search engine to retrieve studies that have been conducted with the terminologies but limited to Ghana. A search strategy was designed to search the following databases: PubMed, CINAHL, and Medline. The strategy was modified across different databases. References of identified studies, as well as 8 University of Ghana http://ugspace.ug.edu.gh grey literature, was searched by using Google search engine, a reference list of published studies and government websites that helped identify unpublished studies was also used. 2.3 Empirical literature The objectives of the study examine three key variables; level of WASH services; patient satisfaction on WASH services; and influence of demographic factors on patient satisfaction of WASH services. Therefore, the study reviews the literature on studies that have explored; patient satisfaction with overall health services; patient satisfaction with WASH services; adequacy of water, sanitation and hygiene services and impact on specific healthcare services and finally relate the literature to the conceptual framework. 2.3.1 Patient satisfaction on overall healthcare services There is evidence to show a strong relationship between health outcomes and patient satisfaction (Smith and Engelbrecht, 2001; Leino-Kilpi and Vuorenheimo, 1992). Patient satisfaction with the services they receive from health facilities is the judgement they make about those services. The United Kingdom Health Boards Executive (2003) views satisfaction to be the level to which patients’ desired goals are attained. Woldeyohanes and colleagues (2015) consider patient satisfaction to be an attitude that emanates from a person's overall alignment with their understanding of healthcare and experience towards health services. In a cross-sectional survey design to measure and describe the level of satisfaction within inpatient healthcare services (Woldeyohanes et al. 2015) found that almost 67% of patients sampled were satisfied by the service, they received from the hospital. Those found to be dissatisfied had concerns with nursing, pharmacy laboratory services health education, communication and information they received about their illness. This study was conducted on only inpatients and was more focused on technical quality and not support services. 9 University of Ghana http://ugspace.ug.edu.gh Anbari and colleagues, (2014) used a cross-sectional SERVQUAL survey questionnaire to examine patients’ views on different types of service in Iranian hospitals. They identified that patients had a high expectation and perception associated with the responsiveness of services provided and a lower expectation and perception associated with the reliability of services. Peprah and Atara (2014) used the SERVQUAL model to assess the satisfaction of 214 outpatients from a regional hospital in Ghana and found that patients were not satisfied with the quality of service they received about reliability, communication/interpersonal relationship, assurance and responsiveness. However, this study was limited to only one regional hospital and conducted on the functional assessment of outpatients alone. The SERVQUAL model applies to the healthcare sector (Herstein & Gamliel, 2006). It has the following characteristics (Herstein & Gamliel, 2006): 1. Reliability: appointments kept on schedule, accurate diagnoses; 2. Responsiveness: accessible services, no waiting, willingness to listen; 3. Assurance: knowledge, skills, credentials, reputation; 4. Empathy: patient acknowledged as a person, awareness of previous problems, good listening, patience; and 5. Tangibles: washrooms, clean environment, waiting room, examination room, available equipment, written materials. For this study, the tangible dimension was applied to measure the client's satisfaction to WASH services in the health facility. Although some researchers have stated this dimension as the least important dimension for the patients from the use of the SERVQUAL model (Yousapronpaiboon & Johnson, 2013), the tangible dimension refers to how the physical environment of the hospital appears to the patient- the neatness, how it looks, if it is good and modern, accessibility, staff. The physical atmosphere may have a psychological impact on the patient either positively or negatively. 10 University of Ghana http://ugspace.ug.edu.gh 2.3.2 Patient satisfaction with WASH services Indeed, the literature shows that studies conducted on patients' satisfaction in low-income countries have focused on nursing and outpatient care with a few on inpatient care and other supportive or functional services such as WASH (Woldeyohanes et al. 2015). Supportive services critical to patients’ health outcome include; Water, sanitation and hygiene (WASH) services in health facilities. Yet in developing countries, there is limited empirical evidence in this area (Bouzid et al. 2018). In a systematic literature review on patient satisfaction, (Bouzid et al. 2018) in Nigeria retrieved only 21 WASH-related articles out of 984 papers on patient satisfaction. Bouzid and colleagues (2018) concluded in their review that WASH was not the main driver of patient satisfaction. The review showed that poor or inadequate WASH services correlated with patient dissatisfaction. However, the findings indicate that the level of dissatisfaction was not strong enough to prevent patients from looking for healthcare in those Nigerian facilities with poor WASH services. This systematic review also highlighted a paucity of research to describe and evaluate interventions to improve WASH conditions in HCF in a low-income setting with a high burden of healthcare-associated infections. Bouzid and colleagues (2018) however suggest that improving WASH services in healthcare facilities will potentially reduce patience dissatisfaction - resulting in increasing care-seeking behaviour and improved health outcomes. WASH services include several interventions ranging from health campaigns to the creation of awareness and stimulation of interest in sanitation and hygiene behaviours, infrastructure for water and sanitation improvements, and regulation of quality service and cost dimension to drinking water (Bartram and Cairncross 2010). Increasing concerns about health-related infections due to inadequate hygiene practices has resulted in several initiatives on patient safety by the World Health Organization (WHO, 2010). The WHO guidelines on hand hygiene 11 University of Ghana http://ugspace.ug.edu.gh in healthcare facilities also recognize the importance of water and, to a minor extent, sanitation as determinants of safe hand hygiene (Pittet, 2009). Weber, et al. (2018) used in-depth interviews and document reviews to assess the extent of WASH FIT in 3 healthcare facilities in Togo. WASH FIT is a set of 65 WASH indicators developed by the World Health Organization to assess the extent of WASH in healthcare facilities. The assessment showed that on average, the facilities improved from 18% of total indicators meeting standards at baseline to 44% after 7 months. Examples of WASH services that realized improvements include drinking water supply, medical waste segregation, and availability of soap at handwashing points. Participants reported improvements in staff and patient satisfaction, hand hygiene, and occupational safety. Findings suggest that WASH FIT, coupled with training and supervision, may help facilities improve WASH services and practices, thus contributing to global health security. The SERVQUAL model with its associated questionnaire was adopted to determine patients' level of satisfaction with the quality of WASH services in this study. The questionnaire was designed to assess patients' level of satisfaction using two categories: 1) expectation; and 2) perception (Khamis & Njau, 2014). The patients’ satisfaction scores were computed by comparing the patients’ experience or their perception of service quality scores compared with their expectation scores: Perception - Expectation = Satisfaction (Yousapronpaiboon & Johnson, 2013). Patients' satisfaction was measured by asking the level to which patients were satisfied with the WASH services accessed based on them using four point-Likert Scale questions (Strongly disagree, Disagree, Agree, Strongly Agree). 12 University of Ghana http://ugspace.ug.edu.gh 2.3.3 Water, Sanitation and Hygiene (WASH) and Health Services --Provision Low and middle-income countries have recorded poor access to water and sanitation (WATSAN) services in health facilities. The World Health Organization (WHO, 2015) indicates that 38% of healthcare facilities across 54 countries in poorly resourced countries do not have access to basic water sources and 19% do not have access to basic sanitation infrastructure. A Ghanaian study in the Bongo and Kassena Nankana west districts in Ghana among 29 health care facilities revealed that concerning availability of water, 76% of healthcare facilities had uninterrupted water supply while only 55% had storage tanks. In the same study, 48% had toilet facilities for outpatients. However, half of these toilet facilities were shared by both male and female patients contrary to WHO standards. Among the health facilities, 50% disposed their fecal matter manually while 27% use sewage system, 19% use puller services and the remaining use the dig and bury method. General and medical wastes were disposed using incinerators (21%), shallow pit burning (69%) whilst the remainder used waste bins or dig and bury method. The study also noted that 93% had hand washing centres, 100% had alcohol hand rubs but only 14% had one near toilet facilities (WaterAid n.d.). A recent study evaluating the WASH status of seven COVID-19 treatment centres in Ghana using the WHO/UNICEF water and sanitation for health facility improvement tool (WASH FIT) revealed that the centres averaged 90.5% standard score for water across the seven centres, followed by management (66.9%) and hygiene (58.7%). Poor performance was recorded in the sanitation and waste practices of the treatment centres with an average score of 44.6% (Ashinyo et al., 2021). A study involving 16,456 health facilities from eighteen sub Saharan countries excluding Ghana noted that 88 % of health facilities had an improved water source, 94 % had an improved toilet, 74 % had soap and running water or alcohol-based hand rub, and 17 % had standard precautions for infection prevention available. The study also noted a wide variability 13 University of Ghana http://ugspace.ug.edu.gh in access to water, sanitation and hygiene services between rural and urban health facilities and between public and private facilities, with consistently lower access in both rural and public facilities (Kanyangarara et al., 2021). Access to safe drinking water and improved hygiene is essential for preventing diarrheal diseases. Russo et al. 2012 evaluated water treatment and hygiene practices of 275 non- pregnant friends and relatives of the hygiene kit recipients in Malawi using kit recipients as a baseline to evaluate the intervention. The results showed that friends and relatives who did not receive kits or education were more likely to purchase and use a water treatment solution. They also demonstrated correct hand washing practices in the facilities. This antenatal clinic-based program resulted in improved water treatment and hygiene behaviours among non-pregnant friends and relatives living in the same communities as hygiene kit recipients, suggesting that program benefits extended beyond direct beneficiaries. For specific service provision in health facilities, the World Health Organization (WHO, 2015) has shown that absence of water, sanitation and hygiene (WASH) services endanger the ability of midwives and birth attendants to undertake appropriate hygiene and infection prevention and control measures. Gon et al (2016) used global datasets from 58 countries to examine the effect of water and sanitation on childbirth in homes and health facilities. The results show that among the health facilities that conducted deliveries, only 44% of them had safe water and sanitation facilities and just 24% of facility delivery rooms had safe WATSAN services. The investigation indicated regional disparities in WATSAN infrastructure within health facilities with countries from Sub-Saharan Africa adversely affected. This challenge has been a long-standing issue over the years in low-income countries. For example, Gould and Gordon (2010) showed a link between maternal mortality and hygiene at birth in health facilities in developing countries. Investigations on the interplay between poor hygiene and childbirth in 14 University of Ghana http://ugspace.ug.edu.gh health facilities have provided enough evidence to suggest that at least 9% of maternal deaths and 680 000 neonatal deaths recorded in health facilities yearly are caused by poor hygiene (Kassebaum et al., 2013; Seale et al., 2012). Even though hospital infections in babies can occur anywhere irrespective of the economic status of the country, research has shown that infection rate in babies is 3–20 higher in developing countries than developed countries (Zaidi et al., 2005). Yet there is enough expert view to suggest that about 27% of these deaths could be reduced with clean delivery in health facilities (Blencowe et al., 2011). Many researchers have questioned the constituents of clean delivery in health facilities. Blencowe et al. (2011) argue that clean delivery can only be achieved through access to appropriate WATSAN facilities. According to Blencowe et al., clean delivery comprises; 'clean hands of the birth attendant, clean perineum, clean birth surface, clean cord preparation and cutting, and appropriate newborn postpartum skincare. Collignon, et al (2018) have shown that improving sanitation, increasing access to clean water, are important contributing factors towards the reduction of antimicrobial resistance. Assessment of WASH Services The assessment of WASH services in the health facilities was done by using a check list and categorizing the level of services for each of the four WASH components by adapting the WASH service ladder categorizing WHO/UNICEF JMP (2017) for Water, Sanitation, Hygiene and Waste Management. 15 University of Ghana http://ugspace.ug.edu.gh Water Sanitation Hygiene Healthcare Waste Basic service Basic service Basic service Basic service Water is available Improved sanitation Functional hand Waste is safely from an improved facilities are usable hygiene facilities segregated into at source located on with at least one (with water and least three bins premises. toilet dedicated for soap and/or and sharps and staff, at least one sex- alcohol- based infectious waste separated toilet with hand rub) are are treated and menstrual hygiene available at points facilities, and at least of care, and within disposed of safely one toilet accessible 5 meters of toilets for people with limited mobility Limited service Limited service Limited service Limited service An improved water At least one improved Functional hand There is limited source is within sanitation facility, but hygiene facilities separation and/ or 500 meters of the not all requirements are available at treatment and facility, but not all for basic service are either points of disposal of sharps requirements for met. care or toilets, but and infectious basic service are not both. waste, but not all met. requirements for basic service are met No service No service No service No service Water is taken from Toilet facilities are No functional There are no unprotected dug unimproved (pit hand hygiene separate bins for wells or springs, latrines without a slab facilities are sharps or infectious or platform, hanging available at either waste, and sharps or surface water latrines and bucket points of care or and/or infectious sources; or an latrines), or there are toilets. waste are not improved source no toilets or latrines at treated/disposed of that is more than the facility. 500 m from the facility; or the facility has no water source. Figure 3 1: JMP Service Ladders for Monitoring WASH in HCF Source WHO & UNICEF (2019), WASH in HCF Baseline Report Note: 16 University of Ghana http://ugspace.ug.edu.gh Improved water sources include piped water, borehole, tube wells, rainwater, and protected springs. Improved toilets include flush/poor toilets connected to piped sewer system, septic tanks or pit latrines. Hand Hygiene facilities include sink and tap, veronica buckets, tank with Waste segregation into 3 bins for general waste, infectious waste and sharps. Safe treatment of waste includes incinerated, autoclaved and buried in a protected pit Figure 3.1 is the JMP ladder used for WASH services for the study. The categorization for WASH services was defined to establish a benchmark for assessing WASH indicators and was used for the Global baseline report on WASH in Healthcare facilities. These indicators are used for monitoring progress in WASH targets for the Sustainable Development Goals. This service ladder has also been adapted by Ghana (UNCG SDGs 2017). Summary The literature has provided enough evidence to demonstrate that water, sanitation, and hygiene (WASH) affect diarrhoea diseases, maternal and newborn health. This means that ensuring adequate attention and monitoring of WASH services in healthcare facilities is critical to improving maternal and newborn health indicators. The evaluation of WASH activities in healthcare facilities is needed to identify effective interventions to improve WASH and consequent progress in maternal and newborn health. However, in Ghana, these links have not been adequately explored. 17 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODS 3.1 Introduction This chapter of the dissertation focuses on the various procedures that was used in the study. The Study Design, Study Areas and Study Population, Sampling Technique, Study Variables, Data Collection Methods and Instruments, Data Analysis, and Ethical Consideration are described in this chapter. 3.2 Study Design In line with objective research principles, this study used quantitative research methods to collect, quantitative data and this was informed by the nature of research questions that were not easily answered by qualitative approaches and required strong statistical analysis. This study was an analytical cross-sectional design among patients aged 18 years and above accessing healthcare in 8 selected health facilities in the Ga West Municipal of the Greater Accra Region. 3.3 Study Areas The study was carried out in the Ga West Municipal of the Greater Accra Region of the Republic of Ghana. Ga West Municipal is one of the 29 Administrative districts in the Greater Accra Region with Amasaman as the Municipal capital. The Municipal shares boundaries with Ga East and Accra Metropolitan Assembly to the East, Akuapem South to the North and Ga South to the South and West. The municipal has a population of 219,788 people with 51% females as per the 2010 housing and population census (Ghana Statistical Service, 2010). The population is mostly urban (63%) and covers 193 communities. The predominant religion is Christianity. There are however several traditional religious practitioners and Moslems. Health service provision is mainly by the Government through the Ghana Health Service and supported by private facilities. The Municipal has 30 health facilities made up of; 1 Municipal 18 University of Ghana http://ugspace.ug.edu.gh Hospital, 15 CHPS compounds, 6 clinics, 3 health centres, 1 private hospital, 3 maternity homes and 1 Polyclinic. 3.4 Study Population The study population included all patients, both men and women seeking healthcare at the time of the study in the health facilities in Ga West Municipal and the administrator in each of the surveyed health facilities who provided general information about the facility. 3.4.1 Inclusion Criteria Eligible participants for this study were all patients aged 18 years and above, willing to provide answers to the study instrument, and who have made at least one visit and utilized the WASH services in the selected facilities. The administrator who has oversight responsibility at each of the selected health facility was included in the study. The study was conducted in English, Twi and Ga for the benefit of respondents who not literate. 3.4.2 Exclusion Criteria Patients who cannot speak or hear (deaf), those who are in serious health conditions, those who have mental health conditions, and minors were excluded from the study. No hospital administrator was excluded from the study. 3.5 Sampling Technique 3.5.1 Selection of health facilities A total of 8 health facilities were selected to be part of this study. This number represents 28% of the 30 health facilities in the municipal that provide primary and secondary healthcare to the population. The facilities were a combination of government and private sampled randomly based on facility type (CHPS, Hospital, Health Centre, Maternity Home, and Clinic). The breakdown was; 2 CHPS compounds, 1 Municipal Hospital, 1 Clinic, 1 Health Centre, 1 Policlinic, 1 Private Hospital and 1 Maternity Home (private). 19 University of Ghana http://ugspace.ug.edu.gh Table 3.1: List of health facilities Facility Type Description Facility A Government Serves a population of 151,039 persons. Average monthly outpatients are 5,376, operates 7 days a week, has 88 beds. Provides both outpatient and inpatient care. Facility B Government The catchment population is 52, 864, operates 7 days a week, average monthly patients are 1,000, has 28 beds, provides both inpatient and outpatient care. Facility C Government Catchment population 15,104 persons. The health centre operates 7 days and mainly on an outpatient basis, however has 7 beds and detains patients both day and night as needed. Facility D Private Provides both outpatient and inpatient care and operates 7 days a week. Average monthly patients are 95. The bed capacity is 9. Facility E Private Provides both outpatient and inpatient care and operates 7 days a week. Average monthly patients are 1,500. The bed capacity is 60. Facility F Government The catchment population is 1,510, operates 5 days a week (Monday to Friday), Average monthly patients seen are 60. Mainly provides outpatient services with 4 beds (2 for males and 2 for females) for detainment for about 2 hours Facility G Government Catchment population 6,326, operates 7 days a week. Average monthly patients seen is 60. Mainly provides outpatient care. Has two beds for short detainment. Facility H Government The catchment population is 7,000, operates 5 days a week (Monday to Friday). Mainly provides outpatient care, no inpatient admissions. Average monthly patients seen are 110. Table 3.2: Names of Health Facilities according to Level and Type Facility Name of Health Facility Level Type Facility A Ga West Municipal Secondary Government Hospital Facility B Oduman Polyclinic Primary 1 Government Facility C Mayera Health Centre Primary 2 Government Facility D Edith Maternity Home *Primary 2 Private Facility E M&D Medical Centre *Primary 1 Private 20 University of Ghana http://ugspace.ug.edu.gh Facility F SamSam Community Primary 2 Government Clinic Facility G Akramaman CHPS Primary 3 Government Facility H Ahiabukope CHPS Primary 3 Government Categories for Disaggregation of Data Category A (Levels, Secondary and Primary) 1. Ga West Municipal Hospital 2. Oduman Polyclinic, *M&D Medical Centre 3. Mayera Health Centre, Samsam Clinic, *Edith Maternity Home 4. Akramaman CHPS, Ahiabukope CHPS Category B (Public and Private) 1. PUBLIC: Ga West Municipal, Oduman Polyiclinic, Mayera Health Centre, Samsam Clinic, Akramaman CHPS, Ahiabukope CHPS 2. PRIVATE: M&D Medical Centre, Edith Maternity Home 3.5.2 Sampling Size Determination All Administrators of the selected health facilities were included in the sample, which is a total of 8 administrators. The proportion of patients' satisfaction with OPD services reported by a study by Sagaro and friends (2015) was used in calculating the required sample size for this study. The study reported 54.2% of patients' satisfaction (Sagaro et al., 2015). Thus, the sample size of this 21 University of Ghana http://ugspace.ug.edu.gh study was calculated at a 95% confidence interval using a formula by Cochran. The formula is given by: 𝑍2𝑝𝑞 n= 2 (Cochran, 1977) 𝑒 Where: ● n= required sample size ● Z2 = standard normal deviate for two tailed-test based on 95% confidence level = 1.96 ● P= 54.2% satisfaction level based on a study in Ethiopia (Sagaro et al., 2015). ● q = 1-0.542= 0.458 ● e= margin of error = 5% = 0.05 ● Therefore, the sample size will be calculated as follows 𝑧2𝑝𝑞 ● N= 𝑒2 (1.96)2×0.542×0.458 ● N= 0.05×0.05 3.8416×0.542×0.458 ● N = 0.05×0.05 ● N =381 ● However, to cater to a non-response rate of 10% was used to upwardly adjust the sample size. Thus, 1.1 × 380 = 418.This number was increased to 418 to make up for a possible 10% non-response rate. 3.5.3 Selection of Participants within the Selected Facilities In each facility, the selection of patients (outpatients and in-patients) was done by consecutive sampling. Out-patients were recruited at the OPD after receiving treatment at the health facility. All consecutive OPD patients, if eligible were enrolled in the study if they gave consent. 22 University of Ghana http://ugspace.ug.edu.gh For facilities that have in-patients, there were two categories, small facilities with one or two wards, these were all were included in the study, for larger health facilities the wards were visited in alphabetical order of their names and in order of bed numbers to recruit participants for the study. Wards visited were the children wards, general ward, maternity ward and surgical ward. 3.5. 4 Sampling Process Using proportionate sampling, the number of patients were distributed among the health facilities as shown in table 3.3 below. Table 3.3 Distribution of Patients among the Health care Facilities Sub Sub Sub Average Proportion sample sample sample monthly OPD (x/sample (x/sample size N - size N - Health facility attendance (x) size) in % size*N) OPD Inpatient 1. Ga West Municipal Yes Hospital 5,043 55.4 232 207 2. Oduman Yes* Polyclinc 1427 15.0 63 3. Mayera Health Yes* Centre 660 7.0 29 4. Edith Maternity Home 78 0.8 3 5. M&D Medical Yes* Centre 1676 18.0 75 6. Samsam Community Clinic 99 1.0 4 7. Akramaman CHPS 108 1.2 5 8. Ahiabukope CHPS 149 1.6 7 • Yes 24 hour detention exists but not in DHIMS Total Sample Size 418, over response rate of 2% 1. Ga West Municipal Hospital 23 University of Ghana http://ugspace.ug.edu.gh 2. Oduman Polyclinic 3. Mayera Health Centre 4. Edith Maternity Home 5. M&D Medical Centre 6. Samsam Community Clinic 7. Akramaman CHPS 8. Ahiabukope CHPS Ga West outpatient 5403 + 662 (Inpatient) = 6065 Proportion of inpatient = 10.9% Total sample size = 232; inpatient = 232(0.109) = 25 (Outpatient) = 207 3.6 Study Variables The variables measured in the study were categorized into dependent and independent variables. Dependent variable The dependent variable measured in this study was patients' satisfaction. Independent variables Patients related factors / Socio-demographic characteristics (sex, age, educational level, marital status, occupation, income). 3.7 Data Collection Method and Instruments Data were collected in two phases: i. Assessment of WASH facilities and facility administrator interviews ii. Survey questionnaires administered to patients. Phase 1: This phase involved an initial interview with the hospital administrators on general information about the health facility followed by the use of the WHO/UNICEF Core Indicators 24 University of Ghana http://ugspace.ug.edu.gh WASH in Healthcare facilities assessment tool (WHO & UNICEF, 2018) to assess the WASH infrastructure in health facilities. The process included observations of the water supply, toilets and waste management facilities and informant interviews for clarifications. The Assessment Tool was used in collecting the data on availability and status of WASH services in health facilities. The WHO/UNICEF tool examines the water, sanitation and hygiene situation in health facilities. It assesses water from sources, availability and accessibility. On sanitation, the tool assesses toilet types, separation for patients and staff, separation for males and females, disability friendliness, and cleanliness. With regards to hygiene, the tool examines the flow of water and the use of soap or alcohol solution for hand washing. Waste management was also covered due to its relevance during the COVID-19 outbreak which was on-going at the time of the survey. Phase 2: Patients who fell within the sample group, that is above 18 years accessed services at the facility either out-patient and in-patient and utilized WASH facilities at the facility were interviewed using a pre-designed questionnaire (Appendix 2). A total of 428 patients were interviewed, which is an over-response rate of 2%. Patients' satisfaction was measured by asking the level to which patients were satisfied with the WASH services accessed based on them using four point-Likert Scale questions (Strongly disagree, Disagree, Agree, Strongly Agree). 3.8 Training of Data Collectors and Supervision A team of six data collectors and a supervisor were recruited to carry out the data collection. The researcher trained the team thoroughly on the rationale of the study, the data collection tools, i.e. Administrator and Patient Questionnaires and WASH assessment checklist, research ethics and COVID-19 protocols. Each member of the team was provided with a set of data 25 University of Ghana http://ugspace.ug.edu.gh collection tools, a copy of the WHO/UNICEF WASH in Healthcare Facilities Core Questions and Indicators Document as reference materials. They were also oriented on the COVID-19 protocols and provided with face masks and sanitizers for use during the training, pre-testing and data collection. 3.9 Pretesting and Data Collection The developed questionnaires and WASH Assessment checklist were pre-tested at a Ga South Municipal Hospital. The pre-testing was done for 30 patients; 20 outpatients and 10 inpatients. The pre-testing was done to test the validity and reliability of the instruments. This helped to identify, exclude or modify ambiguous items; a situation that might lead to biased responses (Bowden, Fox-Rushby, Nyandieka, & Wanjau, 2002). Following the pre-testing, a few corrections were made in the questionnaires and the data collection tools were revised for the final data collection. The data collection was carried out over a 3 week period in September 2020. The data collectors were assigned to health facilities and the team compositions varied depending on the size of the facility and the sample size. The questionnaires were reviewed daily by the supervisor and the researcher to ensure all gaps were addressed. 3.10 Data Analysis Pre-coded data was entered and cleaned in an Excel Spreadsheet and analyzed using STATA version 16.0. The WASH Infrastructure (availability of toilets, functionality accessibility, cleanliness, water source, availability, hand washing facilities was categorized into 3 WASH service ladders. The service ladders are (i) no service (ii) limited service and (iii) basic service, figure 3.2, as defined for the WASH in Healthcare Facilities Core Indicators (WHO/UNICEF2018). Evaluation of 26 University of Ghana http://ugspace.ug.edu.gh WASH infrastructure was computed by calculating the proportion of health facilities that met the criteria for each indicator. Descriptive and analytical statistics were employed to determine patients' level of satisfaction. To calculate the mean gap, score for patients' level of satisfaction, the following procedures were used. A total mean score was calculated for the dimension (e.g. Tangibles) for both expectation and perception questions. The total gap score was derived by subtracting mean perception score from the mean expectation score. A paired t-test was conducted to assess whether the two scores are statistically different from each other. The gap was considered as the level of patients' satisfaction on the quality of care. Quality of care was deemed indifferent or sufficient when patients' level of satisfaction is equal or greater than the expected level of service or vice versa (Senel & Senel, 2006). This was to dichotomize patients into "satisfied" and "not satisfied". Following this, a test of the association on factors associated with patients' satisfaction was done using Chi-Square / simple logistic regression. The association between patients' satisfaction and each independent variable was analyzed using multiple logistic regression analysis with statistical significance set at p-values< 0.05. This was done by first running a bivariate analysis (Chi-Square/simple logistic regression) between patients' satisfaction and all the independent variables selecting those with p-values ≤ 0.2. These were then fitted in a final multiple logistic regression model and the strength of association was assessed looking at Adjusted Odds Ratio (AOR) with 95% confidence interval (CI). 3.11 Ethical Consideration Permission Approval of the study was obtained from the Ghana Health Service Ethics Review Committee (GHS-ERC). Following this, permission was sought from the Ghana Health Services at both the regional and district level and hospital authorities of the selected health facilities before 27 University of Ghana http://ugspace.ug.edu.gh data was collected. All respondents were assured of the confidentiality of any information given and their consent was also obtained before they were interviewed. Respondents were all also made aware of their right to withdraw from the survey at any point if they so wished. The respondents were given further assurance that only the research team, principal investigator and supervisor would have access to the information and data was stored securely under lock and key. Risk and Benefits Respondents were assured that the research did not present any risk to them and would not harm them in any way nor cost them anything except their precious time that they would use to fill the questionnaire. However due to the ongoing COVID-19 outbreak, before the interview began both the interviewer and the respondent sanitized their hands with alcohol- based sanitizer, wore facemasks and kept a few meters apart to ensure physical distancing protocols throughout the interview. Respondents did not receive any monetary or material compensation for the study. 28 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.1 Introduction This chapter presents the results obtained from the study. The results are presented under the specific objectives. The socio-demographic characteristics of the respondents are presented first after which the results on the specific objectives are presented. 4.2 Socio-demographic characteristics of respondents Table 4.1 below shows the socio-demographic characteristics of respondents. The mean age of respondents is 34.1 years (SD± 11.9). Majority of the respondents were females 330 (77.1%). Also, 39.7% of respondents had senior high school education. More than half of the respondents 235(54.9%) were married with 158(36.9%) residing in peri-urban areas. Nearly seventy percent (69.6%) of respondents had nuclear families with 255(59.6%) residing in compound houses. Out of the 428 respondents, 43.2% had to fetch water outside their homes and 49.8% also had toilet facilities in their homes. Majority of the respondents 347(81.1%) were employed with 39.0% earning a monthly income between GH₵500 - GH₵1000. More than half of the respondents 226(52.8%) indicated that they had used the health facility more than once with 51.4% also stating they had used the health facility for less than 6 months. 29 University of Ghana http://ugspace.ug.edu.gh Table 4.1: Socio-demographic characteristics of respondents (n = 428) Variables Frequency Percent (%) Age in years (M ± SD) 34.1 ± 11.9 Sex Male 98 22.9 Female 330 77.1 Educational level No education 17 4.0 Primary school 17 4.0 Junior high school 116 27.1 Senior high school 170 39.7 First degree 96 22.4 Master’s degree 8 1.9 Not applicable 4 0.9 Marital status Single 115 26.9 Married 235 54.9 Widowed 19 4.4 Separated 25 5.8 Divorced 10 2.3 No answer 24 5.6 Place of residence Urban 142 33.2 Peri-urban 158 36.9 Rural 128 29.9 Family structure Nuclear 298 69.6 Extended 116 27.1 No answer 14 3.3 Type of residence Standalone residence 171 40.0 Compound house 255 59.6 Other 2 0.5 30 University of Ghana http://ugspace.ug.edu.gh Table 4.1 Continued: Socio-demographic characteristics of respondents (n = 428) Variables Frequency Percent (%) Main water source Piped into compound 119 27.8 Fetch outside house/premise 185 43.2 Buy water from a tanker 110 25.7 Other 14 3.3 Type of toilet facilities at home Household has own toilet facilities 213 49.8 Shared household toilet facilities 196 45.8 No toilet facilities 18 4.2 No answer 1 0.2 Employment status Employed 347 81.1 Student 23 5.4 Unemployed 48 11.2 Other 1 0.2 No answer 9 2.1 Household monthly income (GH₵) < 500 158 36.9 500-1000 167 39.0 1001-3000 77 18.0 3001-5000 23 5.4 5001-7000 3 0.7 First time / user of facility First time user 202 47.2 Recurrent user 226 52.8 Duration of use of health facility <6 months 220 51.4 6months - 1year 136 31.8 1 - 3years 48 11.2 3 - 5years 18 4.2 > 5 years 6 1.4 31 University of Ghana http://ugspace.ug.edu.gh 4.3 Health Facility Assessment of WASH Facilities The table below (4.2) shows assessment of the availability of water, sanitation and hygiene facilities available in the eight health facilities surveyed. All the 8 facilities had water available from an improved water source (piped water, borehole and rain water) located on-premises. Functional improved toilets (flush and pour flush toilets,) were available in all health facilities. The proportion of health facilities with toilets dedicated to staff was 6 (75%), three health facilities (37.5%) had toilets that were sex segregated and 62.5% had facilities for menstrual hygiene. Only one health facility had improved toilets which are functional sex-separated, provided for menstrual hygiene management, separated for patients and staff and accessible for ill, aged or disabled/handicapped people with limited mobility The proportion of health facilities with hand washing/hygiene facilities (veronica buckets, or sink and tap) at points of care with water and soap and/or alcohol for sanitizing/rubbing hands available and hand washing facilities within 5 metres of toilets with water and soap available was 7(87.5%). Waste was segregated correctly in 87.5% of health facilities, However only 3(37.5%) health facility correctly segregated waste (3 bins for general waste, infectious waste and sharps) in the consultation and treatment areas and disposed of infectious and sharps waste safely (autoclaved, incinerated or buried in lined protected pit). Table 4.2: Health Facility Assessment of WASH Facilities Frequency (No. of Health Indicator Facilities) Percent (%) Water Health facility with improved water supply within 500 metres 0 0 Health facility with an improved water supply on-premises 8 100 8 100 32 University of Ghana http://ugspace.ug.edu.gh Table 4.2: Health Facility Assessment of WASH Facilities Frequency (No. of Health Indicator Facilities) Percent (%) Health facility with an improved water supply with water available Sanitation Health facility with improved toilets 8 100 Health facility with usable improved toilets 8 100 Clean toilet 8 100 Toilet with unpleasant smell 1 12.5 Toilet with flies 1 12.5 Toilet with good lighting 7 87.5 Toilets with secure door` 8 100 Health facility with improved toilets dedicated to staff 6 75 Health facility with improved toilets which are sex separated 3 37.5 Health facility with improved toilets and facilities for menstrual hygiene management 5 62.5 Health facility with improved toilets accessible for people with limited mobility 2 25 Health facility with improved toilets, usable, sex-separated, provide for menstrual hygiene management, separate for patients and staff and accessible for people with limited mobility 1 12.5 33 University of Ghana http://ugspace.ug.edu.gh Table 4.2: Health Facility Assessment of WASH Facilities Frequency (No. of Health Indicator Facilities) Percent (%) Hand Hygiene Health facility with hand hygiene facilities at points of care with water and soap and/or alcohol hand rub available 8 100 Health facility with handwashing facilities within 5 metres of toilets with water and soap available 7 87.5 Health facility with hand hygiene facilities at points of care with water and soap and/or alcohol hand rub available and handwashing facilities within 5 metres of toilets with water and soap available 7 87.5 Healthcare Waste Health facility with waste correctly segregated 7 87.5 Health facility with infectious waste safely treated/disposed 4 50 Health facility with sharps waste safely treated/disposed 5 62.5 Health facility with waste correctly segregated in the consultation area and infectious and sharps waste safely treated/disposed 3 37.5 Level of WASH Services The level of WASH services is presented in Figure 4.1 below. All health facilities (100%) had basic services for water. Only one health facilities (12.5%) had basic services for sanitation. The hand hygiene was 87.5% for basic services, with only one facility with limited service. In terms of healthcare waste, the majority of health facilities had limited service (62.5%). 34 University of Ghana http://ugspace.ug.edu.gh Level of WASH Services 120 100 80 60 40 20 0 Water Sanitation Hygiene Health Care Waste Basic 100 12.5 87.5 37.5 Limited 0 87.5 12.5 62.5 No service 0 0 0 0 Basic Limited No service Figure 4. 1 Level of WASH Services according to the JMP WASH Service ladders 4.4 Patient Satisfaction with WASH Services Tables 4.3 and figure 4.2 present results on patient satisfaction with WASH services. From figure 4.2 below, four dimensions (satisfaction with toilet facilities, satisfaction with availability of water, satisfaction with hand hygiene facilities and satisfaction with waste management) were used to assess patient satisfaction with WASH services in health care facilities in the Ga West Municipal. Satisfaction was analyzed by a paired t test of mean perception score and mean expectation score for each dimension. Satisfaction was determined by the mean perception score minus the mean expectation score. A negative mean score gap equalled dissatisfaction whilst a positive mean gap score equalled satisfaction. Of these dimensions, patients’ were most satisfied with waste management which had an expectation score of 3.34 and standard error (SE) 0.05, mean perception score of 3.40 and SE 0.02. The mean gap score was 0.05 (table 4.3). However, all three items (waste bins provision, waste 35 Percentage University of Ghana http://ugspace.ug.edu.gh bins covered, fenced and protected waste storage facility) used to determine the satisfaction of patients’ with waste management was not statistically significant. Patients’ were also satisfied with availability of water at the WASH facilities. The mean expectation score was 3.36 and SE 0.11 and the mean perception score was 3.36 and SE 0.05. The mean gap score was 0.00. Patients’ were satisfied with the availability of water on the wards (0.11; SE = 0.05; p = 0.031). However, they were dissatisfied with the availability of hot water for bathing (-0.25; SE = 0.11; p = 0.031). Patients’ were also dissatisfied with hand hygiene facilities provided by the health facilities. This dimension had a mean expectation score of 3.36 and SE 0.10, mean perception score of 3.33 and SE 0.045. The mean gap score was -0.03. Respondents were dissatisfied with sanitizers available for usage (-0.61; SE = 0.07; p < 0.001). They were less dissatisfied with the drying materials available for usage (- 0.25; SE = 0.07; p < 0.001). The availability of hand washing facilities at the OPD satisfied the patients (0.11; SE = 0.05; p = 0.032). In addition, patients were mostly dissatisfied with toilet facilities. The mean expectation score was 3.20 and SE 0.06 and the mean perception score was 3.12 and SE = 0.02. The mean gap score was -0.08. Female respondents were however disappointed with provisions made for menstrual hygiene management in the health facilities (-0.72; SE = 0.07; p < 0.001). 36 University of Ghana http://ugspace.ug.edu.gh Figure 4.2 Mean score for items used to assess satisfaction with WASH services 37 University of Ghana http://ugspace.ug.edu.gh Table 4.3 Patient Satisfaction with WASH Services Mean Mean Mean perception Standard expectation Standard gap Standard Expectation, experience quality of WASH Services score error (SE) score error (SE) score error (SE) p-value I Expectation/Perception of Toilet Facilities Toilets designated/available for patients use 3.27 0.02 3.27 0.05 -0.002 0.05 0.964 Toilets at the health facility to be accessible to patients 3.29 0.03 3.26 0.05 0.03 0.05 0.624 Separate toilets for males and females 3.21 0.03 3.32 0.05 -0.11 0.06 0.056 Toilets not broken and function or work well 3.17 0.03 3.19 0.05 -0.02 0.05 0.692 A working flush system 3.13 0.03 3.20 0.05 -0.07 0.05 0.235 Flow of water and ease of flushing 3.17 0.02 3.19 0.05 -0.02 0.05 0.656 Clean toilets 3.18 0.03 3.17 0.05 0.01 0.05 0.857 Smell from toilets 3.21 0.03 3.20 0.05 0.01 0.05 0.819 Female toilets with provision for management of menstrual hygiene 2.55 0.05 3.27 0.06 -0.72 0.07 0.000* Average Satisfaction with Toilet facilities 3.12 0.02 3.20 0.06 -0.08 0.05 0.125 II Expectation/Perception of Water Availability Availability of water at the health facility 3.36 0.02 3.37 0.05 0.01 0.05 0.856 Improvement to source of water 3.31 0.03 3.36 0.05 -0.05 0.05 0.345 Availability of water on the premises 3.33 0.02 3.29 0.05 0.04 0.05 0.512 Availability on the wards 3.33 0.03 3.22 0.05 0.11 0.05 0.031* Access to water whenever it's needed 3.41 0.07 3.36 0.11 0.05 0.11 0.607 Enough water available for bathing and washing 3.30 0.09 3.25 0.12 0.05 0.10 0.590 Availability of hot water for bathing 2.89 0.10 3.13 0.13 -0.25 0.11 0.031* Availability of water every day 3.39 0.06 3.36 0.11 0.03 0.10 0.741 Availability of water storage facilities 3.48 0.06 3.36 0.11 0.12 0.10 0.229 38 University of Ghana http://ugspace.ug.edu.gh Average Satisfaction with Availability of Water 3.36 0.05 3.36 0.11 0.00 0.08 0.989 III Expectation/Perception of Hand Hygiene Facilities Hand washing facilities for patient use 3.35 0.02 3.32 0.05 0.03 0.05 0.585 Flowing water at hand washing facilities 3.36 0.03 3.32 0.05 0.04 0.05 0.478 Availability of soap for hand washing 3.25 0.03 3.21 0.05 0.04 0.06 0.445 Availability of sanitizer for patient use 2.57 0.05 3.19 0.05 -0.61 0.07 0.000* Availability of hand drying materials for patient use 2.90 0.04 3.15 0.05 -0.25 0.07 0.000* Availability of hand washing facilities at the toilet 3.18 0.03 3.16 0.05 0.02 0.06 0.748 Availability of hand washing facilities at the OPD 3.33 0.03 3.21 0.05 0.11 0.05 0.032* Availability of hand washing facilities at the wards 3.41 0.06 3.43 0.11 -0.02 0.10 0.834 Availability of hand washing facilities at/near the nurses and doctors treatment areas 3.24 0.03 3.15 0.05 0.09 0.06 0.103 Average Satisfaction with Hand Hygiene Facilities 3.33 0.04 3.36 0.10 -0.03 0.09 0.753 IV Expectation/Perception of Waste Management Provision of waste bins at all areas/departments 3.45 0.03 3.36 0.05 0.09 0.05 0.075 Proper coverage of waste bins 3.43 0.03 3.35 0.05 0.08 0.05 0.089 Availability of a fenced and protected waste storage facility for waste awaiting disposal 3.31 0.03 3.32 0.05 -0.01 0.05 0.820 Average Satisfaction with Waste Management 3.40 0.02 3.34 0.05 0.05 0.05 0.264 Overall Satisfaction 3.23 0.02 3.25 0.05 -0.02 0.05 0.663 Statistically significant (p ≤ 0.05) 39 University of Ghana http://ugspace.ug.edu.gh 4.5 Patient satisfaction with WASH services in health care facilities The proportion of respondents who were satisfied (mean gap score > 0) with WASH services in their respective health facilities was 21.7% (percentage = 21.7%; 95% CI = 17.9% - 25.9%) is shown in Figure 4.3. Figure 4.3 Proportion of patients satisfied with WASH services in health care facilities In terms of overall satisfaction with WASH services in the health facilities a large majority 78.3% were not satisfied. 4.6 Bivariate analysis of Socio-demographic factors associated with patient satisfaction with WASH Services Results from a Chi-squared/Fischer’s exact test and a the paired t-test showed that, the socio- demographic factors associated with patient satisfaction with WASH Services are as follows; place of residence (p = 0.015), type of residence (p < 0.001), main water source (p < 0.001), type of toilet facilities at home (p < 0.001), employment status (p = 0.002), household monthly income (p = 0.002), category of health facility (p < 0.001) and level of health facility (p < 0.001). (Table 4.4). 40 University of Ghana http://ugspace.ug.edu.gh Table 4.4 Association between socio-demographic factors and patient satisfaction with WASH Services Variables Satisfaction χ2 Satisfied Not satisfied (n = 93) (n = 335) p-value Age in years (M ± SD) 34.0 ± 11.7 34.3 ± 12.8 0.867 Sex 0.140 Male 16(16.3) 82(83.7) Female 77(23.3) 253(76.7) Educational level + 0.069 No education 3(17.6) 14(82.4) Primary school 6(35.3) 11(64.7) Junior high school 30(25.9) 86(74.1) Senior high school 41(24.1) 129(75.9) First degree 12(12.5) 84(87.5) Master’s degree 0(0) 8(100) Not applicable 1(25) 3(75) Marital status + 0.094 Never married 32(27.8) 83(72.2) Married 53(25.5) 182(77.5) Widowed 3(15.8) 16(84.2) Separated 2(8) 23(92) Divorced 0(0) 10(100) No answer 3(12.5) 21(87.5) Place of residence + 0.015* Urban 39(27.5) 103(72.5) Peri-urban 23(14.6) 135(85.4) Rural 31(24.2) 97(75.8) Family structure + 0.157 Nuclear 72(24.2) 226(75.8) Extended 20(17.2) 96(82.8) No answer 1(7.1) 13(92.9) Type of residence + 0.000* Standalone residence 57(33.3) 114(66.7) Compound house 35(13.7) 220(86.3) Other 1(50) 1(50) + (fisher’s exact) *(statistically significant, p≤0.05) 41 University of Ghana http://ugspace.ug.edu.gh Table 4.4 continued Association between socio-demographic factors and patient satisfaction with WASH Services Variables Satisfaction χ2 Satisfied Not satisfied (n = 93) (n = 335) p-value Main water source 0.000* Piped into compound 41(34.5) 78(65.5) Fetch outside house/premise 35(18.9) 150(81.1) Buy water from a tanker 9(8.2) 101(91.8) Other 8(57.1) 6(42.9) Type of toilet facilities at home 0.000* Household has own toilet facilities 64(30) 149(70) Shared household toilets 27(13.8) 169(86.2) No toilet facilities 1(5.6) 17(94.4) No answer 1(100) 0(0) Employment status + 0.002* Employed 67(19.3) 280(80.7) Student 12(52.2) 11(47.8) Unemployed 10(20.8) 38(79.2) Other 0(0) 1(100) No answer 4(44.4) 5(55.6) Household monthly income 0.002* < 500 50(31.6) 108(68.4) 500-1000 31(18.6) 136(81.4) 1001-3000 11(14.3) 66(85.7) 3001-5000 1(4.4) 22(95.6) 5001-7000 0(0) 3(100) First time / user of facility 0.361 First time user 40(19.8) 162(80.2) Recurrent user 53(23.5) 173(76.5) Duration of use of health facility + 0.216 <6 months 54(24.5) 166(75.5) 6months - 1yr 31(22.8) 105(77.2) 1 - 3years 6(12.5) 42(87.5) 3 - 5years 2(11.1) 16(88.9) > 5 years 0(0) 6(100) Category of health facility 0.000* Public 90(25.6) 261(74.4) Private 3(3.9) 74(96.1) 42 University of Ghana http://ugspace.ug.edu.gh Level of health facility 0.000* Level 1 21(8.7) 221(91.3) Level 2 74(54.0) 63(46.0) Level 3 9(27.3) 24(72.7) Level 4 0(0.0) 16(100.0) + (fisher’s exact) *(statistically significant, p≤0.05) Level 1 corresponds to secondary level / district Level Hospital Level 2 corresponds to primary level A Polyclinic and Private Hospital Level 3 corresponds to primary level B Health Centres and Community Clinic Level 4 corresponds to primary level C Community Health Planning Services (CHPS) 4.7 Factors associated with patient satisfaction with WASH Services Table 4.5 below show results from a multiple logistic regression on factors associated with patient satisfaction with WASH Services. After adjusting for potential confounders (type of residence, main water source, type of toilet facilities at home, employment status, household monthly income, category of health facility and level of health facility), patients who resided in rural areas were 5.13 times more likely to be satisfied with WASH services as compared to those who resided in urban areas (aOR = 5.13; 95% CI = 1.83 – 14.39; p = 0.002). Also, after adjustment for confounders, patients who visit private health facilities (place of residence, type of residence, main water source, type of toilet facilities at home, employment status, household monthly income and level of health facility) were significantly less likely to be satisfied with the WASH services available as compared to patients who visit public health facilities (aOR = 0.003; 95% CI = 0.0004 – 0.02; p < 0.001). After adjusting for all variables, (place of residence, type of residence, main water source, type of toilet facilities at home, employment status, household monthly income, category of health facility), the odds of respondents being satisfied with WASH services was significantly increased by nearly 200 fold and 4 fold among those who visited level 2 (aOR = 228.32; 95% CI = 62.03 – 840.40; p < 0.001) and level 3 (aOR = 4.31; 95% CI = 1.70 – 10.94; p = 0.002) health facilities respectively compared to those who visited level 1 health facilities. For level 4 43 University of Ghana http://ugspace.ug.edu.gh which are CHPS compounds no comparison could be made as all respondents who visited these health facilities were not satisfied with the WASH services (Table 4.4). Table 4.5 Factors associated with patient satisfaction with WASH Services Variables cOR(95% CI) p-value aOR(95% CI) p-value Place of residence Urban 1.00 1.00 Peri-urban 0.45(0.25 - 0.80) 0.007* 1.32(0.39 - 4.55) 0.656 Rural 0.84(0.49 - 1.46) 0.544 5.13(1.83 - 14.39) 0.002* Type of residence Standalone residence 1.00 1.00 Compound house 0.32(0.19 - 0.51) 0.000* 0.45(0.11 - 1.81) 0.261 Other 2.00(0.12 - 32.56) 0.626 25.67(0.53 - 1237.61) 0.101 Main water source Piped into compound 1.00 1.00 Fetch outside house/premise 0.44(0.26 - 0.75) 0.003* 0.28(0.07 - 1.11) 0.070 Buy water from a tanker 0.17(0.08 - 0.37) 0.000* 0.37(0.09 - 1.39) 0.141 Other 2.54(0.82 - 7.81) 0.105 0.28(0.03 - 2.98) 0.291 Type of toilet facilities at home Household has own toilet facilities 1.00 1.00 Shared household toilet facilities 0.37(0.23 - 0.61) 0.000* 0.68(0.15 - 3.16) 0.627 No toilet facilities 0.14(0.02 - 1.05) 0.056 0.69(0.04 - 11.45) 0.800 No answer 1 1 *(statistically significant, p≤0.05) 44 University of Ghana http://ugspace.ug.edu.gh Table 4.5 continued Factors associated with patient satisfaction with WASH Services Variables cOR(95% CI) p-value aOR(95% CI) p-value Employment status Employed 1.00 1.00 Student 4.56(1.93 - 10.78) 0.001* 2.11(0.32 - 13.83) 0.438 Unemployed 1.09(0.52 - 2.32) 0.803 1.30(0.27 - 6.21) 0.742 Other 1 1 No answer 3.34(0.87 - 12.79) 0.078 2.52(0.22 - 29.16) 0.460 Household monthly income < 500 1.00 1.00 500-1000 0.49(0.29 - 0.82) 0.007* 1.44(0.49 - 4.29) 0.509 1001-3000 0.36(0.18 - 0.74) 0.005* 0.72(0.17 - 3.15) 0.664 3001-5000 0.09(0.01 - 0.75) 0.025* 0.33(0.03 - 4.07) 0.390 5001-7000 1 1 Category of health facility Public 1.00 1.00 Private 0.12(0.04 - 0.38) 0.000* 0.003(0.0004 - 0.02) 0.000* Level of health facility Level 1 1.00 1.00 Level 2 8.96(5.12 - 15.68) 0.000* 228.32(62.03 – 840.40)) 0.000* Level 3 3.95(1.63 - 9.58) 0.002* 4.31(1.70 – 10.94) 0.000* Level 4 1 1 *(statistically significant, p≤0.05) Level 1 corresponds to secondary level / district Level Hospital Level 2 corresponds to primary level A Polyclinic and Private Hospital Level 3 corresponds to primary level B Health Centres and Community Clinic Level 4 corresponds to primary level C Community Health Planning Services (CHPS) 45 University of Ghana http://ugspace.ug.edu.gh 4.8 Expectations and Considerations of Patients Tables 4.6 below shows the WASH facilities expected by patients and amenities considered before choosing any health facility. Out of the 428 patients, 40.2% stated that they expected more toilets for patients. More than half of the respondents 235(54.9%) indicated that toilet facilities are considered in choosing a facility for ANC or childbirth. Also, 190 out of 428 patients (44.4%) stated their desire that hand sanitizers should be provided at hand washing facilities. Generally, 140 (32.7%) of patients were impressed with the maintenance of the health facilities surveyed. Table 4.6 Expectations and Considerations Variables Frequency Percent (%) Expected changes in toilet facilities Better toilets 28 6.5 More toilets for patients 172 40.2 Separate toilets for males and females 47 11.0 Female toilets with provision for the management of menstrual hygiene 39 9.1 Water and soap in toilets 88 20.6 Other, specify 37 8.6 No answer/do not want to answer 17 4.0 Consideration of toilets in choosing a facility for ANC or childbirth Yes 235 54.9 No 115 26.9 No answer/do not want to answer 78 18.2 Expected changes in water supply An improved water source 34 7.9 Improved water quantity 117 27.3 Constant flow of water 24-7 152 35.5 Other, please specify 59 13.8 No answer/do not want to answer 66 15.4 Table 4.6 Continuation Expectations and Considerations 46 University of Ghana http://ugspace.ug.edu.gh Variables Frequency Percent (%) Consideration of water availability in choosing a facility for ANC or childbirth Yes 241 56.3 No 110 25.7 No answer/do not want to answer 77 18.0 Location of hand washing facilities At the toilets 109 25.5 At OPD 125 29.2 In the wards 34 7.9 At/ near the nurses treatment area 87 20.3 At/ near the doctors treatment area 49 11.5 Other, please specify 24 5.6 Desired changes in hand washing facilities Provide flowing water for hand washing 19 4.4 Provide soap 71 16.6 Provide sanitizer 190 44.4 Provide hand drying tissues 66 15.4 Permit patients to use hand washing facilities at point of care 62 14.5 Other, please specify 20 4.7 Consideration of soap and water for hand washing and hand drying materials Yes 270 63.1 No 156 36.5 No answer/do not want to answer 2 0.4 General impression of the health facility Facility is clean 123 28.7 Facility is well maintained 140 32.7 Staff are nice to clients 117 27.3 Facility is not clean 6 1.4 Facility is not well maintained 4 0.9 Staff are not nice to clients 4 0.9 Other, please specify 34 7.9 47 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION OF FINDINGS 5.1 Introduction This chapter presents a discussion of the results obtained from the study. The chapter presents the discussions under the specific objectives which includes the adequacy of water, sanitation and hygiene (WASH) services in health facilities, the level of patient’s satisfaction with the WASH services in the health facilities and the influence of socio-demographic factors on patients’ satisfaction with WASH services in the municipality. 5.2 Discussions This section presents a discussion of the results. The discussions are presented under the specific objectives and done in line with related studies. 5.2.1 Availability and level of water, sanitation and hygiene (WASH) services in health facilities in the municipality The study revealed that all the facilities had an improved water supply with water available on the premises at the time of the survey. This shows that the availability of improved water sources in health facilities in the municipality is high. The WHO (2015) revealed that 38% of healthcare facilities across 54 countries in poorly resourced settings do not have access to basic water sources. The WHO finding is consistent with a study conducted by Gon and colleagues (2016) who revealed that among the health facilities that conducted deliveries in East Africa, coverage for water was only 30%. These results suggest that the unavailability of water sources makes it difficult for health institutions to provide adequate WASH services. This in the long run can lead to an increase in infection and in some cases death. Availability of water is therefore critical to infection control as supported by Blencowe and colleagues (2011) who indicated that clean delivery can only be achieved through access to appropriate WATSAN facilities. They explained that clean delivery comprises; 'clean hands of the birth attendant, 48 University of Ghana http://ugspace.ug.edu.gh clean perineum, clean birth surface, clean cord preparation and cutting, and appropriate newborn postpartum skincare’. In other words, the lack of water makes it impossible to engage in these activities which can lead to infections. This study also revealed that 87.5% of health facilities had hand washing facilities at points of care with water and soap and/or alcohol for hand sanitizing available and hand washing facilities that are within 5 meters of toilets with water and soaps available. A Ghanaian study in the Bongo and Kassena Nankana west districts revealed that water was available in 76% of healthcare facilities. The study noted that 93% had hand washing centres, 100% had alcohol hand rubs but only 14% had one near toilet facilities (WaterAid n.d.). Another recent study in Ghana showed that all the health centres assessed scored 90.5% standard score for water (Ashinyo et al., 2021). This finding is contrary to a study conducted in Uganda where only 38% of the health care facilities had hand washing facilities at the toilets (Mulogo et al, 2018). A possible reason for the high availability of hand hygiene services could be because of the time of the study which was during the COVID-19 pandemic when the implementation of hygiene protocols was quite high. Improved compliance to hand hygiene protocols has been reported elsewhere (Isreal et al. 2020). Sanitation on the other hand was a bit of a challenge, in as much as all health facilities had improved toilets, 87.5% had limited services as not all facilities could satisfy all the other requirements of having toilets dedicated to patients and staff, sex segregated, with facilities for menstrual hygiene and disability friendly facilities. This finding is in line with a study conducted in Indonesia (Odagiri et al., 2018) to determine baseline WASH indicators for the SDGs which found that the majority of health facilities had limited services when it comes to sanitation. In the Bongo and Kassena Nankana west districts only 48% had toilet facilities for outpatients of which half of these toilet facilities were shared by both male and female patients. 49 University of Ghana http://ugspace.ug.edu.gh Another study recorded poor performance in the sanitation and waste practices of the treatment centres with an average score of 44.6% (Ashinyo et al., 2021). Another component of WASH that had lower level of services was healthcare waste management with 62.5% of health facilities having limited services. The proper segregation of waste into three bins colour coded and clearly labelled as per WHO standards (2015) was not found in most of the health facilities. Healthcare waste management, segregation, treatment and disposal remain a challenge in developing countries (WHO, 2015). Similar findings have been found in a study conducted in Bangladesh (Unicomb et al 2018). In the Upper East Region, 50% of health facilities disposed their fecal matter manually, 27% use sewage system, 19% use puller services and the remaining use the dig and bury method. General and medical wastes were disposed using incinerators (21%), shallow pit burning (69%) whilst the remainder used waste bins or dig and bury method (WaterAid n.d.). 5.2.2 The level of patients’ satisfaction with the WASH services in health facilities in the Municipal The level of patients' satisfaction is dependent on the kind of service being provided. Thus, Woldeyohanes et al. (2015) indicated that poor or inadequate WASH services correlated with patients' dissatisfaction. In this study, patients were most satisfied with waste management, based on the provision of waste bins in all areas of the hospital and the availability of water at the health facility. They were also satisfied with water availability in the facility and on the wards which were both significant when comparing their expectation prior to their visit and their perception. They were however less satisfied with the lack of hot water on the wards. The patients' perception are somehow in line with the health facility WASH assessment as all facilities had basic services for water. However, findings from the assessment of health care waste and patients' satisfaction with waste management cannot be compared as the parameters assessed were not the same. Whilst the assessment looked at the waste segregation, treatment 50 University of Ghana http://ugspace.ug.edu.gh and disposal, the patients’ perception was based mainly on the environmental cleanliness and the provision of waste bins by the facility. The high ranking perception of general cleanliness and the availability of waste bins was also reported in a study of patient satisfaction with WASH in health facilities (Steinmann et al, 2015). This result shows that a clean environment is perceived to be an indicator of a good hospital which leads to an increase in patient satisfaction. This study revealed that only 1 (12.5%) health facilities had basic services for sanitation. The lack of toilets dedicated to patients and the lack of facilities for the management of menstrual hygiene among female patients may be some of the reasons for the lower level of patient satisfaction with the sanitation services in the health facilities surveyed. These findings are in line with a similar study conducted at the Sunyani regional hospital, Ghana by Peprah and Atarah (2014) that revealed a low patient satisfaction with the quality of sanitation service they received in the health facilities surveyed in their study. An interesting finding of this study is that although patients were satisfied that they had handwashing facilities for their use, they were, however, dissatisfied that there were no hand sanitizers and hand drying materials available. The expectations of these items may have been heightened by the COVID-19 pandemic as sanitizers are perceived to be more effective than handwashing with water and soap. Effective use of hand hygiene protocols has been shown to reduce hospital acquired infections or cross infections in health facilities (WHO, 2010). In fact, increasing concerns about health-related infections due to inadequate hygiene practices has resulted in several initiatives on patient safety by the World Health Organization (WHO, 2010) yet patients are not satisfied because most health facilities are unable to go by the guidelines made available by the WHO (Weber et al, 2018). In terms of overall satisfaction with WASH services in the facilities, this study found that majority of patients (78.3%) were not satisfied. This is partly attributed to the deficiencies in the provision of some WASH services identified by the patients. 51 University of Ghana http://ugspace.ug.edu.gh 5.2.3 The influence of socio-demographic factors on patient’s satisfaction with WASH services Socio-demographic factors of people determine how they perceive issues and the kind of approach they might consider in addressing the issues. Thus Cronk et al (2015) explained that socio-demographic factors of a patient influence their level of satisfaction. The current study revealed that there were socio-demographic factors that affected patients’ satisfaction with WASH services. The result showed that health facility type influences a patient's level of satisfaction. In this case, if the hospital is a level 2 or 3 health facilities (polyclinics, clinics and health centres), the possibility of patient satisfaction is high as compared to a level 1 hospital (district level facility), serving more of an urban population. This is better explained with the results from the study which revealed that patients who resided in rural areas had a high chance of being satisfied with WASH services as compared to those who reside in urban areas. Similarly, patients who visit level 2 and level 3 hospitals are more likely to be satisfied with WASH services as compared to those who visit level 1 hospitals. Again, the study found that patients who visited private health facilities were less likely to be satisfied with WASH services available as compared to patients who visit public health facilities. These results mean that a high level of patient satisfaction is recorded among patients who live in rural areas and visit level 2 and 3 hospitals whereas patients who visit private hospitals are not satisfied with WASH services as compared to those who visit public hospitals. These findings may be because people living in rural areas have lower level of service at the household when it comes to sanitation services such as toilet facilities and therefore find better sanitation facilities at the facility and are therefore more satisfied. On the contrary the patients visiting private health facilities are from probably from higher income brackets and have higher expectations and therefore tend to less be satisfied with the sanitation services they find in the health facilities. According to Mohammed et al (2013), patients' perception of the adequacy of WASH services affects their 52 University of Ghana http://ugspace.ug.edu.gh level of satisfaction. The findings of this study confirmed the influence of socio-demographic factors on patient satisfaction. The study also found that a clean environment increases the satisfaction of patients whereas an unclean environment leads to a decrease in patient satisfaction. Mohammed and colleagues also indicated that some of the socio-demographic factors that affect patient satisfaction are the availability of water supply, cleanliness and functionality of toilets and hand washing facilities at vantage points. Russo et al. (2012) and Bouzid et al. (2017) indicated that there is an increasing concern to monitor WASH services in settings like health facilities if patients' satisfaction is a critical challenge. 5.3 Strengths and Limitations The study used a cross sectional study design which is was able to measure satisfaction to WASH facilities as well as factors influencing the satisfaction at the same time. The statistical methods employed, t test and logistic regression were robust making the empirical evidence found in this study statistically sound. However, since the study was conducted in selected facilities, generalization to other facilities in other districts and Ghana as whole is a limitation. Factors found to be associated with satisfaction to WASH facilities are not temporal due to the selected study design. 53 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSION AND RECOMMENDATION 6.1 Introduction This chapter presents the conclusions of the study which are made based on the results obtained from the study. The chapter also presents recommendations which are made based on the results obtained from the study. 6.2 Conclusion The study aimed to assess WASH facilities in selected health facilities in the Ga West Municipal of the Greater Accra region and ascertain patient satisfaction with these services. From the results obtained from the study, the following conclusions are made: i. Availability and level of WASH services in the municipality Clean water was available in health facilities in the municipality. Sanitation and health care waste services were not available in some health facilities in the municipality. ii. Patients’ satisfaction with WASH services in the Municipal The study concludes that the level of patients’ satisfaction with the WASH services in health facilities was generally low (21.7%). iii. Socio-demographic factors affecting patient’s satisfaction of WASH services Finally, the study concludes that the socio-demographic factors of patients’ satisfaction with WASH services are the patients’ place of residence, and the level of the health facility. 6.3 Recommendation Based on the results obtained from the study, the following recommendations are made: 54 University of Ghana http://ugspace.ug.edu.gh I. The study recommends that health facilities, particularly government facilities must improve the infrastructure of water and sanitation and hand washing facilities. They should take into consideration gender and make appropriate provisions in setting up these WASH facilities to improve the health of patients and prevent the spread of diseases such as urinary tract infections. Gender sensitive facilities also improve privacy, increase patient satisfaction and protect the dignity of patients, which are all essential components for improving quality of care. The low level of satisfaction could affect attendance to health facilities resulting in poor health outcomes. II. It is recommended that the WASH in HCF Technical Guidelines developed by the Ghana Health Services should be implemented particularly for new upcoming facilities and old facilities should be renovated to meet the said WASH standards. These guidelines provide the minimum WASH standards per type of health facility. Monitoring of WASH services to ensure adherence to standards and protocols as well as maintenance upkeep is equally important. III. Finally, the study recommends that future studies should consider adopting or adding on a qualitative research approach in data collection and analysis. 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The Lancet, 365, 1175-1188. 61 University of Ghana http://ugspace.ug.edu.gh APPENDICES APPENDIX 1 RESPONDENT INFORMATION SHEET AND CONSENT FORM Institutional Affiliation: Department of Biological Environment and Occupational Health Sciences, School of Public Health, University of Ghana, Legon Project Title: Assessment of water, sanitation and hygiene and patient satisfaction in health facilities in Ga West Municipal of Greater Accra Region I am Akosua Takyiwa Kwakye, a student of the Department of Biological, Environmental and Occupational Health Sciences in the School of Public Health, University of Ghana Legon pursuing a Master of Public Health Degree Programme. Contact: 0243 316 706 E-mail: akostak04@gmail.com I am here with my research assistants to carry out a research to find out about Patient satisfaction with water, sanitation and hygiene in health facilities in Ga West Municipal of Greater Accra Region. This is purely for academic purposes and forms part of the requirement for the award of Master of Public Health Degree. Procedure To find answers that will meet the study objectives, I invite you to take part in this research. If you accept, you will be required to participate in a survey with the principal investigator or a representative. Your selection into this survey was based on a simple random sampling. You are assured that any information you provide will be kept strictly confidential and anonymous and will used for the purpose of this study. Benefits and Risks 62 University of Ghana http://ugspace.ug.edu.gh There will be no monetary or material compensation for the study. There are also no known risks associated with this study and I am always available to assist with any questions. However due to the ongoing COVID-19 outbreak, before the start of the interview, you would have to wash your hands under running water with soap, sanitize your hands with alcohol-based sanitizer wear a face mask and keep it on throughout the interview, and I will maintain a physical distance of 6 feet. I will keep the interview as short as possible to limit the length of interaction with you. Confidentiality I will not record your name on the questionnaire. Your name and identity are not needed in the study and the information you are going to provide will be treated strictly confidential. You are assured of total confidentiality to the information you will give. Apart from the researcher and supervisor of this research, no one else will have access to the information provided whether in part or whole. Data collected will be stored under lock and key then destroyed after a minimum of three years as per research protocol. Right to refuse Your participation in this study is voluntary you are doing so at own free will. You therefore have the right to withdraw from the study at any point in time. If you wish to withdraw, you may do so and no one will be upset with your decision. You will just have to inform the interviewer and your request would be granted. Nonetheless, your full participation is highly encouraged. Dissemination of results Findings and recommendations would be available at the School of Public Health and it will also be disseminated through a meeting with different stakeholders at the end of the study. 63 University of Ghana http://ugspace.ug.edu.gh Before Taking Consent Do you have any questions you wish to ask about the study? Yes/No If yes, please indicate the questions below ………………………………………………………………………………………………..… …………………………………………………………………………………………………. ……………………………………………………………………………….............................. ...................................................................................................................................................... I will give you a copy of this information sheet and consent form to keep and refer to as needed. If you have any question(s) or further clarification concerning this study and/or the conduct of the primary investigator and research assistants, please do not hesitate to contact the following: Akosua Takyiwa Kwakye, School of Public Health, University of Ghana, Legon Email: akostak04@gmail.com Tel: 0243 316 706 ; Dr Prudence Tettey, School of Public Health, University of Ghana, Legon, Email: narhtsay@gmail.com / ptettey@ug.edu.gh Tel: 055 042 4815 and; Nana Abena Kwaa Ansah Apatu (Administrator), Ghana Health Service Ethical Review Committee Secretariat, Accra. Tel: 0503539896 Email: ethics.reasearch@ghsmail.org 64 University of Ghana http://ugspace.ug.edu.gh APPENDIX II INFORMED CONSENT STUDY TITLE: ASSESSMENT OF WATER, SANITATION AND HYGIENE AND PATIENT SATISFACTION IN HEALTH FACILITIES IN GA WEST MUNICIPAL PARTICIPANTS’ STATEMENT I acknowledge that I have read or have had the purpose and contents of the Participants’ Information Sheet read and all questions satisfactorily explained to me in a language I understand (English, Akan, Ga). I fully understand the contents and any potential implications as well as my right to change my mind (i.e. withdraw from the research) even after I have signed this form. I voluntarily agree to be part of this research and I have been given a copy of the consent form for my own records. Name or Initials of Participant…………………………..……………………….. Participants’ Signature ……………………...OR Thumb Print…………………………… Date:…………………………………. INVESTIGATOR STATEMENT AND SIGNATURE I certify that the participant has been given ample time to read and learn about the study. All questions and clarifications raised by the participant have been addressed. Researcher’s name………………………………………. Signature …………………………………………………. Date…………………………………………………………. APPENDIX III: QUESTIONNAIRES 65 University of Ghana http://ugspace.ug.edu.gh Health Facility Administrator / In-charge Questionnaire_ Survey – WASH in Health Care Facilities Name of Interviewer: Date: Name of Health Facility: Location of health facility: Type of Facility: Interviewee Code: Function of Interviewee: General Hospital Information: Sr. No. Question Categories/Codes Answer Q1. What is the catchment ___________________ population of the health facility? What is your Cadre of Staff i Write No. staff strength? Q2. What services Tick and Write No. do you provide? 1. Out-patient services  _________________ 2. In-patient services __________________ 3. A 24-hour emergency services __________________ Ambulance services (functioning __________________ 24/7) __________________ 4. Primary health care services __________________ 5. Antenatal Care __________________ 6. Deliveries 7. Other, Specify _____________________ Q3. On average how many patients  are seen per month? 66 University of Ghana http://ugspace.ug.edu.gh Q4. On average how many days in a  month are outpatient seen? Q5. What is your bed-capacity of  this facility? Q6. On average how many inpatients  are at the health facility? WASH Infrastructure Q7. What is the 01. Piped supply from outside the main source of facility  water? 02. Borehole 03. Protected dug well 04. Rain Water 05. Tanker truck 06. Other Q8. Where is the 01. On premises main source of 02. Off premises within 500m  water located? 03. Off premises, further than 500m 04. No water source Q9. Is water 01. Yes accessible to all 02. No, patients and care givers do not  users of the have access at times facility at all 03. No, staff do not have access at times? times 04. No, both staff and patients/caregivers do not have access at times Q10. How often is the 01. For part of the day, rarely main water 02. For part of the day frequently  source 03. For part of the year (seasonal unavailable? problem), frequently 04. For part of the year (seasonal problem), rarely Q11. Is the re a time of 01. Yes the year when 02. No  the facility has a severe shortage If Yes when or lack of water? _____________________ 67 University of Ghana http://ugspace.ug.edu.gh Q12. Does the facility 01. Yes has water 02. No  storage facilities to cater for water If Yes shortage? specify_____________________ Q13. How many departments do  you have? Q14. How many List the departments and number of functional toilets functional toilets do you have at each department? Q15. On av erage what Calculate using average number of is the inpatient patients and number of usable toilets ________________ usable improved available (no. of toilets for every 20 toilet ratio? patients) Q16. Is fec al waste 01. Yes from toilet 02. No  safely managed? If Yes specify how fecal waste is managed ____________________ Q17. Does the heath List areas within the facility where facility provide provision has been made hand washing facilities for patients? 68 University of Ghana http://ugspace.ug.edu.gh HEALTH FACILITY ASSESSMENT OF WASH FACILITIES TOOL Name of Interviewer: Date: Name of Health Facility: Location of Health Facility: Type of Health Facility: SECTION W: WATER SUPPLY W1. What is the main water supply for the facility? 01.Piped supply inside the building 0 2. Piped supply outside the building 03. Tube well / Borehole 04. Protected dug well 05. Unprotected dug well 06. Protected spring 07. Unprotected spring 08. Rain water 09. Tanker truck 10. Surface water (river/dam/lake/pond) Other (specify) ____________________ No water source (skip to Section S- Sanitation) 69 University of Ghana http://ugspace.ug.edu.gh W2. Where is the main water supply for the facility located? 01. On premises 02. Up to 500 m 02. 500 m or further W3. Is water available from the main water supply at the time of the survey? 01. Yes 02. No W4. Is water available in all departments? OPD 01. Yes 03. No M a t e r n i t y 0 1 . Y e s N o 02. No NChoi ld Health 01. Yes 04. No Yes S u r g e r y 0 1 . Y e s No 02. No Medical 01. Yes 02. No W5. Is water piped into the wards? Check ward for availability of water at the time of the survey M aternity Ward 01. Yes 0 5. No P ediatric Ward 01. Yes 0 6. No M s u er v d e iy c a vl a i l a b l e s u r v e y ? 0 1 . Y e s No 07. No 70 University of Ghana http://ugspace.ug.edu.gh SECTION S – SANITATION S1. What type of toilets/latrines are at the facility for patients? Department / Ward: 01. Flush / Pour-flush toilet to sewer connection 02. Flush / Pour-flush toilet to tank or pit 03. Pit latrine with slab 04. Composting toilet 05. Flush / Pour-flush toilet to open drain 06. Pit latrine without slab/open pit 07. Bucket 08. Hanging toilet/latrine 09. No toilet/latrine (skip to Section H on Hand Hygiene) 10. Other (specify) ___________ Note If more than one type of toilet is used, the most common type of toilet/latrine in the service area should be selected. A separate form should be completed for each department / ward if applicable S2. Is at least one toilet usable (available, functional, private)? 01. Yes 02. No S 3. Are there toilets that … 01. Yes 02. No Are dedicated for staff? Are in sex-separated or gender-neutral rHoaovme sm? enstrual hygiene facilities? Are accessible for people with limited mobility? 71 University of Ghana http://ugspace.ug.edu.gh S 4. Are the toilets clean? 0 1. Yes 02. No Is the toilet block visibly clean, with no presence of feces, blood or bodily substances? Is there an unpleasant smell (of urine or feces) on the block? Do usable improved toilets have flies? S 5. Are the toilets Private and Safe? 1.Yes 2.No Do the toilet blocks have adequate light, including at night? Do the toilets have doors or screens that can be locked when needed? Section H: HAND HYGIENE H1. Is there a functional handwashing facility at the toilets on the day of the survey? 01. Yes, functional with soap and water and or alcohol-based hand rub 02. No, there are handwashing facilities near the toilets but lacking soap and/or water 03. No, no handwashing facilities near toilets (within 5 meters) H2. Is there a functional hand hygiene facility at points of care on the day of the survey? 01. Yes, functional with soap and water and or alcohol-based hand rub 72 University of Ghana http://ugspace.ug.edu.gh 02. No, there are hand hygiene facilities at points of care but not functional, or lacking soap and water or alcohol-based hand rub. 03. No, no hand hygiene facilities at points of care 04. No, no hand hygiene facilities at the health care facility G-WM1. Is waste correctly segregated into at least three labelled bins in the consultation area? Yes, waste is segregated into three labelled bins No, bins are present but do not meet all requirements or waste is not correctly segregated No, bins are not present Note For facilities with multiple consultation rooms, select one at random and observe whether sharps waste, infectious waste and non-infectious general waste are segregated into three different bins. The bins should be colour-coded and/or clearly labelled, no more than three quarters (75%) full, and each bin should not contain waste other than that corresponding to its label. Bins should be appropriate to the type of waste they are to contain; sharps containers should be puncture-proof and others should be leak-proof. Bins for sharps waste and infectious waste should have lids. G-WM2. How does this facility usually treat/ dispose of infectious waste? Autoclaved Incinerated (two chamber, 850-1000 °C incinerator) Incinerated (other) Burning in a protected pit Not treated, but buried in lined, protected pit Not treated, but collected for medical waste disposal off- site Open dumping without treatment Open burning Not treated and added to general waste Other (specify) Note If more than one applies, select the method used most often. Methods considered to meet the basic service level include autoclaving; incineration; burial in a lined, protected pit; and collection for medical waste disposal off-site. 73 University of Ghana http://ugspace.ug.edu.gh G-WM3. How is COVID-19 Waste Treated (Facemasks, PPEs, used tissue etc..) Autoclaved Incinerated (two chamber, 850-1000 °C incinerator) Incinerated (other) Burning in a protected pit Not treated, but buried in lined, protected pit Not treated, but collected for medical waste disposal off-site Open dumping without treatment Open burning Not treated and added to general waste Other (specify) G-WM4. How does this facility usually treat/ dispose of sharps waste? Autoclaved Incinerated (two chamber, 850-1000 °C incinerator) Incinerated (other) Burning in a protected pit Not treated, but buried in lined, protected pit Not treated, but collected for medical waste disposal off- site Open dumping without treatment Open burning Not treated and added to general waste Other (specify) Note If more than one applies, select the method used most often. Methods considered to meet the basic service level include autoclaving; incineration; burial in a lined, protected pit; and collection for medical waste disposal off-site. Patient Questionnaire – WASH in Health Care Facilities 74 University of Ghana http://ugspace.ug.edu.gh Name of Health Facility __________________________________________ Department __________________ Outpatient _______________ Inpatient  _______ Name of Interviewer Date SECTION 1. Demographic information Sr. No. Question Categories/Codes Answer (one only unless indicated “all that apply”) Q1. Name / ID number Write name ________________ Q2. Age In years  Q3. Sex 01. Male 02. Female  Q4. Education level 01. No education / formal schooling 02. Primary School  03. Middle/JSS/JHS 04. Secondary School/ SHS 05. Completed graduate course 06. Completed Postgraduate course 77. Not Applicable Q5. Marital Status 01. Never married 02. Currently married / co-habiting  03. Widowed 04 Separated 05. Divorced 99. No answer/do not want to answer Q6. Place of Residence 0.1 Urban 0.2 Peri-urban  0.3 Rural Q7. Family structure 01. Nuclear 02. Joint/Extended  99. No answer/do not want to answer 75 University of Ghana http://ugspace.ug.edu.gh Name of Health Facility __________________________________________ Department __________________ Outpatient _______________ Inpatient  _______ Name of Interviewer Date SECTION 1. Demographic information Sr. No. Question Categories/Codes Answer (one only unless indicated “all that apply”) Q8. Type of Residence 0.1 Standalone Residence (House / apartment)  0.2 Compound House 0.3 Other 99 No answer / do not want to answer Q9. Type of facilities in 0.1 Piped into compound 0.2 Fetch outside house/premise home setting – Main  0.3 Buy water from a tanker Water Source 0.4 Other 0.5 99 did not answer Q10. Type of toilet 0.1 Household has own toilet facilities facilities at home  0.2 Shared household toilet facilities 0.3 No toilet facilities 99. No answer Q11. Primary occupation 01. Technical / Professional 02. Managerial (respondent)  03. Clerical 04. Sales and Services 05. Skilled manual 06. Un skilled manual 07. Agricultural 08. Student 09. Unemployed 11. Other (specify) 99. No answer/do not want to answer 76 University of Ghana http://ugspace.ug.edu.gh Name of Health Facility __________________________________________ Department __________________ Outpatient _______________ Inpatient  _______ Name of Interviewer Date SECTION 1. Demographic information Sr. No. Question Categories/Codes Answer (one only unless indicated “all that apply”) Q12. Household Monthly 01. <500 GHC 02. 500 -1000GHC Income  03. 1001 – 3000GHC 04. 30001 - 5000GHC 05. 5001 – 7,000GHC 06. >7000GHC Q13. First time /user of 01. First time user 02. Recurrent user facility  Q14. How long have you 01. < 6 months 02. 6months – 1 year been using this  03. 1 -3 years health facility? 04. 3-5 years 05. > 5 years 77 University of Ghana http://ugspace.ug.edu.gh Section 2 Expectation, Experience Quality of WASH Services SECTION 2.1 EXPECTATION of Toilets For the next set of questions, TICK (√) whether you; 1-Strongly disagree, 2- Disagree, 3- Agree, 4- Strongly Agree. The first part has to do with your EXPECTATIONS. Indicate whether the patient strongly disagree, disagree, agree or strongly Agree with the expectation from the Hospital. No. QUESTIONNAIRE 1 2 3 4 CODE Q15. I expect toilets to be designated / available for patients EOT1 use Q16. I expect the toilets at the health facility to be accessible EOT2 to patients Q17. I expect separate toilets for males and females EOT2 Q18. I expect the health facility to have enough toilets for EOT3 patients (no long queues) Q19. I expect the toilets are not broken and function or work EOT4 well Q20. I expect the flush system to work well EOT5 Q21. I expect the water to flow and easy to flush EOT6 Q22. I expect that the toilets are clean EOT7 Q23. I expect that the toilets do not smell bad and EOT8 Q24. I expect female toilets with provision for the EOT9 management of menstrual hygiene Q25. I expect water and soap in toilets EOT10 SECTION 2.2 PERCEPTION (EXPERIENCE) of Toilets For the next set of questions, TICK (√) whether you; 1-Strongly disagree, 2- Disagree, 3- Agree, 4- Strongly Agree. For the next set of questions, TICK (√) whether you; 1-Strongly disagree, 2- Disagree, 3- Agree, 4- Strongly Agree. The second part has to do with your PERCEPTION. Indicate whether you strongly disagree, disagree, agree or strongly Agree with the perception (based on experience) from the Hospital No. QUESTIONNIARE 1 2 3 4 CODE Q26. I am satisfied that toilets were available for patient use POT1 Q27. I am satisfied that the toilet I used was easily accessible POT2 Q28. I am satisfied that the toilet I used was specifically for POT3 male / female (depending on sex of patient) 78 University of Ghana http://ugspace.ug.edu.gh Q29. I am satisfied that the toilets I used are functioning well POT4 Q30. I am satisfied the toilets flush system in the toilet I used POT5 was working well Q31. I am satisfied water was flowing in the toilet I used POT6 Q32. I am satisfied the toilets I used were clean POT7 Q33. I am satisfied the toilets I used did not smell bad POT8 Q34. I am satisfied the toilets I used had provision for the POT9 management of menstrual hygiene Ask to female patients SECTION 2.3 EXPECTATION of Water Availability For the next set of questions, TICK (√) whether you; 1-Strongly disagree, 2- Disagree, 3- Agree, 4- Strongly Agree. The first part has to do with your EXPECTATIONS. Indicate whether the patient strongly disagree, disagree, agree or strongly Agree with the expectation from the Hospital. Q35. I expect water to be available at the health facility EWA1 Q36. I expect the source of the water to be improved (piped, EWA2 borehole, rain water, tanker truck) Q37. I expect the water to be located on the premises EWA3 Q38. I expect to have access to water whenever I need it EWA4 For In patient EWA5 Q39. I expect water to be available on the wards (in toilets EWA6 and bathroom) Q40. I expect that there is enough water available for bathing EWA7 and washing Q41. I expect hot water for bathing EWA8 Q42. I expect water to be available every day EWA9 Q43. I expect the facility to have water storage facilities for EWA10 interrupted service SECTION 2.4 PERCEPTION of Water Availability For the next set of questions, TICK (√) whether you; 1-Strongly disagree, 2- Disagree, 3- Agree, 4- Strongly Agree. The first part has to do with your PERCEPTIONS. Indicate whether the patient strongly disagree, disagree, agree or strongly Agree with the perception (based on experience) from the Hospital. Q44. I am happy that water is available at the health facility PWA1 Q45. I am satisfied with the source of water I found at the PWA2 health facility Q46. I am satisfied that the water I used is on the premises of PWA3 the facility Q47. I am satisfied that I had access to water whenever I PWA4 needed 79 University of Ghana http://ugspace.ug.edu.gh Q48. I am satisfied that there is water on the ward in the PWA5 (toilets and bathrooms) where I am admitted Q49. I am satisfied I have enough water for bathing and PWA6 washing Q50. I am satisfied that I have hot water for bathing PWA7 Q51. I am satisfied that water flows every day PWA8 Q52. I am satisfied that water storage facilities are available PWA9 at the health facility SECTION 2.5 EXPECTATION of Hand Hygiene Facilities For the next set of questions, TICK (√) whether you; 1-Strongly disagree, 2- Disagree, 3- Agree, 4- Strongly Agree. The first part has to do with your EXPECTATIONS. Indicate whether the patient strongly disagree, disagree, agree or strongly Agree with the expectation from the Hospital. Q53. I expect the health facility to have hand washing EHH1 facilities for patient use Q54. I expect the hand facilities to have flowing water (from EHH2 tap/sink or veronica bucket) Q55. I expect soap to be available for hand washing EHH3 Q56. I expect sanitizer to be available for patient use EHH4 Q57. I expect hand drying materials to be available for EHH5 patient use Q58. I expect to find hand washing facilities at the toilet EHH6 Q59. I expect to find hand washing facilities at the OPD EHH7 Q60. I expect to find hand washing facilities at the wards EHH8 Q61. I expect to find hand washing facilities at/near the EHH9 nurses and doctors treatment areas SECTION 2.6 PERCEPTION of Hand Hygiene Facilities For the next set of questions, TICK (√) whether you; 1-Strongly disagree, 2- Disagree, 3- Agree, 4- Strongly Agree. The first part has to do with your PERCEPTIONS. Indicate whether the patient strongly disagree, disagree, agree or strongly Agree with the perception (based on experience) from the Hospital. Q62. I am satisfied that the health facility has hand washing PHH1 facilities for patient use Q63. I am satisfied that the hand facilities I used had flowing PHH2 water from tap/sink or veronica bucket Q64. I am satisfied I used soap for hand washing PHH3 Q65. I am satisfied I used sanitizer PHH4 Q66. I am satisfied I used hand drying materials (disposable PHH5 tissues) Q67. I am satisfied the toilets I used had hand washing PHH6 facilities 80 University of Ghana http://ugspace.ug.edu.gh Q68. I am satisfied the OPD I attended had hand washing PHH7 facilities Q69. I am satisfied the wards I am admitted has hand PHH8 washing facilities Q70. I am satisfied the nurses and doctors treatment areas PHH9 where I was attended to has hand washing facilities SECTION 2.6 EXPECTION of Waste Management For the next set of questions, TICK (√) whether you; 1-Strongly disagree, 2- Disagree, 3- Agree, 4- Strongly Agree. The first part has to do with your PERCEPTIONS. Indicate whether the patient strongly disagree, disagree, agree or strongly Agree with the perception (based on experience) from the Hospital Q71. I expect waste bins are provided at all areas EWM1 /departments (OPD waiting area, consultation room, ward on the compound) Q72. I expect the waste bins to be properly covered and not EWM2 overflowing Q73. I expect fenced and protected areas will be available for EWM2 the storage of waste awaiting disposal or removal? SECTION 2.6 PERCEPTION of Waste Management For the next set of questions, TICK (√) whether you; 1-Strongly disagree, 2- Disagree, 3- Agree, 4- Strongly Agree. The first part has to do with your PERCEPTIONS. Indicate whether the patient strongly disagree, disagree, agree or strongly Agree with the perception (based on experience) from the Hospital Q74. I am satisfied waste bins are provided at all areas PWM1 /departments (OPD waiting area, consultation room, ward, on the compound) Q75. I am satisfied the waste bins are properly covered and PWM2 not overflowing Q76. I am satisfied fenced and protected areas are available PWM3 for the storage of waste awaiting disposal or removal? 81 University of Ghana http://ugspace.ug.edu.gh CONCLUDING QUESTIONS WASH IN HEALTH FACILITIES Sr. No. Questions Categories/Codes Answer (one only unless indicated “all that apply”) Q77. What would you like 01. Better toilets (more modern and to see changed in the updated toilets)  toilets at the health 02. More toilets for patients facility to make you 03. Separate toilets for males and happier? females  04. Female toilets with provision for the management of menstrual hygiene  05. Water and soap in toilets 06. Other, specify ________________________ Q78. Do you consider the 01. Yes toilets when you 02. No  decide which health 99. No answer/do not want to care facility to use answer for antenatal care or childbirth? Q79. What would you like 01. An improved water source to see changed about 02. Improved water quantity  the water at the 03. Constant flow of water 24 – 7 health facility to 04. Other , please specify make you happier?  ____________________________ ___  Q80. Do you consider 01. Yes water availability 02. No  when you decide 99. No answer/do not want to which health care answer facility to use for antenatal care or childbirth? 82 University of Ghana http://ugspace.ug.edu.gh Q81. Where in the health 01. At the toilets facility are hand 02. At OPD  washing facilities 03. In the wards available? 04. At/ near the nurses treatment area  05. At/near the doctors treatment area 06. Other, please specify  ____________________________  Q82. What would you like 01. Provide flowing water for hand to see changed about washing  the hand washing 02. Provide soap facilities at the 03. Provide sanitizer health facility? 04. Provide hand drying tissues  05. Permit patients to use hand washing facilities at point of care  06. Other, please specify  ____________________________ Q83. Do you consider 01. Yes availability of soap 02. No  and water for hand washing and hand drying materials when deciding which health facility to go for care? Q84. What is your general 01. Facility is clean impression of this 02. Facility is well maintained  facility 03. Staff are nice to clients 04. Facility is not clean 05. Facility is not well maintained  06. Staff are not nice to clients 07. Other, please specify  ____________________________  83 University of Ghana http://ugspace.ug.edu.gh Notes 84 University of Ghana http://ugspace.ug.edu.gh APPENDIX IV ETHICAL APPROVAL LETTER 85