Water Sanitation and Hygiene (WASH) Implementation Status and implications on Surgical Site Infections: the case of three Hospitals in the Kwahu Municipality-Ghana

Water Sanitation and Hygiene (WASH) Implementation Status and implications on Surgical Site Infections: the case of three Hospitals in the Kwahu Municipality-Ghana | 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 Water Sanitation and Hygiene (WASH) Implementation Status and implications on Surgical Site Infections: the case of three Hospitals in the Kwahu Municipality-Ghana Michael Dorwu, Elijah Kwasi Peprah, Millicent Boadiwa-Yirenkyi, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6123709/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 The provision of WASH services in healthcare facilities (HCFs) is fundamental for the provision of quality care. Therefore, this study assessed WASH status using standard WHO indicators in health facilities and its impacts on patients’ health in three HCFs. Methodology: A cross-sectional study was conducted among 221 healthcare practitioners working in the three HCFs, in addition to an observational checklist. Availability of WASH services was assessed using a validated WASH Conditions (WASHCon) tool comprising structured questionnaires and a records review tool. Results The study revealed that most of the healthcare workers (55%) had moderate knowledge of WASH and all HCFs (100%) had access to pipe-borne water supplied from outside the healthcare facility. However, about 63.4% of respondents indicated that there was an erratic supply when the main water source was unavailable. Furthermore, about 90% of the healthcare practitioners complied with most of the hygiene measures instituted within the facilities. Finally, the microbiology laboratory register was used to review the records of surgery patients with post-operative infections at their surgical sites whilst in the health facility. A total of 63 surgical site infections were recorded, with Staphylococcus aureus emerging as the commonest pathogen. Conclusion Healthcare practitioners in the three HCFs possess a moderate level of knowledge regarding WASH practices. Most healthcare facilities (HCFs) in this municipality have sufficient WASH resources, even though they frequently experience interruptions in the water supply. Healthcare practitioners demonstrate a commendable level of adherence to hygiene and sanitation protocols. However, the research findings highlight a concerning issue: the negative impact of WASH on patient health, evidenced by a notably high occurrence of nosocomial infections, particularly surgical site infections. WASH Health Care Facilities Patient Safety Nosocomial Infections Ghana Figures Figure 1 Figure 2 Figure 3 Figure 4 Keys Messages Water, sanitation, and hygiene (WASH) services are crucial for quality care, infection prevention, and patient safety in healthcare facilities. Many facilities, especially in low-resource settings like sub-Saharan Africa, face challenges such as inadequate clean water, poor sanitation, and insufficient hygiene facilities, leading to high infection rates. This study assesses WASH conditions in Ghana's Kwahu Municipality, examines the prevalence of surgical site infection (SSI), and evaluates healthcare workers' adherence to WASH protocols. It highlights moderate knowledge and high compliance among practitioners but notes inconsistencies in guideline application. The study emphasizes the need for comprehensive training, and improved infection prevention measures, and addresses disparities in WASH resource reliability, such as frequent water supply disruptions and inadequate waste management. Additionally, it underscores the importance of addressing critical gaps in WASH services, such as the absence of WHO hand-washing manuals and inadequate waste treatment, while enabling microbiological studies on infection control. At the policy level, it advocates for tailored strategies to address WASH challenges, including mandating WHO hand-washing guidelines, investing in infrastructure, and aligning healthcare facility standards with the 2030 Sustainable Development Goals, particularly Goal 6.2 on equitable water access and sanitation. Introduction Water, Sanitation, and Hygiene (WASH) within Health Care Facilities (HCFs) include services for water supply, sanitation, healthcare waste management, hand hygiene, and environmental cleanliness (Patel et al., 2019 ). Quality healthcare delivery fundamentally depends on the provision of WASH services in HCFs. Effective WASH services, especially in maternity and primary care settings, can reduce healthcare-acquired infections (HAIs), build trust and increase the utilization of healthcare services, and enhance efficiency. Improved WASH bolsters the essential components of universal healthcare, emphasizing quality, equity, and dignity for all individuals (Chaitkin et al., 2022 ). Consequently, WASH in HCFs is widely acknowledged and documented in the 2030 Agenda for Sustainable Development. (WHO, 2023). Target 6.2 specifically calls for paying special attention to the needs of immunocompromised people, including individuals admitted or seeking health care within facilities. On a global scale, addressing WASH in HCF remains a significant public health challenge. Baseline estimates worldwide indicate that 26% of HCFs lack access to an improved water source on their premises, 14% have a limited water supply, and 12% have no water supply at all (Hirai et al., 2021 ). The situation is more critical in low-resourced countries, where 45% of HCFs lack access to basic water supply (Bouzid et al., 2018 ). Still, on a global scale, 16% of HCFs lack hand hygiene facilities at points of care, and they also lack soap and water at toilet facilities (Patel et al., 2019 ). The situation is no different in sub-Saharan Africa where over 21% of HCFs globally rely on unimproved toilets or have no toilets at all, while, only 23% of HCFs have basic sanitation (Kanyangarara et al., 2021 ). Sanitation, along with proper hygiene and safe water, is essential for good health and social and economic development. Incremental improvements in these components can enhance the quality of life for vast populations, especially children, in low- and middle-income countries (Kayiwa et al., 2020 ). Improved sanitation in healthcare facilities entails effectively separating excreta from human contact and preventing its re-entry into the immediate environment. Adequate sanitation facilities at healthcare facilities are those situated close to the facility, accessible to all users, including adults, children, the elderly, and those with physical disabilities, and provide separate facilities for males and females, as well as for adults and children (Chaitkin et al., 2022 ). The availability of sufficient water-collection points and water-use facilities in healthcare facilities, convenient access and utilization for various purposes such as medical activities, drinking, personal hygiene, food preparation, laundry, and cleaning (Hirai et al., 2021 ). The adequacy of WASH facilities in healthcare facilities is crucial for ensuring quality and safe care, reducing the risk of infection for patients, caregivers, and healthcare workers. Therefore, the delivery of healthcare services has patient safety consequences due to the absence of sanitation facilities, and adequate and clean water supply. And so, without proper WASH services, individuals seeking treatment are at risk daily worldwide, and their safety in hospitals is jeopardized by healthcare-acquired infections (HCAIs) (Appiah-Effah et al., 2020 ). Therefore, this research holds substantial importance in establishing a foundation for subsequent studies in the domains of water and sanitation, infection prevention, and control in healthcare settings, among others. Secondly, the research provides crucial information for the healthcare facilities under investigation, offering insights that can enhance understanding and implementation of WASH (Water, Sanitation, and Hygiene) strategies, to ultimately improve the quality of healthcare services. Furthermore, the findings of this research can play a pivotal role in policy implementation; policymakers at various levels can leverage this information to develop policies specifically tailored to address challenges and concerns within the water and sanitation sectors to ensure positive changes and improvements in the overall health and safety of patients within health care facilities. Therefore, this study investigated the WASH implementation status of healthcare facilities and possible implications on surgical site infections, within the Kwahu Municipality in Ghana. Methods Study Design A cross-sectional study design was employed in this research. This approach allows for data collection particular timeframe and makes it well-suited to capture a momentary representation of the outcome and its associated characteristics at a specific point in time. However, the cross-sectional design cannot establish causality between variables, as it captures data at a specific moment, making it challenging to determine the sequence of events or causal relationships. Settings The municipal area where the study was conducted has a total of thirty-one (31) healthcare facilities. This includes five (5) health centers, and twenty-two (22) functional CHPS (Community-Based Health Planning and Services) zones, with ten (10) having designated compounds. In addition to these, a District Hospital, two private hospitals, and a private maternity home. Sampling Technique and Data Collection Participants for this study were recruited using a purposive sampling method, with quotas determined by the relative size of each hospital. This approach ensured that the sample reflected the distribution of healthcare professionals across the three hospitals. Data was gathered through structured questionnaires, which were administered face-to-face to the participants, and Laboratory Records Review checklists. This method facilitated immediate clarification of any questions and ensured a higher response rate. Each session lasted approximately 25 minutes, allowing participants to complete the questionnaires at their convenience. The WASH Conditions (WASHCon) tool was adapted from the Service Availability and Readiness Assessment (SARA) and WHO Patient Safety Questionnaire for Health workers. Data was collected and analyzed WASH knowledge and practices among the health workers. The records of surgery patients who developed post-operative infections on surgical sites while in the health facility were assessed by reviewing the microbiology laboratory register. This process involved a thorough review of relevant information from the laboratory records. The Laboratory Records Review was conducted during the same period as the administration of questionnaires in each healthcare facility. This concurrent approach ensured a comprehensive and synchronized assessment of both microbiological data and questionnaire responses, contributing to a more holistic understanding of post-operative infections among surgery patients within the health facilities, concurrently across all three hospitals under investigation. These hospitals were selected based on the criterion of offering surgical services in the district, aligning with the research objectives. Participants for this study included all healthcare professionals across various roles who were employed in the three hospitals situated in Municipality, specifically facilities A, B, and C. The healthcare workers, comprising Doctors, Physician Assistants, Nurses, and Midwives, were actively engaged in direct patient care for a minimum of one year preceding the study period. To select participants for the research, a purposive sampling method was employed, which falls under the category of non-probability sampling techniques. The rationale behind opting for this technique was driven by several factors. Firstly, there was difficulty in establishing a comprehensive sample frame for the participants within the study period due to the demanding nature of their work. The busy schedules of healthcare professionals made it challenging to gather a complete and representative list. Additionally, time constraints influenced the decision to use purposive sampling. Sample size The total population of Doctors, Physician Assistants, Nurses, and midwives across the three hospitals was 496, with a breakdown of 248 in Hospital A, 165 in Hospital B, and 82 in Hospital C. The distribution ratio among the hospitals was 3:2:1, with a calculated sample size of 221, using Slovin’s formulae. All healthcare workers within their respective professions employed in the three hospitals situated in the Municipality constituted the sampling population for this study. Distributing this sample size based on the 3:2:1 ratio among the three hospitals resulted in allocated sample sizes of 110, 74, and 37 for facilities A, B, and C. Data was analyzed using descriptive analysis of frequencies and cross-tabulations. Background characteristics were analyzed using frequencies. Data were presented in tables, and pie charts. Results This chapter presents the findings and a discussion of the data obtained from the study. The arrangement of this chapter was mainly influenced by the specific study objectives which were used to organize the data into themes and sub-themes. This included themes such as the demographic characteristics of respondents, the knowledge level of respondents on WASH, the availability of WASH infrastructure and services, the level of hygiene compliance among respondents, and the level of nosocomial infections in healthcare facilities. Socio-demographic characteristics of respondents Table 1 shows the socio-demographic characteristics of the 94 respondents who consented to the study. The mean age of the respondents was 31 years with a majority of them 39 (41.5%) within the age group of 28-33 years. Furthermore, about 61 (64.9%) were females while 82 (87.2%) were Christians, with most of the respondents being nurses 43 (45.7%). Knowledge Level of Respondents on WASH Table 2 shows the responses to questions aimed at seeking knowledge of respondents on WASH. An overwhelming majority of 89 (94.7%) of the respondents indicated they had received formal training on hand hygiene in the last three years and they routinely used an alcohol-based hand rub for hand hygiene 93(98.9%). Again, when asked which was better when comparing handwashing and hand disinfection, almost all 76 (80.9%) of them indicated handwashing was better than hand disinfection. On the most frequent source of germs responsible for healthcare-associated infections (HAIs), a majority 67 (71.3%) indicated that it was the hospital environment (surfaces). Next on the main route of transmission of the HAIs, about 72 (76.6%) indicated that it occurred through contact when hands were not clean. When further asked when hand cleansing must be performed, most 53 (56.9%) selected doing so before performing a clean/aseptic procedure. Lastly, on the minimal time needed for alcohol-based hand rub to kill most germs on your hands, a greater proportion of 67 (71.3%) indicated it needed 10 seconds. Figure 1 shows the knowledge level of respondents on WASH. The overall knowledge level of respondents was calculated based on average (mean) score of the responses to questions asked. A score of more than average(mean) was considered as good and less than the average(mean) considered as poor knowledge. Overall, most 54 (57.5%) of the respondents were found to have poor knowledge on WASH. Knowledge Level of Respondents on WASH. Table 3 above represents the chi-square and fisher’s exact test of association between socio-demographic characteristics and knowledge on WASH practices among health workers in Kwahu district. The study revealed that the associations age (p=0.008) was the only statistically significant to the level of knowledge on WASH practices among health workers in Kwahu district; all other demographics were not significant. Figure 2 indicates that medical doctors demonstrated a comparatively better understanding, with 80.0% of participants exhibiting good knowledge and 20.0% showing poor knowledge. However, midwives had the highest percentage of participants with poor knowledge scores (65.0%), followed by physician assistants (58.8%), nurses (53.5%), and allied health professionals (44.4%). Availability of WASH Infrastructure and Services in Health Facilities Table 4 shows the availability of WASH infrastructure and services in health facilities. Almost all the respondents 86 (91.5%) indicated that their facilities’ main water source came from a pipe supply from outside the healthcare facility (HCF). Again, almost all the respondents agreed that water was piped into the wards 92 (97.9%). When asked whether there were instances when water from the main water source was unavailable, a greater proportion of 54 (57.5%) of the respondents responded in the affirmative. On the type of toilet facilities available, all the respondents 91 (96.8%) indicated that their facilities had flush toilets. Furthermore, a greater proportion of 45 (47.9%) of the respondents indicated that their facilities used a sewerage system as a method of excreta disposal. Consecutively, an overwhelming majority 87 (92.6%) of the respondents indicated that there was no presence of flies in improved toilets, there was visible cleanliness of toilet facilities 87 (92.6%) and there was presence of soap/detergent 92 (97.9%). Moreover, there was the availability of protected areas for the storage of health care facility waste awaiting disposal or removal 89 (95.9%). Lastly, most 80 (85.1%) of the respondents indicated that Chemical disinfection with hypochlorite was the commonest means of treating infectious waste before disposal. Overall Availability Score of Wash Infrastructure/Services at Health Facilities of Respondents. The majority 59.6% of the respondents indicated that WASH infrastructure/services was available as shown in Figure 3 . This shows the level of availability of healthcare infrastructure/services at health facilities of healthcare practitioners. The overall level of availability was calculated on average (mean) score of the responses to questions asked. A score of more than average(mean) was considered as available and less than the average(mean) was considered as not available. It was found that most 53(59.6%) of the respondents indicated that WASH infrastructure/services were available. Level of Hygiene Compliance among Respondents Table 5 shows the responses to the level of hygiene compliance among respondents. A majority 75 (79.8%) of the respondents indicated they always washed their hands in between patient contacts. Also, a greater proportion of 87 (93.6%) of the respondents indicated that they always used alcoholic hand rubs as an alternative if their hands were not visibly soiled. On if they put used sharp articles into sharps boxes, all 94 (100%) of the respondents indicated they always did so. About 63 (67.7%) respondents indicated they always covered their wound(s) or lesion(s) with waterproof dressing before patient contacts. On the gloves wearing habit of the respondents, almost all them 91 (98.9%) indicated that they always change gloves between patient contacts with an overwhelming majority also indicating they always washed their hands immediately after removal of gloves 89 (96.7%). Lastly, when asked if they reused a surgical mask or disposable Personal Protective Equipment, most of them 65 (69.9%) indicated never doing so Figure 4 shows the level of hygiene compliance among healthcare practitioners. The overall level of hand hygiene compliance was calculated on average (mean) score of the responses to questions asked. A score of more than average(mean) was considered as good and less than the average(mean) was considered as poor. It was found that most 53(56.4%) of the healthcare workers had moderate hygiene compliance. Level of Nosocomial Infections in Healthcare Facilities From Table 6, the study identified 65 nosocomial infection cases among in-patients which were all surgical site infections. Bacterial agents of the surgical sites included Staphylococcus aureus (30.8% ), Klebsiella spp. (20.0%) , Pseudomonas spp (15.4%) ., Proteus spp. (10.8%) , Escherichia coli ( 17.0%) and Enterococcus spp. (6.0%) . (Table 6 must be on page 17). Table 7 presents significant associations between various predictor variables and level of hygiene compliance among respondents, following adjustment for potential confounding variables. After adjusting for the confounding effects of each predictor variable, respondents working at facilities where there is availability of WASH infrastructure/services are 0.6 times more likely to comply with hygiene practices (aOR=0.6, 95%CI=0.0-0.2, p< 0.000 ). Discussion Level of knowledge of healthcare workers on WASH Inadequate drinking water, sanitation, and hygiene (WASH) in healthcare facilities significantly impacts health, particularly in low and middle-income countries. Despite its importance, there is limited knowledge of the status of WASH in some of these settings (Patel et al., 2019). Meanwhile, this study showed moderately satisfactory knowledge among the healthcare workers which is similar to findings from a study in Pakistan which also showed moderate knowledge of healthcare practitioners on WASH (Afzal et al. , 2019). Another study in Saudi Arabia showed a 52.0% level of knowledge among healthcare practitioners indicating a moderate knowledge level (Al Mutairi et al. , 2020). While demonstrating an overate moderate knowledge of WASH, 98.9% of participants in this study reported routine use of alcohol-based hand rubs which was in coherence with that of a previous study where 94.8% of the healthcare workers routinely used an alcohol-based hand rub (Al Mutairi et al. , 2020). However, previous studies that examined the sensory properties and acceptability of different alcohol-based hand rubs concluded that sensory characteristics and properties of hand rubs impacted healthcare workers' hand hygiene compliance, hence recommends that strategies to improve hand hygiene compliance should include the accessibility of alcohol-based hand rubs, education, psychological theory, and quality improvement strategies (Mezaache et al., 2021). Despite this, reports confirm compliance with alcohol-based hand rubs among healthcare workers has massively increased especially after the COVID-19 pandemic (Ahmadipour et al. , 2022; Ragusa et al. , 2021), particularly following adequate education and evidence on its efficacy in improving hand hygiene and reduce spread of infection. Availability of WASH Infrastructure and Services in Health Facilities Availability of WASH services in health facilities in sub-Saharan Africa has improved but remains below the global target of 80% in many countries, meanwhile, ensuring adequate access to WASH services and enforcing adherence to safety and hygiene practices in health facilities was essential to minimize the risk of COVID-19 transmission (Kanyangarara et al.,2022). In this study however, while healthcare facilities in the Municipality had access to adequate and improved water supply, it was noted that the water supply was sometimes sourced from piped supplies outside the facility, which fails to meet the JMP indicators requiring facilities to have piped water supplies on their premises (WHO, 2020). This was contrasted to reports in the study in the Bongo and Kassena Nankana West District by WaterAid Ghana which reported that 52% of healthcare facilities in the districts relied on hand-dug boreholes, 17% relied on water via indoor plumbing and 3% relied on hand dug wells (WaterAid Ghana, 2018). About 97.9% of the healthcare practitioners indicated that water was available and pumped into all the wards. The findings indicate that HCFs are in line to meet the WHO target of 100% water coverage by 2030 (WHO, 2019b). The findings of adequate access to safe water among health facilities in the study is similar to a study among health facilities in the Asokore Mampong Municipality by Doku et al. , (2022). However, about 41.5% of the workers indicated there were instances when water from the main water source was unavailable. Still, on the issue of intermittent water supply or shortages to HCFs, a study assessing WASH in Rwanda also indicated seasonal water shortages in HCFs (Huttinger et al. , 2017). This poses a serious challenge, especially in urban settings where the population and the number of clients seeking care from HCFs are large. Furthermore, it was indicated by 96.8% that HCF had flush toilets which were mostly visibly clean (87%) The majority (79.0%) stated that the HCFs did not segregate waste safely into separate bins which was parallel to what has been reported in previous studies (Abebe et al. , 2017; Yazie et al. , 2019). In addition to that, HCFs did not treat infectious waste before disposal. Autoclaving, one of the most effective ways of sterilizing infectious waste (Windfeld et al. , 2015), was done rarely by healthcare facilities (9.6%). The findings concur with an Ethiopian study where there was no pre-treatment of infectious wastes by the HCFs (Tadesse et al. , 2014). Level of Hygiene Compliance among Healthcare Practitioners A large proportion of the infections acquired in healthcare facilities are attributed to cross-contamination and transmission of microbes from the hands of healthcare workers to patients (Samuel et al. , 2010). The majority of the healthcare practitioners in the study indicated they always washed their hands regularly in between patient contacts (79.8%). In contrast to the findings of this study, Shanu, (2011) found that only 38% of respondents' health workers washed their hands frequently with soap and water after patient contact. The most reported reason for noncompliance was an inadequate supply of water, soap, and towels. Remaining on the topic of nosocomial infection, another possible source of these infections is contaminated gloves. Gloves are not only necessary for contact precautions, but also essential for preventing the transmission of infectious bacteria, viruses, and microorganisms that can spread by direct or indirect contact with an infected person or contaminated environment (Trampuz et al. , 2004). It was found in the study that a little over half of the practitioners (55.3%) changed gloves in between patient contacts. A common reason given by health care practitioners for not changing gloves in between patient contacts is the perception that gloves remain clean as long as they appear visually unsoiled. This misconception can contribute to the transmission of nosocomial infections. This is evidenced in studies by Kpadeh-Rogers et al. , (2019) where both studies found bacteria from patients on the hands of healthcare workers who had worn gloves for each patient contact. Almost all of the respondents (93.6%) indicated that they always used alcoholic hand rubs as an alternative if their hands were not visibly soiled. Alcohol-based hand rubs have been suggested as a potential solution in high-demand situations like emergency wards (Pittet, 2001). One finding worthy of note in this study was the fact that WHO hand-washing manuals were absent in HCFs as indicated by 65.9% of the practitioners. As a result, the hand washing compliance of healthcare practitioners according to WHO standards is not guaranteed. Research by Uneke et al. , (2014), the reason given for non-compliance with hand hygiene methods by doctors and nurses was the absence of WHO guidelines on hand hygiene and disinfection practices. Level of surgical site infections in healthcare facilities A total of 65 cases were recorded indicating a high level of nosocomial infections. In a multicenter point-prevalence survey of hospital-acquired infections in Ghana, a total of 184 health associations were recorded among healthcare facilities (Labi et al. , 2019). According to (Sattar et al. , 2019), surgical site infections are one of the most common nosocomial infections second only to urinary tract infections, and commonly occur between the fifth and tenth days after surgery (Mulu et al. , 2012). The findings underscore the critical impact nosocomial infections can have on healthcare systems including the potential for extended hospital stays, increased healthcare costs, and adverse patient outcomes. S. aureus was the most common hospital-acquired pathogen among inpatients in the current study, followed by Klebsiella spp., Escherichia coli ., Pseudomonas spp., Proteus spp., and Enterococcus spp. The bacteria isolated in this study aligns with those findings from prior research by (Oni et al. , 2006) and (Khan et al. , 2015) suggesting consistency in the types of pathogens responsible for hospital-acquired infections. Limitations of the Study Data collection in the study relied on self-reporting from healthcare practitioners which could introduce social desirability bias. Participants might provide answers they believe are expected rather than reflecting their actual behaviors or knowledge, but this limitation was augmented by field observations. Also, there could have been selection bias in the choice of healthcare facilities or workers included in the study. For example, if only certain types of facilities or particularly compliant workers were included, the results may not accurately reflect the broader population. Interpretation The study revealed that most of the healthcare workers (56.4%) had poor knowledge of WASH. Despite almost all the respondents (91.5%) that the HCFs had access to pipe-borne water supplied from outside the healthcare facility. However, about 41.5% of them indicated there were instances when water from the main water source was unavailable. Almost all the HCFs were indicated by the practitioners to have flush toilets (96.8%) with the sewerage system as the method of excreta disposal (47.9%). Furthermore, about 43.6% of the healthcare practitioners complied with most of the hygiene measures instituted within the facilities. On the treatment of infectious waste before disposal, however, most (76.9%) indicated that the waste was not treated at all. Finally, a total of 65 nosocomial surgical site infections were recorded with Staphylococcus aureus emerging as the commonest pathogen. In conclusion, there is a good knowledge of WASH among healthcare practitioners within the Municipality. Most of the HCFs have been found to have adequate WASH resources even though the water supply is reported to suffer regular disruptions. Compliance of healthcare practitioners to hygiene and sanitation was found to be also moderate. However, the study has revealed the negative impact of WASH on patient health as a high incidence of nosocomial infections, specifically surgical site infections was recorded. Recommendations Based on the findings from the study, the following recommendations have been made: The health authorities in various health facilities to regularly organize and carry out WASH workshops and training for the healthcare practitioners to supplement their knowledge of WASH activities and practices at the health facilities The issue of intermittent water supply must be addressed by exploring alternative water sources, installing backup systems, or improving the reliability of the main water source. A consistent and dependable water supply is fundamental to maintaining hygiene standards within healthcare facilities. It is imperative to promote a culture of rigorous hand hygiene among healthcare workers. Hand hygiene facilities must be consistently accessible and well-stocked with soap or detergent. Regular training and reminders can reinforce the importance of this practice. Lastly, clear protocols for the proper treatment of infectious waste before disposal such as autoclaving are recommended in all health facilities. Effective management of infectious waste is crucial in preventing the transmission of nosocomial infections. Declarations Ethical Issues: Ethical clearance was sought fromthe UHAS Research Ethics Committee, with ethical approval number B051 , before the commencement of the research. Permission was also sought from the Kwahu South Municipal Health Directorate and the administration of the hospitals that were used for the study. Written informed consent was obtained from participants. Competing Interest: Authors declare no competing Interests. Funding: There is no funding for this work. Authors Contribution: F.A.N conceived and designed the paper and M.D. contributed to writing, I.K.B, W.K.Y reviewed the paper, contributed ideas, and wrote, and E.K.P also reviewed the final draft of the paper. 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Nosocomial infections and their control strategies. Asian pacific journal of tropical biomedicine , 5 (7), 509-514. Kpadeh-Rogers, Z., Robinson, G. L., Alserehi, H., Morgan, D. J., Harris, A. D., Herrera, N. B., Rose, L. J., Noble-Wang, J., Johnson, J. K., & Leekha, S. (2019). Effect of glove decontamination on bacterial contamination of healthcare personnel hands. Clinical Infectious Diseases , 69 (Supplement_3), S224-S227. Labi, A., Obeng-Nkrumah, N., Owusu, E., Bjerrum, S., Bediako-Bowan, A., Sunkwa-Mills, G., Akufo, C., Fenny, A., Opintan, J., & Enweronu-Laryea, C. (2019). Multi-centre point-prevalence survey of hospital-acquired infections in Ghana. Journal of hospital infection , 101 (1), 60-68. Mezaache, S., Briand-Madrid, L., Rahni, L., Poireau, J., Branchu, F., Moudachirou, K., ... & Roux, P. (2021). A two-component intervention to improve hand hygiene practices and promote alcohol-based hand rub use among people who inject drugs: a mixed-methods evaluation. BMC Infectious Diseases , 21 , 1-13. Modi, P. D., Kumar, P., Solanki, R., Modi, J., Chandramani, S., & Gill, N. (2017). Hand hygiene practices among Indian medical undergraduates: a questionnaire-based survey. Cureus , 9 (7). Mulu, W., Kibru, G., Beyene, G., & Damtie, M. (2012). Postoperative nosocomial infections and antimicrobial resistance pattern of bacteria isolates among patients admitted at Felege Hiwot Referral Hospital, Bahirdar, Ethiopia. Ethiopian journal of health sciences , 22 (1), 7-18. Oni, A., Ewete, A., Gbaja, A., Kolade, A., Mutiu, W., Adeyemo, D., & Bakare, R. (2006). Nosocomial infections: surgical site infection in UCH Ibadan, Nigeria. Nigerian Journal of Surgical Research , 8 (1). Patel, K., Kalpana, P., Trivedi, P., Yasobant, S., & Saxena, D. (2019). Assessment of water, sanitation and hygiene in HCFs: which tool to follow? Reviews on Environmental Health, 34(4), 435-440. Pittet, D. (2001). Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerging infectious diseases , 7 (2), 234. Ragusa, R., Marranzano, M., Lombardo, A., Quattrocchi, R., Bellia, M. A., & Lupo, L. (2021). Has the COVID 19 virus changed adherence to hand washing among healthcare workers? Behavioral sciences , 11 (4), 53. Samuel, S., Kayode, O., Musa, O., Nwigwe, G., Aboderin, A., Salami, T., & Taiwo, S. (2010). Nosocomial infections and the challenges of control in developing countries. African Journal of Clinical and Experimental Microbiology , 11 (2). Sattar, F., Sattar, Z., Zaman, M., & Akbar, S. (2019). Frequency of post-operative surgical site infections in a Tertiary care hospital in Abbottabad, Pakistan. Cureus , 11 (3). Shanu, S. (2011). A study to assess the hand hygiene practices among health care workers in CSICU, SCTIMST. Tadesse, M. L., & Kumie, A. (2014). Healthcare waste generation and management practice in government health centers of Addis Ababa, Ethiopia. BMC public health , 14 (1), 1-9. Trampuz, A., & Widmer, A. F. (2004). Hand hygiene: a frequently missed lifesaving opportunity during patient care. Mayo clinic proceedings, Uneke, C. J., Ndukwe, C. D., Oyibo, P. G., Nwakpu, K. O., Nnabu, R. C., & Prasopa-Plaizier, N. (2014). Promotion of hand hygiene strengthening initiative in a Nigerian teaching hospital: implication for improved patient safety in low-income health facilities. Brazilian Journal of Infectious Diseases , 18 , 21-27. WaterAid Ghana. (2018). Situational analysis on WASH in healthcare facilities in Bongo and Kassena Nankana West. https://washmatters.wateraid.org/sites/g/files/jkxoof256/files/wash-in-healthcare-facilities-in-ghana.pdf WHO. (2019b). Water, sanitation and hygiene in health care facilities: practical steps to achieve universal access to quality care. WHO, U. (2020). Global progress report on water, sanitation and hygiene in health care facilities: fundamentals first. Geneva: World Health Organization , 2020. World Health Organization. (2023). Addressing climate change: supplement to the WHO water, sanitation and hygiene strategy 2018–2025 . World Health Organization. Windfeld, E. S., & Brooks, M. S.-L. (2015). Medical waste management–A review. Journal of environmental management , 163 , 98-108. Yazie, T. D., Tebeje, M. G., & Chufa, K. A. (2019). Healthcare waste management current status and potential challenges in Ethiopia: a systematic review. BMC research notes , 12 , 1-7. Tables Tables 1 to 7 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.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. 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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-6123709","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":424469916,"identity":"79bb48f5-938a-4eca-a68b-c9b1781817e2","order_by":0,"name":"Michael Dorwu","email":"","orcid":"","institution":"University of Health and Allied Sciences - Fred N. Binka School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Dorwu","suffix":""},{"id":424469917,"identity":"ec644245-ebf6-4a1c-a84a-a03e1e85879f","order_by":1,"name":"Elijah Kwasi Peprah","email":"data:image/png;base64,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","orcid":"","institution":"University of Health and Allied Sciences - Fred N. 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Binka School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Nathaniel","middleName":"","lastName":"Annang-Armah","suffix":""},{"id":424469920,"identity":"746b5e0b-94f1-438b-90c8-ce3ffbccbdcf","order_by":4,"name":"Forgive Awo Norvivor","email":"","orcid":"","institution":"University of Health and Allied Sciences - Fred N. Binka School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Forgive","middleName":"Awo","lastName":"Norvivor","suffix":""}],"badges":[],"createdAt":"2025-02-27 20:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6123709/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6123709/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78656373,"identity":"9add3052-abfe-45d1-b222-7fe7e1b97f14","added_by":"auto","created_at":"2025-03-17 09:30:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":7420,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLevel of knowledge of respondents on WASH\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6123709/v1/7e1ae45626b3bc02093691f0.png"},{"id":78656388,"identity":"fd91f38c-285b-4d5d-81af-01738d3bc3ca","added_by":"auto","created_at":"2025-03-17 09:30:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":18528,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLevel of knowledge of respondents on WASH by Profession\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6123709/v1/c95e833665f023f677b61cc9.png"},{"id":78656994,"identity":"1322b062-3e77-4df5-8603-260566daf670","added_by":"auto","created_at":"2025-03-17 09:38:18","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":13254,"visible":true,"origin":"","legend":"\u003cp\u003eAvailability of healthcare infrastructure/services at health facilities\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6123709/v1/8bbcf444c9e23c0b68bd2bca.png"},{"id":78656995,"identity":"c28d4cc0-84a1-4792-92a2-6e751d557722","added_by":"auto","created_at":"2025-03-17 09:38:19","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":15973,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLevel of Hygiene Compliance among Healthcare Practitioners\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6123709/v1/07e11f72003e5225c6063697.png"},{"id":78658248,"identity":"f1ca46e2-e813-4e56-a780-bafcdbe09492","added_by":"auto","created_at":"2025-03-17 09:46:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":830880,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6123709/v1/17fee301-07ae-4114-9a27-6450e656a1d5.pdf"},{"id":78656372,"identity":"06a52b5f-b876-4a65-b8a5-5e637b0ec8b3","added_by":"auto","created_at":"2025-03-17 09:30:18","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":51426,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6123709/v1/ce094dc8d2c1cf0393ca296f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Water Sanitation and Hygiene (WASH) Implementation Status and implications on Surgical Site Infections: the case of three Hospitals in the Kwahu Municipality-Ghana","fulltext":[{"header":"Keys Messages","content":"\u003cp\u003eWater, sanitation, and hygiene (WASH) services are crucial for quality care, infection prevention, and patient safety in healthcare facilities. Many facilities, especially in low-resource settings like sub-Saharan Africa, face challenges such as inadequate clean water, poor sanitation, and insufficient hygiene facilities, leading to high infection rates. This study assesses WASH conditions in Ghana's Kwahu Municipality, examines the prevalence of surgical site infection (SSI), and evaluates healthcare workers' adherence to WASH protocols. It highlights moderate knowledge and high compliance among practitioners but notes inconsistencies in guideline application. The study emphasizes the need for comprehensive training, and improved infection prevention measures, and addresses disparities in WASH resource reliability, such as frequent water supply disruptions and inadequate waste management. Additionally, it underscores the importance of addressing critical gaps in WASH services, such as the absence of WHO hand-washing manuals and inadequate waste treatment, while enabling microbiological studies on infection control. At the policy level, it advocates for tailored strategies to address WASH challenges, including mandating WHO hand-washing guidelines, investing in infrastructure, and aligning healthcare facility standards with the 2030 Sustainable Development Goals, particularly Goal 6.2 on equitable water access and sanitation.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eWater, Sanitation, and Hygiene (WASH) within Health Care Facilities (HCFs) include services for water supply, sanitation, healthcare waste management, hand hygiene, and environmental cleanliness (Patel et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Quality healthcare delivery fundamentally depends on the provision of WASH services in HCFs. Effective WASH services, especially in maternity and primary care settings, can reduce healthcare-acquired infections (HAIs), build trust and increase the utilization of healthcare services, and enhance efficiency. Improved WASH bolsters the essential components of universal healthcare, emphasizing quality, equity, and dignity for all individuals (Chaitkin et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e). Consequently, WASH in HCFs is widely acknowledged and documented in the 2030 Agenda for Sustainable Development. (WHO, 2023).\u003c/p\u003e\n\u003cp\u003eTarget 6.2 specifically calls for paying special attention to the needs of immunocompromised people, including individuals admitted or seeking health care within facilities.\u003c/p\u003e\n\u003cp\u003eOn a global scale, addressing WASH in HCF remains a significant public health challenge. Baseline estimates worldwide indicate that 26% of HCFs lack access to an improved water source on their premises, 14% have a limited water supply, and 12% have no water supply at all (Hirai et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). The situation is more critical in low-resourced countries, where 45% of HCFs lack access to basic water supply (Bouzid et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). Still, on a global scale, 16% of HCFs lack hand hygiene facilities at points of care, and they also lack soap and water at toilet facilities (Patel et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). The situation is no different in sub-Saharan Africa where over 21% of HCFs globally rely on unimproved toilets or have no toilets at all, while, only 23% of HCFs have basic sanitation (Kanyangarara et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). Sanitation, along with proper hygiene and safe water, is essential for good health and social and economic development. Incremental improvements in these components can enhance the quality of life for vast populations, especially children, in low- and middle-income countries (Kayiwa et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eImproved sanitation in healthcare facilities entails effectively separating excreta from human contact and preventing its re-entry into the immediate environment. Adequate sanitation facilities at healthcare facilities are those situated close to the facility, accessible to all users, including adults, children, the elderly, and those with physical disabilities, and provide separate facilities for males and females, as well as for adults and children (Chaitkin et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e). The availability of sufficient water-collection points and water-use facilities in healthcare facilities, convenient access and utilization for various purposes such as medical activities, drinking, personal hygiene, food preparation, laundry, and cleaning (Hirai et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). The adequacy of WASH facilities in healthcare facilities is crucial for ensuring quality and safe care, reducing the risk of infection for patients, caregivers, and healthcare workers. Therefore, the delivery of healthcare services has patient safety consequences due to the absence of sanitation facilities, and adequate and clean water supply. And so, without proper WASH services, individuals seeking treatment are at risk daily worldwide, and their safety in hospitals is jeopardized by healthcare-acquired infections (HCAIs) (Appiah-Effah et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eTherefore, this research holds substantial importance in establishing a foundation for subsequent studies in the domains of water and sanitation, infection prevention, and control in healthcare settings, among others. Secondly, the research provides crucial information for the healthcare facilities under investigation, offering insights that can enhance understanding and implementation of WASH (Water, Sanitation, and Hygiene) strategies, to ultimately improve the quality of healthcare services.\u003c/p\u003e\n\u003cp\u003eFurthermore, the findings of this research can play a pivotal role in policy implementation; policymakers at various levels can leverage this information to develop policies specifically tailored to address challenges and concerns within the water and sanitation sectors to ensure positive changes and improvements in the overall health and safety of patients within health care facilities. Therefore, this study investigated the WASH implementation status of healthcare facilities and possible implications on surgical site infections, within the Kwahu Municipality in Ghana.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eA cross-sectional study design was employed in this research. This approach allows for data collection particular timeframe and makes it well-suited to capture a momentary representation of the outcome and its associated characteristics at a specific point in time. However, the cross-sectional design cannot establish causality between variables, as it captures data at a specific moment, making it challenging to determine the sequence of events or causal relationships.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSettings\u003c/h3\u003e\n\u003cp\u003eThe municipal area where the study was conducted has a total of thirty-one (31) healthcare facilities. This includes five (5) health centers, and twenty-two (22) functional CHPS (Community-Based Health Planning and Services) zones, with ten (10) having designated compounds. In addition to these, a District Hospital, two private hospitals, and a private maternity home.\u003c/p\u003e\n\u003ch3\u003eSampling Technique and Data Collection\u003c/h3\u003e\n\u003cp\u003e Participants for this study were recruited using a purposive sampling method, with quotas determined by the relative size of each hospital. This approach ensured that the sample reflected the distribution of healthcare professionals across the three hospitals.\u003c/p\u003e \u003cp\u003eData was gathered through structured questionnaires, which were administered face-to-face to the participants, and Laboratory Records Review checklists. This method facilitated immediate clarification of any questions and ensured a higher response rate. Each session lasted approximately 25 minutes, allowing participants to complete the questionnaires at their convenience.\u003c/p\u003e \u003cp\u003eThe WASH Conditions (WASHCon) tool was adapted from the Service Availability and Readiness Assessment (SARA) and WHO Patient Safety Questionnaire for Health workers. Data was collected and analyzed WASH knowledge and practices among the health workers.\u003c/p\u003e \u003cp\u003eThe records of surgery patients who developed post-operative infections on surgical sites while in the health facility were assessed by reviewing the microbiology laboratory register. This process involved a thorough review of relevant information from the laboratory records. The Laboratory Records Review was conducted during the same period as the administration of questionnaires in each healthcare facility. This concurrent approach ensured a comprehensive and synchronized assessment of both microbiological data and questionnaire responses, contributing to a more holistic understanding of post-operative infections among surgery patients within the health facilities, concurrently across all three hospitals under investigation. These hospitals were selected based on the criterion of offering surgical services in the district, aligning with the research objectives.\u003c/p\u003e \u003cp\u003eParticipants for this study included all healthcare professionals across various roles who were employed in the three hospitals situated in Municipality, specifically facilities A, B, and C. The healthcare workers, comprising Doctors, Physician Assistants, Nurses, and Midwives, were actively engaged in direct patient care for a minimum of one year preceding the study period.\u003c/p\u003e \u003cp\u003eTo select participants for the research, a purposive sampling method was employed, which falls under the category of non-probability sampling techniques. The rationale behind opting for this technique was driven by several factors. Firstly, there was difficulty in establishing a comprehensive sample frame for the participants within the study period due to the demanding nature of their work. The busy schedules of healthcare professionals made it challenging to gather a complete and representative list. Additionally, time constraints influenced the decision to use purposive sampling.\u003c/p\u003e\n\u003ch3\u003eSample size\u003c/h3\u003e\n\u003cp\u003eThe total population of Doctors, Physician Assistants, Nurses, and midwives across the three hospitals was 496, with a breakdown of 248 in Hospital A, 165 in Hospital B, and 82 in Hospital C. The distribution ratio among the hospitals was 3:2:1, with a calculated sample size of 221, using Slovin\u0026rsquo;s formulae. All healthcare workers within their respective professions employed in the three hospitals situated in the Municipality constituted the sampling population for this study. Distributing this sample size based on the 3:2:1 ratio among the three hospitals resulted in allocated sample sizes of 110, 74, and 37 for facilities A, B, and C. Data was analyzed using descriptive analysis of frequencies and cross-tabulations. Background characteristics were analyzed using frequencies. Data were presented in tables, and pie charts.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis chapter presents the findings and a discussion of the data obtained from the study. The arrangement of this chapter was mainly influenced by the specific study objectives which were used to organize the data into themes and sub-themes. This included themes such as the demographic characteristics of respondents, the knowledge level of respondents on WASH, the availability of WASH infrastructure and services, the level of hygiene compliance among respondents, and the level of nosocomial infections in healthcare facilities.\u003c/p\u003e\n\u003ch2 id=\"_Toc146732219\"\u003e\u003cstrong\u003eSocio-demographic characteristics of respondents\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eTable 1 shows the socio-demographic characteristics of the 94 respondents who consented to the study. The mean age of the respondents was 31 years with a majority of them 39 (41.5%) within the age group of 28-33 years. Furthermore, about 61 (64.9%) were females while 82 (87.2%) were Christians, with most of the respondents being nurses 43 (45.7%).\u003c/p\u003e\n\u003cp\u003eKnowledge Level of Respondents on WASH\u003c/p\u003e\n\u003cp\u003eTable 2 shows the responses to questions aimed at seeking knowledge of respondents on WASH. \u0026nbsp;An overwhelming majority of 89 (94.7%) of the respondents indicated they had received formal training on hand hygiene in the last three years and they routinely used an alcohol-based hand rub for hand hygiene 93(98.9%). Again, when asked which was better when comparing handwashing and hand disinfection, almost all 76 (80.9%) of them indicated handwashing was better than hand disinfection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the most frequent source of germs responsible for healthcare-associated infections (HAIs), a majority 67 (71.3%) indicated that it was the hospital environment (surfaces). Next on the main route of transmission of the HAIs, about 72 (76.6%) indicated that it occurred through contact when hands were not clean. When further asked when hand cleansing must be performed, most 53 (56.9%) selected doing so before performing a clean/aseptic procedure. Lastly, on the minimal time needed for alcohol-based hand rub to kill most germs on your hands, a greater proportion of 67 (71.3%) indicated it needed 10 seconds.\u003c/p\u003e\n\u003cp\u003eFigure 1 shows the knowledge level of respondents on WASH. The overall knowledge level of respondents was calculated based on average (mean) score of the responses to questions asked. A score of more than average(mean) was considered as good and less than the average(mean) considered as poor knowledge. Overall, most 54 (57.5%) of the respondents were found to have poor knowledge on WASH.\u003c/p\u003e\n\u003cp\u003eKnowledge Level of Respondents on WASH.\u003c/p\u003e\n\u003cp\u003eTable 3 above represents the chi-square and fisher\u0026rsquo;s exact test of association between socio-demographic characteristics and knowledge on WASH practices among health workers in Kwahu district. The study revealed that the associations age \u003cstrong\u003e(p=0.008)\u0026nbsp;\u003c/strong\u003ewas the only statistically significant to the level of knowledge on WASH practices among health workers in Kwahu district; all other demographics were not significant.\u003c/p\u003e\n\u003cp\u003eFigure 2 indicates that medical doctors demonstrated a comparatively better understanding, with 80.0% of participants exhibiting good knowledge and 20.0% showing poor knowledge. However, midwives had the highest percentage of participants with poor knowledge scores (65.0%), followed by physician assistants (58.8%), nurses (53.5%), and allied health professionals (44.4%).\u003c/p\u003e\n\u003cp\u003eAvailability of WASH Infrastructure and Services in Health Facilities\u003c/p\u003e\n\u003cp\u003eTable 4 shows the availability of WASH infrastructure and services in health facilities. Almost all the respondents 86 (91.5%) indicated that their facilities\u0026rsquo; main water source came from a pipe supply from outside the healthcare facility (HCF). Again, almost all the respondents agreed that water was piped into the wards 92 (97.9%). When asked whether there were instances when water from the main water source was unavailable, a greater proportion of 54 (57.5%) of the respondents responded in the affirmative.\u003c/p\u003e\n\u003cp\u003eOn the type of toilet facilities available, all the respondents 91 (96.8%) indicated that their facilities had flush toilets. Furthermore, a greater proportion of 45 (47.9%) of the respondents indicated that their facilities used a sewerage system as a method of excreta disposal. Consecutively, an overwhelming majority 87 (92.6%) of the respondents indicated that there was no presence of flies in improved toilets, there was visible cleanliness of toilet facilities 87 (92.6%) and there was presence of soap/detergent 92 (97.9%).\u003c/p\u003e\n\u003cp\u003eMoreover, there was the availability of protected areas for the storage of health care facility waste awaiting disposal or removal 89 (95.9%). Lastly, most 80 (85.1%) of the respondents indicated that Chemical disinfection with hypochlorite was the commonest means of treating infectious waste before disposal.\u003c/p\u003e\n\u003cp\u003eOverall Availability Score of Wash Infrastructure/Services at Health Facilities of Respondents.\u003c/p\u003e\n\u003cp\u003eThe majority 59.6% of the respondents indicated that WASH infrastructure/services was available as shown in Figure 3\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eThis shows the level of availability of healthcare infrastructure/services at health facilities of healthcare practitioners. The overall level of availability was calculated on average (mean) score of the responses to questions asked. A score of more than average(mean) was considered as available and less than the average(mean) was considered as not available. It was found that most 53(59.6%) of the respondents indicated that WASH infrastructure/services were available.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLevel of Hygiene Compliance among Respondents\u003c/p\u003e\n\u003cp\u003eTable 5 shows the responses to the level of hygiene compliance among respondents. A majority 75 (79.8%) of the respondents indicated they always washed their hands in between patient contacts. Also, a greater proportion of 87 (93.6%) of the respondents indicated that they always used alcoholic hand rubs as an alternative if their hands were not visibly soiled. On if they put used sharp articles into sharps boxes, all 94 (100%) of the respondents indicated they always did so. About 63 (67.7%) respondents indicated they always covered their wound(s) or lesion(s) with waterproof dressing before patient contacts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the gloves wearing habit of the respondents, almost all them 91 (98.9%) indicated that they always change gloves between patient contacts with an overwhelming majority also indicating they always washed their hands immediately after removal of gloves 89 (96.7%). Lastly, when asked if they reused a surgical mask or disposable Personal Protective Equipment, most of them 65 (69.9%) indicated never doing so\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure 4 shows the level of hygiene compliance among healthcare practitioners. The overall level of hand hygiene compliance was calculated on average (mean) score of the responses to questions asked. A score of more than average(mean) was considered as good and less than the average(mean) was considered as poor. It was found that most 53(56.4%) of the healthcare workers had moderate hygiene compliance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of Nosocomial Infections in Healthcare Facilities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom Table 6, the study identified 65 nosocomial infection cases among in-patients which were all surgical site infections. Bacterial agents of the surgical sites included \u003cem\u003eStaphylococcus aureus\u0026nbsp;\u003c/em\u003e(30.8%\u003cem\u003e), Klebsiella spp.\u0026nbsp;\u003c/em\u003e(20.0%)\u003cem\u003e, Pseudomonas spp\u0026nbsp;\u003c/em\u003e(15.4%)\u003cem\u003e., Proteus spp.\u003c/em\u003e (10.8%)\u003cem\u003e, Escherichia coli (\u003c/em\u003e17.0%) and \u003cem\u003eEnterococcus spp.\u0026nbsp;\u003c/em\u003e(6.0%)\u003cem\u003e.\u0026nbsp;\u003c/em\u003e(Table 6 must be on page 17).\u003c/p\u003e\n\u003cp\u003eTable 7 presents significant associations between various predictor variables and\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003elevel of hygiene compliance among respondents, following adjustment for potential confounding variables. After adjusting for the confounding effects of each predictor variable, respondents working at facilities where there is availability of WASH infrastructure/services are 0.6 times more likely to comply with hygiene practices (aOR=0.6, 95%CI=0.0-0.2, p\u0026lt;\u003cstrong\u003e0.000\u003c/strong\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003eLevel of knowledge of healthcare workers on WASH\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInadequate drinking water, sanitation, and hygiene (WASH) in healthcare facilities significantly impacts health, particularly in low and middle-income countries. Despite its importance, there is limited knowledge of the status of WASH in some of these settings (Patel et al., 2019). Meanwhile, this study showed moderately satisfactory knowledge among the healthcare workers which is similar to findings from a study in Pakistan which also showed moderate knowledge of healthcare practitioners on WASH (Afzal\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2019). Another study in Saudi Arabia showed a 52.0% level of knowledge among healthcare practitioners indicating a moderate knowledge level (Al Mutairi\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2020). \u0026nbsp;While demonstrating an overate moderate knowledge of WASH, 98.9% of participants in this study reported routine use of alcohol-based hand rubs which was in coherence with that of a previous study where 94.8% of the healthcare workers routinely used an alcohol-based hand rub (Al Mutairi\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, previous studies that examined the sensory properties and acceptability of different alcohol-based hand rubs concluded that sensory characteristics and properties of hand rubs impacted healthcare workers\u0026apos; hand hygiene compliance, hence recommends that strategies to improve hand hygiene compliance should include the accessibility of alcohol-based hand rubs, education, psychological theory, and quality improvement strategies (Mezaache et al., 2021).\u003c/p\u003e\n\u003cp\u003eDespite this, reports confirm compliance with alcohol-based hand rubs among healthcare workers has massively increased especially after the COVID-19 pandemic (Ahmadipour\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2022; Ragusa\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2021), particularly following adequate education and evidence on its efficacy in improving hand hygiene and reduce spread of infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of WASH Infrastructure and Services in Health Facilities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAvailability of WASH services in health facilities in sub-Saharan Africa has improved but remains below the global target of 80% in many countries, meanwhile, ensuring adequate access to WASH services and enforcing adherence to safety and hygiene practices in health facilities was essential to minimize the risk of COVID-19 transmission (Kanyangarara et al.,2022).\u003c/p\u003e\n\u003cp\u003eIn this study however, while healthcare facilities in the Municipality had access to adequate and improved water supply, it was noted that the water supply was sometimes sourced from piped supplies outside the facility, which fails to meet the JMP indicators requiring facilities to have piped water supplies on their premises (WHO, 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis was contrasted to reports in the study in the Bongo and Kassena Nankana West District by WaterAid Ghana which reported that 52% of healthcare facilities in the districts relied on hand-dug boreholes, 17% relied on water via indoor plumbing and 3% relied on hand dug wells (WaterAid Ghana, 2018). \u0026nbsp;About 97.9% of the healthcare practitioners indicated that water was available and pumped into all the wards. The findings indicate that HCFs are in line to meet the WHO target of 100% water coverage by 2030 (WHO, 2019b). \u0026nbsp;The findings of adequate access to safe water among health facilities in the study is similar to a study among health facilities in the Asokore Mampong Municipality by Doku\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, (2022). \u0026nbsp;However, about 41.5% of the workers indicated there were instances when water from the main water source was unavailable. Still, on the issue of intermittent water supply or shortages to HCFs, a study assessing WASH in Rwanda also indicated seasonal water shortages in HCFs (Huttinger\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2017). \u0026nbsp;This poses a serious challenge, especially in urban settings where the population and the number of clients seeking care from HCFs are large. \u0026nbsp; Furthermore, it was indicated by 96.8% that HCF had flush toilets which were mostly visibly clean (87%)\u003c/p\u003e\n\u003cp\u003eThe majority (79.0%) stated that the HCFs did not segregate waste safely into separate bins which was parallel to what has been reported in previous studies (Abebe\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2017; Yazie\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2019). In addition to that, HCFs did not treat infectious waste before disposal. Autoclaving, one of the most effective ways of sterilizing infectious waste (Windfeld\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2015), was done rarely by healthcare facilities (9.6%). The findings concur with an Ethiopian study where there was no pre-treatment of infectious wastes by the HCFs (Tadesse\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2014). \u0026nbsp;\u003c/p\u003e\n\u003ch2 id=\"_Toc146732223\"\u003e\u003cstrong\u003eLevel of Hygiene Compliance among Healthcare Practitioners\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eA large proportion of the infections acquired in healthcare facilities are attributed to cross-contamination and transmission of microbes from the hands of healthcare workers to patients (Samuel\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2010). The majority of the healthcare practitioners in the study indicated they always washed their hands regularly in between patient contacts (79.8%). \u0026nbsp;In contrast to the findings of this study, Shanu, (2011) found that only 38% of respondents\u0026apos; health workers washed their hands frequently with soap and water after patient contact. The most reported reason for noncompliance was an inadequate supply of water, soap, and towels. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRemaining on the topic of nosocomial infection, another possible source of these infections is contaminated gloves. Gloves are not only necessary for contact precautions, but also essential for preventing the transmission of infectious bacteria, viruses, and microorganisms that can spread by direct or indirect contact with an infected person or contaminated environment (Trampuz\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2004). It was found in the study that a little over half of the practitioners (55.3%) changed gloves in between patient contacts. A common reason given by health care practitioners for not changing gloves in between patient contacts is the perception that gloves remain clean as long as they appear visually unsoiled. This misconception can contribute to the transmission of nosocomial infections. This is evidenced in studies by Kpadeh-Rogers\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, (2019) where both studies found bacteria from patients on the hands of healthcare workers who had worn gloves for each patient contact. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlmost all of the respondents (93.6%) indicated that they always used alcoholic hand rubs as an alternative if their hands were not visibly soiled. Alcohol-based hand rubs have been suggested as a potential solution in high-demand situations like emergency wards (Pittet, 2001). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne finding worthy of note in this study was the fact that WHO hand-washing manuals were absent in HCFs as indicated by 65.9% of the practitioners. As a result, the hand washing compliance of healthcare practitioners according to WHO standards is not guaranteed. \u0026nbsp;Research by Uneke\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, (2014), the reason given for non-compliance with hand hygiene methods by doctors and nurses was the absence of WHO guidelines on hand hygiene and disinfection practices. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of surgical site infections in healthcare facilities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A total of 65 cases were recorded indicating a high level of nosocomial infections. In a multicenter point-prevalence survey of hospital-acquired infections in Ghana, a total of 184 health associations were recorded among healthcare facilities (Labi\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2019). According to (Sattar\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2019), surgical site infections are one of the most common nosocomial infections second only to urinary tract infections, and commonly occur between the fifth and tenth days after surgery (Mulu\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2012). The findings underscore the critical impact nosocomial infections can have on healthcare systems including the potential for extended hospital stays, increased healthcare costs, and adverse patient outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eS. aureus\u003c/em\u003e was the most common hospital-acquired pathogen among inpatients in the current study, followed by \u003cem\u003eKlebsiella spp., Escherichia coli\u003c/em\u003e., \u003cem\u003ePseudomonas spp., Proteus spp.,\u0026nbsp;\u003c/em\u003eand \u003cem\u003eEnterococcus spp.\u003c/em\u003e The bacteria isolated in this study aligns with those findings from prior research by (Oni\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2006) and (Khan\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e, 2015) suggesting consistency in the types of pathogens responsible for hospital-acquired infections. \u0026nbsp;\u003c/p\u003e\n\u003ch2 id=\"_Toc146732224\"\u003e\u003cstrong\u003eLimitations of the\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eStudy\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eData collection in the study relied on self-reporting from healthcare practitioners which could introduce social desirability bias. Participants might provide answers they believe are expected rather than reflecting their actual behaviors or knowledge, but this limitation was augmented by field observations.\u003c/p\u003e\n\u003cp\u003eAlso, there could have been selection bias in the choice of healthcare facilities or workers included in the study. For example, if only certain types of facilities or particularly compliant workers were included, the results may not accurately reflect the broader population.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eInterpretation\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study revealed that most of the healthcare workers (56.4%) had poor knowledge of WASH. Despite almost all the respondents (91.5%) that the HCFs had access to pipe-borne water supplied from outside the healthcare facility. However, about 41.5% of them indicated there were instances when water from the main water source was unavailable. Almost all the HCFs were indicated by the practitioners to have flush toilets (96.8%) with the sewerage system as the method of excreta disposal (47.9%). Furthermore, about 43.6% of the healthcare practitioners complied with most of the hygiene measures instituted within the facilities. On the treatment of infectious waste before disposal, however, most (76.9%) indicated that the waste was not treated at all. Finally, a total of 65 nosocomial surgical site infections were recorded with \u003cem\u003eStaphylococcus aureus\u003c/em\u003e emerging as the commonest pathogen.\u003c/p\u003e\n\u003cp\u003eIn conclusion, there is a good knowledge of WASH among healthcare practitioners within the Municipality. Most of the HCFs have been found to have adequate WASH resources even though the water supply is reported to suffer regular disruptions. Compliance of healthcare practitioners to hygiene and sanitation was found to be also moderate. However, the study has revealed the negative impact of WASH on patient health as a high incidence of nosocomial infections, specifically surgical site infections was recorded.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eRecommendations\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eBased on the findings from the study, the following recommendations have been made:\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eThe health authorities in various health facilities to regularly organize and carry out WASH workshops and training for the healthcare practitioners to supplement their knowledge of WASH activities and practices at the health facilities\u003c/li\u003e\n \u003cli\u003eThe issue of intermittent water supply must be addressed by exploring alternative water sources, installing backup systems, or improving the reliability of the main water source. A consistent and dependable water supply is fundamental to maintaining hygiene standards within healthcare facilities.\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;It is imperative to promote a culture of rigorous hand hygiene among healthcare workers. Hand hygiene facilities must be consistently accessible and well-stocked with soap or detergent. Regular training and reminders can reinforce the importance of this practice.\u003c/li\u003e\n \u003cli\u003eLastly, clear protocols for the proper treatment of infectious waste before disposal such as autoclaving are recommended in all health facilities. Effective management of infectious waste is crucial in preventing the transmission of nosocomial infections.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Issues:\u0026nbsp;\u003c/strong\u003eEthical clearance was sought fromthe UHAS Research Ethics Committee, with ethical approval number \u003cstrong\u003eB051\u003c/strong\u003e, before the commencement of the research. Permission was also sought from the Kwahu South Municipal Health Directorate and the administration of the hospitals that were used for the study. Written informed consent was obtained from participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest:\u0026nbsp;\u003c/strong\u003eAuthors declare no competing Interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThere is no funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contribution:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eF.A.N conceived and designed the paper and M.D. contributed to writing, I.K.B, W.K.Y reviewed the paper, contributed ideas, and wrote, and E.K.P also reviewed the final draft of the paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCredit authorship contribution statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.B.Y and M.D\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eFormal analysis, F.A.N Conceptualization, Supervision, Writing – original draft, Writing – review \u0026amp; editing. N.A.A:Writing – review \u0026amp; editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAbebe, S., Raju, R., \u0026amp; Berhanu, G. (2017). Health care solid waste generation and its management in Hawassa Referral Hospital of Hawassa University, Southern, Ethiopia. \u003cem\u003eInternational Journal of Innovative Research and Development\u003c/em\u003e,\u003cem\u003e\u0026nbsp;6\u003c/em\u003e(5). \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAfzal, M. F., Hamid, M. H., Parveen, A., \u0026amp; Hanif, A. (2019). Educational intervention to improve the knowledge of hand hygiene in pediatric residents and nurses. \u003cem\u003ePakistan Journal of Medical Sciences\u003c/em\u003e,\u003cem\u003e\u0026nbsp;35\u003c/em\u003e(3), 771.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAhmadipour, M., Dehghan, M., Ahmadinejad, M., Jabarpour, M., Mangolian Shahrbabaki, P., \u0026amp; Ebrahimi Rigi, Z. (2022). 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Nosocomial infections and their control strategies. \u003cem\u003eAsian pacific journal of tropical biomedicine\u003c/em\u003e,\u003cem\u003e\u0026nbsp;5\u003c/em\u003e(7), 509-514.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKpadeh-Rogers, Z., Robinson, G. L., Alserehi, H., Morgan, D. J., Harris, A. D., Herrera, N. B., Rose, L. J., Noble-Wang, J., Johnson, J. K., \u0026amp; Leekha, S. (2019). Effect of glove decontamination on bacterial contamination of healthcare personnel hands. \u003cem\u003eClinical Infectious Diseases\u003c/em\u003e,\u003cem\u003e\u0026nbsp;69\u003c/em\u003e(Supplement_3), S224-S227.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLabi, A., Obeng-Nkrumah, N., Owusu, E., Bjerrum, S., Bediako-Bowan, A., Sunkwa-Mills, G., Akufo, C., Fenny, A., Opintan, J., \u0026amp; Enweronu-Laryea, C. (2019). Multi-centre point-prevalence survey of hospital-acquired infections in Ghana. \u003cem\u003eJournal of hospital infection\u003c/em\u003e,\u003cem\u003e\u0026nbsp;101\u003c/em\u003e(1), 60-68.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMezaache, S., Briand-Madrid, L., Rahni, L., Poireau, J., Branchu, F., Moudachirou, K., ... \u0026amp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Roux, P. (2021). A two-component intervention to improve hand hygiene practices and \u0026nbsp; \u0026nbsp; \u0026nbsp; promote alcohol-based hand rub use among people who inject drugs: a mixed-methods \u0026nbsp; \u0026nbsp; \u0026nbsp;evaluation. \u003cem\u003eBMC Infectious Diseases\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e, 1-13.\u003c/li\u003e\n \u003cli\u003eModi, P. D., Kumar, P., Solanki, R., Modi, J., Chandramani, S., \u0026amp; Gill, N. (2017). Hand hygiene practices among Indian medical undergraduates: a questionnaire-based survey. \u003cem\u003eCureus\u003c/em\u003e,\u003cem\u003e\u0026nbsp;9\u003c/em\u003e(7).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMulu, W., Kibru, G., Beyene, G., \u0026amp; Damtie, M. (2012). Postoperative nosocomial infections and antimicrobial resistance pattern of bacteria isolates among patients admitted at Felege Hiwot Referral Hospital, Bahirdar, Ethiopia. \u003cem\u003eEthiopian journal of health sciences\u003c/em\u003e,\u003cem\u003e\u0026nbsp;22\u003c/em\u003e(1), 7-18.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eOni, A., Ewete, A., Gbaja, A., Kolade, A., Mutiu, W., Adeyemo, D., \u0026amp; Bakare, R. (2006). Nosocomial infections: surgical site infection in UCH Ibadan, Nigeria. \u003cem\u003eNigerian Journal of Surgical Research\u003c/em\u003e,\u003cem\u003e\u0026nbsp;8\u003c/em\u003e(1).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePatel, K., Kalpana, P., Trivedi, P., Yasobant, S., \u0026amp; Saxena, D. (2019). Assessment of water, \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; sanitation and hygiene in HCFs: which tool to follow? Reviews on Environmental \u0026nbsp; \u0026nbsp; Health, 34(4), 435-440.\u003c/li\u003e\n \u003cli\u003ePittet, D. (2001). Improving adherence to hand hygiene practice: a multidisciplinary approach. \u003cem\u003eEmerging infectious diseases\u003c/em\u003e,\u003cem\u003e\u0026nbsp;7\u003c/em\u003e(2), 234.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRagusa, R., Marranzano, M., Lombardo, A., Quattrocchi, R., Bellia, M. A., \u0026amp; Lupo, L. (2021). Has the COVID 19 virus changed adherence to hand washing among healthcare workers? \u003cem\u003eBehavioral sciences\u003c/em\u003e,\u003cem\u003e\u0026nbsp;11\u003c/em\u003e(4), 53.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSamuel, S., Kayode, O., Musa, O., Nwigwe, G., Aboderin, A., Salami, T., \u0026amp; Taiwo, S. (2010). Nosocomial infections and the challenges of control in developing countries. \u003cem\u003eAfrican Journal of Clinical and Experimental Microbiology\u003c/em\u003e,\u003cem\u003e\u0026nbsp;11\u003c/em\u003e(2).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSattar, F., Sattar, Z., Zaman, M., \u0026amp; Akbar, S. (2019). Frequency of post-operative surgical site infections in a Tertiary care hospital in Abbottabad, Pakistan. \u003cem\u003eCureus\u003c/em\u003e,\u003cem\u003e\u0026nbsp;11\u003c/em\u003e(3).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShanu, S. (2011). A study to assess the hand hygiene practices among health care workers in CSICU, SCTIMST.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTadesse, M. L., \u0026amp; Kumie, A. (2014). Healthcare waste generation and management practice in government health centers of Addis Ababa, Ethiopia. \u003cem\u003eBMC public health\u003c/em\u003e,\u003cem\u003e\u0026nbsp;14\u003c/em\u003e(1), 1-9.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTrampuz, A., \u0026amp; Widmer, A. F. (2004). Hand hygiene: a frequently missed lifesaving opportunity during patient care. Mayo clinic proceedings,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eUneke, C. J., Ndukwe, C. D., Oyibo, P. G., Nwakpu, K. O., Nnabu, R. C., \u0026amp; Prasopa-Plaizier, N. (2014). Promotion of hand hygiene strengthening initiative in a Nigerian teaching hospital: implication for improved patient safety in low-income health facilities. \u003cem\u003eBrazilian Journal of Infectious Diseases\u003c/em\u003e,\u003cem\u003e\u0026nbsp;18\u003c/em\u003e, 21-27.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWaterAid Ghana. (2018). Situational analysis on WASH in healthcare facilities in Bongo and\u003c/li\u003e\n \u003cli\u003eKassena Nankana West. https://washmatters.wateraid.org/sites/g/files/jkxoof256/files/wash-in-healthcare-facilities-in-ghana.pdf\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWHO. (2019b). Water, sanitation and hygiene in health care facilities: practical steps to achieve universal access to quality care.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWHO, U. (2020). Global progress report on water, sanitation and hygiene in health care facilities: fundamentals first. \u003cem\u003eGeneva: World Health Organization\u003c/em\u003e, 2020.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2023). \u003cem\u003eAddressing climate change: supplement to the WHO water, \u0026nbsp;sanitation and hygiene strategy 2018\u0026ndash;2025\u003c/em\u003e. World Health Organization.\u003c/li\u003e\n \u003cli\u003eWindfeld, E. S., \u0026amp; Brooks, M. S.-L. (2015). Medical waste management\u0026ndash;A review. \u003cem\u003eJournal of environmental management\u003c/em\u003e,\u003cem\u003e\u0026nbsp;163\u003c/em\u003e, 98-108.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eYazie, T. D., Tebeje, M. G., \u0026amp; Chufa, K. A. (2019). Healthcare waste management current status and potential challenges in Ethiopia: a systematic review. \u003cem\u003eBMC research notes\u003c/em\u003e,\u003cem\u003e\u0026nbsp;12\u003c/em\u003e, 1-7.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 7 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"WASH, Health Care Facilities, Patient Safety, Nosocomial Infections, Ghana","lastPublishedDoi":"10.21203/rs.3.rs-6123709/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6123709/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe provision of WASH services in healthcare facilities (HCFs) is fundamental for the provision of quality care. Therefore, this study assessed WASH status using standard WHO indicators in health facilities and its impacts on patients\u0026rsquo; health in three HCFs.\u003c/p\u003e\u003ch2\u003eMethodology:\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted among 221 healthcare practitioners working in the three HCFs, in addition to an observational checklist. Availability of WASH services was assessed using a validated WASH Conditions (WASHCon) tool comprising structured questionnaires and a records review tool.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study revealed that most of the healthcare workers (55%) had moderate knowledge of WASH and all HCFs (100%) had access to pipe-borne water supplied from outside the healthcare facility. However, about 63.4% of respondents indicated that there was an erratic supply when the main water source was unavailable. Furthermore, about 90% of the healthcare practitioners complied with most of the hygiene measures instituted within the facilities. Finally, the microbiology laboratory register was used to review the records of surgery patients with post-operative infections at their surgical sites whilst in the health facility. A total of 63 surgical site infections were recorded, with \u003cem\u003eStaphylococcus aureus\u003c/em\u003e emerging as the commonest pathogen.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eHealthcare practitioners in the three HCFs possess a moderate level of knowledge regarding WASH practices. Most healthcare facilities (HCFs) in this municipality have sufficient WASH resources, even though they frequently experience interruptions in the water supply. Healthcare practitioners demonstrate a commendable level of adherence to hygiene and sanitation protocols. However, the research findings highlight a concerning issue: the negative impact of WASH on patient health, evidenced by a notably high occurrence of nosocomial infections, particularly surgical site infections.\u003c/p\u003e","manuscriptTitle":"Water Sanitation and Hygiene (WASH) Implementation Status and implications on Surgical Site Infections: the case of three Hospitals in the Kwahu Municipality-Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-17 09:30:14","doi":"10.21203/rs.3.rs-6123709/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":"443c7d4b-9c34-4e2e-8ad8-1c40e57d4f43","owner":[],"postedDate":"March 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-17T09:30:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-17 09:30:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6123709","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6123709","identity":"rs-6123709","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}