A process evaluation for a Water and Sanitation for Health Facility Improvement Tool (WASHFIT) intervention in Northern Uganda

A process evaluation for a Water and Sanitation for Health Facility Improvement Tool (WASHFIT) intervention in Northern Uganda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A process evaluation for a Water and Sanitation for Health Facility Improvement Tool (WASHFIT) intervention in Northern Uganda Doreen Nakalembe, Martha Akulume, Tonny Ssekamatte, John Bosco Isunju, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6784690/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Water, sanitation, and hygiene are essential for public health in healthcare facilities, with many lacking basic services, especially in rural sub-Saharan Africa, including Uganda. WASH impacts health security, staff morale, quality of care, and gender equality. Although the WASHFIT has been tested and recommended for enhancing WASH and IPC practices, it has not been extensively evaluated in various healthcare settings. We, therefore, employed a qualitative case study design to explore the fidelity of the WASHFIT process, as well as the barriers and facilitators to its application in HCFs in Northern Uganda. Methodology: The study was conducted in the districts of Amuru and Nwoya in Northern Uganda. We used a combination of snowball and purposive sampling techniques to select 20 key informants and 36 focus group discussants associated with the eight healthcare facilities that implemented the WASHFIT intervention. We used Atlas. Version 24 to code the data and the RE-AIM framework to guide our analysis. Results: The WASHFIT intervention, implemented by knowledgeable trainers, distinguished itself from others by incorporating a structured risk assessment and rating, stakeholder participation, and an emphasis on the governance, operation, and maintenance of WASH/IPC facilities. Through weekly CMEs and regular status meetings, the participants acquired knowledge which they used to implement WASH/IPC interventions. A lack of customised assessment tools, a heavy workload, a negative attitude among staff, a shortage of human resources competent in using WASHFIT, inadequate inter-departmental collaboration, and insufficient technical support from implementing partners and district healthcare managers hindered the use of the WASHFIT methodology. Healthcare providers' awareness of the challenges posed by WASH in healthcare facilities, as well as expectations related to reporting and accountability. Conclusions: Based on these findings, addressing challenges with the customisation and localisation of the WASHFIT, managing the healthcare provider workload, and defining task boundaries, as well as addressing governance, are likely to stimulate the implementation of the WASHFIT intervention. Figures Figure 1 Figure 2 Background Water, sanitation, and hygiene (WASH) in healthcare facilities (HCFs) remain a significant public health challenge. In 2021, only 78% of HCFs globally had a basic water service, 51% had a basic hygiene service, 10% had unimproved or no toilets, and 27% did not have systems for segregating waste [ 1 ]. Over 3.85 billion people globally use HCFs without basic hand hygiene services, 1.7 billion lack basic water services, and 780 million use unimproved toilets [ 2 , 3 ]. Almost half, 41%, of HCFs in sub-Saharan Africa didn’t have basic water services, 61% had no basic healthcare waste services, and 27% had no hand hygiene facilities at points of care [ 1 , 4 ]. The coverage of basic sanitation services in sub-Saharan Africa was four times higher in urban areas than in rural HCFs [ 5 ]. Uganda is no exception to the global WASH in the HCFs crisis. Only 31% of HCFs have basic water services, 12% have basic sanitation services, and 57% lack basic healthcare waste management services [ 6 ]. About 85% of HCFs in Northern Uganda, the focus of the current study, have a limited water supply, 57% do not have a basic waste management service, and 88% lack basic sanitation [ 6 ]. Given its central role in health security and infection prevention and control (IPC), WASH in healthcare remains “non-negotiable.” Improvements in WASH are central to upholding dignity and respect and improving staff morale, preparedness, response efforts, quality of care, staff performance, and gender equality [ 7 ]. Poor sanitation and hygiene, inadequate environmental cleaning, improper healthcare waste management and the use of contaminated water increase the risk of antimicrobial resistance and healthcare-associated infections (HAIs) [ 8 – 10 ]. HAIs prolong hospital stays, increase morbidity and mortality, and place a financial burden on patients, families, and the healthcare system [ 11 , 12 ]. Despite the importance of WASH, Uganda’s progress towards achieving the desired local and international standards remains suboptimal [ 13 ]. Nonetheless, the Ugandan government developed guidelines on injection safety in 2004, WASH in HCFs in 2022, and healthcare waste management in 2013 to strengthen WASH programming in HCFs [ 14 – 16 ]. Implementing partners such as GIZ, WaterAid, and Amref supplement existing policies and guidelines with the customisation of quality improvement tools such as the Water and Sanitation for Health Facility Improvement Tool (WASH FIT) to provide practical context-based guidance on improving WASH in HCFs [ 17 ]. WASH FIT is a risk-based, quality improvement tool for HCFs to address gaps in water, sanitation, hygiene, environmental cleaning, healthcare waste management, energy, building, and facility management [ 18 ]. As a risk-based and quality improvement process, the WASHFIT involves a situational analysis and thorough assessment of WASH conditions in HCFs, establishing, monitoring, evaluating, and reviewing improvement plans, regular spot checks, and using available resources to make incremental and sustainable changes [ 19 , 20 ]. Environmental sustainability and climate resilience, gender equality, disability and social inclusion, emergency and pandemic preparedness, quality of care, and IPC are central to the WASHFIT process [ 19 , 20 ]. Although the WASHFIT has been tested and recommended for enhancing WASH and IPC practices [ 21 , 22 ], it has not been extensively evaluated in various healthcare settings [ 23 ]. Additionally, there is limited evidence on the fidelity of the WASHFIT process, barriers and facilitators to its application. We, therefore, conducted a process evaluation to explore the fidelity of the WASHFIT process, barriers, facilitators of its application in the HCFs in Northern Uganda. Process evaluation offers a thorough assessment of a program's strengths, weaknesses, and areas for improvement in program delivery, such as in design or execution, which may not be evident from routine monitoring data [ 24 ]. Process evaluations can guide decisions on future development and implementation practices, determine whether a program or project is a worthwhile investment, assess alignment with stakeholders' needs, and facilitate working toward the intended outcomes [ 19 ]. Theoretical underpinnings The RE-AIM framework (Fig. 1 ) guided the process evaluation. The RE-AIM framework can guide the translation of research into practice and help understand the effectiveness of programs implemented in real-world community settings [ 25 ]. The RE-AIM framework encourages program evaluators, researchers, and policymakers to focus on essential program elements, particularly external validity, to enhance the long-term adoption and implementation of various interventions [ 26 ]. The RE-AIM framework has five constructs, i.e., reach (R), effectiveness (E), maintenance (M), adoption (A), implementation (I), and maintenance (M) [ 25 ]. Description of the intervention The implementation of WASHFIT activities commenced in January 2023 and was completed in January 2024. These activities took place in Otwee HCIII, Amuru HCII, and Lacor HCIII, all situated within the Amuru Town Council, Amuru District. In Nwoya District, the intervention extended to Purongo, Anaka, Koch Goma, and Olwiyo sub-counties. Healthcare facilities (HCFs) in these areas included Pungo HCIII, Kibar HCII, Wi Anaka HCIII, Anaka Hospital, St Francis HCII-Anaka, Koch Goma HCIII, and Aparanga HCII, respectively. The WASHFIT indicators encompassed crucial water, sanitation, and hygiene aspects within HCFs. These indicators included water supply, sanitation, hand hygiene, environmental cleaning, and healthcare waste management. The tool assessed the quality and availability of these services, ensuring safe, reliable, and hygienic environments. By addressing these indicators, the HCFs enhanced patient safety and health outcomes. The WASHFIT intervention was implemented following the stages in Fig. 2 . The first stage involved establishing a WASH-IPC improvement committee or team within the HCFs. Implementing partners, including St. Mary’s Lacor Hospital (Founded by Comboni Missionaries, administered and managed by Roman Catholics in Northern Uganda), district local government staff, and the Makerere University School of Public Health (MAKSPH) collaborated to form multidisciplinary and dedicated WASH/IPC improvement teams. Before forming new WASH improvement teams, implementing partners engaged with other leaders, such as IPC focal persons/facility in-charges, the IPC team and the VHTs across eight healthcare facilities to determine the presence or absence of existing WASH/IPC committees. These committees underwent training and were supposed to hold regular meetings, address WASH and IPC challenges, and prioritise action items. Meetings served as platforms for reporting findings from supervision and evaluation rounds, as well as identifying and prioritising actions to enhance WASH in the facility. A meeting record sheet was utilised to document discussion items, decisions, and action points, enabling the tracking of progress and key WASH components. In the second stage, the HCF staff in the eight facilities received support from implementing partners and the district's local government staff to conduct a comprehensive situational analysis. This assessment aimed to determine the current status of WASH and IPC within the HCFs. The situational analysis data were used to identify intervention and training needs and gaps in the eight HCFs, assess the existence of infrastructure for WASH and IPC improvements, and determine available resources. The situational analysis data also provided an opportunity to refine WASH-IPC assessment tools (WASHFIT) to capture data that might have otherwise been overlooked. In the third stage, implementing partners (St. Mary’s Lacor Hospital) and the healthcare facility staff undertook hazard and risk assessment and noted according to seriousness. They conducted sanitary inspections of water and sanitation systems, ensuring updated information and ongoing monitoring of the current status. Sanitary inspection, a visual survey of risk factors contributing to fecal contamination in water systems, was employed as an effective and low-cost risk assessment tool. During the sanitary inspections, potential hazards, hazardous events, and problematic conditions related to water abstraction facilities, distribution systems, and storage reservoirs were identified, along with improvement needs in the facility's water system. Risk profiling, using tools modified from WASHFIT sanitary inspection forms, was conducted, and required corrective measures were implemented by HCF Management with technical guidance from the implementing partners. Additionally, follow-up assessments captured information on IPC status and identified gaps requiring attention during intervention implementation. The third stage focused on developing and implementing an improvement plan tailored to address specific deficiencies or inefficiencies within the eight HCFs. This plan outlined clear goals, objectives, actions, and timelines aimed at improving the performance and effectiveness of available WASH activities. It involved identifying areas for improvement, establishing measurable targets, implementing corrective actions, and closely monitoring progress to achieve desired outcomes. Throughout this stage, the WASH/IPC team members, under the guidance of implementing partners, reviewed the improvement plans, assessed the progress of implementation, determined completion levels, and identified necessary steps to ensure the timely execution of planned actions. The last step was to continuously assess and improve the plans regarding WASH activities as part of wider quality improvements in HCFs. Novelty of the WASHFIT WASHFIT is an iterative quality improvement approach designed to enhance WASH services in healthcare facilities (HCFs). Its ultimate goal is to improve the quality of care and health outcomes by reducing infections, increasing service uptake, and boosting the productivity and confidence of healthcare staff. The WASHFIT approach involves analysing both process and outcome data regarding the establishment and training of the WASHFIT team, as well as documenting decisions. This includes undertaking HCF assessments, conducting risk assessments to identify and prioritise areas for improvement, developing incremental action plans, and continuously monitoring, reviewing, and adapting to enhance these prioritised areas. Thus, systematically working to improve performance and adhere to local, national, and global standards [ 29 , 30 ]. The WASHFIT approach engages every stakeholder in the healthcare facility (HCF) in implementing iterative, measurable changes to make health services more effective, safe, and patient-centred. It encompasses a continuous process of assessments and spot checks to identify gaps in WASH infrastructure and practices that could affect the quality of care. Given the participatory nature of the WASHFIT, it encourages interdisciplinary and multisectoral collaboration by uniting those responsible for WASH services, including legislators, policymakers, district health officers, hospital administrators, water and sanitation engineers, climate and environmental specialists, and users [ 31 ]. The WASHFIT process has previously been used to improve WASH in HCFs in 40 low- and middle-income countries, including Uganda [ 30 ]. Materials and methods Study setting This paper presents data collected in July 2024 from HCFs in the Amuru and Nwoya districts of Northern Uganda. Amuru is 60 kilometres northwest of Gulu, the largest city in Northern Uganda. Amuru shares its borders with Adjumani district to the north, South Sudan and Lamwo district to the northeast, Gulu district to the east, Nwoya district to the south, Nebbi district to the southwest, and Arua district to the west [ 32 ]. Amuru has a total population of 237,700, of which 121,000 are females [ 33 ]. Amuru district has 42 HCFs, of which 26 are public, nine are private for-profit, and seven are private not-for-profit. Nwoya district is approximately 372 kilometres from Kampala, Uganda’s capital. Nwoya shares borders with Omoro and Oyam districts to the east, Kiryadongo and Bullisa districts to the south, Pakwach district to the west, and Amuru district to the north [ 34 ]. Nwoya has a total population of 220,593, of which 112,845 are females. Nwoya district has 23 HCFs, of which 13 are public, 5 are private for-profit, and 5 are private not-for-profit [ 35 ]. Study design and approach We employed a qualitative case study design guided by a process evaluation approach to assess the implementation fidelity of the WASHFIT intervention. The case study design allowed for an in-depth investigation of the intervention within a real-world, bounded context defined by time, geographic location, and programmatic scope. A case study design facilitates exploring a program or process in its natural setting through multiple data sources gathered over a sustained period [ 36 ]. The case study approach enabled a holistic understanding of the implementation of the WASH FIT, factors that influenced fidelity (barriers and facilitators), and lessons learned during the process. The RE-AIM framework explored reach, adoption, fidelity of implementation, perceived effectiveness, and early signs of sustainability. Sample size and sampling procedures The study employed a combination of snowball and purposive sampling techniques to select participants from the eight healthcare facilities that implemented the WASHFIT intervention. First, purposive sampling was used to recruit individuals directly involved in implementing the WASHFIT intervention. Interviewing those directly engaged in the implementation, such as healthcare providers, district health officials, and project team members, allowed the research team to gather detailed and contextually relevant data from individuals with firsthand experience, thereby enhancing the credibility and rigour of the findings [ 37 ]. Second, we asked the initial study participants (purposive sample) to identify other potential stakeholders who implemented the WASHFIT intervention within the eight healthcare facilities [ 38 ]. Using snowball sampling enabled researchers to target individuals knowledgeable about the implementation of the WASHFIT intervention and their experiences during its application [ 38 ]. Snowball sampling helped the research team identify individuals who did not have formal documentation of their roles but had contributed meaningfully to the implementation process. This approach ensured the inclusive representation of actors across different levels of the intervention, which strengthened the completeness and reliability of the data collected [ 39 ]. Within the participating healthcare facilities, respondents were selected from the WASHFIT team meeting recording sheet and contacted. This strategy allowed the research team to verify participants’ involvement and ensure that only those who had actively contributed to WASHFIT activities were included. The study involved 20 key informant interviews (KIIs) moderated using an interview guide (Supplementary file 1) and six focus group discussions (FGDs) facilitated with the aid of a focus group interview guide (Supplementary file 2). We used the level of theoretical saturation, i. e., a stage where we did not yield new insights on the barriers and facilitators of implementing the WASHFIT intervention, to determine the actual number of KIIs and FGDs [ 40 – 42 ]. Data collection methods and tools The data collection team conducted face-to-face KIIs with IPC focal persons, healthcare facility in-charges, implementing partners’ representatives, and district local government staff from Amuru and Nwoya using an open-ended guide, specifically developed for this study. We selected key informants based on their direct involvement in implementing the WASHFIT in the study healthcare facilities. By engaging with these participants, the research team gained insights into the challenges faced, lessons learned, and the implementation fidelity of the intervention. Aside from the KIIs, we conducted six focus group discussions (FGDs), each with 6–8 participants. These FGDs were held within the premises of selected healthcare facilities, including HC IIIs and one hospital. We conducted more FGDs in Nwoya than in Amuru since the latter had fewer benefiting HCFs. The FGD participants included members of the IPC committees and community health workers/VHTs who were directly involved in implementing the intervention. The FGDs were homogeneous, comprising participants directly involved from the training phase to the implementation of the WASHFIT intervention. This homogeneity was intended to foster open and meaningful dialogue, as participants shared common experiences and challenges related to the intervention [ 37 ]. Bringing together participants with shared experiences in implementing WASH-FIT fostered a safe and supportive environment for discussion [ 38 ]. Each FGD was conducted by a moderator and note-taker, taking about 1.0-1.5 hours. The note-taker captured detailed verbatim notes, including key contextual elements such as tone shifts, humour, emphasis, and repeated themes or questions. The data collection team digitally audio-recorded the discussions to capture the participants’ spoken words verbatim. Variables Implementation fidelity was measured using the constructs of the RE-AIM framework (Reach, Effectiveness, Adoption, and Implementation) (Table 1 ). The reach domain evaluated the extent to which the implementers reached the target population, while effectiveness focused on how the intervention achieved the desired outcomes. We assessed the adoption construct by exploring participant responsiveness, i.e., the degree to which participants were involved in intervention tasks [ 27 , 28 ] and implementation fidelity based on 1) program differentiation, i.e., the presence of distinguishing features of a particular program, 2) quality of delivery (the degree to which the intervention contributed to the desired goals and objectives), 3) exposure (the sessions delivered or the targeted trained participants), and 4) adherence (the extent to which practitioners complied with the intervention protocol guidelines) to the WASHFIT guidelines. During the assessment, we asked about the barriers and facilitators encountered and the key lessons learned from the implementation process. The WASHFIT process included assembling and training the WASHFIT team and holding regular meetings, conducting healthcare facility assessments, undertaking hazard and risk assessments, developing and implementing an improvement plan, and continuously evaluating and improving the implementation plans. Table 1 The RE-AIM indicators by dimension Dimension Indicator Reach Did the intervention reach the target population? Effectiveness Did the intervention affect the status quo? Adoption To what extent did those targeted to deliver the intervention participate? How did they develop organisational support to deliver the intervention? Implementation To what extent did the implementers undertake the intervention according to the protocol? Maintenance What have the HCFs done to maintain the implemented WASHFIT intervention activities? Data management and analysis Three qualitative experts transcribed all the audio recordings verbatim [ 39 ]. Transcription involved listening multiple times carefully to create a detailed transcript that captured essential elements such as emphasis, tone of voice, timing, and pauses, which were crucial for accurately interpreting the data [ 40 ]. The data analysis team compared the transcripts with the field notes recorded by the note-takers to ensure consistency and accuracy. Interviews carried out in the local language were transcribed and translated into English. For translations, the study investigator developed a list of terms and phrases in both languages to guide the translator, including how to interpret the data from the original language into English. When a word lacked an exact translation, the translator maintained the original word in quotes and provided the closest description in brackets or as a footnote. This approach facilitated discussions with the study investigator about the specific words' meanings to ensure everyone understood them in the study context [ 41 ]. The data management team undertook an interviewee transcript review (ITR) to improve the transcripts, including adding specific details, correcting/changing transcript details, and adding new information to the study participants [ 42 ]. ITR is a form of respondent validation where researchers share interview transcripts with study participants to review and verify the accuracy of the information [ 42 ]. Data analysis combined deductive and inductive approaches. Deductively, the RE-AIM framework guided initial coding and thematic organisation, focusing on dimensions such as reach, implementation fidelity, and sustainability. Inductively, the research team used themes that emerged beyond the framework to capture context-specific insights grounded in participants’ experiences. Combining the inductive and deductive dual approaches enabled a structured yet flexible understanding of the implementation process [ 43 , 44 ]. The data analysis team read the transcripts multiple times to develop codes and codebook definitions based on the WASHFIT process and the RE-AIM framework. The data analysis team reviewed the codebook and refined it through discussions between the principal investigator and the supervisory team to agree on definitions and categorisations. Afterwards, the data analysis team developed a coding tree to guide analysis with the aid of Atlas-ti version 24. A coding tree is a hierarchical structure used in qualitative data analysis to organise and manage the codes developed during the coding process [ 45 ]. Developing a coding tree allowed the principal investigator to systematically organise and consistently apply codes across the data [ 45 ]. The parent codes presented broad, overarching themes or categories, while the child codes captured sub-themes within those broader categories [ 45 ]. We established a 90% agreement between two coders (intercoder reliability) to ensure transparency and validity in the coding process. Upon the analysis, the team agreed on the dominant themes, sub-themes, and key codes within the WASHFIT process and RE-AIM framework. Quality assurance and quality control We used research assistants with a health or social sciences background to ensure quality data collection. Research assistants participated in a two-day training to familiarise themselves with the study protocol's data collection tools, study objectives, and ethical considerations. As part of the training, the study team piloted the data collection tools from a health centre III in Kampala that had implemented the WASHFIT methodology. Before collecting data from the main study population, the pilot test allowed researchers to identify and resolve any issues or limitations in the tools, such as unclear questions and potential response biases [ 46 ]. All interviews and discussions were audio-recorded with consent and supplemented with detailed field notes to capture non-verbal cues and contextual information. The data collection team labelled audio files with the interview type, the date, the healthcare facility, the participant’s ID, and the initials of the moderator (e.g., FGD1/11/2024_HCF/001/DN or KII1/11/2024_HCF/001/DN) for easy identification and retrieval. During fieldwork, the research team conducted daily debriefings to discuss interview progress, emerging themes, and any challenges encountered. These sessions allowed real-time adjustments and reinforced adherence to the data collection protocol. RESULTS Socio-demographic characteristics of the key informants A total of 20 key informants were interviewed. Of these, close to a quarter 20.0% (4/20) were attached to a general hospital, 70.0% (14/20) came from Amuru district, 40.0% (8/20) worked in HC III, 30.0% (6/20) were females, 55.0% (11/20) were above 40 years and 70.0% (14/20) had worked in the healthcare facility between 4 to 10 years (Table 2 ). Table 2 Socio-demographic characteristics of the respondents Variable Attribute Frequency (N = 20) Percentage (%) Level of healthcare facility Hospital 6 30.0 HC III 9 45.0 HC II 5 25.0 Ownership of the HCF Government 18 90.0 Private 2 10.0 Sex Female 6 30.0 Male 14 70.0 Highest level of education Bachelors 10 50.0 Diploma 7 35.0 Masters 3 15.0 Age-category (Years) 35–40 9 45.0 > 40 11 55.0 Period worked at this healthcare facility 4–10 14 70.0 > 10 6 30.0 Period worked in the WASH/IPC sector 4–10 13 65.0 > 10 7 35.0 Socio-demographic characteristics of focus group discussants Thirty-six respondents participated in the FGDs. Of these, about 72.2% (26/36) were females, 36.1% (13/36) had attained a secondary level of education, 25.0% (9/36) were Catholics, 47.2% (17/36) were married, and 58.3% (21/36) were above 40 years (Table 3 ). Table 3 Socio-demographic characteristics of focus group discussants Variable Attribute Frequency (N = 36) Percentage (%) Sex Female 26 72.2 Male 10 27.8 Education Status Primary 12 33.3 Secondary 13 36.1 Tertiary 11 30.6 Religion Anglican 7 19.4 Catholic 9 25.0 Muslim 7 19.4 Pentecost 7 19.4 SDA 6 16.7 Marital Status Married 17 47.2 Separated/divorced 12 33.3 Widowed 7 19.4 Age category (Years) 32–40 15 41.7 > 40 21 58.3 Duration worked in the WASH activities in years 2–10 30 83.3 > 10 6 16.7 Implementation fidelity of the WASHFIT intervention The intervention involved structured risk assessment and rating, broader stakeholder participation, and an emphasis on governance, operation, and maintenance of WASH/IPC facilities, distinguishing it from other WASH/IPC-related interventions ( intervention differentiation ). The implementers showcased the quality of the intervention's delivery by using competent facilitators and practical methodologies, including hand hygiene and environmental cleaning simulations. The participants engaged with the intervention (participant responsiveness) using the acquired knowledge to implement WASH/IPC interventions. The participants also received weekly CMEs (exposure) to reinforce the knowledge they acquired through the training, and adhered to the intervention protocol by conducting regular meetings about the progress of the WASH/IPC interventions. The intervention improved environmental hygiene and budgetary allocations for WASH/IPC activities (effectiveness) (Table 4 ). Table 4 Implementation fidelity of a WASHFIT intervention in Northern Uganda Guiding question Organising themes Basic themes Was the program distinguishable from other interventions? Intervention differentiation Structured risk assessment and rating Stakeholder participation Emphasis on governance, operation, and maintenance of WASH/IPC facilities How well was it delivered? Quality of delivery Trainers were knowledgeable and used practical methodologies. How well did the participants react to or engage with the intervention? Participant responsiveness Use of acquired knowledge How much of the program did participants receive? Exposure Intervention delivered through weekly CMEs Was the intervention delivered as planned (content, frequency, duration)? Adherence Conducting meetings about the progress of the WASH/IPC Did the intervention meet the set objectives? Effectiveness Improved environmental hygiene and budgetary allocations Program differentiation Structured risk assessment and rating Unlike previous IPC interventions and hygiene promotion approaches, the WASHFIT process incorporated structured risk assessment and rating. The series of indicators in the WASHFIT assessment tool made it easy for the healthcare facility staff to evaluate the risk of infections and thus take appropriate measures. Additionally, none of the healthcare providers had received an IPC training that involves risk assessments. The WASHFIT included sanitary inspections, setting it apart from the other interventions. "In our previous IPC interventions, we haven't been identifying and rating risks, so it has done a great job in risk assessment and identifying risks. For example, in one of the facilities in Amuru, if you say that a healthcare facility has a high risk of infection or hospital-acquired infection, people will easily understand because there are a series of indicators showing that this facility has a high risk of infection. This made it stand out compared to other approaches to promoting hygiene in healthcare facilities." KII with a district health team member, Amuru. Stakeholder participation The WASHFIT process was perceived as more practical than previous interventions. The WASHFIT process engaged stakeholders, including in-charges, IPC focal persons, departmental heads, healthcare workers, health assistants, and community health workers, to identify WASH/IPC gaps and define practical solutions. The intervention allowed the stakeholders to co-create solutions to improve the WASH/IPC situation at the HCFs. "To me, WASHFIT was more practical than other similar programs. It involved many people, especially healthcare workers, who came to understand the WASHFIT components and objectives, identified problems related to WASH, and determined what they immediately needed to improve the situation. We had challenges with infection prevention and control in healthcare facilities in Amuru, and this project helped us in that area. The project worked hand in hand with different stakeholders, including healthcare workers, health assistants, and VHTs." KII with an HCF In-charge, HC III. Emphasis on governance and operation and maintenance of WASH/IPC facilities Unlike other WASH/IPC interventions, the WASHFIT intervention emphasised governance, operation, and maintenance of water, sanitation, and hygiene facilities. The WASHFIT process led to the establishment of WASH/IPC committees and illuminated their importance in addressing healthcare facility WASH/IPC needs, including monitoring of WASH/IPC improvement plans. "You know, WASHFIT had some pillars, such as governance at the facility, water, sanitation, and hygiene. When you look at the components of governance and the guidance in the operation and maintenance of those facilities, they trained us that having functional committees would help address all the needs at the facility. For example, there was a water shortage at Hospital XX, and we had waterborne sanitation, which couldn't function without water. After receiving the training, we resolved some key issues at the facility and elected water management committees to support improvements in water at both the facility and the community. In addition, the water committee monitored WASH/IPC areas in the facilities and found that everything was progressing according to plan because we created a monitoring plan. This wasn't just at XXX (hospital); it was also implemented in other facilities. We at least informed them about what they were supposed to do regarding WASHFIT.” FGD with IPC committee members Quality of delivery of the WASHFIT Intervention Use of practical methodologies to enhance learning: The intervention was delivered using practical methods, such as hand hygiene demonstrations, PowerPoint presentations, and training charts, while focusing on the WASHFIT core components. These tools enhanced understanding of the WASHFIT processes, aligning the delivery approach well with the intervention's goals. "As for the trainers, they taught well theoretically. They used PowerPoint presentations, but there were also many posters and practical sessions where we could physically handle items related to WASH/IPC, which helped us understand everything". KII with a medical director of a hospital Participant responsiveness Use of acquired knowledge: During the implementation of the intervention, healthcare facility staff, cleaners, VHTs, departmental heads, environmental health personnel, and local authorities, including the town clerk, assumed their assigned roles under the WASHFIT intervention as expected. Health assistants conducted facility assessments and communicated gaps to the in-charge, who responded by providing necessary resources such as chlorine. Community health workers promoted hand hygiene within facilities and communities, whilst IPC committees aligned the WASHFIT intervention with their ongoing activities, including health education. Furthermore, it became common for healthcare facilities to ensure the sustained availability of essential IPC materials. The involvement of the various stakeholders reflected the understanding gained from training that implementation should engage all relevant actors.To elaborate on the roles of the stakeholders in enhancing WASH/IPC, it was pointed out that; "The health assistants were responsible for conducting all the facility assessments and informing the in-charge about the indicators that were poorly performing. It was the role of the in-charge to provide financial support; for instance, if the health inspector reported a lack of chlorine for treating water, it was the in-charge's responsibility to ensure it was provided at the facility or included in the plan. The VHTs supported the community by promoting hand washing within the facility and in the community, which was also part of the assessment usually done under WASHFIT. The IPC committee participated actively because WASHFIT aligned with the activities they were already involved in" (IPC focal person Amuru). Concerning adopting new practices, the healthcare facility in charge said: "We adopted new practices into our daily work routine by ensuring that all necessary IPC materials and other required items were in place. Although some items were occasionally missing, the goal was to maintain at least a minimum level of IPC at our facilities. Health talks on WASH/IPC were also consistently conducted, particularly during our health education sessions". KII with an HCF in charge Exposure to the intervention Weekly CMEs: The WASHFIT team was formed based on a specific cadre and prior training. The training was conducted over several days through two daily sessions, covering WASHFIT orientation, IPC, hand hygiene, and waste management. The practical sessions concentrated on sanitation inspections, hand hygiene audits, and waste segregation. Additionally, the team convened every six months to monitor implementation progress and take corrective action where necessary. This approach improved participants' exposure and ability to apply WASHFIT tools. “The selection of team members was based on the available staff within the facility, considering their cadre and how they had been trained. We assembled the WASHFIT team at the facility, and we were supposed to meet every six months to review our progress with the WASH/IPC activities within the facility. Participants received the full programme over several days, with two daily training sessions. The sessions covered key areas such as WASH-FIT orientation, infection prevention and control (IPC) measures, hand hygiene, and healthcare waste management. In addition, two practical sessions were held, focusing on facility-based assessments including sanitation facility inspections, hand hygiene audits, and waste segregation practices. This approach helped ensure participants gained knowledge and practised applying it in real-life settings”. IPC focal person. Participants received continuous exposure to the WASHFIT intervention through weekly facility-based CME sessions after the main training. These sessions involved reviewing the training content, identifying key learnings, and conducting brainstorming and demonstration exercises. This approach ensured that participants not only completed the core training but also engaged in regular reinforcement and hands-on practice of WASHFIT procedures. “We conducted a Continuous Medical Education (CME) session once a week on the WASHFIT procedures. We reviewed the implementation processes after the training and identified the key learnings. We then engaged in brainstorming sessions and demonstrations to practice and refine these procedures.” FGD with IPC committee members Adherence As planned by the intervention team, the participants received training on WASH/IPC, including planning and budgeting for related activities, which they applied through weekly planning meetings lasting one to two hours. During these sessions, they addressed real IPC issues such as infrastructure repairs and improving waste management by acquiring waste bins for departments. This regular application of training content supported practical problem-solving and strengthened implementation. After learning about budgeting and planning, we applied that knowledge in practice, particularly through our weekly planning meetings that lasted about one to two hours. In these meetings, we discussed actual IPC issues and explored ways to address problems, such as repairing or replacing damaged infrastructure. We also focused on acquiring waste bins for each department to improve waste management. This approach was very helpful in implementing practical solutions.” (In-charge, HC II). Effectiveness Improved environmental hygiene and budgetary allocations: The participants received continuous training and orientation to build their capacity to deliver the WASHFIT interventions within their healthcare facilities. Those who had received training on the earlier version of the WASHFIT process and tool were retrained to improve their capacity and familiarity with the revised (version 2.0) WASHFIT process and tools. Consequently, the intervention resulted in noticeable improvement in environmental hygiene within the HCFs but also influenced planning and budgetary allocation for WASH/IPC activities. Unlike before, HCFs started to allocate a fair share of resources to WASH/IPC activities, indicating successful integration into priorities. "This is evident in the noticeable improvement in the cleanliness of the facility, which is now at a very high level. That's one clear success of the project. Additionally, planning and budget allocation, WASH/IPC now receives a fair share of resources”. (IPC focal person). "We had challenges with infection prevention and control in healthcare facilities in Amuru, and this project helped us in that area." KII with an HCF In-charge, HC III. The effectiveness of the WASHFIT process largely depended on the team’s capacity to employ it. The previously trained teams and those involved in similar assessments were likely to effectively undertake the WASHFIT processes and implement other WASH/IPC interventions. "This depends on the capacity of the person. For instance, my team and I in Amuru had already been exposed to it, so it was more like a refresher training. We were familiar with WASHFIT, having participated in several trainings and assessments. There was a WASH project XXX in Acholi, and I was the focal person supporting WASHFIT implementation. Through that, I learned a lot, but they revised the version, and it was version two that I didn't actively participate in. I received orientation through XXX, which improved our capacity and made us more familiar with WASHFIT. Regarding outcomes, people, especially healthcare workers and health assistants, learned the WASHFIT process.” (District health team member, Amuru district). Barriers to the implementation of the WASHFIT intervention A lack of customised assessment tools, a heavy workload, a negative attitude among staff, a shortage of human resources competent in using WASHFIT, inadequate inter-departmental collaboration, and insufficient technical support from implementing partners and district healthcare managers hindered healthcare staff from implementing the WASHFIT intervention. Lack of customised WASHFIT assessment tools HCFs lacked customised WASHFIT assessment tools, which hindered the effective implementation of interventions, particularly healthcare facility assessments and sanitary inspections. The lack of customised assessment tools led to inconsistencies in the assessment process across HCFs. To address related challenges in the future, some participants recommended the provision of customised standard tools to enhance consistency in assessments across HCFs. “We don’t have localised assessment tools for conducting these regular or irregular evaluations. This lack of tools makes it difficult to carry out the assessments effectively. Our main challenge was the absence of a standard tool for conducting these assessments. As a result, how we conducted them may have differed from how it was done in other healthcare facilities. Having minimum standard tools designed to assist with these assessments would be beneficial. Although the level of risks and hazards varies from facility to facility, having standard tools could help ensure consistency and effectiveness in the assessment process.” FGD with IPC committee members Heavy workload A heavy workload and staff reluctance to take on responsibilities beyond their formal roles hindered the implementation of the WASHFIT intervention. Healthcare providers felt overwhelmed by tasks related to implementing the WASHFIT intervention. The unclear task boundaries compromised the participation of stakeholders, such as facility in-charges, despite their crucial role in driving the WASHFIT process. “First of all, the health inspectors conducted the assessments late, and some of the key stakeholders, such as the health in-charges and other core team members at the facility, were not present to provide feedback on the WASH/IPC action points. When you try to guide or instruct a staff member, you might hear them express fatigue or frustration. Sometimes, they might say they are tired from performing tasks that fall outside their job description, especially when they are taking on additional roles that were not originally part of their responsibilities.” IPC focal person, HC III A heavy workload, coupled with competing workload priorities, reduced the active participation of the teams in implementing WASHFIT interventions. Over time, the WASHFIT team became inactive, which made it difficult to follow up on the implemented WASHFIT activities. “The WASH/IPC team existed but became inactive due to a lack of supervision and monitoring of the intervention. Although we typically conduct integrated supervision in these healthcare facilities, sometimes the workload becomes overwhelming, leading to the neglect of certain areas, and eventually, the system breaks down. The participants included healthcare workers and the village health teams.” IPC focal person HC III Many healthcare workers, especially those on the IPC committee, were often too busy to participate in some of the assessments. This led them to delegate the task to individuals who were not knowledgeable and struggled to understand how the assessment was being conducted, making implementation difficult in some facilities. “There was a lack of collaboration between the different departments at the facilities. The assessment forms were sometimes given to individuals who were not knowledgeable and, as a result, did not provide the correct information needed for the assessment. For instance, on the day of the assessment, some or even all members of the IPC committee might have been occupied, and the person available to assist with tasks like moving around the facility or conducting a risk assessment of the water sources may not have had the necessary knowledge. Additionally, the language used for communication could sometimes be difficult for them to understand, and they may not have been familiar with the facility assessment process since they were assigned to different departments within the healthcare facilities. FGD, IPC, R2, IPC Committee.” Poor leadership and coordination The lack of structured follow-up and coordination between district teams and implementing partners resulted in incomplete implementation and discontinuity of planned WASHFIT activities. Additionally, inadequate inter-departmental collaboration and the delegation of assessment tasks to untrained staff significantly compromised the effectiveness of WASH/IPC interventions. Healthcare facility staff reported a lack of sustained commitment from implementing partners, which hindered the consistent execution and monitoring of WASHFIT activities. “We had the knowledge and skills, but somehow we started certain initiatives and then left them unfinished. For example, when we attended the meeting with the implementing partner XXX, I included a plan in our district strategy to conduct continuous monitoring of the WASHFIT indicators within our facilities. However, when we spoke to the team from the implementing partner, they didn’t provide a specific date for us to meet and plan the continuous actions. As a result, we didn’t implement it effectively. It was done for a period, but the continuous evaluation of the plan was not carried out.” District health team member, Amuru district. Facilitators for the implementation of the WASHFIT intervention Healthcare provider awareness of WASH as a challenge in healthcare settings, along with reporting and accountability expectations, facilitated the implementation of the WASHFIT intervention. Awareness of WASH as a challenge in healthcare settings Recognition of visible WASH/IPC challenges, especially in high-volume facilities and in light of the COVID-19 experience, catalysed stakeholder engagement and improved healthcare workers’ participation in the WASHFIT implementation. “One significant contributing factor is the visible presence of the problem at the facility that needs attention. For instance, we have a busy facility with hundreds of patients, and it’s clear that the facility needs proper hand hygiene practices for effective management. When we realised this, along with various stakeholders, and considering the recent experience with the COVID-19 pandemic, it became evident that something needed to be done. As a result, there has been a noticeable change in attitude among healthcare workers in IPC and WASH activities.” In charge, HC III The WASHFIT intervention helped healthcare workers identify gaps at their facilities and develop plans to address them. This approach improved operations, particularly in waste management. The identification of WASH/IPC gaps through assessment enabled targeted planning and resource mobilisation, strengthening overall operational improvements within the facility. “Identifying these gaps helped the department develop plans to address them, ensuring that the necessary resources and measures were in place to improve their operations. This approach has led to significant improvements in waste management within the facility.” FGD, R6, IPC Committee Healthcare providers demonstrated a strong willingness to engage with the WASHFIT process, motivated by the desire to ensure the safety of both patients and staff. Their positive attitude toward the intervention facilitated its integration into existing practices, such as Continuing Medical Education (CME) sessions, thereby further strengthening implementation. “Willingness was a major factor, along with considering the safety of healthcare workers and patients in the facility, knowing that it is a place for service delivery. Therefore, we needed to be keen and follow instructions in the healthcare setting. This mindset, combined with the knowledge gained from the WASHFIT training and continuous CMEs, which we attended once or twice a week, has enabled the successful implementation of the WASHFIT intervention.” FGD, R2, IPC Committee Community support, particularly in supplementing essential WASH supplies like soap, played a key and vital role in contributing to the intervention's objective. This was especially true during periods of high patient load and resource constraints. The community's ability to provide these crucial resources to the healthcare facilities was invaluable, helping to facilitate the implementation of WASHFIT components. To some extent, the community provided resources when there were insufficient supplies due to the increased number of patients. For instance, handwashing with soap is required at the facility, but there are times when the number of community members is so large that the soap runs out in just one day, and sometimes, it gets stolen. Additionally, the rooms we work in can become dirty quickly if there are many patients, requiring frequent cleaning, which becomes a challenge. As a result, community members often have to step in and provide soap.” In-charge, In-charge HC III.” Reporting and accountability expectations Routine reporting and accountability mechanisms encouraged facilities to consistently plan, budget for, and monitor progress on WASHFIT implementation. The need to report on the status and progress of IPC, along with being held accountable for all funds spent during the implementation of the WASHFIT intervention, facilitated its execution. Additionally, the reporting requirement to provide updates on IPC status and progress further supported the implementation of the WASHFIT intervention. “The need to report on IPC is important. For instance, the status of IPC, regarding the current status, and is there any progress compared to before? Additionally, since they have planned for it, they must follow through because, in the end, they are held accountable for the money budgeted under the WASHFIT components, so they are compelled to budget and plan for it. Another factor is that it’s a reporting requirement. During the WASH/IPC meetings, they must report on how frequently they met and the progress of the WASH/IPC components.” In charge, hospital.” DISCUSSION Using the RE-AIM model, this qualitative study examined implementation fidelity and identified barriers and facilitators to the implementation of a WASHFIT intervention in Northern Uganda. The study also evaluated the reach and effectiveness of the WASHFIT intervention. The barriers included a lack of customised assessment tools, a heavy workload, a negative attitude among staff, a shortage of human resources competent in using WASHFIT, inadequate inter-departmental collaboration, and insufficient technical support from implementing partners and district healthcare managers. The facilitators of implementing the WASHFIT intervention included healthcare providers' awareness of WASH as a challenge in healthcare settings, as well as expectations for reporting and accountability. The WASHFIT intervention distinguished itself from other similar WASH/IPC programs by incorporating risk assessments at the healthcare facility. Risk assessments help identify the seriousness of WASH/IPC problems that could cause harm to facility users, such as patients, pregnant mothers, newborns, caregivers, the community, and the environment [ 47 ]. By conducting these assessments, facilities could estimate the likelihood of these problems occurring and pinpoint specific WASH/IPC areas for improvement, leading to incremental enhancements in their practices [ 48 ]. This proactive approach has a positive influence on IPC-related outcomes, including reductions in healthcare-associated infections, antimicrobial resistance, and disease outbreaks [ 47 , 49 ]. Conducting risk assessments in healthcare facilities (HCFs) has been highlighted in studies examining occupational risks to healthcare workers and the benefits and risks of routine child immunisation during the COVID-19 pandemic [ 50 , 51 ]. The intervention emphasised the role of governance and exemplary leadership in fostering WASH/IPC improvements. Governance and good leadership are crucial in developing various teams, such as the WASHFIT team, which requires a leader who oversees all members by assigning them roles and responsibilities, enabling them to work together to achieve the intervention's objectives. Additionally, the overall leadership establishes rules and regulations that align with the goals of the implemented project, making it easier to manage, track progress, and identify any gaps or bottlenecks that could limit the achievement of the intended project objectives [ 52 ]. The governance aspect might also be practical in decision-making to improve WASH/IPC activities [ 53 ]. For example, the introduction of reporting mechanisms for each team leader, such as those of the IPC committee, the VHTs, the HUMC, and the water user committee at the community level, helps ensure evidence-based resource allocation based on transparency, proper record-keeping, and effective communication. A Ul Musawir, CEM Serra, O Zwikael and I Ali [ 54 ] documented the importance of good governance in achieving project success [ 54 ]. Our study highlights the limited resources and understaffing of healthcare workers in the selected healthcare facilities (HCFs). The limited resources might be due to insufficient funds to procure WASH/IPC equipment, as most healthcare facilities rely on PHC funds, which may not be enough to meet the WASH/IPC needs at the facilities [ 55 – 57 ]. Some rural healthcare facilities rely on the hope that implementing partners will support their WASH/IPC activities, which slows implementation because the facilities lack the resources to apply the knowledge they have gained from the training. Furthermore, most rural healthcare facilities in Uganda are understaffed [ 58 ]; for example, HC IIs should be led by an enrolled nurse working with a midwife and two nursing assistants. [ 59 ], and the WASHFIT committee needs around six cadres to perform the WASHFIT process. However, upon examining the staffing at these facilities, the situation remains alarming. This could likely be due to delayed payment from the government, delays in deploying healthcare workers to areas where they are most needed, and a lack of tools and support to do their jobs effectively. This understaffing may result in heavy workloads for the existing staff, affecting the performance of the healthcare facility [ 64 ], which in turn impacts the overall service delivery objective and WASH/IPC [ 60 ]. Understaffing and limited resources in the healthcare system in Uganda have been documented and identified as significant factors affecting the overall performance of healthcare facilities [ 61 , 62 ]. However, upon examining the staffing at these facilities, the situation remains alarming. This is likely due to delayed payments from the government, delays in deploying healthcare workers to areas where they are most needed, and many healthcare workers lacking the necessary tools and support to perform their jobs effectively [ 63 ]. This understaffing may result in heavy workloads for the existing staff, affecting healthcare facility performance and ultimately impacting overall service delivery objectives, including WASH/IPC. Understaffing and limited resources in the healthcare system in Uganda have been documented [ 64 , 65 ] as significant factors affecting the overall performance of healthcare facilities. Our study highlights the absence of standardised assessment tools suitable for local healthcare facility settings. The lack of these standardised tools could potentially affect the overall objectives of the WASHFIT intervention [ 66 ]. This is because, during the assessment at an HC III, it is essential to recognise that some indicators may not apply to this facility level and are more relevant to an HC IV or a hospital. Similarly, when assessing an HC II, specific indicators pertinent to HC IIIs may not be suitable for HC IIs. Therefore, to enhance the objectives of the WASHFIT intervention, there is a need for different implementing partners and the Ministry of Health to tailor the assessment tools and criteria to the specific level of each HCF to ensure accurate, consistent, and relevant evaluations. This study revealed that self-motivation and the desire to experiment with the WASHFIT tool were key factors that facilitated its implementation. This may be due to the knowledge gained from training on the WASHFIT tool and becoming familiar with it at their facility to understand its effectiveness in improving WASH/IPC conditions [ 53 ]. Additionally, this could be attributed to the need to test all the indicators in the WASHFIT tool to determine which ones work and which ones do not apply to their facility [ 53 ]. Self-motivation and the desire to experiment with the WASHFIT tool have been documented to improve WASH in government health facilities in Tamil Nadu [ 67 ]. This study highlights that the need to report on the status and progress of IPC facilitated the implementation of WASH/IPC. This may be probably to identify WASH/IPC areas that need to be prioritised to improve service delivery at healthcare facilities [ 68 ]. It might also be to assess the changes that have occurred over time and determine where support is needed by developing plans to enhance WASH/IPC in the different healthcare facilities and communities [ 69 ]. The need to report on the status and progress of IPC has been documented in Tanzania [ 70 ]. The study highlighted that raising awareness about the WASHFIT intervention was a key lesson learned from its implementation. Being aware of the importance of the WASHFIT intervention could improve understanding of its benefits and the positive impact it could have on WASH/IPC in communities and HCFs [ 53 ]. This awareness could probably help people decide whether they are supportive or hesitant about participating in the implementation. Additionally, if people are informed, they gain knowledge, and with knowledge comes the interest to understand what needs to be done and the direction to take to make improvements and achieve success during the intervention's implementation [ 52 ]. Awareness raising has been documented to improve behavioural change in WASH/IPC activities [ 71 , 72 ]. The study reveals that stakeholder involvement, planning, and budgeting were important lessons learned during the implementation of the WASHFIT intervention. Involving stakeholders could increase ownership of the intervention, making it easier to implement. Additionally, stakeholders could help ensure that the budget reflects the needs of both the healthcare facilities and the communities, increasing the intervention's transparency and effectiveness. Furthermore, involving stakeholders in planning could help tailor strategies to effectively address specific challenges and drive improvement in the intervention's implementation. Stakeholder involvement, planning and budgeting have been documented in improving WASH/IPC interventions [ 73 – 76 ] Strengths and limitations Although this may have been one of the few studies to examine the implementation fidelity of WASHFIT globally so far, it was prone to recall and social desirability biases. Participants may have provided responses that they believed were socially acceptable or desirable rather than reflecting their true thoughts, attitudes, or behaviours. Recall bias could have arisen from the implementation of various interventions after WASHFIT, making it challenging for participants to recall specific details accurately amidst other interventions, potentially affecting their responses. Recall and social desirability bias were managed through thorough training of research assistants in probing techniques and the use of life events to stimulate recall. Conclusions Using the RE-AIM model, this study assessed the fidelity and effectiveness of the WASHFIT intervention in healthcare facilities. The intervention was delivered by knowledgeable trainers and distinguished itself from others by incorporating a structured risk assessment and rating, stakeholder participation, and emphasis on governance, operation, and maintenance of WASH/IPC facilities. Through weekly CMEs and regular status meetings, the participants acquired knowledge which they used to implement WASH/IPC interventions. The barriers to implementing the WASHFIT intervention included a lack of customised assessment tools, a heavy workload, a negative attitude among staff, a shortage of human resources competent in using WASHFIT, inadequate inter-departmental collaboration, and insufficient technical support from implementing partners and district healthcare managers, while the facilitators were healthcare provider awareness of WASH as a challenge in healthcare settings, and expectations related to reporting and accountability. Based on these findings, addressing challenges with the localization of the WASHFIT, managing the healthcare provider workload and defining task boundaries, and addressing governance, are likely to stimulate the implementation of the WASHFIT intervention. Abbreviations DLGS District Local Government Staff DHO District Health Officers HBV Hepatitis B virus HCAIs Healthcare-associated infections HCFs Healthcare facilities HCP Healthcare Providers HCWM Healthcare Waste Management IPC Infection Prevention and Control IP Implementing partner IPCAF Infection Prevention and Control Assessment Framework JMP Joint Monitoring Programme MoH Ministry of Health MOH-EHD Ministry of Health Environmental Health Department SDGs Sustainable Development Goals WASH Water Sanitation and Hygiene WHO World Health Organization WASHFIT Water and sanitation for health facility improvement tool Declarations Ethical approval This study was conducted in compliance with the Declaration of Helsinki. Ethical approval was obtained from the Makerere University School of Public Health Higher Degrees and Research Ethics Committee (MakSPH HDREC) (Protocol Number-473). Administrative clearance for the study was sought from the Chief Administrative Officers (CAOs) and the District Health Officers (DHOs) in the Amuru and Nwoya districts. All interactions with participants adhered to the principles of respect, beneficence, justice, confidentiality, and obtaining informed consent. Consent to publish Not applicable Availability of data and materials The transcripts analysed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was funded by the Reckitt Global Hygiene Institute (RGHI). The study protocol was independently peer-reviewed by the funding body, however, any opinions, conclusions, or recommendations expressed in this article are those of the authors alone and do not necessarily reflect the views of RGHI. Authors' contributions RKM obtained the funding for this study. DN, MA, TS and JBI conceptualised the study, participated in data collection and analysis and drafted the manuscript. BNT, WJM, AN, AT, JG, FN, and STW participated in the analysis and drafting of the manuscript. All authors read and approved this manuscript before submission to this journal. Acknowledgement We want to thank the administrations of the Amuru and Nwoya District Local Governments for granting us clearance to undertake this study. We remain indebted to the administration of the healthcare facilities that implemented the WASHFIT, allowing their facilities to participate in the study, and to the healthcare providers who responded to the study tools. Finally, we would like to thank our diligent team of research assistants (Naamala Mirandah, Kabarungi Evelyn Sanyu, and Bwire Geoffrey) and coordinators who made this study a success. References Progress on WASH in health care facilities 2000–2021: special focus on WASH and infection prevention and control (IPC) [https://washdata.org/reports/jmp-2022-wash-hcf] Progress on WASH in health care facilities 2000-2021: Special focus on WASH and infection prevention and control (IPC) [https://data.unicef.org/resources/jmp-wash-in-health-care-facilities-2022/] Improving the Quality of Health Care Services by Strengthening IPC at Centers of Excellence: Technical Report [https://pdf.usaid.gov/pdf_docs/PA00ZZJH.pdf] Half of health care facilities globally lack basic hygiene services – WHO, UNICEF [https://www.who.int/news/item/30-08-2022-half-of-health-care-facilities-globally-lack-basic-hygiene-services---who--unicef] Progress on WASH in health care facilities 2000–2021 [file:///C:/Users/DELL/Downloads/9789240058699-eng.pdf] More schools and health centres supported with WASH services in northern Uganda [https://www.unicef.org/uganda/stories/more-schools-and-health-centres-supported-wash-services-northern-uganda] WASH in health care facilities [https://data.unicef.org/topic/water-and-sanitation/wash-in-health-care-facilities/] WASH in health care facilities [https://www.who.int/teams/environment-climate-change-and-health/water-sanitation-and-health-(wash)/health-care-facilities/wash-in-health-care-facilities] National Standards for WASH in Health Care Facilities [https://www.unicef.org/sop/reports/national-standards-wash-health-care-facilities] Ditai J, Mudoola M, Gladstone M, Abeso J, Dusabe-Richards J, Adengo M, Olupot-Olupot P, Carrol ED, Storr J, Medina-Lara A et al : Preventing neonatal sepsis in rural Uganda: a cross-over study comparing the tolerance and acceptability of three alcohol-based hand rub formulations . BMC Public Health 2018, 18 (1):1279. Kisaka YN: Factors affecting compliance to infection prevention and control measures among frontline health workers: a case study of the Kitale County Referral Hospital . Strathmore University; 2021. Sahiledengle B, Tekalegn Y, Woldeyohannes D: The critical role of infection prevention overlooked in Ethiopia, only one-half of health-care workers had safe practice: A systematic review and meta-analysis . PloS one 2021, 16 (1):e0245469. Blueprint for Acceleration: Sustainable Development Goal 6 Synthesis Report on Water and Sanitation 2023 [https://www.unwater.org/publications/sdg-6-synthesis-report-2023] Watson J, D'Mello-Guyett L, Flynn E, Falconer J, Esteves-Mills J, Prual A, Hunter P, Allegranzi B, Montgomery M, Cumming O: Interventions to improve water supply and quality, sanitation and handwashing facilities in healthcare facilities, and their effect on healthcare-associated infections in low-income and middle-income countries: a systematic review and supplementary scoping review . BMJ Glob Health 2019, 4 (4):e001632. NATIONAL GUIDELINES FOR WASH IN HEALTH CARE FACILITIES [https://www.washinhcf.org/wp-content/uploads/2022/09/WASH-Guidelines-2022-Final-with-foreword.pdf] Uganda National Infection Prevention And Control Guidelines [http://library.health.go.ug/sites /default/files/resources/Uganda%20National %20Infection%20Prevention%20 and%20Control%20Guidelines%20Dec%202013.pdf] WASH in healthcare facilities [https://www.washinhcf.org/country/uganda/#/] The Water and Sanitation for Health Facility Improvement Tool (WASH FIT) [https://www.washinhcf.org/wp-content/uploads/2021/07/What-is-WASH-FIT.pdf] Chen H-C, Tseng T-P, Cheng K, Sriarkarin S, Xu W, Ferdin AE, Nguyen VV, Zong C, Lee C-H: Conducting an evaluation framework of importance-performance analysis for sustainable forest management in a rural area . Forests 2021, 12 (10):1357. WASH IN HEALTH CARE FACILITIES [https://www.unicef.org/esa/media/4826/file/UNICEF-WASH-in-Health-Care-Facilities-2019.pdf] A field guide to improving water, sanitation, and hygiene in health care facilities in lowand middle-income countries as part of broader quality of care improvements [https://pdf.usaid.gov/pdf_docs/PA00TWRS.pdf] Lineberger H, Cronk R, Kpodzro S, Salzberg A, Anderson DM: Does WASH FIT improve water, sanitation, and hygiene and related health impacts in healthcare facilities? A systematic review . medRxiv 2024:2024.2004. 2005.24305396. Water Safety Portal [https://wsportal.org/] Macura B, Del Duca L, Soto A, Carrard N, Gosling L, Hannes K, Thomas J, Sara L, Sommer M, Waddington HS et al : PROTOCOL: What is the impact of complex WASH interventions on gender and social equality outcomes in low- and middle-income countries? A mixed-method systematic review protocol . Campbell systematic reviews 2021, 17 (2):e1164. Glasgow RE, Harden SM, Gaglio B, Rabin B, Smith ML, Porter GC, Ory MG, Estabrooks PA: RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review . Frontiers in public health 2019, 7 :64. Description of the RE-AIM framework [https://re-aim.org/learn/what-is-re-aim/#:~:text=The%20overall%20goal%20of%20the,and%20implementation%20of% 20effective%2C%20generalizable%2C] Bishop DC, Pankratz MM, Hansen WB, Albritton J, Albritton L, Strack J: Measuring Fidelity and Adaptation: Reliability of a Instrument for School-Based Prevention Programs . Evaluation & the health professions 2014, 37 (2):231-257. Pettigrew J, Graham JW, Miller-Day M, Hecht ML, Krieger JL, Shin YJ: Adherence and delivery: implementation quality and program outcomes for the seventh-grade keepin' it REAL program . Prevention science : the official journal of the Society for Prevention Research 2015, 16 (1):90-99. WASH FIT: A practical guide for improving quality of care through water, sanitation and hygiene in health care facilities [https://iris.who.int/bitstream/handle/10665/353411/9789240043237-eng.pdf?sequence=1] WASH FIT: A practical guide for improving quality of care through water, sanitation and hygiene in health care facilities [https://iris.who.int/bitstream/handle/10665/353411/9789240043237-eng.pdf?sequence=1] WASH FIT A practical guide for improving quality of care through water, sanitation and hygiene in health care facilities [https://iris.who.int/bitstream/handle/10665/353411/9789240043237-eng.pdf?sequence=1] Amuru District Local government [https://amuru.go.ug/lg/overview] Population & Censuses [https://www.ubos.org/explore-statistics/20/] Nwoya district local governmnet [https://nwoya.go.ug/lg/overview] NATIONAL HEALTH FACILITY MASTER LIST 2018 [https://www.health.go.ug/wp-content/uploads/2020/02/National-Health-Facility-Master-List-2018.pdf] Creswell JW, Hanson WE, Clark Plano VL, Morales A: Qualitative research designs: Selection and implementation . The counseling psychologist 2007, 35 (2):236-264. O. Nyumba T, Wilson K, Derrick CJ, Mukherjee N: The use of focus group discussion methodology: Insights from two decades of application in conservation . Methods in Ecology and evolution 2018, 9 (1):20-32. Greenwood N, Ellmers T, Holley J: The influence of ethnic group composition on focus group discussions . BMC medical research methodology 2014, 14 :1-13. Creswell JW, Poth CN: Qualitative inquiry and research design: Choosing among five approaches : Sage publications; 2016. Bailey J: First steps in qualitative data analysis: transcribing . Family practice 2015, 25 (2):127-131. Baker M: In other words: A coursebook on translation : Routledge; 2018. Rowlands J: Interviewee transcript review as a tool to improve data quality and participant confidence in sensitive research . International Journal of Qualitative Methods 2021, 20 :16094069211066170. Robinson OC: Conducting thematic analysis on brief texts: The structured tabular approach . Qualitative Psychology 2022, 9 (2):194. Neuendorf KA: Content analysis and thematic analysis . In: Advanced research methods for applied psychology. edn.: Routledge; 2018: 211-223. Roy P, Tremblay G, David A: Quebec’s Model for Men’s Health: Connecting Community, Research, Practice, and Policies . International Journal of Men's Social and Community Health 2022, 5 (1):27-42. Buschle C, Reiter H, Bethmann A: The qualitative pretest interview for questionnaire development: outline of programme and practice . Quality & Quantity 2022, 56 (2):823-842. Embrey M, Parveen S, Hafner T, Islam H, Zahid A, Joshi MP: Integration of IPC/WASH critical conditions into quality of care and quality improvement tools and processes: Bangladesh case study . Antimicrobial Resistance & Infection Control 2024, 13 (1):100. Water, Sanitation, and Hygiene (WASH) in Healthcare Facilities [https://www.cdc.gov/global-water-sanitation-hygiene/prevention/index.html] Ali SM, Ali SM, Ali AO, Faulkner S, Gon G, Graham WJ, Haji HS, Kabole I, Kahabuka C, Morrison E: IMPROVING MATERNAL AND NEWBORN HEALTH IN ZANZIBAR: A needs assessment of IPC and WASH . Eyre DW, Lumley SF, O'Donnell D, Campbell M, Sims E, Lawson E, Warren F, James T, Cox S, Howarth A: Differential occupational risks to healthcare workers from SARS-CoV-2 observed during a prospective observational study . elife 2020, 9 :e60675. Abbas K, Procter SR, van Zandvoort K, Clark A, Funk S, Mengistu T, Hogan D, Dansereau E, Jit M, Flasche S: Routine childhood immunisation during the COVID-19 pandemic in Africa: a benefit–risk analysis of health benefits versus excess risk of SARS-CoV-2 infection . The Lancet Global Health 2020, 8 (10):e1264-e1272. Khader Y, Alyahya M, Saadeh R: Water, Sanitation, and Hygiene (WASH) and Infection Prevention and Control (IPC) in Primary Healthcare Facilities in Jordan in the Context of COVID-19 . Primary Health Care 2022:229. Weber N, Martinsen AL, Sani A, Assigbley EKE, Azzouz C, Hayter A, Ayite K, Baba AAB, Davi KM, Gelting R: Strengthening healthcare facilities through water, sanitation, and hygiene (WASH) improvements: a pilot evaluation of “WASH FIT” in Togo . Health security 2018, 16 (S1):S-54-S-65. Ul Musawir A, Serra CEM, Zwikael O, Ali I: Project governance, benefit management, and project success: Towards a framework for supporting organizational strategy implementation . International Journal of Project Management 2017, 35 (8):1658-1672. Kadowa I: A case study of the Uganda National Minimum Healthcare Package . In . : Ministry of Health, EQUINET Uganda; 2017. Guo A, Bowling JM, Bartram J, Kayser G: Water, sanitation, and hygiene in rural health-care facilities: a cross-sectional study in Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia . The American journal of tropical medicine and hygiene 2017, 97 (4):1033. Medard T, Yawe BL, Bosco OJ: Health care delivery system in Uganda: a review . 2023. Tweheyo R, Reed C, Campbell S, Davies L, Daker-White G: ‘I have no love for such people, because they leave us to suffer’: a qualitative study of health workers’ responses and institutional adaptations to absenteeism in rural Uganda . BMJ global health 2019, 4 (3):e001376. Kim J-H, Bell GA, Bitton A, Desai EV, Hirschhorn LR, Makumbi F, Nabiwemba E, Ratcliffe HL, Wabwire-Mangen F, Kibira SP: Health facility management and primary health care performance in Uganda . BMC health services research 2022, 22 (1):275. Isunju JB, Ssekamatte T, Wanyenze R, Mselle JS, Wafula ST, Kansiime WK, Bateganya NL, Nalugya A, Wagaba B, Denny L: Analysis of management systems for sustainability of infection prevention and control, and water sanitation and hygiene in healthcare facilities in the Greater Kampala Area, Uganda . PLoS Water 2022, 1 (5):e0000021. Ssekamatte T, Mugambe RK, Isunju JB, Wanyenze RK, Nalugya A, Adyedo C, Wafula ST, Buregyeya E, Nuwematsiko R, Bateman J: Application of the behaviour-centred design to understand facilitators and deterrents of hand hygiene among healthcare providers: findings from a formative phase of a cluster randomised trial in the Kampala Metropolitan area . BMC Health Services Research 2024, 24 (1):1031. Fejfar D, Guo A, Kelly E, Tidwell JB, Ochieng O, Cronk R: Healthcare provider satisfaction with environmental conditions in rural healthcare facilities of 14 low-and middle-income countries . International journal of hygiene and environmental health 2021, 236 :113802. Udho S, Kabunga A: Burnout and Associated Factors among Hospital‐Based Nurses in Northern Uganda: A Cross‐Sectional Survey . BioMed Research International 2022, 2022 (1):8231564. Mulegi T: An Overview of Performance of Health Workers in Uganda . IDOSR Journal of Humanities and Social Sciences 2022, 7 (1):113-124. Mukasa MN, Sensoy Bahar O, Ssewamala FM, KirkBride G, Kivumbi A, Namuwonge F, Damulira C: Examining the organizational factors that affect health workers' attendance: findings from southwestern Uganda . The International journal of health planning and management 2019, 34 (2):644-656. Setty K, Cronk R, George S, Anderson D, O’Flaherty G, Bartram J: Adapting translational research methods to water, sanitation, and hygiene . International journal of environmental research and public health 2019, 16 (20):4049. Subramaniam S, Selvavinayagam T: Supportive supervision as an effective intervention in improving water, sanitation and hygiene facilities in government health facilities of Tamil Nadu . International Journal of Community Medicine and Public Health 2018, 5 (3):1082. Howard G, Bartram J, Brocklehurst C, Colford Jr JM, Costa F, Cunliffe D, Dreibelbis R, Eisenberg JNS, Evans B, Girones R: COVID-19: urgent actions, critical reflections and future relevance of ‘WaSH’: lessons for the current and future pandemics . Journal of water and health 2020, 18 (5):613-630. Palo SK, Kanungo S, Samal M, Priyadarshini S, Sahoo D, Pati S: Water, Sanitation, and Hygiene (WaSH) practices and morbidity status in a rural community: findings from a cross-sectional study in Odisha, India . Journal of Preventive Medicine and Hygiene 2021, 62 (2):E392. Hokororo J, Eliakimu E, Ngowi R, German C, Bahegwa R, Msigwa Y: Report of trend for compliance of infection prevention and control standards in Tanzania from 2010 to 2017 in Tanzania mainland . Microbiol Infect Dis 2021, 5 (3):1-10. Leclert LM, Affolter JS, Ndenga J: From awareness raising to sustainable behaviour change in school: the WASH in school road map . 2018. Seimetz E, Kumar S, Mosler H-J: Effects of an awareness raising campaign on intention and behavioural determinants for handwashing . Health education research 2016, 31 (2):109-120. De Buck E, Hannes K, Cargo M, Van Remoortel H, Vande Veegaete A, Mosler H-J, Govender T, Vandekerckhove P, Young T: Engagement of stakeholders in the development of a Theory of Change for handwashing and sanitation behaviour change . International journal of environmental health research 2018, 28 (1):8-22. Chirgwin H, Cairncross S, Zehra D, Sharma Waddington H: Interventions promoting uptake of water, sanitation and hygiene (wash) technologies in low‐and middle‐income countries: an evidence and gap map of effectiveness studies . Campbell systematic reviews 2021, 17 (4):e1194. Jacob Arriola KR, Ellis A, Webb-Girard A, Ogutu EA, McClintic E, Caruso B, Freeman MC: Designing integrated interventions to improve nutrition and WASH behaviors in Kenya . Pilot and feasibility studies 2020, 6 :1-16. Tantum LK, Cronk R, Asingwire N, Bohara P, Kharal Chettry L, Hirai M, Kpodzro S, Mavi T, Miller JD, Ripkey C: What is next for costing WASH in healthcare facilities? Applying evidence for policy and practice . medRxiv 2024:2024.2008. 2014.24311992. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1.docx Supplementaryfile2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6784690","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475423039,"identity":"c077a57a-5434-4dee-b332-3493f85fa53b","order_by":0,"name":"Doreen Nakalembe","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Doreen","middleName":"","lastName":"Nakalembe","suffix":""},{"id":475423040,"identity":"d4114374-146d-4b90-a1cd-0d7e0798d91f","order_by":1,"name":"Martha Akulume","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Martha","middleName":"","lastName":"Akulume","suffix":""},{"id":475423041,"identity":"b03c187b-a2e1-4994-a368-601bce68ff5c","order_by":2,"name":"Tonny Ssekamatte","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYJACxgYo/QBEGhBSzgPTwsPGwGxAshY2CaK02PMff/hwRs02eXv55mNVN9vq8swZmB9+YGyrxW2LRI6x4YZjtw172NjSbue2HS62bGAzlmBsO45HCw+b5AO224w9bDxmQC0HEjccYDBjYGw7hlsL//HnPx/8u23fw8b/rTi3rQ6ohf0bfi0MCWaMG9tuJwJtYWPObWMGauEB2VKDW8uNHGPJmX23k3uOpRlL55w7XGxwmKdYIuHcAZxa2PuPP/zY8+22bXvz4Yefc8rq8gyOt2/88KGsDqcWDJDAwAwmD5OiBQJIsGUUjIJRMAqGOwAAqwFV+zuCTZQAAAAASUVORK5CYII=","orcid":"","institution":"Makerere University","correspondingAuthor":true,"prefix":"","firstName":"Tonny","middleName":"","lastName":"Ssekamatte","suffix":""},{"id":475423042,"identity":"1694fe36-5a97-4133-b15e-0193e14eadd2","order_by":3,"name":"John Bosco Isunju","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"John","middleName":"Bosco","lastName":"Isunju","suffix":""},{"id":475423043,"identity":"1a10e28d-3adf-49ac-842c-77258fb8c6cc","order_by":4,"name":"Bridget Nagawa Tamale","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Bridget","middleName":"Nagawa","lastName":"Tamale","suffix":""},{"id":475423044,"identity":"026d2992-1a74-4360-b405-125226e40260","order_by":5,"name":"Wejuli Junior Mike","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Wejuli","middleName":"Junior","lastName":"Mike","suffix":""},{"id":475423045,"identity":"76fdd26a-d532-4a2d-b1b3-b24e43ae7d21","order_by":6,"name":"Aisha Nalugya","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Aisha","middleName":"","lastName":"Nalugya","suffix":""},{"id":475423046,"identity":"49c32823-06e6-4487-89b6-cc301fa0ac58","order_by":7,"name":"Akello Trophy","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Akello","middleName":"","lastName":"Trophy","suffix":""},{"id":475423047,"identity":"e31e5c97-c5c8-426b-b084-0efe2efed38c","order_by":8,"name":"Jovan Galiwango","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Jovan","middleName":"","lastName":"Galiwango","suffix":""},{"id":475423048,"identity":"42b9380c-f048-419c-b7c3-c019011f0c43","order_by":9,"name":"Fred Nuwagaba","email":"","orcid":"","institution":"GIZ- Sanitation for Millions Programme","correspondingAuthor":false,"prefix":"","firstName":"Fred","middleName":"","lastName":"Nuwagaba","suffix":""},{"id":475423049,"identity":"80276545-d77c-4ebd-b7d0-db43e0ab0be6","order_by":10,"name":"Solomon Tsebeni Wafula","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Solomon","middleName":"Tsebeni","lastName":"Wafula","suffix":""},{"id":475423050,"identity":"8b579680-f50b-4217-9a21-2fa7698b290f","order_by":11,"name":"Richard K. Mugambe","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"K.","lastName":"Mugambe","suffix":""}],"badges":[],"createdAt":"2025-05-30 12:23:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6784690/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6784690/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85731694,"identity":"5ed781e1-4f21-4874-b597-edd562a23ec3","added_by":"auto","created_at":"2025-07-01 07:26:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":142181,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConceptual framework for evaluating the WASHFIT intervention among HCFs in Northern Uganda, adapted from [25, 27, 28].\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6784690/v1/14ab2a6118562dd6a9783815.png"},{"id":85731693,"identity":"f110dab2-eb90-47d9-ae81-7077585ec3d1","added_by":"auto","created_at":"2025-07-01 07:26:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":151255,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA summary of the steps that were undertaken during the WASHFIT intervention [18].\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6784690/v1/63560229d6524f298dfa9cc2.png"},{"id":101851056,"identity":"3133682e-60d8-47c0-8357-f6a2c2627724","added_by":"auto","created_at":"2026-02-04 10:00:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4684654,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6784690/v1/89d5d837-7c3e-43a6-b865-e4d0d37b05c5.pdf"},{"id":85732287,"identity":"e35fa4e0-6e4f-4b45-87cb-b13596e8cade","added_by":"auto","created_at":"2025-07-01 07:34:04","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18578,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6784690/v1/fdf9ce93e247fab41eaf1168.docx"},{"id":85733547,"identity":"3d657095-827f-4cee-a72c-065382a72f09","added_by":"auto","created_at":"2025-07-01 07:42:04","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":17935,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6784690/v1/ef9e15e586b4d4f6022889ee.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A process evaluation for a Water and Sanitation for Health Facility Improvement Tool (WASHFIT) intervention in Northern Uganda","fulltext":[{"header":"Background","content":"\u003cp\u003eWater, sanitation, and hygiene (WASH) in healthcare facilities (HCFs) remain a significant public health challenge. In 2021, only 78% of HCFs globally had a basic water service, 51% had a basic hygiene service, 10% had unimproved or no toilets, and 27% did not have systems for segregating waste [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Over 3.85\u0026nbsp;billion people globally use HCFs without basic hand hygiene services, 1.7\u0026nbsp;billion lack basic water services, and 780\u0026nbsp;million use unimproved toilets [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Almost half, 41%, of HCFs in sub-Saharan Africa didn\u0026rsquo;t have basic water services, 61% had no basic healthcare waste services, and 27% had no hand hygiene facilities at points of care [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The coverage of basic sanitation services in sub-Saharan Africa was four times higher in urban areas than in rural HCFs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Uganda is no exception to the global WASH in the HCFs crisis. Only 31% of HCFs have basic water services, 12% have basic sanitation services, and 57% lack basic healthcare waste management services [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. About 85% of HCFs in Northern Uganda, the focus of the current study, have a limited water supply, 57% do not have a basic waste management service, and 88% lack basic sanitation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven its central role in health security and infection prevention and control (IPC), WASH in healthcare remains \u0026ldquo;non-negotiable.\u0026rdquo; Improvements in WASH are central to upholding dignity and respect and improving staff morale, preparedness, response efforts, quality of care, staff performance, and gender equality [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Poor sanitation and hygiene, inadequate environmental cleaning, improper healthcare waste management and the use of contaminated water increase the risk of antimicrobial resistance and healthcare-associated infections (HAIs) [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. HAIs prolong hospital stays, increase morbidity and mortality, and place a financial burden on patients, families, and the healthcare system [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Despite the importance of WASH, Uganda\u0026rsquo;s progress towards achieving the desired local and international standards remains suboptimal [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Nonetheless, the Ugandan government developed guidelines on injection safety in 2004, WASH in HCFs in 2022, and healthcare waste management in 2013 to strengthen WASH programming in HCFs [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImplementing partners such as GIZ, WaterAid, and Amref supplement existing policies and guidelines with the customisation of quality improvement tools such as the Water and Sanitation for Health Facility Improvement Tool (WASH FIT) to provide practical context-based guidance on improving WASH in HCFs [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. WASH FIT is a risk-based, quality improvement tool for HCFs to address gaps in water, sanitation, hygiene, environmental cleaning, healthcare waste management, energy, building, and facility management [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. As a risk-based and quality improvement process, the WASHFIT involves a situational analysis and thorough assessment of WASH conditions in HCFs, establishing, monitoring, evaluating, and reviewing improvement plans, regular spot checks, and using available resources to make incremental and sustainable changes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Environmental sustainability and climate resilience, gender equality, disability and social inclusion, emergency and pandemic preparedness, quality of care, and IPC are central to the WASHFIT process [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the WASHFIT has been tested and recommended for enhancing WASH and IPC practices [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], it has not been extensively evaluated in various healthcare settings [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Additionally, there is limited evidence on the fidelity of the WASHFIT process, barriers and facilitators to its application. We, therefore, conducted a process evaluation to explore the fidelity of the WASHFIT process, barriers, facilitators of its application in the HCFs in Northern Uganda.\u003c/p\u003e \u003cp\u003eProcess evaluation offers a thorough assessment of a program's strengths, weaknesses, and areas for improvement in program delivery, such as in design or execution, which may not be evident from routine monitoring data [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Process evaluations can guide decisions on future development and implementation practices, determine whether a program or project is a worthwhile investment, assess alignment with stakeholders' needs, and facilitate working toward the intended outcomes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTheoretical underpinnings\u003c/p\u003e \u003cp\u003eThe RE-AIM framework (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) guided the process evaluation. The RE-AIM framework can guide the translation of research into practice and help understand the effectiveness of programs implemented in real-world community settings [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The RE-AIM framework encourages program evaluators, researchers, and policymakers to focus on essential program elements, particularly external validity, to enhance the long-term adoption and implementation of various interventions [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The RE-AIM framework has five constructs, i.e., reach (R), effectiveness (E), maintenance (M), adoption (A), implementation (I), and maintenance (M) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDescription of the intervention\u003c/p\u003e \u003cp\u003eThe implementation of WASHFIT activities commenced in January 2023 and was completed in January 2024. These activities took place in Otwee HCIII, Amuru HCII, and Lacor HCIII, all situated within the Amuru Town Council, Amuru District. In Nwoya District, the intervention extended to Purongo, Anaka, Koch Goma, and Olwiyo sub-counties. Healthcare facilities (HCFs) in these areas included Pungo HCIII, Kibar HCII, Wi Anaka HCIII, Anaka Hospital, St Francis HCII-Anaka, Koch Goma HCIII, and Aparanga HCII, respectively. The WASHFIT indicators encompassed crucial water, sanitation, and hygiene aspects within HCFs. These indicators included water supply, sanitation, hand hygiene, environmental cleaning, and healthcare waste management. The tool assessed the quality and availability of these services, ensuring safe, reliable, and hygienic environments. By addressing these indicators, the HCFs enhanced patient safety and health outcomes.\u003c/p\u003e \u003cp\u003eThe WASHFIT intervention was implemented following the stages in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The first stage involved establishing a WASH-IPC improvement committee or team within the HCFs. Implementing partners, including St. Mary\u0026rsquo;s Lacor Hospital (Founded by Comboni Missionaries, administered and managed by Roman Catholics in Northern Uganda), district local government staff, and the Makerere University School of Public Health (MAKSPH) collaborated to form multidisciplinary and dedicated WASH/IPC improvement teams.\u003c/p\u003e \u003cp\u003eBefore forming new WASH improvement teams, implementing partners engaged with other leaders, such as IPC focal persons/facility in-charges, the IPC team and the VHTs across eight healthcare facilities to determine the presence or absence of existing WASH/IPC committees. These committees underwent training and were supposed to hold regular meetings, address WASH and IPC challenges, and prioritise action items. Meetings served as platforms for reporting findings from supervision and evaluation rounds, as well as identifying and prioritising actions to enhance WASH in the facility. A meeting record sheet was utilised to document discussion items, decisions, and action points, enabling the tracking of progress and key WASH components.\u003c/p\u003e \u003cp\u003eIn the second stage, the HCF staff in the eight facilities received support from implementing partners and the district's local government staff to conduct a comprehensive situational analysis. This assessment aimed to determine the current status of WASH and IPC within the HCFs. The situational analysis data were used to identify intervention and training needs and gaps in the eight HCFs, assess the existence of infrastructure for WASH and IPC improvements, and determine available resources. The situational analysis data also provided an opportunity to refine WASH-IPC assessment tools (WASHFIT) to capture data that might have otherwise been overlooked. In the third stage, implementing partners (St. Mary\u0026rsquo;s Lacor Hospital) and the healthcare facility staff undertook hazard and risk assessment and noted according to seriousness. They conducted sanitary inspections of water and sanitation systems, ensuring updated information and ongoing monitoring of the current status. Sanitary inspection, a visual survey of risk factors contributing to fecal contamination in water systems, was employed as an effective and low-cost risk assessment tool.\u003c/p\u003e \u003cp\u003eDuring the sanitary inspections, potential hazards, hazardous events, and problematic conditions related to water abstraction facilities, distribution systems, and storage reservoirs were identified, along with improvement needs in the facility's water system. Risk profiling, using tools modified from WASHFIT sanitary inspection forms, was conducted, and required corrective measures were implemented by HCF Management with technical guidance from the implementing partners. Additionally, follow-up assessments captured information on IPC status and identified gaps requiring attention during intervention implementation. The third stage focused on developing and implementing an improvement plan tailored to address specific deficiencies or inefficiencies within the eight HCFs. This plan outlined clear goals, objectives, actions, and timelines aimed at improving the performance and effectiveness of available WASH activities. It involved identifying areas for improvement, establishing measurable targets, implementing corrective actions, and closely monitoring progress to achieve desired outcomes. Throughout this stage, the WASH/IPC team members, under the guidance of implementing partners, reviewed the improvement plans, assessed the progress of implementation, determined completion levels, and identified necessary steps to ensure the timely execution of planned actions. The last step was to continuously assess and improve the plans regarding WASH activities as part of wider quality improvements in HCFs.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNovelty of the WASHFIT\u003c/p\u003e \u003cp\u003eWASHFIT is an iterative quality improvement approach designed to enhance WASH services in healthcare facilities (HCFs). Its ultimate goal is to improve the quality of care and health outcomes by reducing infections, increasing service uptake, and boosting the productivity and confidence of healthcare staff. The WASHFIT approach involves analysing both process and outcome data regarding the establishment and training of the WASHFIT team, as well as documenting decisions. This includes undertaking HCF assessments, conducting risk assessments to identify and prioritise areas for improvement, developing incremental action plans, and continuously monitoring, reviewing, and adapting to enhance these prioritised areas. Thus, systematically working to improve performance and adhere to local, national, and global standards [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The WASHFIT approach engages every stakeholder in the healthcare facility (HCF) in implementing iterative, measurable changes to make health services more effective, safe, and patient-centred. It encompasses a continuous process of assessments and spot checks to identify gaps in WASH infrastructure and practices that could affect the quality of care. Given the participatory nature of the WASHFIT, it encourages interdisciplinary and multisectoral collaboration by uniting those responsible for WASH services, including legislators, policymakers, district health officers, hospital administrators, water and sanitation engineers, climate and environmental specialists, and users [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The WASHFIT process has previously been used to improve WASH in HCFs in 40 low- and middle-income countries, including Uganda [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting\u003c/h2\u003e \u003cp\u003eThis paper presents data collected in July 2024 from HCFs in the Amuru and Nwoya districts of Northern Uganda. Amuru is 60 kilometres northwest of Gulu, the largest city in Northern Uganda. Amuru shares its borders with Adjumani district to the north, South Sudan and Lamwo district to the northeast, Gulu district to the east, Nwoya district to the south, Nebbi district to the southwest, and Arua district to the west [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Amuru has a total population of 237,700, of which 121,000 are females [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Amuru district has 42 HCFs, of which 26 are public, nine are private for-profit, and seven are private not-for-profit. Nwoya district is approximately 372 kilometres from Kampala, Uganda\u0026rsquo;s capital. Nwoya shares borders with Omoro and Oyam districts to the east, Kiryadongo and Bullisa districts to the south, Pakwach district to the west, and Amuru district to the north [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Nwoya has a total population of 220,593, of which 112,845 are females. Nwoya district has 23 HCFs, of which 13 are public, 5 are private for-profit, and 5 are private not-for-profit [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy design and approach\u003c/h3\u003e\n\u003cp\u003eWe employed a qualitative case study design guided by a process evaluation approach to assess the implementation fidelity of the WASHFIT intervention. The case study design allowed for an in-depth investigation of the intervention within a real-world, bounded context defined by time, geographic location, and programmatic scope. A case study design facilitates exploring a program or process in its natural setting through multiple data sources gathered over a sustained period [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The case study approach enabled a holistic understanding of the implementation of the WASH FIT, factors that influenced fidelity (barriers and facilitators), and lessons learned during the process. The RE-AIM framework explored reach, adoption, fidelity of implementation, perceived effectiveness, and early signs of sustainability.\u003c/p\u003e\n\u003ch3\u003eSample size and sampling procedures\u003c/h3\u003e\n\u003cp\u003eThe study employed a combination of snowball and purposive sampling techniques to select participants from the eight healthcare facilities that implemented the WASHFIT intervention. First, purposive sampling was used to recruit individuals directly involved in implementing the WASHFIT intervention. Interviewing those directly engaged in the implementation, such as healthcare providers, district health officials, and project team members, allowed the research team to gather detailed and contextually relevant data from individuals with firsthand experience, thereby enhancing the credibility and rigour of the findings [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Second, we asked the initial study participants (purposive sample) to identify other potential stakeholders who implemented the WASHFIT intervention within the eight healthcare facilities [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Using snowball sampling enabled researchers to target individuals knowledgeable about the implementation of the WASHFIT intervention and their experiences during its application [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Snowball sampling helped the research team identify individuals who did not have formal documentation of their roles but had contributed meaningfully to the implementation process. This approach ensured the inclusive representation of actors across different levels of the intervention, which strengthened the completeness and reliability of the data collected [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Within the participating healthcare facilities, respondents were selected from the WASHFIT team meeting recording sheet and contacted. This strategy allowed the research team to verify participants\u0026rsquo; involvement and ensure that only those who had actively contributed to WASHFIT activities were included. The study involved 20 key informant interviews (KIIs) moderated using an interview guide (Supplementary file 1) and six focus group discussions (FGDs) facilitated with the aid of a focus group interview guide (Supplementary file 2). We used the level of theoretical saturation, i. e., a stage where we did not yield new insights on the barriers and facilitators of implementing the WASHFIT intervention, to determine the actual number of KIIs and FGDs [\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eData collection methods and tools\u003c/h3\u003e\n\u003cp\u003eThe data collection team conducted face-to-face KIIs with IPC focal persons, healthcare facility in-charges, implementing partners\u0026rsquo; representatives, and district local government staff from Amuru and Nwoya using an open-ended guide, specifically developed for this study. We selected key informants based on their direct involvement in implementing the WASHFIT in the study healthcare facilities. By engaging with these participants, the research team gained insights into the challenges faced, lessons learned, and the implementation fidelity of the intervention. Aside from the KIIs, we conducted six focus group discussions (FGDs), each with 6\u0026ndash;8 participants. These FGDs were held within the premises of selected healthcare facilities, including HC IIIs and one hospital. We conducted more FGDs in Nwoya than in Amuru since the latter had fewer benefiting HCFs. The FGD participants included members of the IPC committees and community health workers/VHTs who were directly involved in implementing the intervention. The FGDs were homogeneous, comprising participants directly involved from the training phase to the implementation of the WASHFIT intervention. This homogeneity was intended to foster open and meaningful dialogue, as participants shared common experiences and challenges related to the intervention [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Bringing together participants with shared experiences in implementing WASH-FIT fostered a safe and supportive environment for discussion [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Each FGD was conducted by a moderator and note-taker, taking about 1.0-1.5 hours. The note-taker captured detailed verbatim notes, including key contextual elements such as tone shifts, humour, emphasis, and repeated themes or questions. The data collection team digitally audio-recorded the discussions to capture the participants\u0026rsquo; spoken words verbatim.\u003c/p\u003e\n\u003ch3\u003eVariables\u003c/h3\u003e\n\u003cp\u003eImplementation fidelity was measured using the constructs of the RE-AIM framework (Reach, Effectiveness, Adoption, and Implementation) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The reach domain evaluated the extent to which the implementers reached the target population, while effectiveness focused on how the intervention achieved the desired outcomes. We assessed the adoption construct by exploring participant responsiveness, i.e., the degree to which participants were involved in intervention tasks [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and implementation fidelity based on 1) program differentiation, i.e., the presence of distinguishing features of a particular program, 2) quality of delivery (the degree to which the intervention contributed to the desired goals and objectives), 3) exposure (the sessions delivered or the targeted trained participants), and 4) adherence (the extent to which practitioners complied with the intervention protocol guidelines) to the WASHFIT guidelines. During the assessment, we asked about the barriers and facilitators encountered and the key lessons learned from the implementation process. The WASHFIT process included assembling and training the WASHFIT team and holding regular meetings, conducting healthcare facility assessments, undertaking hazard and risk assessments, developing and implementing an improvement plan, and continuously evaluating and improving the implementation plans.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe RE-AIM indicators by dimension\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDid the intervention reach the target population?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffectiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDid the intervention affect the status quo?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdoption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo what extent did those targeted to deliver the intervention participate?\u003c/p\u003e \u003cp\u003eHow did they develop organisational support to deliver the intervention?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo what extent did the implementers undertake the intervention according to the protocol?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaintenance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat have the HCFs done to maintain the implemented WASHFIT intervention activities?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData management and analysis\u003c/h2\u003e \u003cp\u003eThree qualitative experts transcribed all the audio recordings verbatim [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Transcription involved listening multiple times carefully to create a detailed transcript that captured essential elements such as emphasis, tone of voice, timing, and pauses, which were crucial for accurately interpreting the data [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The data analysis team compared the transcripts with the field notes recorded by the note-takers to ensure consistency and accuracy. Interviews carried out in the local language were transcribed and translated into English. For translations, the study investigator developed a list of terms and phrases in both languages to guide the translator, including how to interpret the data from the original language into English. When a word lacked an exact translation, the translator maintained the original word in quotes and provided the closest description in brackets or as a footnote. This approach facilitated discussions with the study investigator about the specific words' meanings to ensure everyone understood them in the study context [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The data management team undertook an interviewee transcript review (ITR) to improve the transcripts, including adding specific details, correcting/changing transcript details, and adding new information to the study participants [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. ITR is a form of respondent validation where researchers share interview transcripts with study participants to review and verify the accuracy of the information [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eData analysis combined deductive and inductive approaches. Deductively, the RE-AIM framework guided initial coding and thematic organisation, focusing on dimensions such as reach, implementation fidelity, and sustainability. Inductively, the research team used themes that emerged beyond the framework to capture context-specific insights grounded in participants\u0026rsquo; experiences. Combining the inductive and deductive dual approaches enabled a structured yet flexible understanding of the implementation process [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. The data analysis team read the transcripts multiple times to develop codes and codebook definitions based on the WASHFIT process and the RE-AIM framework. The data analysis team reviewed the codebook and refined it through discussions between the principal investigator and the supervisory team to agree on definitions and categorisations. Afterwards, the data analysis team developed a coding tree to guide analysis with the aid of Atlas-ti version 24. A coding tree is a hierarchical structure used in qualitative data analysis to organise and manage the codes developed during the coding process [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Developing a coding tree allowed the principal investigator to systematically organise and consistently apply codes across the data [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The parent codes presented broad, overarching themes or categories, while the child codes captured sub-themes within those broader categories [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. We established a 90% agreement between two coders (intercoder reliability) to ensure transparency and validity in the coding process. Upon the analysis, the team agreed on the dominant themes, sub-themes, and key codes within the WASHFIT process and RE-AIM framework.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQuality assurance and quality control\u003c/h3\u003e\n\u003cp\u003eWe used research assistants with a health or social sciences background to ensure quality data collection. Research assistants participated in a two-day training to familiarise themselves with the study protocol's data collection tools, study objectives, and ethical considerations. As part of the training, the study team piloted the data collection tools from a health centre III in Kampala that had implemented the WASHFIT methodology. Before collecting data from the main study population, the pilot test allowed researchers to identify and resolve any issues or limitations in the tools, such as unclear questions and potential response biases [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. All interviews and discussions were audio-recorded with consent and supplemented with detailed field notes to capture non-verbal cues and contextual information. The data collection team labelled audio files with the interview type, the date, the healthcare facility, the participant\u0026rsquo;s ID, and the initials of the moderator (e.g., FGD1/11/2024_HCF/001/DN or KII1/11/2024_HCF/001/DN) for easy identification and retrieval. During fieldwork, the research team conducted daily debriefings to discuss interview progress, emerging themes, and any challenges encountered. These sessions allowed real-time adjustments and reinforced adherence to the data collection protocol.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic characteristics of the key informants\u003c/h2\u003e \u003cp\u003eA total of 20 key informants were interviewed. Of these, close to a quarter 20.0% (4/20) were attached to a general hospital, 70.0% (14/20) came from Amuru district, 40.0% (8/20) worked in HC III, 30.0% (6/20) were females, 55.0% (11/20) were above 40 years and 70.0% (14/20) had worked in the healthcare facility between 4 to 10 years (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of the respondents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttribute\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (N\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLevel of healthcare facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHC III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHC II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOwnership of the HCF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e90.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eHighest level of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMasters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge-category (Years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePeriod worked at this healthcare facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePeriod worked in the WASH/IPC sector\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic characteristics of focus group discussants\u003c/h2\u003e \u003cp\u003eThirty-six respondents participated in the FGDs. Of these, about 72.2% (26/36) were females, 36.1% (13/36) had attained a secondary level of education, 25.0% (9/36) were Catholics, 47.2% (17/36) were married, and 58.3% (21/36) were above 40 years (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of focus group discussants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttribute\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (N\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e72.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEducation Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnglican\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCatholic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePentecost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSDA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeparated/divorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge category (Years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDuration worked in the WASH activities in years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e83.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eImplementation fidelity of the WASHFIT intervention\u003c/h2\u003e \u003cp\u003eThe intervention involved structured risk assessment and rating, broader stakeholder participation, and an emphasis on governance, operation, and maintenance of WASH/IPC facilities, distinguishing it from other WASH/IPC-related interventions (\u003cb\u003eintervention differentiation\u003c/b\u003e). The implementers showcased the \u003cb\u003equality of the intervention's delivery\u003c/b\u003e by using competent facilitators and practical methodologies, including hand hygiene and environmental cleaning simulations. The participants engaged with the intervention \u003cb\u003e(participant responsiveness)\u003c/b\u003e using the acquired knowledge to implement WASH/IPC interventions. The participants also received weekly CMEs \u003cb\u003e(exposure)\u003c/b\u003e to reinforce the knowledge they acquired through the training, and \u003cb\u003eadhered\u003c/b\u003e to the intervention protocol by conducting regular meetings about the progress of the WASH/IPC interventions. The intervention improved environmental hygiene and budgetary allocations for WASH/IPC activities \u003cb\u003e(effectiveness)\u003c/b\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eImplementation fidelity of a WASHFIT intervention in Northern Uganda\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuiding question\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrganising themes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBasic themes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWas the program distinguishable from other interventions?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIntervention differentiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStructured risk assessment and rating\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStakeholder participation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmphasis on governance, operation, and maintenance of WASH/IPC facilities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow well was it delivered?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuality of delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTrainers were knowledgeable and used practical methodologies.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow well did the participants react to or engage with the intervention?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipant responsiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUse of acquired knowledge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow much of the program did participants receive?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExposure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention delivered through weekly CMEs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWas the intervention delivered as planned (content, frequency, duration)?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConducting meetings about the progress of the WASH/IPC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid the intervention meet the set objectives?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEffectiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImproved environmental hygiene and budgetary allocations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eProgram differentiation\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eStructured risk assessment and rating\u003c/strong\u003e \u003cp\u003eUnlike previous IPC interventions and hygiene promotion approaches, the WASHFIT process incorporated structured risk assessment and rating. The series of indicators in the WASHFIT assessment tool made it easy for the healthcare facility staff to evaluate the risk of infections and thus take appropriate measures. Additionally, none of the healthcare providers had received an IPC training that involves risk assessments. The WASHFIT included sanitary inspections, setting it apart from the other interventions.\u003c/p\u003e \u003c/p\u003e\u003cdiv\u003e\n \u003cp\u003e\u0026quot;In our previous IPC interventions, we haven\u0026apos;t been identifying and rating risks, so it has done a great job in risk assessment and identifying risks. For example, in one of the facilities in Amuru, if you say that a healthcare facility has a high risk of infection or hospital-acquired infection, people will easily understand because there are a series of indicators showing that this facility has a high risk of infection. This made it stand out compared to other approaches to promoting hygiene in healthcare facilities.\u0026quot; KII with a district health team member, Amuru.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eStakeholder participation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe WASHFIT process was perceived as more practical than previous interventions. The WASHFIT process engaged stakeholders, including in-charges, IPC focal persons, departmental heads, healthcare workers, health assistants, and community health workers, to identify WASH/IPC gaps and define practical solutions. The intervention allowed the stakeholders to co-create solutions to improve the WASH/IPC situation at the HCFs.\u003c/p\u003e\n\u003cdiv\u003e\n \u003cp\u003e\u0026quot;To me, WASHFIT was more practical than other similar programs. It involved many people, especially healthcare workers, who came to understand the WASHFIT components and objectives, identified problems related to WASH, and determined what they immediately needed to improve the situation. We had challenges with infection prevention and control in healthcare facilities in Amuru, and this project helped us in that area. The project worked hand in hand with different stakeholders, including healthcare workers, health assistants, and VHTs.\u0026quot; KII with an HCF In-charge, HC III.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eEmphasis on governance and operation and maintenance of WASH/IPC facilities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnlike other WASH/IPC interventions, the WASHFIT intervention emphasised governance, operation, and maintenance of water, sanitation, and hygiene facilities. The WASHFIT process led to the establishment of WASH/IPC committees and illuminated their importance in addressing healthcare facility WASH/IPC needs, including monitoring of WASH/IPC improvement plans.\u003c/p\u003e\n\u003cdiv\u003e\n \u003cp\u003e\u0026quot;You know, WASHFIT had some pillars, such as governance at the facility, water, sanitation, and hygiene. When you look at the components of governance and the guidance in the operation and maintenance of those facilities, they trained us that having functional committees would help address all the needs at the facility. For example, there was a water shortage at Hospital XX, and we had waterborne sanitation, which couldn\u0026apos;t function without water. After receiving the training, we resolved some key issues at the facility and elected water management committees to support improvements in water at both the facility and the community. In addition, the water committee monitored WASH/IPC areas in the facilities and found that everything was progressing according to plan because we created a monitoring plan. This wasn\u0026apos;t just at XXX (hospital); it was also implemented in other facilities. We at least informed them about what they were supposed to do regarding WASHFIT.\u0026rdquo; FGD with IPC committee members\u003c/p\u003e\n\u003c/div\u003e\n\u003ch4\u003e\u003cstrong\u003eQuality of delivery of the WASHFIT Intervention\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eUse of practical methodologies to enhance learning:\u003c/strong\u003e The intervention was delivered using practical methods, such as hand hygiene demonstrations, PowerPoint presentations, and training charts, while focusing on the WASHFIT core components. These tools enhanced understanding of the WASHFIT processes, aligning the delivery approach well with the intervention\u0026apos;s goals.\u003c/p\u003e\n\u003cp\u003e\u0026quot;As for the trainers, they taught well theoretically. They used PowerPoint presentations, but there were also many posters and practical sessions where we could physically handle items related to WASH/IPC, which helped us understand everything\u0026quot;. KII with a medical director of a hospital\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eParticipant responsiveness\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eUse of acquired knowledge:\u0026nbsp;\u003c/strong\u003eDuring the implementation of the intervention, healthcare facility staff, cleaners, VHTs, departmental heads, environmental health personnel, and local authorities, including the town clerk, assumed their assigned roles under the WASHFIT intervention as expected. Health assistants conducted facility assessments and communicated gaps to the in-charge, who responded by providing necessary resources such as chlorine. Community health workers promoted hand hygiene within facilities and communities, whilst IPC committees aligned the WASHFIT intervention with their ongoing activities, including health education. Furthermore, it became common for healthcare facilities to ensure the sustained availability of essential IPC materials. The involvement of the various stakeholders reflected the understanding gained from training that implementation should engage all relevant actors.To elaborate on the roles of the stakeholders in enhancing WASH/IPC, it was pointed out that;\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026quot;The health assistants were responsible for conducting all the facility assessments and informing the in-charge about the indicators that were poorly performing. It was the role of the in-charge to provide financial support; for instance, if the health inspector reported a lack of chlorine for treating water, it was the in-charge\u0026apos;s responsibility to ensure it was provided at the facility or included in the plan. The VHTs supported the community by promoting hand washing within the facility and in the community, which was also part of the assessment usually done under WASHFIT. The IPC committee participated actively because WASHFIT aligned with the activities they were already involved in\u0026quot; (IPC focal person Amuru).\u003c/p\u003e\n\u003cp\u003eConcerning adopting new practices, the healthcare facility in charge said:\u003c/p\u003e\n\u003cp\u003e\u0026quot;We adopted new practices into our daily work routine by ensuring that all necessary IPC materials and other required items were in place. Although some items were occasionally missing, the goal was to maintain at least a minimum level of IPC at our facilities. Health talks on WASH/IPC were also consistently conducted, particularly during our health education sessions\u0026quot;. KII with an HCF in charge\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eExposure to the intervention\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eWeekly CMEs:\u003c/strong\u003e The WASHFIT team was formed based on a specific cadre and prior training. The training was conducted over several days through two daily sessions, covering WASHFIT orientation, IPC, hand hygiene, and waste management. The practical sessions concentrated on sanitation inspections, hand hygiene audits, and waste segregation. Additionally, the team convened every six months to monitor implementation progress and take corrective action where necessary. This approach improved participants\u0026apos; exposure and ability to apply WASHFIT tools.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The selection of team members was based on the available staff within the facility, considering their cadre and how they had been trained. We assembled the WASHFIT team at the facility, and we were supposed to meet every six months to review our progress with the WASH/IPC activities within the facility. Participants received the full programme over several days, with two daily training sessions. The sessions covered key areas such as WASH-FIT orientation, infection prevention and control (IPC) measures, hand hygiene, and healthcare waste management. In addition, two practical sessions were held, focusing on facility-based assessments including sanitation facility inspections, hand hygiene audits, and waste segregation practices. This approach helped ensure participants gained knowledge and practised applying it in real-life settings\u0026rdquo;. IPC focal person.\u003c/p\u003e\n\u003cp\u003eParticipants received continuous exposure to the WASHFIT intervention through weekly facility-based CME sessions after the main training. These sessions involved reviewing the training content, identifying key learnings, and conducting brainstorming and demonstration exercises. This approach ensured that participants not only completed the core training but also engaged in regular reinforcement and hands-on practice of WASHFIT procedures.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We conducted a Continuous Medical Education (CME) session once a week on the WASHFIT procedures. We reviewed the implementation processes after the training and identified the key learnings. We then engaged in brainstorming sessions and demonstrations to practice and refine these procedures.\u0026rdquo; FGD with IPC committee members\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eAdherence\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eAs planned by the intervention team, the participants received training on WASH/IPC, including planning and budgeting for related activities, which they applied through weekly planning meetings lasting one to two hours. During these sessions, they addressed real IPC issues such as infrastructure repairs and improving waste management by acquiring waste bins for departments. This regular application of training content supported practical problem-solving and strengthened implementation.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAfter learning about budgeting and planning, we applied that knowledge in practice, particularly through our weekly planning meetings that lasted about one to two hours. In these meetings, we discussed actual IPC issues and explored ways to address problems, such as repairing or replacing damaged infrastructure. We also focused on acquiring waste bins for each department to improve waste management. This approach was very helpful in implementing practical solutions.\u0026rdquo; (In-charge, HC II).\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eEffectiveness\u0026nbsp;\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eImproved environmental hygiene and budgetary allocations:\u003c/strong\u003e The participants received continuous training and orientation to build their capacity to deliver the WASHFIT interventions within their healthcare facilities. Those who had received training on the earlier version of the WASHFIT process and tool were retrained to improve their capacity and familiarity with the revised (version 2.0) WASHFIT process and tools. Consequently, the intervention resulted in noticeable improvement in environmental hygiene within the HCFs but also influenced planning and budgetary allocation for WASH/IPC activities. Unlike before, HCFs started to allocate a fair share of resources to WASH/IPC activities, indicating successful integration into priorities.\u003c/p\u003e\n\u003cp\u003e\u0026quot;This is evident in the noticeable improvement in the cleanliness of the facility, which is now at a very high level. That\u0026apos;s one clear success of the project. Additionally, planning and budget allocation, WASH/IPC now receives a fair share of resources\u0026rdquo;. (IPC focal person).\u003c/p\u003e\n\u003cp\u003e\u0026quot;We had challenges with infection prevention and control in healthcare facilities in Amuru, and this project helped us in that area.\u0026quot; KII with an HCF In-charge, HC III.\u003c/p\u003e\n\u003cp\u003eThe effectiveness of the WASHFIT process largely depended on the team\u0026rsquo;s capacity to employ it. The previously trained teams and those involved in similar assessments were likely to effectively undertake the WASHFIT processes and implement other WASH/IPC interventions.\u003c/p\u003e\n\u003cp\u003e\u0026quot;This depends on the capacity of the person. For instance, my team and I in Amuru had already been exposed to it, so it was more like a refresher training. We were familiar with WASHFIT, having participated in several trainings and assessments. There was a WASH project XXX in Acholi, and I was the focal person supporting WASHFIT implementation. Through that, I learned a lot, but they revised the version, and it was version two that I didn\u0026apos;t actively participate in. I received orientation through XXX, which improved our capacity and made us more familiar with WASHFIT. Regarding outcomes, people, especially healthcare workers and health assistants, learned the WASHFIT process.\u0026rdquo; (District health team member, Amuru district).\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eBarriers to the implementation of the WASHFIT intervention\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eA lack of customised assessment tools, a heavy workload, a negative attitude among staff, a shortage of human resources competent in using WASHFIT, inadequate inter-departmental collaboration, and insufficient technical support from implementing partners and district healthcare managers hindered healthcare staff from implementing the WASHFIT intervention.\u003c/p\u003e\n\u003ch4 id=\"_Toc178939938\"\u003e\u003cstrong\u003eLack of customised WASHFIT assessment tools\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eHCFs lacked customised WASHFIT assessment tools, which hindered the effective implementation of interventions, particularly healthcare facility assessments and sanitary inspections. The lack of customised assessment tools led to inconsistencies in the assessment process across HCFs. To address related challenges in the future, some participants recommended the provision of customised standard tools to enhance consistency in assessments across HCFs.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We don\u0026rsquo;t have localised assessment tools for conducting these regular or irregular evaluations. This lack of tools makes it difficult to carry out the assessments effectively. Our main challenge was the absence of a standard tool for conducting these assessments. As a result, how we conducted them may have differed from how it was done in other healthcare facilities. Having minimum standard tools designed to assist with these assessments would be beneficial. Although the level of risks and hazards varies from facility to facility, having standard tools could help ensure consistency and effectiveness in the assessment process.\u0026rdquo; FGD with IPC committee members\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eHeavy workload\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eA heavy workload and staff reluctance to take on responsibilities beyond their formal roles hindered the implementation of the WASHFIT intervention. Healthcare providers felt overwhelmed by tasks related to implementing the WASHFIT intervention. The unclear task boundaries compromised the participation of stakeholders, such as facility in-charges, despite their crucial role in driving the WASHFIT process.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;First of all, the health inspectors conducted the assessments late, and some of the key stakeholders, such as the health in-charges and other core team members at the facility, were not present to provide feedback on the WASH/IPC action points. When you try to guide or instruct a staff member, you might hear them express fatigue or frustration. Sometimes, they might say they are tired from performing tasks that fall outside their job description, especially when they are taking on additional roles that were not originally part of their responsibilities.\u0026rdquo; IPC focal person, HC III\u003c/p\u003e\n\u003cp\u003eA heavy workload, coupled with competing workload priorities, reduced the active participation of the teams in implementing WASHFIT interventions. Over time, the WASHFIT team became inactive, which made it difficult to follow up on the implemented WASHFIT activities.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The WASH/IPC team existed but became inactive due to a lack of supervision and monitoring of the intervention. Although we typically conduct integrated supervision in these healthcare facilities, sometimes the workload becomes overwhelming, leading to the neglect of certain areas, and eventually, the system breaks down. The participants included healthcare workers and the village health teams.\u0026rdquo; IPC focal person HC III\u003c/p\u003e\n\u003cp\u003eMany healthcare workers, especially those on the IPC committee, were often too busy to participate in some of the assessments. This led them to delegate the task to individuals who were not knowledgeable and struggled to understand how the assessment was being conducted, making implementation difficult in some facilities.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;There was a lack of collaboration between the different departments at the facilities. The assessment forms were sometimes given to individuals who were not knowledgeable and, as a result, did not provide the correct information needed for the assessment. For instance, on the day of the assessment, some or even all members of the IPC committee might have been occupied, and the person available to assist with tasks like moving around the facility or conducting a risk assessment of the water sources may not have had the necessary knowledge. Additionally, the language used for communication could sometimes be difficult for them to understand, and they may not have been familiar with the facility assessment process since they were assigned to different departments within the healthcare facilities. FGD, IPC, R2, IPC Committee.\u0026rdquo;\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003ePoor leadership and coordination\u0026nbsp;\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe lack of structured follow-up and coordination between district teams and implementing partners resulted in incomplete implementation and discontinuity of planned WASHFIT activities. Additionally, inadequate inter-departmental collaboration and the delegation of assessment tasks to untrained staff significantly compromised the effectiveness of WASH/IPC interventions. Healthcare facility staff reported a lack of sustained commitment from implementing partners, which hindered the consistent execution and monitoring of WASHFIT activities.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We had the knowledge and skills, but somehow we started certain initiatives and then left them unfinished. For example, when we attended the meeting with the implementing partner XXX, I included a plan in our district strategy to conduct continuous monitoring of the WASHFIT indicators within our facilities. However, when we spoke to the team from the implementing partner, they didn\u0026rsquo;t provide a specific date for us to meet and plan the continuous actions. As a result, we didn\u0026rsquo;t implement it effectively. It was done for a period, but the continuous evaluation of the plan was not carried out.\u0026rdquo; District health team member, Amuru district.\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cspan id=\"_Toc178939941\"\u003eFacilitators for the implementation of the WASHFIT intervention\u003c/span\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eHealthcare provider awareness of WASH as a challenge in healthcare settings, along with reporting and accountability expectations, facilitated the implementation of the WASHFIT intervention.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eAwareness of WASH as a challenge in healthcare settings\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eRecognition of visible WASH/IPC challenges, especially in high-volume facilities and in light of the COVID-19 experience, catalysed stakeholder engagement and improved healthcare workers\u0026rsquo; participation in the WASHFIT implementation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026ldquo;One significant contributing factor is the visible presence of the problem at the facility that needs attention. For instance, we have a busy facility with hundreds of patients, and it\u0026rsquo;s clear that the facility needs proper hand hygiene practices for effective management. When we realised this, along with various stakeholders, and considering the recent experience with the COVID-19 pandemic, it became evident that something needed to be done. As a result, there has been a noticeable change in attitude among healthcare workers in IPC and WASH activities.\u0026rdquo; In charge, HC III\u003c/p\u003e\n\u003cp\u003eThe WASHFIT intervention helped healthcare workers identify gaps at their facilities and develop plans to address them. This approach improved operations, particularly in waste management. The identification of WASH/IPC gaps through assessment enabled targeted planning and resource mobilisation, strengthening overall operational improvements within the facility.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Identifying these gaps helped the department develop plans to address them, ensuring that the necessary resources and measures were in place to improve their operations. This approach has led to significant improvements in waste management within the facility.\u0026rdquo; FGD, R6, IPC Committee\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare providers demonstrated a strong willingness to engage with the WASHFIT process, motivated by the desire to ensure the safety of both patients and staff. Their positive attitude toward the intervention facilitated its integration into existing practices, such as Continuing Medical Education (CME) sessions, thereby further strengthening implementation.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Willingness was a major factor, along with considering the safety of healthcare workers and patients in the facility, knowing that it is a place for service delivery. Therefore, we needed to be keen and follow instructions in the healthcare setting. This mindset, combined with the knowledge gained from the WASHFIT training and continuous CMEs, which we attended once or twice a week, has enabled the successful implementation of the WASHFIT intervention.\u0026rdquo; FGD, R2, IPC Committee\u003c/p\u003e\n\u003cp\u003eCommunity support, particularly in supplementing essential WASH supplies like soap, played a key and vital role in contributing to the intervention\u0026apos;s objective. This was especially true during periods of high patient load and resource constraints. The community\u0026apos;s ability to provide these crucial resources to the healthcare facilities was invaluable, helping to facilitate the implementation of WASHFIT components.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eTo some extent, the community provided resources when there were insufficient supplies due to the increased number of patients. For instance, handwashing with soap is required at the facility, but there are times when the number of community members is so large that the soap runs out in just one day, and sometimes, it gets stolen. Additionally, the rooms we work in can become dirty quickly if there are many patients, requiring frequent cleaning, which becomes a challenge. As a result, community members often have to step in and provide soap.\u0026rdquo; In-charge, In-charge HC III.\u0026rdquo;\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eReporting and accountability expectations\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eRoutine reporting and accountability mechanisms encouraged facilities to consistently plan, budget for, and monitor progress on WASHFIT implementation. The need to report on the status and progress of IPC, along with being held accountable for all funds spent during the implementation of the WASHFIT intervention, facilitated its execution. Additionally, the reporting requirement to provide updates on IPC status and progress further supported the implementation of the WASHFIT intervention.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The need to report on IPC is important. For instance, the status of IPC, regarding the current status, and is there any progress compared to before? Additionally, since they have planned for it, they must follow through because, in the end, they are held accountable for the money budgeted under the WASHFIT components, so they are compelled to budget and plan for it. Another factor is that it\u0026rsquo;s a reporting requirement. During the WASH/IPC meetings, they must report on how frequently they met and the progress of the WASH/IPC components.\u0026rdquo; In charge, hospital.\u0026rdquo;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eUsing the RE-AIM model, this qualitative study examined implementation fidelity and identified barriers and facilitators to the implementation of a WASHFIT intervention in Northern Uganda. The study also evaluated the reach and effectiveness of the WASHFIT intervention. The barriers included a lack of customised assessment tools, a heavy workload, a negative attitude among staff, a shortage of human resources competent in using WASHFIT, inadequate inter-departmental collaboration, and insufficient technical support from implementing partners and district healthcare managers. The facilitators of implementing the WASHFIT intervention included healthcare providers' awareness of WASH as a challenge in healthcare settings, as well as expectations for reporting and accountability.\u003c/p\u003e \u003cp\u003eThe WASHFIT intervention distinguished itself from other similar WASH/IPC programs by incorporating risk assessments at the healthcare facility. Risk assessments help identify the seriousness of WASH/IPC problems that could cause harm to facility users, such as patients, pregnant mothers, newborns, caregivers, the community, and the environment [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. By conducting these assessments, facilities could estimate the likelihood of these problems occurring and pinpoint specific WASH/IPC areas for improvement, leading to incremental enhancements in their practices [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. This proactive approach has a positive influence on IPC-related outcomes, including reductions in healthcare-associated infections, antimicrobial resistance, and disease outbreaks [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Conducting risk assessments in healthcare facilities (HCFs) has been highlighted in studies examining occupational risks to healthcare workers and the benefits and risks of routine child immunisation during the COVID-19 pandemic [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe intervention emphasised the role of governance and exemplary leadership in fostering WASH/IPC improvements. Governance and good leadership are crucial in developing various teams, such as the WASHFIT team, which requires a leader who oversees all members by assigning them roles and responsibilities, enabling them to work together to achieve the intervention's objectives. Additionally, the overall leadership establishes rules and regulations that align with the goals of the implemented project, making it easier to manage, track progress, and identify any gaps or bottlenecks that could limit the achievement of the intended project objectives [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. The governance aspect might also be practical in decision-making to improve WASH/IPC activities [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. For example, the introduction of reporting mechanisms for each team leader, such as those of the IPC committee, the VHTs, the HUMC, and the water user committee at the community level, helps ensure evidence-based resource allocation based on transparency, proper record-keeping, and effective communication. A Ul Musawir, CEM Serra, O Zwikael and I Ali [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] documented the importance of good governance in achieving project success [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study highlights the limited resources and understaffing of healthcare workers in the selected healthcare facilities (HCFs). The limited resources might be due to insufficient funds to procure WASH/IPC equipment, as most healthcare facilities rely on PHC funds, which may not be enough to meet the WASH/IPC needs at the facilities [\u003cspan additionalcitationids=\"CR56\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Some rural healthcare facilities rely on the hope that implementing partners will support their WASH/IPC activities, which slows implementation because the facilities lack the resources to apply the knowledge they have gained from the training. Furthermore, most rural healthcare facilities in Uganda are understaffed [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]; for example, HC IIs should be led by an enrolled nurse working with a midwife and two nursing assistants. [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e], and the WASHFIT committee needs around six cadres to perform the WASHFIT process. However, upon examining the staffing at these facilities, the situation remains alarming. This could likely be due to delayed payment from the government, delays in deploying healthcare workers to areas where they are most needed, and a lack of tools and support to do their jobs effectively. This understaffing may result in heavy workloads for the existing staff, affecting the performance of the healthcare facility [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e], which in turn impacts the overall service delivery objective and WASH/IPC [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Understaffing and limited resources in the healthcare system in Uganda have been documented and identified as significant factors affecting the overall performance of healthcare facilities [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, upon examining the staffing at these facilities, the situation remains alarming. This is likely due to delayed payments from the government, delays in deploying healthcare workers to areas where they are most needed, and many healthcare workers lacking the necessary tools and support to perform their jobs effectively [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. This understaffing may result in heavy workloads for the existing staff, affecting healthcare facility performance and ultimately impacting overall service delivery objectives, including WASH/IPC. Understaffing and limited resources in the healthcare system in Uganda have been documented [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e] as significant factors affecting the overall performance of healthcare facilities.\u003c/p\u003e \u003cp\u003eOur study highlights the absence of standardised assessment tools suitable for local healthcare facility settings. The lack of these standardised tools could potentially affect the overall objectives of the WASHFIT intervention [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. This is because, during the assessment at an HC III, it is essential to recognise that some indicators may not apply to this facility level and are more relevant to an HC IV or a hospital. Similarly, when assessing an HC II, specific indicators pertinent to HC IIIs may not be suitable for HC IIs. Therefore, to enhance the objectives of the WASHFIT intervention, there is a need for different implementing partners and the Ministry of Health to tailor the assessment tools and criteria to the specific level of each HCF to ensure accurate, consistent, and relevant evaluations.\u003c/p\u003e \u003cp\u003eThis study revealed that self-motivation and the desire to experiment with the WASHFIT tool were key factors that facilitated its implementation. This may be due to the knowledge gained from training on the WASHFIT tool and becoming familiar with it at their facility to understand its effectiveness in improving WASH/IPC conditions [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Additionally, this could be attributed to the need to test all the indicators in the WASHFIT tool to determine which ones work and which ones do not apply to their facility [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Self-motivation and the desire to experiment with the WASHFIT tool have been documented to improve WASH in government health facilities in Tamil Nadu [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. This study highlights that the need to report on the status and progress of IPC facilitated the implementation of WASH/IPC. This may be probably to identify WASH/IPC areas that need to be prioritised to improve service delivery at healthcare facilities [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. It might also be to assess the changes that have occurred over time and determine where support is needed by developing plans to enhance WASH/IPC in the different healthcare facilities and communities [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. The need to report on the status and progress of IPC has been documented in Tanzania [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study highlighted that raising awareness about the WASHFIT intervention was a key lesson learned from its implementation. Being aware of the importance of the WASHFIT intervention could improve understanding of its benefits and the positive impact it could have on WASH/IPC in communities and HCFs [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. This awareness could probably help people decide whether they are supportive or hesitant about participating in the implementation. Additionally, if people are informed, they gain knowledge, and with knowledge comes the interest to understand what needs to be done and the direction to take to make improvements and achieve success during the intervention's implementation [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Awareness raising has been documented to improve behavioural change in WASH/IPC activities [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study reveals that stakeholder involvement, planning, and budgeting were important lessons learned during the implementation of the WASHFIT intervention. Involving stakeholders could increase ownership of the intervention, making it easier to implement. Additionally, stakeholders could help ensure that the budget reflects the needs of both the healthcare facilities and the communities, increasing the intervention's transparency and effectiveness. Furthermore, involving stakeholders in planning could help tailor strategies to effectively address specific challenges and drive improvement in the intervention's implementation. Stakeholder involvement, planning and budgeting have been documented in improving WASH/IPC interventions [\u003cspan additionalcitationids=\"CR74 CR75\" citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eAlthough this may have been one of the few studies to examine the implementation fidelity of WASHFIT globally so far, it was prone to recall and social desirability biases. Participants may have provided responses that they believed were socially acceptable or desirable rather than reflecting their true thoughts, attitudes, or behaviours. Recall bias could have arisen from the implementation of various interventions after WASHFIT, making it challenging for participants to recall specific details accurately amidst other interventions, potentially affecting their responses. Recall and social desirability bias were managed through thorough training of research assistants in probing techniques and the use of life events to stimulate recall.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eUsing the RE-AIM model, this study assessed the fidelity and effectiveness of the WASHFIT intervention in healthcare facilities. The intervention was delivered by knowledgeable trainers and distinguished itself from others by incorporating a structured risk assessment and rating, stakeholder participation, and emphasis on governance, operation, and maintenance of WASH/IPC facilities. Through weekly CMEs and regular status meetings, the participants acquired knowledge which they used to implement WASH/IPC interventions. The barriers to implementing the WASHFIT intervention included a lack of customised assessment tools, a heavy workload, a negative attitude among staff, a shortage of human resources competent in using WASHFIT, inadequate inter-departmental collaboration, and insufficient technical support from implementing partners and district healthcare managers, while the facilitators were healthcare provider awareness of WASH as a challenge in healthcare settings, and expectations related to reporting and accountability. Based on these findings, addressing challenges with the localization of the WASHFIT, managing the healthcare provider workload and defining task boundaries, and addressing governance, are likely to stimulate the implementation of the WASHFIT intervention.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eDLGS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eDistrict Local Government Staff\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eDHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eDistrict Health Officers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eHBV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eHepatitis B virus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eHCAIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eHealthcare-associated infections\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eHCFs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eHealthcare facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eHCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eHealthcare Providers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eHCWM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eHealthcare Waste Management\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eIPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eInfection Prevention and Control\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eIP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eImplementing partner\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eIPCAF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eInfection Prevention and Control Assessment Framework\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eJMP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eJoint Monitoring Programme\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eMoH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eMinistry of Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eMOH-EHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eMinistry of Health Environmental Health Department\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eSDGs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eSustainable Development Goals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eWASH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eWater Sanitation and Hygiene\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eWHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2222%;\"\u003e\n \u003cp\u003eWASHFIT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7778%;\"\u003e\n \u003cp\u003eWater and sanitation for health facility improvement tool\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical approval\u003c/p\u003e\n\u003cp\u003eThis study was conducted in compliance with the\u0026nbsp;Declaration of Helsinki. Ethical approval was obtained from the Makerere University School of Public Health Higher Degrees and Research Ethics Committee (MakSPH HDREC) (Protocol Number-473). Administrative clearance for the study was sought from the Chief Administrative Officers (CAOs) and the District Health Officers (DHOs) in the Amuru and Nwoya districts. All interactions with participants adhered to the principles of respect, beneficence, justice, confidentiality, and obtaining informed consent.\u003c/p\u003e\n\u003cp\u003eConsent to publish\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe transcripts analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Reckitt Global Hygiene Institute (RGHI). The study protocol was independently peer-reviewed by the funding body, however, any opinions, conclusions, or recommendations expressed in this article are those of the authors alone and do not necessarily reflect the views of RGHI.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eRKM obtained the funding for this study. DN, MA, TS and JBI conceptualised the study, participated in data collection and analysis and drafted the manuscript. BNT, WJM, AN, AT, JG, FN, and STW participated in the analysis and drafting of the manuscript. All authors read and approved this manuscript before submission to this journal.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgement\u003c/p\u003e\n\u003cp\u003eWe want to thank the administrations of the Amuru and Nwoya District Local Governments for granting us clearance to undertake this study. We remain indebted to the administration of the healthcare facilities that implemented the WASHFIT, allowing their facilities to participate in the study, and to the healthcare providers who responded to the study tools. Finally, we would like to thank our diligent team of research assistants (Naamala Mirandah, Kabarungi Evelyn Sanyu, and Bwire Geoffrey) and coordinators who made this study a success.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u003cstrong\u003eProgress on WASH in health care facilities 2000\u0026ndash;2021: special focus on WASH and infection prevention and control (IPC) \u003c/strong\u003e[https://washdata.org/reports/jmp-2022-wash-hcf]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eProgress on WASH in health care facilities 2000-2021: Special focus on WASH and infection prevention and control (IPC) \u003c/strong\u003e[https://data.unicef.org/resources/jmp-wash-in-health-care-facilities-2022/]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eImproving the Quality of Health Care Services by Strengthening IPC at Centers of Excellence: Technical Report \u003c/strong\u003e[https://pdf.usaid.gov/pdf_docs/PA00ZZJH.pdf]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eHalf of health care facilities globally lack basic hygiene services \u0026ndash; WHO, UNICEF \u003c/strong\u003e[https://www.who.int/news/item/30-08-2022-half-of-health-care-facilities-globally-lack-basic-hygiene-services---who--unicef]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eProgress on WASH in health care facilities 2000\u0026ndash;2021 \u003c/strong\u003e[file:///C:/Users/DELL/Downloads/9789240058699-eng.pdf]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eMore schools and health centres supported with WASH services in northern Uganda \u003c/strong\u003e[https://www.unicef.org/uganda/stories/more-schools-and-health-centres-supported-wash-services-northern-uganda]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eWASH in health care facilities \u003c/strong\u003e[https://data.unicef.org/topic/water-and-sanitation/wash-in-health-care-facilities/]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eWASH in health care facilities \u003c/strong\u003e[https://www.who.int/teams/environment-climate-change-and-health/water-sanitation-and-health-(wash)/health-care-facilities/wash-in-health-care-facilities]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eNational Standards for WASH in Health Care Facilities \u003c/strong\u003e[https://www.unicef.org/sop/reports/national-standards-wash-health-care-facilities]\u003c/li\u003e\n\u003cli\u003eDitai J, Mudoola M, Gladstone M, Abeso J, Dusabe-Richards J, Adengo M, Olupot-Olupot P, Carrol ED, Storr J, Medina-Lara A\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003ePreventing neonatal sepsis in rural Uganda: a cross-over study comparing the tolerance and acceptability of three alcohol-based hand rub formulations\u003c/strong\u003e. \u003cem\u003eBMC Public Health \u003c/em\u003e2018, \u003cstrong\u003e18\u003c/strong\u003e(1):1279.\u003c/li\u003e\n\u003cli\u003eKisaka YN: \u003cstrong\u003eFactors affecting compliance to infection prevention and control measures among frontline health workers: a case study of the Kitale County Referral Hospital\u003c/strong\u003e. Strathmore University; 2021.\u003c/li\u003e\n\u003cli\u003eSahiledengle B, Tekalegn Y, Woldeyohannes D: \u003cstrong\u003eThe critical role of infection prevention overlooked in Ethiopia, only one-half of health-care workers had safe practice: A systematic review and meta-analysis\u003c/strong\u003e. \u003cem\u003ePloS one \u003c/em\u003e2021, \u003cstrong\u003e16\u003c/strong\u003e(1):e0245469.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eBlueprint for Acceleration: Sustainable Development Goal 6 Synthesis Report on Water and Sanitation 2023 \u003c/strong\u003e[https://www.unwater.org/publications/sdg-6-synthesis-report-2023]\u003c/li\u003e\n\u003cli\u003eWatson J, D\u0026apos;Mello-Guyett L, Flynn E, Falconer J, Esteves-Mills J, Prual A, Hunter P, Allegranzi B, Montgomery M, Cumming O: \u003cstrong\u003eInterventions to improve water supply and quality, sanitation and handwashing facilities in healthcare facilities, and their effect on healthcare-associated infections in low-income and middle-income countries: a systematic review and supplementary scoping review\u003c/strong\u003e. \u003cem\u003eBMJ Glob Health \u003c/em\u003e2019, \u003cstrong\u003e4\u003c/strong\u003e(4):e001632.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eNATIONAL GUIDELINES FOR WASH IN HEALTH CARE FACILITIES \u003c/strong\u003e[https://www.washinhcf.org/wp-content/uploads/2022/09/WASH-Guidelines-2022-Final-with-foreword.pdf]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eUganda National Infection Prevention And Control Guidelines \u003c/strong\u003e[http://library.health.go.ug/sites\n/default/files/resources/Uganda%20National\n%20Infection%20Prevention%20\nand%20Control%20Guidelines%20Dec%202013.pdf]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eWASH in healthcare facilities \u003c/strong\u003e[https://www.washinhcf.org/country/uganda/#/]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eThe Water and Sanitation for Health Facility Improvement Tool (WASH FIT) \u003c/strong\u003e[https://www.washinhcf.org/wp-content/uploads/2021/07/What-is-WASH-FIT.pdf]\u003c/li\u003e\n\u003cli\u003eChen H-C, Tseng T-P, Cheng K, Sriarkarin S, Xu W, Ferdin AE, Nguyen VV, Zong C, Lee C-H: \u003cstrong\u003eConducting an evaluation framework of importance-performance analysis for sustainable forest management in a rural area\u003c/strong\u003e. \u003cem\u003eForests \u003c/em\u003e2021, \u003cstrong\u003e12\u003c/strong\u003e(10):1357.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eWASH IN HEALTH CARE FACILITIES \u003c/strong\u003e[https://www.unicef.org/esa/media/4826/file/UNICEF-WASH-in-Health-Care-Facilities-2019.pdf]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eA field guide to improving water, sanitation, and hygiene in health care facilities in lowand middle-income countries as part of broader quality of care improvements \u003c/strong\u003e[https://pdf.usaid.gov/pdf_docs/PA00TWRS.pdf]\u003c/li\u003e\n\u003cli\u003eLineberger H, Cronk R, Kpodzro S, Salzberg A, Anderson DM: \u003cstrong\u003eDoes WASH FIT improve water, sanitation, and hygiene and related health impacts in healthcare facilities? A systematic review\u003c/strong\u003e. \u003cem\u003emedRxiv \u003c/em\u003e2024:2024.2004. 2005.24305396.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eWater Safety Portal \u003c/strong\u003e[https://wsportal.org/]\u003c/li\u003e\n\u003cli\u003eMacura B, Del Duca L, Soto A, Carrard N, Gosling L, Hannes K, Thomas J, Sara L, Sommer M, Waddington HS\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003ePROTOCOL: What is the impact of complex WASH interventions on gender and social equality outcomes in low- and middle-income countries? A mixed-method systematic review protocol\u003c/strong\u003e. \u003cem\u003eCampbell systematic reviews \u003c/em\u003e2021, \u003cstrong\u003e17\u003c/strong\u003e(2):e1164.\u003c/li\u003e\n\u003cli\u003eGlasgow RE, Harden SM, Gaglio B, Rabin B, Smith ML, Porter GC, Ory MG, Estabrooks PA: \u003cstrong\u003eRE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review\u003c/strong\u003e. \u003cem\u003eFrontiers in public health \u003c/em\u003e2019, \u003cstrong\u003e7\u003c/strong\u003e:64.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eDescription of the RE-AIM framework \u003c/strong\u003e[https://re-aim.org/learn/what-is-re-aim/#:~:text=The%20overall%20goal%20of%20the,and%20implementation%20of%\n20effective%2C%20generalizable%2C]\u003c/li\u003e\n\u003cli\u003eBishop DC, Pankratz MM, Hansen WB, Albritton J, Albritton L, Strack J: \u003cstrong\u003eMeasuring Fidelity and Adaptation: Reliability of a Instrument for School-Based Prevention Programs\u003c/strong\u003e. \u003cem\u003eEvaluation \u0026amp; the health professions \u003c/em\u003e2014, \u003cstrong\u003e37\u003c/strong\u003e(2):231-257.\u003c/li\u003e\n\u003cli\u003ePettigrew J, Graham JW, Miller-Day M, Hecht ML, Krieger JL, Shin YJ: \u003cstrong\u003eAdherence and delivery: implementation quality and program outcomes for the seventh-grade keepin\u0026apos; it REAL program\u003c/strong\u003e. \u003cem\u003ePrevention science : the official journal of the Society for Prevention Research \u003c/em\u003e2015, \u003cstrong\u003e16\u003c/strong\u003e(1):90-99.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eWASH FIT: A practical guide for improving quality of care through water, sanitation and hygiene in health care facilities \u003c/strong\u003e[https://iris.who.int/bitstream/handle/10665/353411/9789240043237-eng.pdf?sequence=1]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eWASH FIT: A practical guide for improving quality of care through water, sanitation and hygiene in health care facilities \u003c/strong\u003e[https://iris.who.int/bitstream/handle/10665/353411/9789240043237-eng.pdf?sequence=1]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eWASH FIT A practical guide for improving quality of care through \u003cstrong\u003ewater, sanitation and hygiene in health care facilities \u003c/strong\u003e[https://iris.who.int/bitstream/handle/10665/353411/9789240043237-eng.pdf?sequence=1]\u003c/strong\u003e\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eAmuru District Local government \u003c/strong\u003e[https://amuru.go.ug/lg/overview]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003ePopulation \u0026amp; Censuses \u003c/strong\u003e[https://www.ubos.org/explore-statistics/20/]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eNwoya district local governmnet \u003c/strong\u003e[https://nwoya.go.ug/lg/overview]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eNATIONAL HEALTH FACILITY MASTER LIST 2018 \u003c/strong\u003e[https://www.health.go.ug/wp-content/uploads/2020/02/National-Health-Facility-Master-List-2018.pdf]\u003c/li\u003e\n\u003cli\u003eCreswell JW, Hanson WE, Clark Plano VL, Morales A: \u003cstrong\u003eQualitative research designs: Selection and implementation\u003c/strong\u003e. \u003cem\u003eThe counseling psychologist \u003c/em\u003e2007, \u003cstrong\u003e35\u003c/strong\u003e(2):236-264.\u003c/li\u003e\n\u003cli\u003eO. Nyumba T, Wilson K, Derrick CJ, Mukherjee N: \u003cstrong\u003eThe use of focus group discussion methodology: Insights from two decades of application in conservation\u003c/strong\u003e. \u003cem\u003eMethods in Ecology and evolution \u003c/em\u003e2018, \u003cstrong\u003e9\u003c/strong\u003e(1):20-32.\u003c/li\u003e\n\u003cli\u003eGreenwood N, Ellmers T, Holley J: \u003cstrong\u003eThe influence of ethnic group composition on focus group discussions\u003c/strong\u003e. \u003cem\u003eBMC medical research methodology \u003c/em\u003e2014, \u003cstrong\u003e14\u003c/strong\u003e:1-13.\u003c/li\u003e\n\u003cli\u003eCreswell JW, Poth CN: \u003cstrong\u003eQualitative inquiry and research design: Choosing among five approaches\u003c/strong\u003e: Sage publications; 2016.\u003c/li\u003e\n\u003cli\u003eBailey J: \u003cstrong\u003eFirst steps in qualitative data analysis: transcribing\u003c/strong\u003e. \u003cem\u003eFamily practice \u003c/em\u003e2015, \u003cstrong\u003e25\u003c/strong\u003e(2):127-131.\u003c/li\u003e\n\u003cli\u003eBaker M: \u003cstrong\u003eIn other words: A coursebook on translation\u003c/strong\u003e: Routledge; 2018.\u003c/li\u003e\n\u003cli\u003eRowlands J: \u003cstrong\u003eInterviewee transcript review as a tool to improve data quality and participant confidence in sensitive research\u003c/strong\u003e. \u003cem\u003eInternational Journal of Qualitative Methods \u003c/em\u003e2021, \u003cstrong\u003e20\u003c/strong\u003e:16094069211066170.\u003c/li\u003e\n\u003cli\u003eRobinson OC: \u003cstrong\u003eConducting thematic analysis on brief texts: The structured tabular approach\u003c/strong\u003e. \u003cem\u003eQualitative Psychology \u003c/em\u003e2022, \u003cstrong\u003e9\u003c/strong\u003e(2):194.\u003c/li\u003e\n\u003cli\u003eNeuendorf KA: \u003cstrong\u003eContent analysis and thematic analysis\u003c/strong\u003e. In: \u003cem\u003eAdvanced research methods for applied psychology.\u003c/em\u003e edn.: Routledge; 2018: 211-223.\u003c/li\u003e\n\u003cli\u003eRoy P, Tremblay G, David A: \u003cstrong\u003eQuebec\u0026rsquo;s Model for Men\u0026rsquo;s Health: Connecting Community, Research, Practice, and Policies\u003c/strong\u003e. \u003cem\u003eInternational Journal of Men\u0026apos;s Social and Community Health \u003c/em\u003e2022, \u003cstrong\u003e5\u003c/strong\u003e(1):27-42.\u003c/li\u003e\n\u003cli\u003eBuschle C, Reiter H, Bethmann A: \u003cstrong\u003eThe qualitative pretest interview for questionnaire development: outline of programme and practice\u003c/strong\u003e. \u003cem\u003eQuality \u0026amp; Quantity \u003c/em\u003e2022, \u003cstrong\u003e56\u003c/strong\u003e(2):823-842.\u003c/li\u003e\n\u003cli\u003eEmbrey M, Parveen S, Hafner T, Islam H, Zahid A, Joshi MP: \u003cstrong\u003eIntegration of IPC/WASH critical conditions into quality of care and quality improvement tools and processes: Bangladesh case study\u003c/strong\u003e. \u003cem\u003eAntimicrobial Resistance \u0026amp; Infection Control \u003c/em\u003e2024, \u003cstrong\u003e13\u003c/strong\u003e(1):100.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eWater, Sanitation, and Hygiene (WASH) in Healthcare Facilities \u003c/strong\u003e[https://www.cdc.gov/global-water-sanitation-hygiene/prevention/index.html]\u003c/li\u003e\n\u003cli\u003eAli SM, Ali SM, Ali AO, Faulkner S, Gon G, Graham WJ, Haji HS, Kabole I, Kahabuka C, Morrison E: \u003cstrong\u003eIMPROVING MATERNAL AND NEWBORN HEALTH IN ZANZIBAR: A needs assessment of IPC and WASH\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eEyre DW, Lumley SF, O\u0026apos;Donnell D, Campbell M, Sims E, Lawson E, Warren F, James T, Cox S, Howarth A: \u003cstrong\u003eDifferential occupational risks to healthcare workers from SARS-CoV-2 observed during a prospective observational study\u003c/strong\u003e. \u003cem\u003eelife \u003c/em\u003e2020, \u003cstrong\u003e9\u003c/strong\u003e:e60675.\u003c/li\u003e\n\u003cli\u003eAbbas K, Procter SR, van Zandvoort K, Clark A, Funk S, Mengistu T, Hogan D, Dansereau E, Jit M, Flasche S: \u003cstrong\u003eRoutine childhood immunisation during the COVID-19 pandemic in Africa: a benefit\u0026ndash;risk analysis of health benefits versus excess risk of SARS-CoV-2 infection\u003c/strong\u003e. \u003cem\u003eThe Lancet Global Health \u003c/em\u003e2020, \u003cstrong\u003e8\u003c/strong\u003e(10):e1264-e1272.\u003c/li\u003e\n\u003cli\u003eKhader Y, Alyahya M, Saadeh R: \u003cstrong\u003eWater, Sanitation, and Hygiene (WASH) and Infection Prevention and Control (IPC) in Primary Healthcare Facilities in Jordan in the Context of COVID-19\u003c/strong\u003e. \u003cem\u003ePrimary Health Care \u003c/em\u003e2022:229.\u003c/li\u003e\n\u003cli\u003eWeber N, Martinsen AL, Sani A, Assigbley EKE, Azzouz C, Hayter A, Ayite K, Baba AAB, Davi KM, Gelting R: \u003cstrong\u003eStrengthening healthcare facilities through water, sanitation, and hygiene (WASH) improvements: a pilot evaluation of \u0026ldquo;WASH FIT\u0026rdquo; in Togo\u003c/strong\u003e. \u003cem\u003eHealth security \u003c/em\u003e2018, \u003cstrong\u003e16\u003c/strong\u003e(S1):S-54-S-65.\u003c/li\u003e\n\u003cli\u003eUl Musawir A, Serra CEM, Zwikael O, Ali I: \u003cstrong\u003eProject governance, benefit management, and project success: Towards a framework for supporting organizational strategy implementation\u003c/strong\u003e. \u003cem\u003eInternational Journal of Project Management \u003c/em\u003e2017, \u003cstrong\u003e35\u003c/strong\u003e(8):1658-1672.\u003c/li\u003e\n\u003cli\u003eKadowa I: \u003cstrong\u003eA case study of the Uganda National Minimum Healthcare Package\u003c/strong\u003e. In\u003cem\u003e.\u003c/em\u003e: Ministry of Health, EQUINET Uganda; 2017.\u003c/li\u003e\n\u003cli\u003eGuo A, Bowling JM, Bartram J, Kayser G: \u003cstrong\u003eWater, sanitation, and hygiene in rural health-care facilities: a cross-sectional study in Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia\u003c/strong\u003e. \u003cem\u003eThe American journal of tropical medicine and hygiene \u003c/em\u003e2017, \u003cstrong\u003e97\u003c/strong\u003e(4):1033.\u003c/li\u003e\n\u003cli\u003eMedard T, Yawe BL, Bosco OJ: \u003cstrong\u003eHealth care delivery system in Uganda: a review\u003c/strong\u003e. 2023.\u003c/li\u003e\n\u003cli\u003eTweheyo R, Reed C, Campbell S, Davies L, Daker-White G: \u003cstrong\u003e\u0026lsquo;I have no love for such people, because they leave us to suffer\u0026rsquo;: a qualitative study of health workers\u0026rsquo; responses and institutional adaptations to absenteeism in rural Uganda\u003c/strong\u003e. \u003cem\u003eBMJ global health \u003c/em\u003e2019, \u003cstrong\u003e4\u003c/strong\u003e(3):e001376.\u003c/li\u003e\n\u003cli\u003eKim J-H, Bell GA, Bitton A, Desai EV, Hirschhorn LR, Makumbi F, Nabiwemba E, Ratcliffe HL, Wabwire-Mangen F, Kibira SP: \u003cstrong\u003eHealth facility management and primary health care performance in Uganda\u003c/strong\u003e. \u003cem\u003eBMC health services research \u003c/em\u003e2022, \u003cstrong\u003e22\u003c/strong\u003e(1):275.\u003c/li\u003e\n\u003cli\u003eIsunju JB, Ssekamatte T, Wanyenze R, Mselle JS, Wafula ST, Kansiime WK, Bateganya NL, Nalugya A, Wagaba B, Denny L: \u003cstrong\u003eAnalysis of management systems for sustainability of infection prevention and control, and water sanitation and hygiene in healthcare facilities in the Greater Kampala Area, Uganda\u003c/strong\u003e. \u003cem\u003ePLoS Water \u003c/em\u003e2022, \u003cstrong\u003e1\u003c/strong\u003e(5):e0000021.\u003c/li\u003e\n\u003cli\u003eSsekamatte T, Mugambe RK, Isunju JB, Wanyenze RK, Nalugya A, Adyedo C, Wafula ST, Buregyeya E, Nuwematsiko R, Bateman J: \u003cstrong\u003eApplication of the behaviour-centred design to understand facilitators and deterrents of hand hygiene among healthcare providers: findings from a formative phase of a cluster randomised trial in the Kampala Metropolitan area\u003c/strong\u003e. \u003cem\u003eBMC Health Services Research \u003c/em\u003e2024, \u003cstrong\u003e24\u003c/strong\u003e(1):1031.\u003c/li\u003e\n\u003cli\u003eFejfar D, Guo A, Kelly E, Tidwell JB, Ochieng O, Cronk R: \u003cstrong\u003eHealthcare provider satisfaction with environmental conditions in rural healthcare facilities of 14 low-and middle-income countries\u003c/strong\u003e. \u003cem\u003eInternational journal of hygiene and environmental health \u003c/em\u003e2021, \u003cstrong\u003e236\u003c/strong\u003e:113802.\u003c/li\u003e\n\u003cli\u003eUdho S, Kabunga A: \u003cstrong\u003eBurnout and Associated Factors among Hospital‐Based Nurses in Northern Uganda: A Cross‐Sectional Survey\u003c/strong\u003e. \u003cem\u003eBioMed Research International \u003c/em\u003e2022, \u003cstrong\u003e2022\u003c/strong\u003e(1):8231564.\u003c/li\u003e\n\u003cli\u003eMulegi T: \u003cstrong\u003eAn Overview of Performance of Health Workers in Uganda\u003c/strong\u003e. \u003cem\u003eIDOSR Journal of Humanities and Social Sciences \u003c/em\u003e2022, \u003cstrong\u003e7\u003c/strong\u003e(1):113-124.\u003c/li\u003e\n\u003cli\u003eMukasa MN, Sensoy Bahar O, Ssewamala FM, KirkBride G, Kivumbi A, Namuwonge F, Damulira C: \u003cstrong\u003eExamining the organizational factors that affect health workers\u0026apos; attendance: findings from southwestern Uganda\u003c/strong\u003e. \u003cem\u003eThe International journal of health planning and management \u003c/em\u003e2019, \u003cstrong\u003e34\u003c/strong\u003e(2):644-656.\u003c/li\u003e\n\u003cli\u003eSetty K, Cronk R, George S, Anderson D, O\u0026rsquo;Flaherty G, Bartram J: \u003cstrong\u003eAdapting translational research methods to water, sanitation, and hygiene\u003c/strong\u003e. \u003cem\u003eInternational journal of environmental research and public health \u003c/em\u003e2019, \u003cstrong\u003e16\u003c/strong\u003e(20):4049.\u003c/li\u003e\n\u003cli\u003eSubramaniam S, Selvavinayagam T: \u003cstrong\u003eSupportive supervision as an effective intervention in improving water, sanitation and hygiene facilities in government health facilities of Tamil Nadu\u003c/strong\u003e. \u003cem\u003eInternational Journal of Community Medicine and Public Health \u003c/em\u003e2018, \u003cstrong\u003e5\u003c/strong\u003e(3):1082.\u003c/li\u003e\n\u003cli\u003eHoward G, Bartram J, Brocklehurst C, Colford Jr JM, Costa F, Cunliffe D, Dreibelbis R, Eisenberg JNS, Evans B, Girones R: \u003cstrong\u003eCOVID-19: urgent actions, critical reflections and future relevance of \u0026lsquo;WaSH\u0026rsquo;: lessons for the current and future pandemics\u003c/strong\u003e. \u003cem\u003eJournal of water and health \u003c/em\u003e2020, \u003cstrong\u003e18\u003c/strong\u003e(5):613-630.\u003c/li\u003e\n\u003cli\u003ePalo SK, Kanungo S, Samal M, Priyadarshini S, Sahoo D, Pati S: \u003cstrong\u003eWater, Sanitation, and Hygiene (WaSH) practices and morbidity status in a rural community: findings from a cross-sectional study in Odisha, India\u003c/strong\u003e. \u003cem\u003eJournal of Preventive Medicine and Hygiene \u003c/em\u003e2021, \u003cstrong\u003e62\u003c/strong\u003e(2):E392.\u003c/li\u003e\n\u003cli\u003eHokororo J, Eliakimu E, Ngowi R, German C, Bahegwa R, Msigwa Y: \u003cstrong\u003eReport of trend for compliance of infection prevention and control standards in Tanzania from 2010 to 2017 in Tanzania mainland\u003c/strong\u003e. \u003cem\u003eMicrobiol Infect Dis \u003c/em\u003e2021, \u003cstrong\u003e5\u003c/strong\u003e(3):1-10.\u003c/li\u003e\n\u003cli\u003eLeclert LM, Affolter JS, Ndenga J: \u003cstrong\u003eFrom awareness raising to sustainable behaviour change in school: the WASH in school road map\u003c/strong\u003e. 2018.\u003c/li\u003e\n\u003cli\u003eSeimetz E, Kumar S, Mosler H-J: \u003cstrong\u003eEffects of an awareness raising campaign on intention and behavioural determinants for handwashing\u003c/strong\u003e. \u003cem\u003eHealth education research \u003c/em\u003e2016, \u003cstrong\u003e31\u003c/strong\u003e(2):109-120.\u003c/li\u003e\n\u003cli\u003eDe Buck E, Hannes K, Cargo M, Van Remoortel H, Vande Veegaete A, Mosler H-J, Govender T, Vandekerckhove P, Young T: \u003cstrong\u003eEngagement of stakeholders in the development of a Theory of Change for handwashing and sanitation behaviour change\u003c/strong\u003e. \u003cem\u003eInternational journal of environmental health research \u003c/em\u003e2018, \u003cstrong\u003e28\u003c/strong\u003e(1):8-22.\u003c/li\u003e\n\u003cli\u003eChirgwin H, Cairncross S, Zehra D, Sharma Waddington H: \u003cstrong\u003eInterventions promoting uptake of water, sanitation and hygiene (wash) technologies in low‐and middle‐income countries: an evidence and gap map of effectiveness studies\u003c/strong\u003e. \u003cem\u003eCampbell systematic reviews \u003c/em\u003e2021, \u003cstrong\u003e17\u003c/strong\u003e(4):e1194.\u003c/li\u003e\n\u003cli\u003eJacob Arriola KR, Ellis A, Webb-Girard A, Ogutu EA, McClintic E, Caruso B, Freeman MC: \u003cstrong\u003eDesigning integrated interventions to improve nutrition and WASH behaviors in Kenya\u003c/strong\u003e. \u003cem\u003ePilot and feasibility studies \u003c/em\u003e2020, \u003cstrong\u003e6\u003c/strong\u003e:1-16.\u003c/li\u003e\n\u003cli\u003eTantum LK, Cronk R, Asingwire N, Bohara P, Kharal Chettry L, Hirai M, Kpodzro S, Mavi T, Miller JD, Ripkey C: \u003cstrong\u003eWhat is next for costing WASH in healthcare facilities? Applying evidence for policy and practice\u003c/strong\u003e. \u003cem\u003emedRxiv \u003c/em\u003e2024:2024.2008. 2014.24311992.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6784690/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6784690/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Water, sanitation, and hygiene are essential for public health in healthcare facilities, with many lacking basic services, especially in rural sub-Saharan Africa, including Uganda. WASH impacts health security, staff morale, quality of care, and gender equality. Although the WASHFIT has been tested and recommended for enhancing WASH and IPC practices, it has not been extensively evaluated in various healthcare settings. We, therefore, employed a qualitative case study design to explore the fidelity of the WASHFIT process, as well as the barriers and facilitators to its application in HCFs in Northern Uganda.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology: \u003c/strong\u003eThe study was conducted in the districts of Amuru and Nwoya in Northern Uganda. We used a combination of snowball and purposive sampling techniques to select 20 key informants and 36 focus group discussants associated with the eight healthcare facilities that implemented the WASHFIT intervention. We used Atlas. Version 24 to code the data and the RE-AIM framework to guide our analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe WASHFIT intervention, implemented by knowledgeable trainers, distinguished itself from others by incorporating a structured risk assessment and rating, stakeholder participation, and an emphasis on the governance, operation, and maintenance of WASH/IPC facilities. Through weekly CMEs and regular status meetings, the participants acquired knowledge which they used to implement WASH/IPC interventions. A lack of customised assessment tools, a heavy workload, a negative attitude among staff, a shortage of human resources competent in using WASHFIT, inadequate inter-departmental collaboration, and insufficient technical support from implementing partners and district healthcare managers hindered the use of the WASHFIT methodology. Healthcare providers' awareness of the challenges posed by WASH in healthcare facilities, as well as expectations related to reporting and accountability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eBased on these findings, addressing challenges with the customisation and localisation of the WASHFIT, managing the healthcare provider workload, and defining task boundaries, as well as addressing governance, are likely to stimulate the implementation of the WASHFIT intervention.\u003c/p\u003e","manuscriptTitle":"A process evaluation for a Water and Sanitation for Health Facility Improvement Tool (WASHFIT) intervention in Northern Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 07:25:59","doi":"10.21203/rs.3.rs-6784690/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2248d0fb-1388-4115-9ca0-fe989183786c","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-04T09:58:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-01 07:25:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6784690","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6784690","identity":"rs-6784690","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}