Informing Water, Sanitation and Hygiene (WASH) communication through local expertise: a qualitative study with healthcare providers in Northern Uganda

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Mugambe, Solomon Tsebeni Wafula, and 17 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7546174/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Information, Education, and Communication (IEC) materials relay information crucial for improving WASH behaviours in healthcare settings. However, due to a limited in-depth understanding of the status and the involvement of local experts in the IEC material development process, improvements in WASH in HCF remain suboptimal. This qualitative descriptive study employed seven focus groups and nine key informant interviews with local experts to enhance our understanding of WASH status, assess the availability of IEC materials, identify priority topics for messaging, and highlight considerations for optimising their use. This study revealed that HCFs faced numerous challenges, including intermittent supply, low-yield water supply, poor water quality, congestion, inadequate operation and maintenance of water sources, open defecation, limited hand hygiene infrastructure, poor environmental hygiene, and weak healthcare waste management practices. The absence of appropriate IEC materials to promote desired WASH behaviours further compounded the suboptimal status. To address the suboptimal status, local experts recommended that the messages on IEC materials should tackle the attitudes and practices of patients, caregivers, and healthcare providers, as well as water safety, sanitation, and hygiene, healthcare waste management, and environmental cleaning, while being inclusive and considering the display and language used by the target community. The study highlights the crucial role of local experts in guiding the development and utilisation of IEC materials to promote WASH behaviours and enhance conditions in healthcare facilities. Earth and environmental sciences/Environmental sciences Health sciences/Health care IEC Local expertise WASH communication stakeholders Figures Figure 1 Background Water, sanitation, and hygiene (WASH) in healthcare facilities (HCFs) remains a global public health challenge [ 1 – 4 ]. Available evidence indicates that in 2021, 47% of HCFs did not have water from an improved source on their premises, 21% lacked basic sanitation services, 68% lacked functional hand hygiene facilities at points of care, and within 5 metres of toilet blocks, and 66% did not segregate, treat or dispose of waste safely [ 2 ]. In 2023, 9% of the global population (742 million) used HCFs deficient in water services, 8% (660 million) had no access to toilets or used unimproved sanitation facilities, and 9% (722 million) could not access functional hand hygiene facilities at points of care or toilets [ 1 ]. The WASH crisis is more pronounced in low-and middle-income countries (LMICs) [ 5 – 10 ], where in 2024, 59% of HCFs lacked a basic water service, 69% did not have a basic sanitation service, 68% had a basic hand hygiene service, 19% had a basic environmental cleaning service, and only 39% had a basic waste management service [ 1 ]. In 2022, 17.2% of HCFs in Uganda did not have a water service, 10% had no access to a sanitation facility, 11.9% had no hand hygiene service, 44.3% reported a deficiency in basic waste management services, and 31.9% had no environmental cleaning service [ 11 ]. Amuru and Nwoya districts, the focus of this study, are no exception to Uganda’s dire WASH situation in HCFs. The proportions of HCFs without any service in Amuru in 2022 were: 16.1% for water and sanitation services, 38.7% for hand hygiene, and 32.3% for environmental cleaning. Additionally, 5% of HCFs in Nwoya lacked water or sanitation services, 60% had basic hand hygiene, and 25% had limited environmental cleaning services [ 11 ]. Inadequate infrastructure and limited awareness of desirable WASH behaviours, combined with a lack of decision-making support tools, create environments where suboptimal practices such as the consumption of unsafe water, indiscriminate waste disposal, open defecation, and inconsistent hand hygiene become normalised [ 12 – 15 ]. Suboptimal WASH practices heighten the risk of disease transmission, reduce trust, efficiency, staff morale and healthcare service uptake [ 13 , 16 – 19 ]. To counter the undesirable WASH practices, the use of Information, Education, and Communication (IEC) materials as constant reminders of the desired behaviours in HCFs is recommended [ 20 – 24 ]. IEC materials, such as printed brochures, posters, leaflets, mhealth messages, and mass media broadcasts [ 6 , 22 , 24 – 27 ], equip HCF users with knowledge critical for the operation and maintenance of WASH infrastructure, thus contributing to sustainability [ 17 , 28 – 30 ]. Incorporating well-developed IEC materials into WASH programs is also crucial for enhancing the adoption of proper practices and ultimately improving healthcare outcomes [ 31 , 32 ]. IEC material development follows a structured, iterative process to ensure relevance, clarity, and impact [ 33 , 34 ]. The process starts with a formative assessment to understand the determinants of preventive behaviours, potential knowledge gaps, and preferred IEC materials [ 35 ]. The formative stage is followed by selecting the most appropriate IEC materials, considering the target audience’s literacy levels, cultural context, and preferred communication channels to ensure maximum relevance and impact [ 33 , 35 , 36 ]. This stage also involves evaluating the strengths and limitations of various IEC materials, often combining multiple formats for greater reach and reinforcement. Upon selecting the preferred IEC materials and evaluation of their strengths and limitations, the design team develops a creative brief to guide content creation, outlining key messages, tone, format, and delivery strategy. The design team then develops a prototype by creating new content or adapting existing resources [ 33 , 37 ], which undergoes pre-testing to obtain feedback from the target audience. During the pre-test, the design team assesses comprehension, attractiveness, and persuasiveness. Based on pre-test results, materials are revised and refined to enhance clarity and resonance. The development process ends with the dissemination, monitoring and evaluation of the impact of IEC materials through behavioural outcomes [ 38 – 40 ]. Throughout the IEC material development process, engaging local expertise (referred to as individuals involved in the delivery of healthcare services in this paper) is essential for cultural relevance, community trust, and accurate messaging. A bottom-up approach to IEC material development enhances credibility and acceptance, facilitates access to community networks and alignment with societal norms and priorities [ 36 , 38 , 39 , 41 ]. While the participation of local expertise in the IEC material development process provides nuanced insights into community perceptions and barriers to behaviour change [ 36 , 42 , 43 ], our understanding of perspectives of local expertise on the status of WASH in HCFs, priority topics for messaging, and the key considerations for the development of IEC materials on WASH in HCFs is limited [ 44 ]. Drawing on empirical evidence gathered through local expertise, this paper addresses three key questions: 1) What is the current status of WASH in HCFs in Amuru and Nwoya districts? 2) What critical topics must be addressed by IEC materials on WASH in HCFs, and 3) What considerations must be considered when designing and disseminating WASH IEC materials? By considering the local experts' perspectives on message development, dissemination, and feedback loops, IEC materials can be more impactful and foster ownership and sustainability [ 41 , 45 ]. Materials and methods Study setting This manuscript discusses data from healthcare providers from eight HCFs (Fig. 1 ) in Amuru and Nwoya districts, located in Northern Uganda within the Acholi sub-region. The Amuru district headquarters are located approximately 60 kilometres northwest of Gulu city, while the Nwoya district headquarters are 44 kilometres southwest of Gulu City. Amuru district has a population of 247,574, among whom 126,972 are female [ 46 ]. Nwoya has a population of 220,593, among whom 112,845 are female [ 46 ]. Amuru has a total of 42 HCFs, among whom 26 are public, nine are Private for Profit (PFP), and seven are Private Not for Profit (PNFP). Based on the level of HCFs, Amuru district has nine clinics, 22 Health Centre (HC) IIs, ten HC IIIs, and one HC IV [ 47 ]. Nwoya has a total of 23 HCFs—13 public, five PFP, and five PNFP. Based on the level of HCFs, Nwoya district has 19 HCIs, three HCIIIs, and one hospital [ 47 ]. Amuru and Nwoya are post-conflict recovery settings, having suffered from the 1986–2006 civil war between the Government of Uganda and the Lord's Resistance Army [ 48 ]. The war not only led to massive deaths and destruction of WASH infrastructure but also disrupted health, social and economic systems [ 49 – 51 ]. About 63% of northern Uganda is multidimensionally poor—are deprived in education, living standards, employment and financial inclusion, and health [ 52 ]. Only 20.9% of households in Amuru and 20.4% of those in Nwoya use improved sanitation facilities, while 59.6% of households in Amuru and 58.1% of those in Nwoya use an improved water source [ 46 ]. HCFs in the region also face significant challenges in accessing adequate WASH services [ 53 – 55 ]. Study design We employed a qualitative descriptive design to explore perspectives of local expertise on the status of WASH in HCFs, priority topics for messaging, and the key considerations for the development of IEC materials on WASH in HCFs. A qualitative descriptive design is suitable for describing under-researched phenomena rather than explaining them [ 56 , 57 ], as was the case with perspectives of the local expertise on IEC material development. This design recognises the nature of the problem under study, captures straightforward descriptions of experiences and perceptions, and enables presentation of findings in a manner that closely reflects the phenomenon [ 58 – 60 ]. The qualitative descriptive design is ideal for studies that do not focus on increasing theoretical or conceptual understanding, but rather contributing to change and quality improvement in practice settings [ 58 , 61 ]. Study participants and data collection These study participants included local experts, whom we defined as individuals involved in the delivery of healthcare services. Based on the study’s context, the local experts included HCF managers, departmental in-charges, community health workers (village health teams or VHTs), the infection prevention and control teams, environmental health staff such as health inspectors and health assistants, and district healthcare managers. To elicit information on the status of WASH in HCFs, priority topics for messaging, and the key considerations for developing IEC materials on WASH in HCFs, we conducted nine key informant interviews (KIIs), informed by the level of theoretical saturation [ 62 ]. During the KIIs, we asked participants about WASH, healthcare waste management, and environmental cleaning in HCFs, as well as the availability, content, and information gaps in IEC materials on WASH. Additionally, we inquired about their preferred medium for disseminating WASH-related messages. Additionally, we used a focus group discussion (FGD) guide informed by an extensive review of literature [ 3 , 13 , 16 , 17 , 22 , 29 , 33 , 37 , 41 , 54 , 63 , 64 ] to collect data from seven FGDs with members of the Infection Prevention and Control (IPC) committees and VHTs in the study HCFs. During the focus groups, we first explored the local experts' views on the status of water, sanitation, hygiene, environmental cleaning, and healthcare waste management, as well as related behaviours among patients, caregivers, and healthcare providers in the study HCFs. Their insights were invaluable in gaining an in-depth understanding of the behaviours and status of WASH. We then asked the study participants about the availability and information relayed on IEC materials, the nature of information or messages to disseminate on waste management in HCFs, and strategies to enhance the utilisation of IEC materials. Throughout the discussions, research assistants took detailed notes and recordings to capture the valuable insights shared. Subsequently, the recorded discussions were transcribed verbatim before analysis. Data management and analysis The research team transcribed all the digital audio recordings verbatim. We shared the KII transcripts with the research participants for review and verification of the accuracy of the information contained in (a process known as respondent validation). Respondent validation ensured accurate representation of the participants' perspectives and voices in the analysis [ 65 ]. The research team reviewed and cleaned the interview transcripts in preparation for data analysis. We used ATLAS—ti version 24.0 software to facilitate analysis and coding. We used the thematic content analysis approach to describe, create a rich, detailed, and complex account of the study phenomenon, and to interpret perspectives from textual information [ 66 ]. Thematic content analysis is ideal for studies that utilise a qualitative descriptive design because it does not require a theoretical and conceptual framework [ 67 , 68 ]. The thematic content analysis approach involved reading the transcripts several times to familiarise themselves with the data, identifying key words, developing codes and defining the codebook based on the study objectives, development of themes, conceptualisation through the interpretation of keywords, codes, and themes, and the development of a conceptual model [ 69 ]. During the coding process, we applied paraphrases or labels (codes) to passages that were deemed important. We used an abductive approach to coding. We used the inter-coder agreement tool to ascertain the extent of agreement between multiple individuals coding a given transcript. Where the inter-coder agreement fell below 90%, the coders held a meeting to resolve any discrepancies. Results Distribution of the study participants This study presents demographic characteristics of 42 FGD participants and nine KIs from Amuru and Nwoya districts. The age of the FGD participants ranged from 24 to 64, while that of the KIs was between 27 and 47. Twenty-five of the FGD participants were from Nwoya District, 16 were from Health Centre III in Amuru District, 15 were male and from Nwoya District, 14 had attained tertiary education as their highest level of education and were from Amuru District, and 15 were healthcare workers from Amuru District. Seven of the KIs were from Nwoya District, including four hospital staff, five females, three with a bachelor’s degree, and six clinical staff. (Table 1 ). Table 1 Demographic characteristics of study participants Description Response District Amuru Nwoya Distribution of FGD participants (N = 42) Number of participants 17 25 Level of health service provision Health Centre III 16 14 Hospital 0 12 Sex of the respondent Female 9 10 Male 8 15 Marital status Married/Cohabiting 15 21 Single 2 4 Education level Primary 0 2 Secondary 3 10 Tertiary 14 13 Role of the respondent Healthcare worker 15 13 Public servant 1 0 Village health team member 1 12 Key informant participants (N = 9) Number of key informants 2 7 Level of health service provision District health team member 1 0 Health Centre III 1 3 Hospital 0 4 Sex of the respondent Female 0 5 Male 2 2 Education level Master’s degree 1 0 Bachelor's degree 1 3 Professional certificate 0 4 Role of the respondent Health educator/promoter 0 1 Healthcare service manager 1 0 Clinical staff (nurses, midwives and doctors) 1 6 Status of water, sanitation, and hygiene Water supply Inadequate water supply All HCFs found access to water a challenge, with two HCFs spending 2–4 years without a reliable, safe water supply, and another having no water source on the premises. To illustrate the challenge of water supply, it was mentioned in one FGD with IPC committee members that: “ Water is a problem. We have been without water for two years. The only water supply is the borehole, and it is at the administration block." The majority of the HCFs did not have a piped water supply and often relied on boreholes, except during the rainy season when rainwater harvesting became an alternative. A low yield and congestion due to sharing water sources with the community were also challenges contributing to the inadequacy. Aside from the HCFs that had a more reliable water supply, healthcare providers mentioned that water did not reach all the wards, as illustrated in this quote: " No water supply, so it is a problem. We do not have a direct water supply to the ward. We are supposed to have flowing water, but our taps do not have water flowing through them. The taps are non-functional, but we have nearby boreholes where we obtain Water (HCF in charge). The challenge of water reaching all the HCF departments was also expounded by IPC committee members in a focus group discussion: " The water supply is there because we have two boreholes and a tank. However, some departments are lacking adequate water, and they have to move a distance to the water supply source.” An intermittent power supply compromised the water pumping, resulting in an inadequate water supply. In some HCFs, the burden of an inadequate water supply fell on patients and caregivers, who healthcare providers requested to fetch water over long distances, as illustrated in this quote: “ The attendants assist us in fetching water and pouring it into various drums in the facility, as we, the health workers, cannot line up to fetch Water (HCF in-charge). A limited supply of water also compromised sanitation and hygiene, as well as compliance with other infection prevention and control (IPC) measures, including the sterilisation of medical equipment. Healthcare providers, including those in the maternity and surgical departments, had to resort to the use of alcohol-based hand rub even when it was not appropriate, thus compromising the quality of healthcare. “IPC is a challenge in our facility since we have no water. We end up using only sanitiser, so we struggle to do our roles in the wards.” (FGD with IPC committee members). Unsatisfactory water safety The water quality was not satisfactory, yet HCFs did not have treatment options such as chlorination, as explained in one of the FGDs with IPC committee members: " The water in our facility and the community that we use is not safe. We do not have Water Guard (chlorine pellets/tablets) for treating the water.". The water chain, too, was not safe. HCFs had to use dirty jerrycans to fetch water from rainwater tanks, which compromised water safety. To illustrate challenges with water safety, the FGD with community health workers revealed that: " People use rainwater, which is not safe. The containers they use are often dirty, so I think the water is not safe." Aside from that, the water in some of the rain tanks had overstayed, which raised questions about its safety, as reflected in this quote: " We use jerrycans to fetch water from the wells or use rainwater in the tanks, which has its challenges. The rainwater in the tanks has overstayed, and it is what we use." (FGD with IPC committee members). In one of the HCFs, respondents mentioned that some patients and caretakers/attendants cleaned themselves, and others disposed of water containing blood at the boreholes: " The mothers clean themselves and pour water containing blood at the borehole." (FGD with IPC committee members). Despite the unsatisfactory water quality, it was rare for the district staff to conduct water quality tests on boreholes. None of the HCFs reported water quality assessments more than once for a given year, and two reported tests last being done more than five years ago: " Water is not very safe; we use borehole water, but we are not sure of where it comes from, so the safety is not guaranteed. We do test it, but it is not a regular process. It was last tested one year ago. The water quality analysis is typically conducted, but it is infrequent. There are no funds to carry out the process regularly (KII with an IPC focal person). In one district, the health inspectorate staff tested the borehole water after the community expressed fears that it was contaminated: " They rarely test the water from the boreholes. At one point, they (the community) felt the water was contaminated, so they (district authorities) had to come to test it (HCF manager). Poor operation and maintenance Water supply infrastructure, especially boreholes, was reported to break down, thus slowing the delivery of healthcare services: “ The piped water supply has been relatively regular. However, the system continues to fail us, the service providers (healthcare providers). It keeps breaking down, and they (technicians) keep coming back to solve the same issues. The only option we have is to install two boreholes at the facility. We also have pumping points, which pump water into the storage tanks, and pipes that transport water to the tanks, supplying the various departments of the hospital. The issue is that the water pumping to the tanks has problems, as it frequently breaks down. It is currently down, so we have resorted to using boreholes and water tanks (HCFmanager). Healthcare facilities that had a more reliable water supply also struggled with operational and maintenance issues. Due to the frequent use, the breakdown of the water supply infrastructure in HCFs was typical. The IPC committee members acknowledged water supply interruptions due to non-functionality of the borehole at the time of the interviews, as expounded in this quote: “ We do not have running water in the taps, and sometimes the borehole breaks down, thus slowing service delivery.” It was the responsibility of the HCFs to repair the boreholes in the event of a breakdown. At times, HCFs lacked the resources to undertake repairs, prompting patients, attendants, and healthcare providers to fetch them from neighbouring communities with boreholes. “ We have experienced a lack of water, and that was last year when the boreholes broke down, and it took months to be repaired since we had to wait for the PHC funds. Without the PHC funds, we would not have been able to repair the borehole. So, people had to get water from neighbouring communities that had boreholes (KII with an IPC focal person). Sanitation District healthcare managers, HCF staff, and community healthcare workers (also known as village health teams) acknowledged that the sanitation situation in all healthcare facilities was in a dire state. Open defecation was common in all HCFs and was primarily attributed to the poor state of sanitation facilities and limited access due to inadequate and poor operation and maintenance. Inadequate sanitation facilities Sanitation facilities in most healthcare facilities were inadequate. Some HCFs lacked sex-segregated sanitation areas, while in others, healthcare staff had to share toilets with patients. The conditions of the sanitation facilities were often poor, with dirty environments, maggot infestations, and unpleasant odours that limited their usability. As stated by one community health worker during an FGD, “The latrines are dirty, smelly, and have maggots. They are not separated, so men and women sometimes use the same latrines.” Due to the inadequate sanitation facilities, some patients resorted to open defecation. One community health worker noted, “The community just misuses the compound and practices open defecation, making the spread of infection easy.” A district healthcare manager highlighted the severity of the situation: “Sanitation is poor because we have too few latrines. We have approximately 100 patients at this HCF, but they can only use one latrine, and the hygiene is also poor.” Additionally, some HCFs lacked adequate bathing facilities for the maternity ward, while others had poorly maintained bathrooms. One community health worker expressed concern during the FGD, stating, “Sanitation is deplorable, especially in the maternity ward, where mothers do not have a place to bathe. There is only one bathroom, and sometimes the drainage gets blocked.” Poor operation and maintenance The majority of the healthcare facilities had poorly maintained toilets. Some HCFs had sanitation facilities with cracked walls and slabs, while others had grass growing in the toilets. It was reported that due to a lack of anal cleansing materials, users opted for the toilet walls for anal cleansing, which increased the risk of the spread of diseases. “ Patients do not know how to use the toilets. They put faeces on the walls, and children defecate on the toilet floors or slabs. They (patients) do not have toilet paper to use for anal cleansing. When the lab (laboratory) people (staff) request a stool sample, they (patients) defecate openly purposely for that (FGD with community health workers)." Poor operation and maintenance were attributed to the non-involvement of the community and patients in sanitation-related activities, including cleaning. The non-participation of the community and patients in the operation and maintenance of sanitation facilities was attributed to a lack of awareness about infection prevention and control. Thus, the community and patients did not appreciate the value of effective operation and maintenance, nor did they value good sanitation. In the majority of the HCFs, it was difficult to operate and maintain sanitation facilities due to a lack of running water, as expounded in one of the FGDs with community health workers: " The cost of maintenance of the toilets that use water is becoming high and tiresome. We have a broken toilet system because there is no water. The inpatient toilet is also overused and violated. Remember, we pour water from the drums (FGD) with the help of community health workers. Under such circumstances, waterborne toilets often get blocked, prompting the HCFs administration to lock them up/ deny patients access. A lack of access to sanitation facilities was reported to result in open defecation. “ There is open defecation in the compound of the facility because the toilets lack water, so they end up using the free areas like in the corridors of the toilets and the bathrooms of the toilet facilities” (FGD with community health workers). Due to a lack of janitorial staff, the cleaning of wards and toilets in some HCFs was sometimes performed by patients or their caregivers. Although a few believed that the sanitation situation was not too bad, District healthcare managers acknowledged the challenge of operating and maintaining sanitation facilities. One of the HCF managers pointed out that some patients used stones and maise combs as anal cleansing materials, which consequently blocked the toilets. “ Our sanitation is okay. The only concern is the misuse of the toilet facilities. People (patients) use all sorts of funny things to clean themselves. They use stones and maise combs that fill up the toilets.” To mitigate the challenge of poor operation and maintenance, some HCFs utilised Continuous Medical Education (CME) sessions and outpatient department (OPD) health talks to educate healthcare providers and patients, respectively, on the operation and maintenance of sanitation facilities. “ We have CMEs and the Quality improvement team to identify and talk about things like sanitation (HCF manager). Concerning patient sensitisation, one healthcare manager mentioned that: “Also, we provide health education to patients on how to use them (sanitation facilities) (HCF manager). Hand hygiene Hand hygiene among patients, attendants, and healthcare providers was generally poor. This was attributed to limited access to water, low awareness of the benefits of hand hygiene, a negative attitude, and the non-functionality of hand hygiene infrastructure. The challenge of access to water for hand hygiene was expounded in one of the FGDs: "Tap water is not flowing anymore. We have relied on only one water source—the borehole, which makes hand hygiene somewhat challenging. Handwashing facilities are also broken, particularly at the entrance to the gate. We cannot pour water for hand washing!” (FGD with community health workers). The nature of soap also affected hand hygiene compliance. Patients, attendants, and healthcare providers feared washing their hands because the available soap (bar soap) made their hands dry and had an unpleasant smell. One of the healthcare facilities' in-charges mentioned that: "The patients and the health workers used to hate handwashing because of the blue soap (bar soap), but they now wash due to the good-smelling liquid soap (KII with an HCF in charge). In one of the healthcare facilities, the in-charges reported those who did not comply with the rules of hand hygiene to the higher committees for corrective action, as expounded in this quote: "There are difficult people who do not comply with the rules on hygiene. If they fail to abide by them, we report them to the relevant higher committees. The health workers are self-driven regarding washing hands; the handwashing points are almost in every unit." Environmental hygiene Generally, environmental hygiene was poor in most HCFs, and this was attributed to inadequate supervision, lack of work plans, and janitorial staffing. " Environmental hygiene is still poor in the facilities due to poor supervision. The place is not slashed, the outpatient and inpatient wings' floors are not mopped, and surfaces are not dusted. The potters (cleaners) also do not have work plans due to poor supervision (District healthcare manager). In addition to a lack of cleaning supplies, such as soap, due to limited funding, a negative attitude hindered environmental hygiene. Due to a shortage of supplies, some healthcare providers borrowed from the district health office to clean, as illustrated in this quote: As a facility, we lack materials and supplies for cleaning, and when we have a shortage, we usually obtain or borrow from the district health office. In a financial year, we can receive supplies once or twice (according to the HCF manager). The healthcare providers singled out male nurses for being reluctant to contribute to environmental cleaning in some HCFs: " The attitudes of the community and healthcare providers, especially the male nurses who feel special and do not want to clean, but it is self-behaviour (HCF manager). Due to staff shortages, healthcare providers in a few healthcare facilities requested support from patients and caregivers to help clean the wards, as illustrated in this quote: "We have a challenge with the cleaners." We have one cleaner, so we join hands with the patients to clean the wards. The cleaner is responsible for the OPD, the compound, and the toilets. Healthcare waste management Despite the mixed findings on healthcare waste management, it is essential to acknowledge the unwavering commitment of healthcare facilities to this cause. None of the facilities or respondents reported waste management as satisfactory, but those that rated it as fair demonstrated a strong commitment. These facilities made efforts to segregate waste, used colour-coded bins with bin liners, and had waste collected by a government-contracted waste company. One IPC committee member highlighted these efforts, stating: " The bin liners are in plenty and they are enough so every morning we change the containers that were used the day before and replace them with clean and fresh ones, like black for non-infectious, yellow for the infectious, and red for highly infectious. These are segregated according to their colour, making it easy. We dispose of waste correctly since we know the harm it (poor healthcare waste management) brings, like causing diseases to others. The sharps are in the right place, the sharp box and the cotton with blood we put in the red bin liners. Then, other waste without blood is disposed of in a yellow bin liner, while paper is placed in a black liner for easy handling. The government supplies all these bin liners, and they are sufficient and in ample supply. They are supplied by the National Medical Stores (NMS). Sometimes, when they get finished, we borrow or get them from other facilities (healthcare facilities) (KII with an IPC committee member). Some HCFs had waste management infrastructure, including incinerators and placenta pits that were located far away for the safety of HCF users. Others had staff to guide healthcare waste management: “ In this facility, we have a staff member to guide the waste management activity. The porter is not even doing the work.” (FGD with community health workers). Regarding the presence of waste management infrastructure, one of the IPC committee members mentioned that: “We have an incinerator where we burn waste and a well-constructed place for burning the waste” (FGD with community health workers) . There were also posters to remind healthcare providers to manage healthcare waste safely: “The bins have posters showing the segregation of the wastes like infectious and non-infectious wastes.” (FGD with members of the IPC committee). Poor healthcare waste management While a few HCFs reported a fair state of waste management, the majority reported a poor status, underscoring the urgent need for improvement. Some patients and healthcare providers lacked knowledge of waste management and were negligent in segregating waste, despite receiving instructions. The lack of waste bins and IEC materials in HCFs led to the collection of waste in inappropriate bins, and contractors often delayed waste collection for final disposal. In some cases, available incinerators were not properly fenced off, could not attain the required temperatures, and some HCFs lacked ashpits to control indiscriminate disposal of the ash. The severity of the poor healthcare waste management challenge was vividly described in the following quote: " People are often reluctant to put waste in the designated waste bins. They throw waste anywhere in any bin. At times, bin liners of different codes are placed in the wrong bins due to a lack of the correct bin liners. Because we lack the appropriate containers, sharps are disposed of in the wrong bins, which disturbs the people who come to collect the waste for final disposal. Sometimes, the responsible personnel delay picking up the waste for final disposal. The incinerator is up to standard, but it is far, not fenced, and when filled, it generates unpleasant smells (KII with a member of the IPC committee). Some patients and attendants also indiscriminately dumped household waste at HCFs, as illustrated in one of the FGDs with IPC committee members: " The only challenge we have is that some patients come with household waste, like rubbish that they litter at the HCF. There is a heap of rubbish behind the HCF." Poor waste management posed a health risk to HCF users, including children. " We burn the rubbish locally and scatter the rubbish, which is very dangerous for the kids (children) who play around the pit since the waste is infectious." (KII with a member of the IPC committee). Overall, the poor WASH status in all HCFs was attributed to inactive and ineffective IPC committees, as well as a negative attitude among patients, attendants, and healthcare providers. The role of the IPC committee in influencing healthcare waste management practices was expounded in the following quote: " The IPC committee is not fully functional because they know we should meet monthly, but we no longer have meetings monthly. We could have meetings weekly or monthly, but that was during the COVID era, and we received funds to support the IPC–WASH function in the hospital. We could get funding from the other stakeholders and partners (FGD with IPC committee members). The IPC committee used to meet regularly at the peak of the COVID-19 pandemic; however, this had changed due to a lack of resources. " I am a member of this committee, and I work in the LAB (laboratory). I remember during the times of the outbreaks we could meet every week, but the committee is almost dead; we have not had a meeting since the COVID era (peak of COVID-19 in Uganda) (FGD with IPC committee members). Healthcare providers, including those on the IPC committees, often had a negative attitude towards healthcare waste management and lacked self-motivation, except during outbreaks. Besides, infrequent training on IPC/WASH, a lack of work plans and indicators for measuring progress and poor supervision hampered healthcare waste management as elaborated in this quote: "I think they (healthcare providers) lack self-drive, they cannot drive themselves unless there is some sort of outbreak, so basically, it is the attitude (negative attitude)." (District healthcare manager). To improve healthcare waste management, participants recommended a refresher training on WASH/IPC, as the previous one had been conducted almost two years ago. We lack knowledge on IPC and WASH, so a refresher training on these topics is necessary. The last training was conducted two years ago, in response to the COVID-19 outbreak. We need meetings to discuss the challenges we face (KII with a HCF manager). Availability of IEC materials on WASH Generally, HCFs did not have adequate IEC materials to promote desired WASH and IPC behaviours. “ There are some wards with these IEC materials, for example, the general ward. There are no adequate IEC materials (FGD with IPC committee members). Neither the respective districts nor the HCFs had the required financial resources to develop or provide the required IEC materials. Some HCFs requested IEC materials on WASH and IPC, but due to the diversity of dialects, they were unable to access them. However, the process of developing and approving IEC materials was also lengthy. Some HCFs had a few IEC materials; however, these were obsolete and did not cater to users with special needs, such as the blind, individuals with limited mobility, and illiterates. Commenting on the availability of IEC materials, it was noted in one of the FGDs that the posters are outdated and no longer readable. They gave them to us during the COVID-19 pandemic. We lack IPC information and messages for people with special needs, like the blind, those who cannot read, or the disabled. So, when making the IEC material, they should cater to them (FGD with IPC committee members). Some IEC materials were also in languages that could not be read or understood by the user community and were illegible, as expounded in this quote: The posters are in a language that they (HCF users) do not understand. The posters are not readable due to the small writing (font size), they are.” (District healthcare manager). Additionally, most of the IEC materials were located in the maternity department, OPD, and theatre, and were supplied at the onset of the COVID-19 pandemic. Aside from the materials used for the IEC materials, they were not weather-resistant. As a result of inadequacy, the respondents highlighted the need to lobby for IEC materials from implementing partners such as Non-governmental Organisations. The lack of weather-resistant IEC materials was elaborated in this quote: “ Still, these IEC materials include posters showing the procedure for hand washing, directing patients to the male and female toilets and latrines, and those on the bins to indicate which type of waste to be disposed of in the respective bins. Since they use paper, these papers are sometimes washed by the rain (FGD with IPC committee members). Scarcity of IEC materials on water safety and sanitation None of the HCFs were equipped with IEC materials on water safety and sanitation. A few respondents did mention having some sanitation-related IEC materials, such as brochures for community dialogues and other health talks. The dire lack of IEC materials on water safety was starkly evident in this quote: ' We do not have any materials on water safety, never seen any in healthcare facilities.' (KII with an IPC focal person). The shortage of IEC materials on sanitation was further emphasised in this quote: 'We do not have IEC materials on sanitation. The few we have are used for community dialogues. We usually carry a few brochures that we use to perform our duties, such as sensitising the community. The few we have are spread (given out/disseminated) in communities where we give health talks.' (KII with a district healthcare manager). Limited availability of IEC materials on hand washing and healthcare waste management Despite being inadequate, the most commonly available IEC materials were posters on hand hygiene. Most of the available IEC materials on hand hygiene were distributed to HCFs during the peak of the COVID-19 pandemic, as illustrated in the following quote: 'We do have IEC materials, such as posters on COVID.' In the theatre, we have posters on hand washing and waste management, with instructions on which bin to put the waste in. In the department of isolation, we have posters available on hand hygiene, waste management, and mask-wearing. There are also posters on the five steps for hand washing (FGD with IPC committee members). While the majority of the HCFs reported having some IEC materials on healthcare waste management, the focus was solely on the segregation of healthcare waste. This highlights the need for a more comprehensive waste management strategy. Priority topics for messaging Overall, respondents highlighted that IEC materials should be based on the principle that prevention is better than cure and should clearly outline the dos and don’ts of failing to practise the desired behaviours. Additionally, respondents suggested that the IEC materials should specify the repercussions of defaulting. Attitude of the patients, attendants, and healthcare providers Respondents highlighted the need to develop IEC materials that target changing attitudes towards WASH and infection prevention and control among HCF users, as this was identified as the biggest challenge. “ The messages on the IEC materials should address the attitude of the people (patients and attendants) and health workers. The biggest challenge is attitude and how people perceive the information (District healthcare manager). Safe water chain The necessity to develop IEC materials on the safe water chain was apparent. Healthcare facilities lacked IEC materials on protecting water sources, safely handling water from the source to the point of use, and cleaning water vessels. To highlight this need, one district healthcare manager mentioned: "There is a need for information on a safe water chain—that is, keeping water from the source safe, cleaning water containers and the surrounding boreholes." There was also a significant call to create IEC materials promoting water treatment methods such as boiling and using clean containers for water collection, as expressed in the following quote, in response to which priority messages have to be developed to improve WASH in HCFs: "Messages on the treatment of water, boiling of the water, and usage of clean containers to fetch water and also to keep the environment clean." (KII with an IPC focal person). Healthcare providers recommended that IEC materials, such as pictorials and images promoting a safe water chain, should be displayed at water points, entrances, and OPD, as these are familiar gathering places. Some respondents also suggested that the IEC materials should include information about penalties for failing to maintain a safe water chain. Sanitation and hygiene Regarding sanitation, respondents mentioned the urgent need for IEC materials to provide information on the proper use of latrines, including operation and maintenance activities such as cleaning. To illustrate the need for IEC materials on sanitation, one of the IPC focal persons mentioned that: “ The IEC materials should contain messages and information on the proper use of the latrine and cleaning of the latrines, burning of the waste, and using the correct waste bins.” (KII with an IPC focal person). Healthcare providers also highlighted the need to develop IEC materials aimed at promoting good hygiene behaviours. They stressed the importance of targeting key moments for hand hygiene among patients, attendants, and healthcare workers. To clarify the priority topics for messaging, one of the healthcare facilities in charge mentioned, "IEC materials on why one should wash hands are not there yet. The importance of IECs lies in imparting knowledge to people and health workers, thereby guiding them technically. IEC materials should emphasise the washing of hands after toilet visits and before eating.” There was a preference for posters as reminders of vital moments for hand hygiene during patient care. The healthcare providers saw posters as an effective and practical way to deliver instructions or guidelines, highlighting the dos and don’ts, as illustrated in this quote: “We should have information on handwashing pinned on posters. Posters should illustrate the proper handwashing procedure before and after patient contact, including when coming into contact with body fluids. It is essential because people like to follow such information since it gives directives to the workers and patients on what to do and avoid.” Healthcare waste management and environmental cleaning The majority of the respondents highlighted the urgent need to develop IEC materials on adherence to waste management protocols and segregation. Healthcare providers viewed IEC materials on the importance of waste segregation and adhering to these protocols as a practical mechanism for imparting knowledge on health risks. In response to the messages that IEC materials should address, one of the district healthcare managers mentioned that: “ Messages on the safe management of waste from the point of generation to the point of final disposal. It is important to do that, although not well-practised, and the SOPs (standard operating procedures) are yet to be well adhered to (District healthcare manager). Aside from healthcare waste management, the respondents emphasised the need to develop IEC materials that address aspects of environmental cleaning, such as HCF cleanliness and safety, cleaning methods, dusting and disinfection of contaminated surfaces. To illustrate what key messages IEC materials on environmental cleaning should address, one of the district healthcare managers mentioned that: “ The messages on keeping the environment clean and safe. The messages on cleaning and how to clean, slashing of the compound and how to keep and maintain the compound clean, and disinfection of the suspected contaminated areas." Some respondents suggested using talking walls to disseminate information on environmental cleaning. Key considerations for the development and dissemination of IEC materials Language The healthcare providers emphasised that the designers should take language considerations for IEC materials seriously during their development. They recommended that designers use both English and the local language (Acholi) when creating the IEC materials. Additionally, the respondents urged the designers to incorporate translations of key health terms or phrases, or to utilise culturally relevant visual aids that the local community can understand. Healthcare providers noted that designing IEC materials in both English and the local language would enhance message comprehension, as the area is home to people from different dialects and tribes. To emphasise the need for having the IEC materials in English and the local dialect, one of the focus group discussants mentioned that: " The IEC materials should be in the local language and English for those who do not understand the local language (FGD with community health workers). In a community with multiple tribes and dialects, healthcare providers recommended translating IEC materials into these languages, as explained by one of the IPC focal persons. " The language used in the IEC materials should be considered. People like us, the Acholi (tribe), know Acholi (language), and the Luo (tribe) use Luo (language). So, the IEC materials should be in the language of the tribe in a particular location." According to healthcare providers, the designers had to thoroughly review the language used in designing and disseminating IEC materials to ensure the target community clearly understands them and is not misled. Community health workers emphasised the need for thoroughly reviewing the language in the IEC materials, noting the importance of visual aids in enhancing understanding: "The pictures illustrate the water's safety, allowing those who cannot read to understand the message and information through visual means (FGD with community health workers). " This visual component, they argued, would ensure that the IEC materials are inclusive and accessible to all members of the community. Inclusivity Healthcare providers suggested the need to design IEC materials that cater for the health education needs of individuals with special needs, such as the blind. To ensure inclusivity, healthcare providers suggested designing IEC materials for those who cannot read or write. To illustrate the need for inclusive IEC materials, one of the participants in the focus groups mentioned that: “ We lack IEC materials for people with special needs, such as the blind, those who cannot read, or the disabled, so I suggest that when making these IEC materials, they should cater to them. One of the IPC focal persons further emphasised the need for IEC materials that cater to those who cannot read and write by saying: “The IEC on cleanliness of the bore hales showing the 5 moments when one should wash hands, like in the pictorial way, the images trying to bring out the information that the locals understand so that even when one cannot read then that might just look at the picture and get the information that is being passed on.” Display Healthcare providers suggested that IEC materials should be displayed in prominent locations, including facility entrances, sanitation facilities, compound areas, ward walls, waste containers, and notice boards, to ensure accessibility to HCF users. Community health workers recommended that IEC materials designed to discourage undesirable behaviours should include a clear “X” symbol to indicate to HCF users that the behaviour is unacceptable. “ The picture (posters) should be displayed on the facility compound to highlight the dangers of dumping. A cross through a harmful act to someone dumping rubbish, because the client can interpret the situation (FGD with community health workers). There was also a suggestion by healthcare providers to disseminate the IEC materials during the outreaches. Discussion This study aimed to understand the WASH situation for the design of IEC materials for healthcare facilities, explore existing WASH IEC materials, identify priority topics for messaging, and outline key considerations for the development of IEC materials. Themes generated from the findings include the status of WASH, the availability of IEC materials at healthcare facilities, critical topics to be addressed in IEC material development, and key considerations in the development and dissemination of IEC materials. This study found limited WASH services in healthcare facilities, which is consistent with studies conducted in other parts of Uganda [ 3 , 70 ] and similar settings. Water shortages, inadequate water supply, similar to those in HCFs in other parts of Uganda [ 3 ], a poor toilet-to-patient ratio [ 1 ], and limited funds all affect the maintenance of water, hygiene, and sanitation services [ 71 ]. The lack of adequate WASH services implies that healthcare facilities are at risk of poor infection prevention and control, which could threaten patient safety and recovery and may worsen the spread of infections. The study highlights the importance of enhancing WASH infrastructure, as well as IEC materials, to encourage actions that promote proper hygiene behaviours among both staff and HCF users. This study found a limited availability of WASH-related IEC materials, with a notable lack of IEC materials on sanitation. The narrow scope of information in IEC materials primarily focused on healthcare waste management, with limited information on environmental sanitation and water safety. Limited budgetary allocations, exacerbated by the information being provided in a few dialects and non-inclusivity, all contributed to this inadequacy, similar to other studies [ 72 ]. The reduced demand for WASH IEC materials among the HCF managers could be linked to the perceived decrease in urgency following the management of the COVID-19 pandemic, during which hand hygiene IEC materials were heavily utilised [ 44 , 73 ]. Additionally, the reliance on donations from non-governmental organisations (NGOs) for such materials—rather than institutional budgeting—may have led to a gap in availability once the pandemic subsided. This finding is similar to those reported by [ 72 ] in rural Ethiopia, where the numerous IEC materials found in HCFs were due to donations from NGOs. The limited availability of WASH IEC materials can hinder the widespread dissemination of critical health information on WASH that could encourage proper hygiene and sanitation practices. This study found that the existing IEC materials were not weather resistant, and this was similar to a study in Ethiopia where Geleta, Deriba [ 74 ] found IEC materials damp and wasted at HCFs. This could imply that WASH IEC materials were present in the past but were also not weather-resistant, resulting in their waste. IEC materials, especially posters, could be poorly located in areas that are directly hit by the sun or raindrops. Non-weather-resistant IEC materials, when poorly maintained, will have reduced longevity, hence the effect of their presence will barely be achieved. IEC materials should be laminated for resistance against rain and placed in shades to prevent fading. This study also identified priority topics for messaging during WASH IEC materials development, including the attitudes of end-users, and WASH fields such as the safe water chain, sanitation, hand hygiene, healthcare waste management, and environmental cleaning. This study noted that IECs should target the attitudes of healthcare providers (HCPs), patients, and attendants, as knowledge and attitudes in multiple studies have been shown to influence practice. Targeting attitudes in IEC materials is important because many patients, caregivers, and even healthcare providers may not fully understand the importance of IPC in preventing infections and ensuring patient safety. Some studies [ 75 , 76 ] have shown that Health Care Providers (HCPs) are knowledgeable about WASH and IPC, and that factors such as designation, qualification, age, attending risk assessment training, and the presence of sufficient IPC implementation equipment are significant in ensuring better IPC practices. However, other studies [ 77 ] from similar settings have contradicting findings about the knowledge of HCPs towards IPC and also recommend the distribution of IEC materials. Studies [ 8 ] and [ 78 ] have shown that even healthcare providers need continual reminders through sensitisation and the use of IEC materials to maintain proper WASH practices. Some end users, such as caregivers, may lack knowledge about comprehensive IPC implementation or its application in patient recovery. This means that sensitisations should be sustained through IEC materials that communicate about WASH and IPC to instil a culture of WASH and IPC. Although HCPs are knowledgeable, their attitude towards IPC practices could be frustrated due to inadequate hand hygiene infrastructure, water services, PPE and scarce IPC training, all of which hinder IPC practice [ 79 ]. Therefore, the presence of IEC materials that effectively communicate IPC could be another form of IPC communication, hence improving attitude towards IPC practices. This study found respondents in need of IEC materials about the safe water chain. Safe water chain studies in Uganda have been more prevalent in refugee settings and informal settlements, aiming to prevent the onset of outbreaks [ 80 , 81 ]. This means information about water and health has been scarce in HCFs, and IEC materials are one sustainable way of communicating the safe water chain for improved WASH and IPC. Additionally, information on the safe water chain is crucial, especially in rural or resource-poor settings where access to clean water may be limited [ 82 ]. The safe handling and storage of water are essential for reducing waterborne diseases, making this a crucial topic for IEC materials. Sanitation messages should focus on proper latrine use and the management of healthcare waste, while hand hygiene messages must emphasise the five moments of hand hygiene, which are vital for preventing the spread of infections. This study found language to be a key consideration during the development of IEC materials, which concurs with other studies [ 64 ]. Grene and Cleary [ 83 ] emphasised that health IEC materials should be written in plain language for easy understanding of instructions and effective use by patients and caregivers [ 83 ]. Harper and Zimmerman [ 84 ] also described the use of plain language in health IEC materials, considering the target's level of understanding and literacy, simple sentence structure, and defining unfamiliar concepts, among others [ 84 ]. Language barriers and the exclusion of people with special needs can severely limit the reach and impact of IEC materials. Therefore, for IEC materials to be effective, they must be contextually and culturally relevant and must be accessible to individuals who speak different dialects. Messages should be communicated in local languages, using visual aids that reflect the HCF users' environment and understanding. This study also highlighted the need for IEC materials to be inclusive of people with special needs, which aligns with other literature [ 85 – 87 ]. Hachipola, Mweemba [ 87 ] found inadequate access to cervical cancer IEC materials among people with physical and sensory disabilities due to the absence of braille transcription or sign language interpretation [ 87 ]. Health IEC materials are mainly used by the literate and visually able, but exclude those who are visually impaired. Standard Operating Procedures for Disability-Inclusive Health Services emphasise the design of IEC materials, such as videos with captions, audio, braille, pictorial information, and large print, for inclusiveness [ 85 ]. The use of braille and audio aids for individuals with IEC is effective in improving the health status of visually impaired communities [ 86 ]. Consideration of people with special needs in health service delivery and communication is crucial in improving universal health coverage and addressing the lack of awareness about disease prevention in HCFs and their communities [ 39 ]. This study also found the need to display IEC materials in conspicuous areas for the target users, which agrees with other studies [ 88 , 89 ]. IEC materials, such as posters, should be displayed in the most frequented areas of the facility, like entrances, latrines, and waiting zones throughout the entire HCF, rather than at specific points such as OPD and maternity wards. They should be sufficiently visible for end users. This means printed IEC materials need to be accessible and in a clear font size for individuals with visual impairments, including those in wheelchairs, to avoid strain while reading. Strategically placed and inclusive IEC materials can enhance visibility and effectiveness in encouraging positive behaviour change. In conclusion, the development of IEC materials requires participatory involvement to increase their utilisation [ 90 ]. HCFs should be involved in mapping the population distribution of their catchment area and jurisdiction to ensure the inclusiveness of all people groups when designing IEC materials. Healthcare facilities and the communities they serve should be involved in the process of creating and distributing these materials to ensure that they are culturally appropriate, linguistically accessible, and responsive to the specific needs of the target population, thereby having a greater impact on improving WASH practices. Conclusions Despite the poor WASH conditions, healthcare facilities lacked IEC materials, especially on water safety, hand washing, environmental cleaning and waste management. HCFs found it challenging to access IEC materials in the language read and understood by the target community, and those catering for individuals with special needs, such as the blind, individuals with limited mobility, and illiterates. The available IEC materials were mainly found in the maternity, theatre, and outpatient departments, although they were not weather-resistant. The local experts played a crucial role in suggesting that the priority messages should target attitudinal change for patients, attendants, and healthcare providers, water safety practices, proper use of latrines, including operation and maintenance activities, waste segregation, and environmental cleaning, such as HCF cleanliness and safety, cleaning methods, dusting and disinfection of contaminated surfaces. As suggested by the local experts, the IEC materials ought to be in the local language or with translations where English is used, should cater for the health education needs of individuals with special needs, such as the blind, and the illiterate, and needed to be displayed in prominent locations, including facility entrances, sanitation facilities, compound areas, ward walls, waste containers, and notice boards. The findings from this study highlight the critical role played by the local experts in defining priority topics for messaging and the key considerations for the development and dissemination of IEC materials on water, sanitation and hygiene in healthcare facilities. Abbreviations FGD Focus group discussion HC Health Centre HCFs Healthcare Facilities IEC Information, Education, and Communication IPC Infection Prevention and Control KIIs Key Informant Interviews LMICs Low-and middle-income countries WASH Water, Sanitation and Hygiene PFP Private for Profit PNFP Private Not for Profit VHTs Village Health Teams Declarations Ethics approval and consent to participate This study was conducted following the Declaration of Helsinki. Ethics approval was obtained from the AIDS Support Organisation (TASO) Research and Ethics Committee (Protocol TASO-2022-131) and was registered by the Uganda National Council for Science and Technology. Before data collection, the investigators obtained administrative clearance from the Amuru and Nwoya district local governments, as well as the leadership of the respective healthcare facilities. All the respondents provided informed written consent. Consent to publish Not applicable Availability of data and materials The transcripts analysed in this manuscript are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding The GIZ Sanitation for Millions Programme funded this study through its collaboration with Makerere University School of Public Health to promote water, sanitation and hygiene and infection prevention and control in Apac and Nwoya districts. The study protocol was independently peer-reviewed by the funding body; however, any opinions, conclusions, or recommendations expressed in this article are those of the authors alone and do not necessarily reflect the views of the funding agencies. Authors' contributions JBI and TS conceptualised and obtained the funding for this study. JBI, PT, RKM, STW, TA, JG, RN, GA, DN, EO, SM, RN, MN, IFA, FN, MN, MMM, and TS participated in the analysis and drafting of the manuscript. All authors read and approved this manuscript before submission to this journal. Acknowledgement We thank the administration of the Amuru and Nwoya district local governments for granting clearance to undertake the study. We remain indebted to the leadership of the healthcare facilities for allowing us to collect data. Finally, we thank our diligent team of research assistants (Sandra Babirye, Geofrey Bwire, Ronald Tenywa, and Kassim Kaddu Mukasa) who made this study a success. References WHO and UNICEF. 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Wu, J. et al. A Network of Knowledge: Participatory Development of Culturally Sensitive Information, Education, and Communication Materials for the Prevention of Communication Disability in Rural Tanzania , in Handbook of Speech-Language Therapy in Sub-Saharan Africa: Integrating Research and Practice , U.M. Lüdtke, E. Kija, and M.K. Karia, Editors. Springer International Publishing: Cham. pp. 283–313. (2023). Additional Declarations No competing interests reported. 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16:54:16","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":217522,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7546174/v1/f57f27a5b711abf0a5ef393a.html"},{"id":93883392,"identity":"1721363e-b683-425f-acbd-a55bc1000208","added_by":"auto","created_at":"2025-10-19 17:02:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":89500,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of the study healthcare facilities\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7546174/v1/71755ad676638a4d5435f970.png"},{"id":93883790,"identity":"21105b28-0319-4b6a-998a-001167e80854","added_by":"auto","created_at":"2025-10-19 17:10:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1429812,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7546174/v1/cc46aebf-33c2-48a1-b7d0-477ef9759291.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Informing Water, Sanitation and Hygiene (WASH) communication through local expertise: a qualitative study with healthcare providers in Northern Uganda","fulltext":[{"header":"Background","content":"\u003cp\u003eWater, sanitation, and hygiene (WASH) in healthcare facilities (HCFs) remains a global public health challenge [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Available evidence indicates that in 2021, 47% of HCFs did not have water from an improved source on their premises, 21% lacked basic sanitation services, 68% lacked functional hand hygiene facilities at points of care, and within 5 metres of toilet blocks, and 66% did not segregate, treat or dispose of waste safely [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In 2023, 9% of the global population (742\u0026nbsp;million) used HCFs deficient in water services, 8% (660\u0026nbsp;million) had no access to toilets or used unimproved sanitation facilities, and 9% (722\u0026nbsp;million) could not access functional hand hygiene facilities at points of care or toilets [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe WASH crisis is more pronounced in low-and middle-income countries (LMICs) [\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], where in 2024, 59% of HCFs lacked a basic water service, 69% did not have a basic sanitation service, 68% had a basic hand hygiene service, 19% had a basic environmental cleaning service, and only 39% had a basic waste management service [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In 2022, 17.2% of HCFs in Uganda did not have a water service, 10% had no access to a sanitation facility, 11.9% had no hand hygiene service, 44.3% reported a deficiency in basic waste management services, and 31.9% had no environmental cleaning service [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Amuru and Nwoya districts, the focus of this study, are no exception to Uganda\u0026rsquo;s dire WASH situation in HCFs. The proportions of HCFs without any service in Amuru in 2022 were: 16.1% for water and sanitation services, 38.7% for hand hygiene, and 32.3% for environmental cleaning. Additionally, 5% of HCFs in Nwoya lacked water or sanitation services, 60% had basic hand hygiene, and 25% had limited environmental cleaning services [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInadequate infrastructure and limited awareness of desirable WASH behaviours, combined with a lack of decision-making support tools, create environments where suboptimal practices such as the consumption of unsafe water, indiscriminate waste disposal, open defecation, and inconsistent hand hygiene become normalised [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Suboptimal WASH practices heighten the risk of disease transmission, reduce trust, efficiency, staff morale and healthcare service uptake [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. To counter the undesirable WASH practices, the use of Information, Education, and Communication (IEC) materials as constant reminders of the desired behaviours in HCFs is recommended [\u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. IEC materials, such as printed brochures, posters, leaflets, mhealth messages, and mass media broadcasts [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], equip HCF users with knowledge critical for the operation and maintenance of WASH infrastructure, thus contributing to sustainability [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Incorporating well-developed IEC materials into WASH programs is also crucial for enhancing the adoption of proper practices and ultimately improving healthcare outcomes [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIEC material development follows a structured, iterative process to ensure relevance, clarity, and impact [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The process starts with a formative assessment to understand the determinants of preventive behaviours, potential knowledge gaps, and preferred IEC materials [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The formative stage is followed by selecting the most appropriate IEC materials, considering the target audience\u0026rsquo;s literacy levels, cultural context, and preferred communication channels to ensure maximum relevance and impact [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. This stage also involves evaluating the strengths and limitations of various IEC materials, often combining multiple formats for greater reach and reinforcement. Upon selecting the preferred IEC materials and evaluation of their strengths and limitations, the design team develops a creative brief to guide content creation, outlining key messages, tone, format, and delivery strategy. The design team then develops a prototype by creating new content or adapting existing resources [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], which undergoes pre-testing to obtain feedback from the target audience.\u003c/p\u003e\u003cp\u003eDuring the pre-test, the design team assesses comprehension, attractiveness, and persuasiveness. Based on pre-test results, materials are revised and refined to enhance clarity and resonance. The development process ends with the dissemination, monitoring and evaluation of the impact of IEC materials through behavioural outcomes [\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Throughout the IEC material development process, engaging local expertise (referred to as individuals involved in the delivery of healthcare services in this paper) is essential for cultural relevance, community trust, and accurate messaging. A bottom-up approach to IEC material development enhances credibility and acceptance, facilitates access to community networks and alignment with societal norms and priorities [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile the participation of local expertise in the IEC material development process provides nuanced insights into community perceptions and barriers to behaviour change [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], our understanding of perspectives of local expertise on the status of WASH in HCFs, priority topics for messaging, and the key considerations for the development of IEC materials on WASH in HCFs is limited [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Drawing on empirical evidence gathered through local expertise, this paper addresses three key questions: 1) What is the current status of WASH in HCFs in Amuru and Nwoya districts? 2) What critical topics must be addressed by IEC materials on WASH in HCFs, and 3) What considerations must be considered when designing and disseminating WASH IEC materials? By considering the local experts' perspectives on message development, dissemination, and feedback loops, IEC materials can be more impactful and foster ownership and sustainability [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy setting\u003c/h2\u003e\u003cp\u003eThis manuscript discusses data from healthcare providers from eight HCFs (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) in Amuru and Nwoya districts, located in Northern Uganda within the Acholi sub-region. The Amuru district headquarters are located approximately 60 kilometres northwest of Gulu city, while the Nwoya district headquarters are 44 kilometres southwest of Gulu City. Amuru district has a population of 247,574, among whom 126,972 are female [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Nwoya has a population of 220,593, among whom 112,845 are female [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Amuru has a total of 42 HCFs, among whom 26 are public, nine are Private for Profit (PFP), and seven are Private Not for Profit (PNFP). Based on the level of HCFs, Amuru district has nine clinics, 22 Health Centre (HC) IIs, ten HC IIIs, and one HC IV [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Nwoya has a total of 23 HCFs\u0026mdash;13 public, five PFP, and five PNFP. Based on the level of HCFs, Nwoya district has 19 HCIs, three HCIIIs, and one hospital [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Amuru and Nwoya are post-conflict recovery settings, having suffered from the 1986\u0026ndash;2006 civil war between the Government of Uganda and the Lord's Resistance Army [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The war not only led to massive deaths and destruction of WASH infrastructure but also disrupted health, social and economic systems [\u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. About 63% of northern Uganda is multidimensionally poor\u0026mdash;are deprived in education, living standards, employment and financial inclusion, and health [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Only 20.9% of households in Amuru and 20.4% of those in Nwoya use improved sanitation facilities, while 59.6% of households in Amuru and 58.1% of those in Nwoya use an improved water source [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. HCFs in the region also face significant challenges in accessing adequate WASH services [\u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003e We employed a qualitative descriptive design to explore perspectives of local expertise on the status of WASH in HCFs, priority topics for messaging, and the key considerations for the development of IEC materials on WASH in HCFs. A qualitative descriptive design is suitable for describing under-researched phenomena rather than explaining them [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e], as was the case with perspectives of the local expertise on IEC material development. This design recognises the nature of the problem under study, captures straightforward descriptions of experiences and perceptions, and enables presentation of findings in a manner that closely reflects the phenomenon [\u003cspan additionalcitationids=\"CR59\" citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. The qualitative descriptive design is ideal for studies that do not focus on increasing theoretical or conceptual understanding, but rather contributing to change and quality improvement in practice settings [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eStudy participants and data collection\u003c/h3\u003e\n\u003cp\u003eThese study participants included local experts, whom we defined as individuals involved in the delivery of healthcare services. Based on the study\u0026rsquo;s context, the local experts included HCF managers, departmental in-charges, community health workers (village health teams or VHTs), the infection prevention and control teams, environmental health staff such as health inspectors and health assistants, and district healthcare managers. To elicit information on the status of WASH in HCFs, priority topics for messaging, and the key considerations for developing IEC materials on WASH in HCFs, we conducted nine key informant interviews (KIIs), informed by the level of theoretical saturation [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. During the KIIs, we asked participants about WASH, healthcare waste management, and environmental cleaning in HCFs, as well as the availability, content, and information gaps in IEC materials on WASH. Additionally, we inquired about their preferred medium for disseminating WASH-related messages.\u003c/p\u003e\u003cp\u003eAdditionally, we used a focus group discussion (FGD) guide informed by an extensive review of literature [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] to collect data from seven FGDs with members of the Infection Prevention and Control (IPC) committees and VHTs in the study HCFs. During the focus groups, we first explored the local experts' views on the status of water, sanitation, hygiene, environmental cleaning, and healthcare waste management, as well as related behaviours among patients, caregivers, and healthcare providers in the study HCFs. Their insights were invaluable in gaining an in-depth understanding of the behaviours and status of WASH. We then asked the study participants about the availability and information relayed on IEC materials, the nature of information or messages to disseminate on waste management in HCFs, and strategies to enhance the utilisation of IEC materials. Throughout the discussions, research assistants took detailed notes and recordings to capture the valuable insights shared. Subsequently, the recorded discussions were transcribed verbatim before analysis.\u003c/p\u003e\n\u003ch3\u003eData management and analysis\u003c/h3\u003e\n\u003cp\u003eThe research team transcribed all the digital audio recordings verbatim. We shared the KII transcripts with the research participants for review and verification of the accuracy of the information contained in (a process known as respondent validation). Respondent validation ensured accurate representation of the participants' perspectives and voices in the analysis [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. The research team reviewed and cleaned the interview transcripts in preparation for data analysis. We used ATLAS\u0026mdash;ti version 24.0 software to facilitate analysis and coding. We used the thematic content analysis approach to describe, create a rich, detailed, and complex account of the study phenomenon, and to interpret perspectives from textual information [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Thematic content analysis is ideal for studies that utilise a qualitative descriptive design because it does not require a theoretical and conceptual framework [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. The thematic content analysis approach involved reading the transcripts several times to familiarise themselves with the data, identifying key words, developing codes and defining the codebook based on the study objectives, development of themes, conceptualisation through the interpretation of keywords, codes, and themes, and the development of a conceptual model [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. During the coding process, we applied paraphrases or labels (codes) to passages that were deemed important. We used an abductive approach to coding. We used the inter-coder agreement tool to ascertain the extent of agreement between multiple individuals coding a given transcript. Where the inter-coder agreement fell below 90%, the coders held a meeting to resolve any discrepancies.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eDistribution of the study participants\u003c/h2\u003e\u003cp\u003eThis study presents demographic characteristics of 42 FGD participants and nine KIs from Amuru and Nwoya districts. The age of the FGD participants ranged from 24 to 64, while that of the KIs was between 27 and 47. Twenty-five of the FGD participants were from Nwoya District, 16 were from Health Centre III in Amuru District, 15 were male and from Nwoya District, 14 had attained tertiary education as their highest level of education and were from Amuru District, and 15 were healthcare workers from Amuru District. Seven of the KIs were from Nwoya District, including four hospital staff, five females, three with a bachelor\u0026rsquo;s degree, and six clinical staff. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of study participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eDescription\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eResponse\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eDistrict\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eAmuru\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eNwoya\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eDistribution of FGD participants (N\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eNumber of participants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLevel of health service provision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth Centre III\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex of the respondent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried/Cohabiting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eRole of the respondent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealthcare worker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePublic servant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVillage health team member\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eKey informant participants (N\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eNumber of key informants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eLevel of health service provision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDistrict health team member\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth Centre III\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex of the respondent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaster\u0026rsquo;s degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProfessional certificate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eRole of the respondent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth educator/promoter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealthcare service manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClinical staff (nurses, midwives and doctors)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStatus of water, sanitation, and hygiene\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eWater supply\u003c/h2\u003e\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\u003ch2\u003eInadequate water supply\u003c/h2\u003e\u003cp\u003eAll HCFs found access to water a challenge, with two HCFs spending 2\u0026ndash;4 years without a reliable, safe water supply, and another having no water source on the premises. To illustrate the challenge of water supply, it was mentioned in one FGD with IPC committee members that: \u0026ldquo;\u003cem\u003eWater is a problem. We have been without water for two years. The only water supply is the borehole, and it is at the administration block.\"\u003c/em\u003e The majority of the HCFs did not have a piped water supply and often relied on boreholes, except during the rainy season when rainwater harvesting became an alternative.\u003c/p\u003e\u003cp\u003eA low yield and congestion due to sharing water sources with the community were also challenges contributing to the inadequacy. Aside from the HCFs that had a more reliable water supply, healthcare providers mentioned that water did not reach all the wards, as illustrated in this quote: \"\u003cem\u003eNo water supply, so it is a problem. We do not have a direct water supply to the ward. We are supposed to have flowing water, but our taps do not have water flowing through them. The taps are non-functional, but we have nearby boreholes where we obtain Water (HCF in charge).\u003c/em\u003e The challenge of water reaching all the HCF departments was also expounded by IPC committee members in a focus group discussion: \"\u003cem\u003eThe water supply is there because we have two boreholes and a tank. However, some departments are lacking adequate water, and they have to move a distance to the water supply source.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAn intermittent power supply compromised the water pumping, resulting in an inadequate water supply. In some HCFs, the burden of an inadequate water supply fell on patients and caregivers, who healthcare providers requested to fetch water over long distances, as illustrated in this quote: \u0026ldquo;\u003cem\u003eThe attendants assist us in fetching water and pouring it into various drums in the facility, as we, the health workers, cannot line up to fetch Water (HCF in-charge).\u003c/em\u003e A limited supply of water also compromised sanitation and hygiene, as well as compliance with other infection prevention and control (IPC) measures, including the sterilisation of medical equipment. Healthcare providers, including those in the maternity and surgical departments, had to resort to the use of alcohol-based hand rub even when it was not appropriate, thus compromising the quality of healthcare. \u003cem\u003e\u0026ldquo;IPC is a challenge in our facility since we have no water. We end up using only sanitiser, so we struggle to do our roles in the wards.\u0026rdquo; (FGD with IPC committee members).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eUnsatisfactory water safety\u003c/h2\u003e\u003cp\u003eThe water quality was not satisfactory, yet HCFs did not have treatment options such as chlorination, as explained in one of the FGDs with IPC committee members: \"\u003cem\u003eThe water in our facility and the community that we use is not safe. We do not have Water Guard (chlorine pellets/tablets) for treating the water.\".\u003c/em\u003e The water chain, too, was not safe. HCFs had to use dirty jerrycans to fetch water from rainwater tanks, which compromised water safety. To illustrate challenges with water safety, the FGD with community health workers revealed that: \"\u003cem\u003ePeople use rainwater, which is not safe. The containers they use are often dirty, so I think the water is not safe.\"\u003c/em\u003e Aside from that, the water in some of the rain tanks had overstayed, which raised questions about its safety, as reflected in this quote: \"\u003cem\u003eWe use jerrycans to fetch water from the wells or use rainwater in the tanks, which has its challenges. The rainwater in the tanks has overstayed, and it is what we use.\" (FGD with IPC committee members).\u003c/em\u003e In one of the HCFs, respondents mentioned that some patients and caretakers/attendants cleaned themselves, and others disposed of water containing blood at the boreholes: \"\u003cem\u003eThe mothers clean themselves and pour water containing blood at the borehole.\" (FGD with IPC committee members).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDespite the unsatisfactory water quality, it was rare for the district staff to conduct water quality tests on boreholes. None of the HCFs reported water quality assessments more than once for a given year, and two reported tests last being done more than five years ago: \"\u003cem\u003eWater is not very safe; we use borehole water, but we are not sure of where it comes from, so the safety is not guaranteed. We do test it, but it is not a regular process. It was last tested one year ago. The water quality analysis is typically conducted, but it is infrequent. There are no funds to carry out the process regularly (KII with an IPC focal person).\u003c/em\u003e In one district, the health inspectorate staff tested the borehole water after the community expressed fears that it was contaminated: \"\u003cem\u003eThey rarely test the water from the boreholes. At one point, they (the community) felt the water was contaminated, so they (district authorities) had to come to test it (HCF manager).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePoor operation and maintenance\u003c/h2\u003e\u003cp\u003eWater supply infrastructure, especially boreholes, was reported to break down, thus slowing the delivery of healthcare services: \u0026ldquo;\u003cem\u003eThe piped water supply has been relatively regular. However, the system continues to fail us, the service providers (healthcare providers). It keeps breaking down, and they (technicians) keep coming back to solve the same issues. The only option we have is to install two boreholes at the facility. We also have pumping points, which pump water into the storage tanks, and pipes that transport water to the tanks, supplying the various departments of the hospital. The issue is that the water pumping to the tanks has problems, as it frequently breaks down. It is currently down, so we have resorted to using boreholes and water tanks (HCFmanager).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHealthcare facilities that had a more reliable water supply also struggled with operational and maintenance issues. Due to the frequent use, the breakdown of the water supply infrastructure in HCFs was typical. The IPC committee members acknowledged water supply interruptions due to non-functionality of the borehole at the time of the interviews, as expounded in this quote: \u0026ldquo;\u003cem\u003eWe do not have running water in the taps, and sometimes the borehole breaks down, thus slowing service delivery.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIt was the responsibility of the HCFs to repair the boreholes in the event of a breakdown. At times, HCFs lacked the resources to undertake repairs, prompting patients, attendants, and healthcare providers to fetch them from neighbouring communities with boreholes. \u0026ldquo;\u003cem\u003eWe have experienced a lack of water, and that was last year when the boreholes broke down, and it took months to be repaired since we had to wait for the PHC funds. Without the PHC funds, we would not have been able to repair the borehole. So, people had to get water from neighbouring communities that had boreholes (KII with an IPC focal person).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eSanitation\u003c/h2\u003e\u003cp\u003eDistrict healthcare managers, \u003cem\u003eHCF\u003c/em\u003estaff, and community healthcare workers (also known as village health teams) acknowledged that the sanitation situation in all healthcare facilities was in a dire state. Open defecation was common in all HCFs and was primarily attributed to the poor state of sanitation facilities and limited access due to inadequate and poor operation and maintenance.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eInadequate sanitation facilities\u003c/h2\u003e\u003cp\u003eSanitation facilities in most healthcare facilities were inadequate. Some HCFs lacked sex-segregated sanitation areas, while in others, healthcare staff had to share toilets with patients. The conditions of the sanitation facilities were often poor, with dirty environments, maggot infestations, and unpleasant odours that limited their usability. As stated by one community health worker during an FGD, \u003cem\u003e\u0026ldquo;The latrines are dirty, smelly, and have maggots. They are not separated, so men and women sometimes use the same latrines.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDue to the inadequate sanitation facilities, some patients resorted to open defecation. One community health worker noted, \u003cem\u003e\u0026ldquo;The community just misuses the compound and practices open defecation, making the spread of infection easy.\u0026rdquo;\u003c/em\u003e A district healthcare manager highlighted the severity of the situation: \u003cem\u003e\u0026ldquo;Sanitation is poor because we have too few latrines. We have approximately 100 patients at this HCF, but they can only use one latrine, and the hygiene is also poor.\u0026rdquo;\u003c/em\u003e Additionally, some HCFs lacked adequate bathing facilities for the maternity ward, while others had poorly maintained bathrooms. One community health worker expressed concern during the FGD, stating, \u003cem\u003e\u0026ldquo;Sanitation is deplorable, especially in the maternity ward, where mothers do not have a place to bathe. There is only one bathroom, and sometimes the drainage gets blocked.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003ePoor operation and maintenance\u003c/h2\u003e\u003cp\u003eThe majority of the healthcare facilities had poorly maintained toilets. Some HCFs had sanitation facilities with cracked walls and slabs, while others had grass growing in the toilets. It was reported that due to a lack of anal cleansing materials, users opted for the toilet walls for anal cleansing, which increased the risk of the spread of diseases. \u0026ldquo;\u003cem\u003ePatients do not know how to use the toilets. They put faeces on the walls, and children defecate on the toilet floors or slabs. They (patients) do not have toilet paper to use for anal cleansing. When the lab (laboratory) people (staff) request a stool sample, they (patients) defecate openly purposely for that (FGD with community health workers).\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003ePoor operation and maintenance were attributed to the non-involvement of the community and patients in sanitation-related activities, including cleaning. The non-participation of the community and patients in the operation and maintenance of sanitation facilities was attributed to a lack of awareness about infection prevention and control. Thus, the community and patients did not appreciate the value of effective operation and maintenance, nor did they value good sanitation. In the majority of the HCFs, it was difficult to operate and maintain sanitation facilities due to a lack of running water, as expounded in one of the FGDs with community health workers: \"\u003cem\u003eThe cost of maintenance of the toilets that use water is becoming high and tiresome. We have a broken toilet system because there is no water. The inpatient toilet is also overused and violated. Remember, we pour water from the drums (FGD) with the help of community health workers.\u003c/em\u003e Under such circumstances, waterborne toilets often get blocked, prompting the HCFs administration to lock them up/ deny patients access.\u003c/p\u003e\u003cp\u003eA lack of access to sanitation facilities was reported to result in open defecation. \u0026ldquo;\u003cem\u003eThere is open defecation in the compound of the facility because the toilets lack water, so they end up using the free areas like in the corridors of the toilets and the bathrooms of the toilet facilities\u0026rdquo; (FGD with community health workers).\u003c/em\u003e Due to a lack of janitorial staff, the cleaning of wards and toilets in some HCFs was sometimes performed by patients or their caregivers. Although a few believed that the sanitation situation was not too bad, District healthcare managers acknowledged the challenge of operating and maintaining sanitation facilities. One of the HCF managers pointed out that some patients used stones and maise combs as anal cleansing materials, which consequently blocked the toilets. \u0026ldquo;\u003cem\u003eOur sanitation is okay. The only concern is the misuse of the toilet facilities. People (patients) use all sorts of funny things to clean themselves. They use stones and maise combs that fill up the toilets.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTo mitigate the challenge of poor operation and maintenance, some HCFs utilised Continuous Medical Education (CME) sessions and outpatient department (OPD) health talks to educate healthcare providers and patients, respectively, on the operation and maintenance of sanitation facilities. \u0026ldquo;\u003cem\u003eWe have CMEs and the Quality improvement team to identify and talk about things like sanitation (HCF manager).\u003c/em\u003e Concerning patient sensitisation, one healthcare manager mentioned that: \u003cem\u003e\u0026ldquo;Also, we provide health education to patients on how to use them (sanitation facilities) (HCF manager).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eHand hygiene\u003c/h2\u003e\u003cp\u003eHand hygiene among patients, attendants, and healthcare providers was generally poor. This was attributed to limited access to water, low awareness of the benefits of hand hygiene, a negative attitude, and the non-functionality of hand hygiene infrastructure. The challenge of access to water for hand hygiene was expounded in one of the FGDs: \u003cem\u003e\"Tap water is not flowing anymore. We have relied on only one water source\u0026mdash;the borehole, which makes hand hygiene somewhat challenging. Handwashing facilities are also broken, particularly at the entrance to the gate. We cannot pour water for hand washing!\u0026rdquo; (FGD with community health workers).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe nature of soap also affected hand hygiene compliance. Patients, attendants, and healthcare providers feared washing their hands because the available soap (bar soap) made their hands dry and had an unpleasant smell. One of the healthcare facilities' in-charges mentioned that: \u003cem\u003e\"The patients and the health workers used to hate handwashing because of the blue soap (bar soap), but they now wash due to the good-smelling liquid soap (KII with an HCF in charge).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn one of the healthcare facilities, the in-charges reported those who did not comply with the rules of hand hygiene to the higher committees for corrective action, as expounded in this quote: \u003cem\u003e\"There are difficult people who do not comply with the rules on hygiene. If they fail to abide by them, we report them to the relevant higher committees. The health workers are self-driven regarding washing hands; the handwashing points are almost in every unit.\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eEnvironmental hygiene\u003c/h2\u003e\u003cp\u003eGenerally, environmental hygiene was poor in most HCFs, and this was attributed to inadequate supervision, lack of work plans, and janitorial staffing. \"\u003cem\u003eEnvironmental hygiene is still poor in the facilities due to poor supervision. The place is not slashed, the outpatient and inpatient wings' floors are not mopped, and surfaces are not dusted. The potters (cleaners) also do not have work plans due to poor supervision (District healthcare manager).\u003c/em\u003e In addition to a lack of cleaning supplies, such as soap, due to limited funding, a negative attitude hindered environmental hygiene. Due to a shortage of supplies, some healthcare providers borrowed from the district health office to clean, as illustrated in this quote: \u003cem\u003eAs a facility, we lack materials and supplies for cleaning, and when we have a shortage, we usually obtain or borrow from the district health office. In a financial year, we can receive supplies once or twice (according to the HCF manager).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe healthcare providers singled out male nurses for being reluctant to contribute to environmental cleaning in some HCFs: \"\u003cem\u003eThe attitudes of the community and healthcare providers, especially the male nurses who feel special and do not want to clean, but it is self-behaviour (HCF manager).\u003c/em\u003e Due to staff shortages, healthcare providers in a few healthcare facilities requested support from patients and caregivers to help clean the wards, as illustrated in this quote: \u003cem\u003e\"We have a challenge with the cleaners.\" We have one cleaner, so we join hands with the patients to clean the wards. The cleaner is responsible for the OPD, the compound, and the toilets.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eHealthcare waste management\u003c/h2\u003e\u003cp\u003eDespite the mixed findings on healthcare waste management, it is essential to acknowledge the unwavering commitment of healthcare facilities to this cause. None of the facilities or respondents reported waste management as satisfactory, but those that rated it as fair demonstrated a strong commitment. These facilities made efforts to segregate waste, used colour-coded bins with bin liners, and had waste collected by a government-contracted waste company. One IPC committee member highlighted these efforts, stating: \"\u003cem\u003eThe bin liners are in plenty and they are enough so every morning we change the containers that were used the day before and replace them with clean and fresh ones, like black for non-infectious, yellow for the infectious, and red for highly infectious. These are segregated according to their colour, making it easy. We dispose of waste correctly since we know the harm it (poor healthcare waste management) brings, like causing diseases to others. The sharps are in the right place, the sharp box and the cotton with blood we put in the red bin liners. Then, other waste without blood is disposed of in a yellow bin liner, while paper is placed in a black liner for easy handling. The government supplies all these bin liners, and they are sufficient and in ample supply. They are supplied by the National Medical Stores (NMS). Sometimes, when they get finished, we borrow or get them from other facilities (healthcare facilities) (KII with an IPC committee member).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSome HCFs had waste management infrastructure, including incinerators and placenta pits that were located far away for the safety of HCF users. Others had staff to guide healthcare waste management: \u0026ldquo;\u003cem\u003eIn this facility, we have a staff member to guide the waste management activity. The porter is not even doing the work.\u0026rdquo; (FGD with community health workers).\u003c/em\u003e Regarding the presence of waste management infrastructure, one of the IPC committee members mentioned that: \u003cem\u003e\u0026ldquo;We have an incinerator where we burn waste and a well-constructed place for burning the waste\u0026rdquo; (FGD with community health workers)\u003c/em\u003e. There were also posters to remind healthcare providers to manage healthcare waste safely: \u003cem\u003e\u0026ldquo;The bins have posters showing the segregation of the wastes like infectious and non-infectious wastes.\u0026rdquo; (FGD with members of the IPC committee).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003ePoor healthcare waste management\u003c/h2\u003e\u003cp\u003eWhile a few HCFs reported a fair state of waste management, the majority reported a poor status, underscoring the urgent need for improvement. Some patients and healthcare providers lacked knowledge of waste management and were negligent in segregating waste, despite receiving instructions. The lack of waste bins and IEC materials in HCFs led to the collection of waste in inappropriate bins, and contractors often delayed waste collection for final disposal. In some cases, available incinerators were not properly fenced off, could not attain the required temperatures, and some HCFs lacked ashpits to control indiscriminate disposal of the ash. The severity of the poor healthcare waste management challenge was vividly described in the following quote: \"\u003cem\u003ePeople are often reluctant to put waste in the designated waste bins. They throw waste anywhere in any bin. At times, bin liners of different codes are placed in the wrong bins due to a lack of the correct bin liners. Because we lack the appropriate containers, sharps are disposed of in the wrong bins, which disturbs the people who come to collect the waste for final disposal. Sometimes, the responsible personnel delay picking up the waste for final disposal. The incinerator is up to standard, but it is far, not fenced, and when filled, it generates unpleasant smells (KII with a member of the IPC committee).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSome patients and attendants also indiscriminately dumped household waste at HCFs, as illustrated in one of the FGDs with IPC committee members: \"\u003cem\u003eThe only challenge we have is that some patients come with household waste, like rubbish that they litter at the HCF. There is a heap of rubbish behind the HCF.\"\u003c/em\u003e Poor waste management posed a health risk to HCF users, including children. \"\u003cem\u003eWe burn the rubbish locally and scatter the rubbish, which is very dangerous for the kids (children) who play around the pit since the waste is infectious.\" (KII with a member of the IPC committee).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOverall, the poor WASH status in all HCFs was attributed to inactive and ineffective IPC committees, as well as a negative attitude among patients, attendants, and healthcare providers. The role of the IPC committee in influencing healthcare waste management practices was expounded in the following quote: \"\u003cem\u003eThe IPC committee is not fully functional because they know we should meet monthly, but we no longer have meetings monthly. We could have meetings weekly or monthly, but that was during the COVID era, and we received funds to support the IPC\u0026ndash;WASH function in the hospital. We could get funding from the other stakeholders and partners (FGD with IPC committee members).\u003c/em\u003e The IPC committee used to meet regularly at the peak of the COVID-19 pandemic; however, this had changed due to a lack of resources. \"\u003cem\u003eI am a member of this committee, and I work in the LAB (laboratory). I remember during the times of the outbreaks we could meet every week, but the committee is almost dead; we have not had a meeting since the COVID era (peak of COVID-19 in Uganda) (FGD with IPC committee members).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHealthcare providers, including those on the IPC committees, often had a negative attitude towards healthcare waste management and lacked self-motivation, except during outbreaks. Besides, infrequent training on IPC/WASH, a lack of work plans and indicators for measuring progress and poor supervision hampered healthcare waste management as elaborated in this quote: \u003cem\u003e\"I think they (healthcare providers) lack self-drive, they cannot drive themselves unless there is some sort of outbreak, so basically, it is the attitude (negative attitude).\" (District healthcare manager).\u003c/em\u003e To improve healthcare waste management, participants recommended a refresher training on WASH/IPC, as the previous one had been conducted almost two years ago. \u003cem\u003eWe lack knowledge on IPC and WASH, so a refresher training on these topics is necessary. The last training was conducted two years ago, in response to the COVID-19 outbreak. We need meetings to discuss the challenges we face (KII with a HCF manager).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eAvailability of IEC materials on WASH\u003c/h2\u003e\u003cp\u003eGenerally, HCFs did not have adequate IEC materials to promote desired WASH and IPC behaviours. \u0026ldquo;\u003cem\u003eThere are some wards with these IEC materials, for example, the general ward. There are no adequate IEC materials (FGD with IPC committee members).\u003c/em\u003e Neither the respective districts nor the HCFs had the required financial resources to develop or provide the required IEC materials. Some HCFs requested IEC materials on WASH and IPC, but due to the diversity of dialects, they were unable to access them. However, the process of developing and approving IEC materials was also lengthy. Some HCFs had a few IEC materials; however, these were obsolete and did not cater to users with special needs, such as the blind, individuals with limited mobility, and illiterates. Commenting on the availability of IEC materials, it was noted in one of the FGDs that \u003cem\u003ethe posters are outdated and no longer readable. They gave them to us during the COVID-19 pandemic. We lack IPC information and messages for people with special needs, like the blind, those who cannot read, or the disabled. So, when making the IEC material, they should cater to them (FGD with IPC committee members).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSome IEC materials were also in languages that could not be read or understood by the user community and were illegible, as expounded in this quote: \u003cem\u003eThe posters are in a language that they (HCF users) do not understand. The posters are not readable due to the small writing (font size), they are.\u0026rdquo; (District healthcare manager).\u003c/em\u003e Additionally, most of the IEC materials were located in the maternity department, OPD, and theatre, and were supplied at the onset of the COVID-19 pandemic. Aside from the materials used for the IEC materials, they were not weather-resistant. As a result of inadequacy, the respondents highlighted the need to lobby for IEC materials from implementing partners such as Non-governmental Organisations. The lack of weather-resistant IEC materials was elaborated in this quote: \u0026ldquo;\u003cem\u003eStill, these IEC materials include posters showing the procedure for hand washing, directing patients to the male and female toilets and latrines, and those on the bins to indicate which type of waste to be disposed of in the respective bins. Since they use paper, these papers are sometimes washed by the rain (FGD with IPC committee members).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eScarcity of IEC materials on water safety and sanitation\u003c/h2\u003e\u003cp\u003eNone of the HCFs were equipped with IEC materials on water safety and sanitation. A few respondents did mention having some sanitation-related IEC materials, such as brochures for community dialogues and other health talks. The dire lack of IEC materials on water safety was starkly evident in this quote: '\u003cem\u003eWe do not have any materials on water safety, never seen any in healthcare facilities.' (KII with an IPC focal person).\u003c/em\u003e The shortage of IEC materials on sanitation was further emphasised in this quote: \u003cem\u003e'We do not have IEC materials on sanitation. The few we have are used for community dialogues. We usually carry a few brochures that we use to perform our duties, such as sensitising the community. The few we have are spread (given out/disseminated) in communities where we give health talks.' (KII with a district healthcare manager).\u003c/em\u003e\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eLimited availability of IEC materials on hand washing and healthcare waste management\u003c/h2\u003e\u003cp\u003eDespite being inadequate, the most commonly available IEC materials were posters on hand hygiene. Most of the available IEC materials on hand hygiene were distributed to HCFs during the peak of the COVID-19 pandemic, as illustrated in the following quote: \u003cem\u003e'We do have IEC materials, such as posters on COVID.' In the theatre, we have posters on hand washing and waste management, with instructions on which bin to put the waste in. In the department of isolation, we have posters available on hand hygiene, waste management, and mask-wearing. There are also posters on the five steps for hand washing (FGD with IPC committee members).\u003c/em\u003e While the majority of the HCFs reported having some IEC materials on healthcare waste management, the focus was solely on the segregation of healthcare waste. This highlights the need for a more comprehensive waste management strategy.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003ePriority topics for messaging\u003c/h2\u003e\u003cp\u003eOverall, respondents highlighted that IEC materials should be based on the principle that prevention is better than cure and should clearly outline the dos and don\u0026rsquo;ts of failing to practise the desired behaviours. Additionally, respondents suggested that the IEC materials should specify the repercussions of defaulting.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eAttitude of the patients, attendants, and healthcare providers\u003c/h2\u003e\u003cp\u003eRespondents highlighted the need to develop IEC materials that target changing attitudes towards WASH and infection prevention and control among HCF users, as this was identified as the biggest challenge. \u0026ldquo;\u003cem\u003eThe messages on the IEC materials should address the attitude of the people (patients and attendants) and health workers. The biggest challenge is attitude and how people perceive the information (District healthcare manager).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eSafe water chain\u003c/h2\u003e\u003cp\u003eThe necessity to develop IEC materials on the safe water chain was apparent. Healthcare facilities lacked IEC materials on protecting water sources, safely handling water from the source to the point of use, and cleaning water vessels. To highlight this need, one district healthcare manager mentioned: \u003cem\u003e\"There is a need for information on a safe water chain\u0026mdash;that is, keeping water from the source safe, cleaning water containers and the surrounding boreholes.\"\u003c/em\u003e There was also a significant call to create IEC materials promoting water treatment methods such as boiling and using clean containers for water collection, as expressed in the following quote, in response to which priority messages have to be developed to improve WASH in HCFs: \"Messages on the treatment of water, boiling of the water, and usage of clean containers to fetch water and also to keep the environment clean.\" (KII with an IPC focal person). Healthcare providers recommended that IEC materials, such as pictorials and images promoting a safe water chain, should be displayed at water points, entrances, and OPD, as these are familiar gathering places. Some respondents also suggested that the IEC materials should include information about penalties for failing to maintain a safe water chain.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eSanitation and hygiene\u003c/h2\u003e\u003cp\u003eRegarding sanitation, respondents mentioned the urgent need for IEC materials to provide information on the proper use of latrines, including operation and maintenance activities such as cleaning. To illustrate the need for IEC materials on sanitation, one of the IPC focal persons mentioned that: \u0026ldquo;\u003cem\u003eThe IEC materials should contain messages and information on the proper use of the latrine and cleaning of the latrines, burning of the waste, and using the correct waste bins.\u0026rdquo; (KII with an IPC focal person).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHealthcare providers also highlighted the need to develop IEC materials aimed at promoting good hygiene behaviours. They stressed the importance of targeting key moments for hand hygiene among patients, attendants, and healthcare workers. To clarify the priority topics for messaging, one of the healthcare facilities in charge mentioned, \u003cem\u003e\"IEC materials on why one should wash hands are not there yet. The importance of IECs lies in imparting knowledge to people and health workers, thereby guiding them technically. IEC materials should emphasise the washing of hands after toilet visits and before eating.\u0026rdquo;\u003c/em\u003e There was a preference for posters as reminders of vital moments for hand hygiene during patient care. The healthcare providers saw posters as an effective and practical way to deliver instructions or guidelines, highlighting the dos and don\u0026rsquo;ts, as illustrated in this quote: \u003cem\u003e\u0026ldquo;We should have information on handwashing pinned on posters. Posters should illustrate the proper handwashing procedure before and after patient contact, including when coming into contact with body fluids. It is essential because people like to follow such information since it gives directives to the workers and patients on what to do and avoid.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eHealthcare waste management and environmental cleaning\u003c/h2\u003e\u003cp\u003eThe majority of the respondents highlighted the urgent need to develop IEC materials on adherence to waste management protocols and segregation. Healthcare providers viewed IEC materials on the importance of waste segregation and adhering to these protocols as a practical mechanism for imparting knowledge on health risks. In response to the messages that IEC materials should address, one of the district healthcare managers mentioned that: \u0026ldquo;\u003cem\u003eMessages on the safe management of waste from the point of generation to the point of final disposal. It is important to do that, although not well-practised, and the SOPs (standard operating procedures) are yet to be well adhered to (District healthcare manager).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAside from healthcare waste management, the respondents emphasised the need to develop IEC materials that address aspects of environmental cleaning, such as HCF cleanliness and safety, cleaning methods, dusting and disinfection of contaminated surfaces. To illustrate what key messages IEC materials on environmental cleaning should address, one of the district healthcare managers mentioned that: \u0026ldquo;\u003cem\u003eThe messages on keeping the environment clean and safe. The messages on cleaning and how to clean, slashing of the compound and how to keep and maintain the compound clean, and disinfection of the suspected contaminated areas.\"\u003c/em\u003e Some respondents suggested using talking walls to disseminate information on environmental cleaning.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eKey considerations for the development and dissemination of IEC materials\u003c/h2\u003e\u003cdiv id=\"Sec30\" class=\"Section3\"\u003e\u003ch2\u003eLanguage\u003c/h2\u003e\u003cp\u003eThe healthcare providers emphasised that the designers should take language considerations for IEC materials seriously during their development. They recommended that designers use both English and the local language (Acholi) when creating the IEC materials. Additionally, the respondents urged the designers to incorporate translations of key health terms or phrases, or to utilise culturally relevant visual aids that the local community can understand. Healthcare providers noted that designing IEC materials in both English and the local language would enhance message comprehension, as the area is home to people from different dialects and tribes. To emphasise the need for having the IEC materials in English and the local dialect, one of the focus group discussants mentioned that: \"\u003cem\u003eThe IEC materials should be in the local language and English for those who do not understand the local language (FGD with community health workers).\u003c/em\u003e In a community with multiple tribes and dialects, healthcare providers recommended translating IEC materials into these languages, as explained by one of the IPC focal persons. \"\u003cem\u003eThe language used in the IEC materials should be considered. People like us, the Acholi (tribe), know Acholi (language), and the Luo (tribe) use Luo (language). So, the IEC materials should be in the language of the tribe in a particular location.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAccording to healthcare providers, the designers had to thoroughly review the language used in designing and disseminating IEC materials to ensure the target community clearly understands them and is not misled. Community health workers emphasised the need for thoroughly reviewing the language in the IEC materials, \u003cem\u003enoting the importance of visual aids in enhancing understanding: \"The pictures illustrate the water's safety, allowing those who cannot read to understand the message and information through visual means (FGD with community health workers).\u003c/em\u003e\" This visual component, they argued, would ensure that the IEC materials are inclusive and accessible to all members of the community.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003eInclusivity\u003c/h2\u003e\u003cp\u003eHealthcare providers suggested the need to design IEC materials that cater for the health education needs of individuals with special needs, such as the blind. To ensure inclusivity, healthcare providers suggested designing IEC materials for those who cannot read or write. To illustrate the need for inclusive IEC materials, one of the participants in the focus groups mentioned that: \u0026ldquo;\u003cem\u003eWe lack IEC materials for people with special needs, such as the blind, those who cannot read, or the disabled, so I suggest that when making these IEC materials, they should cater to them.\u003c/em\u003e One of the IPC focal persons further emphasised the need for IEC materials that cater to those who cannot read and write by saying: \u003cem\u003e\u0026ldquo;The IEC on cleanliness of the bore hales showing the 5 moments when one should wash hands, like in the pictorial way, the images trying to bring out the information that the locals understand so that even when one cannot read then that might just look at the picture and get the information that is being passed on.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003eDisplay\u003c/h2\u003e\u003cp\u003eHealthcare providers suggested that IEC materials should be displayed in prominent locations, including facility entrances, sanitation facilities, compound areas, ward walls, waste containers, and notice boards, to ensure accessibility to HCF users. Community health workers recommended that IEC materials designed to discourage undesirable behaviours should include a clear \u0026ldquo;X\u0026rdquo; symbol to indicate to HCF users that the behaviour is unacceptable. \u0026ldquo;\u003cem\u003eThe picture (posters) should be displayed on the facility compound to highlight the dangers of dumping. A cross through a harmful act to someone dumping rubbish, because the client can interpret the situation (FGD with community health workers).\u003c/em\u003e There was also a suggestion by healthcare providers to disseminate the IEC materials during the outreaches.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to understand the WASH situation for the design of IEC materials for healthcare facilities, explore existing WASH IEC materials, identify priority topics for messaging, and outline key considerations for the development of IEC materials. Themes generated from the findings include the status of WASH, the availability of IEC materials at healthcare facilities, critical topics to be addressed in IEC material development, and key considerations in the development and dissemination of IEC materials. This study found limited WASH services in healthcare facilities, which is consistent with studies conducted in other parts of Uganda [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e] and similar settings. Water shortages, inadequate water supply, similar to those in HCFs in other parts of Uganda [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], a poor toilet-to-patient ratio [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], and limited funds all affect the maintenance of water, hygiene, and sanitation services [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. The lack of adequate WASH services implies that healthcare facilities are at risk of poor infection prevention and control, which could threaten patient safety and recovery and may worsen the spread of infections. The study highlights the importance of enhancing WASH infrastructure, as well as IEC materials, to encourage actions that promote proper hygiene behaviours among both staff and HCF users.\u003c/p\u003e\u003cp\u003eThis study found a limited availability of WASH-related IEC materials, with a notable lack of IEC materials on sanitation. The narrow scope of information in IEC materials primarily focused on healthcare waste management, with limited information on environmental sanitation and water safety. Limited budgetary allocations, exacerbated by the information being provided in a few dialects and non-inclusivity, all contributed to this inadequacy, similar to other studies [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. The reduced demand for WASH IEC materials among the HCF managers could be linked to the perceived decrease in urgency following the management of the COVID-19 pandemic, during which hand hygiene IEC materials were heavily utilised [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. Additionally, the reliance on donations from non-governmental organisations (NGOs) for such materials\u0026mdash;rather than institutional budgeting\u0026mdash;may have led to a gap in availability once the pandemic subsided. This finding is similar to those reported by [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e] in rural Ethiopia, where the numerous IEC materials found in HCFs were due to donations from NGOs. The limited availability of WASH IEC materials can hinder the widespread dissemination of critical health information on WASH that could encourage proper hygiene and sanitation practices.\u003c/p\u003e\u003cp\u003eThis study found that the existing IEC materials were not weather resistant, and this was similar to a study in Ethiopia where Geleta, Deriba [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e] found IEC materials damp and wasted at HCFs. This could imply that WASH IEC materials were present in the past but were also not weather-resistant, resulting in their waste. IEC materials, especially posters, could be poorly located in areas that are directly hit by the sun or raindrops. Non-weather-resistant IEC materials, when poorly maintained, will have reduced longevity, hence the effect of their presence will barely be achieved. IEC materials should be laminated for resistance against rain and placed in shades to prevent fading.\u003c/p\u003e\u003cp\u003eThis study also identified priority topics for messaging during WASH IEC materials development, including the attitudes of end-users, and WASH fields such as the safe water chain, sanitation, hand hygiene, healthcare waste management, and environmental cleaning. This study noted that IECs should target the attitudes of healthcare providers (HCPs), patients, and attendants, as knowledge and attitudes in multiple studies have been shown to influence practice. Targeting attitudes in IEC materials is important because many patients, caregivers, and even healthcare providers may not fully understand the importance of IPC in preventing infections and ensuring patient safety. Some studies [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e] have shown that Health Care Providers (HCPs) are knowledgeable about WASH and IPC, and that factors such as designation, qualification, age, attending risk assessment training, and the presence of sufficient IPC implementation equipment are significant in ensuring better IPC practices. However, other studies [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e] from similar settings have contradicting findings about the knowledge of HCPs towards IPC and also recommend the distribution of IEC materials. Studies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and [\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e] have shown that even healthcare providers need continual reminders through sensitisation and the use of IEC materials to maintain proper WASH practices. Some end users, such as caregivers, may lack knowledge about comprehensive IPC implementation or its application in patient recovery. This means that sensitisations should be sustained through IEC materials that communicate about WASH and IPC to instil a culture of WASH and IPC. Although HCPs are knowledgeable, their attitude towards IPC practices could be frustrated due to inadequate hand hygiene infrastructure, water services, PPE and scarce IPC training, all of which hinder IPC practice [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]. Therefore, the presence of IEC materials that effectively communicate IPC could be another form of IPC communication, hence improving attitude towards IPC practices.\u003c/p\u003e\u003cp\u003eThis study found respondents in need of IEC materials about the safe water chain. Safe water chain studies in Uganda have been more prevalent in refugee settings and informal settlements, aiming to prevent the onset of outbreaks [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e]. This means information about water and health has been scarce in HCFs, and IEC materials are one sustainable way of communicating the safe water chain for improved WASH and IPC. Additionally, information on the safe water chain is crucial, especially in rural or resource-poor settings where access to clean water may be limited [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]. The safe handling and storage of water are essential for reducing waterborne diseases, making this a crucial topic for IEC materials. Sanitation messages should focus on proper latrine use and the management of healthcare waste, while hand hygiene messages must emphasise the five moments of hand hygiene, which are vital for preventing the spread of infections.\u003c/p\u003e\u003cp\u003eThis study found language to be a key consideration during the development of IEC materials, which concurs with other studies [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Grene and Cleary [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e] emphasised that health IEC materials should be written in plain language for easy understanding of instructions and effective use by patients and caregivers [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e]. Harper and Zimmerman [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e] also described the use of plain language in health IEC materials, considering the target's level of understanding and literacy, simple sentence structure, and defining unfamiliar concepts, among others [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. Language barriers and the exclusion of people with special needs can severely limit the reach and impact of IEC materials. Therefore, for IEC materials to be effective, they must be contextually and culturally relevant and must be accessible to individuals who speak different dialects. Messages should be communicated in local languages, using visual aids that reflect the HCF users' environment and understanding.\u003c/p\u003e\u003cp\u003eThis study also highlighted the need for IEC materials to be inclusive of people with special needs, which aligns with other literature [\u003cspan additionalcitationids=\"CR86\" citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e]. Hachipola, Mweemba [\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e] found inadequate access to cervical cancer IEC materials among people with physical and sensory disabilities due to the absence of braille transcription or sign language interpretation [\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e]. Health IEC materials are mainly used by the literate and visually able, but exclude those who are visually impaired. Standard Operating Procedures for Disability-Inclusive Health Services emphasise the design of IEC materials, such as videos with captions, audio, braille, pictorial information, and large print, for inclusiveness [\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e]. The use of braille and audio aids for individuals with IEC is effective in improving the health status of visually impaired communities [\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e]. Consideration of people with special needs in health service delivery and communication is crucial in improving universal health coverage and addressing the lack of awareness about disease prevention in HCFs and their communities [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study also found the need to display IEC materials in conspicuous areas for the target users, which agrees with other studies [\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e, \u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e]. IEC materials, such as posters, should be displayed in the most frequented areas of the facility, like entrances, latrines, and waiting zones throughout the entire HCF, rather than at specific points such as OPD and maternity wards. They should be sufficiently visible for end users. This means printed IEC materials need to be accessible and in a clear font size for individuals with visual impairments, including those in wheelchairs, to avoid strain while reading. Strategically placed and inclusive IEC materials can enhance visibility and effectiveness in encouraging positive behaviour change.\u003c/p\u003e\u003cp\u003eIn conclusion, the development of IEC materials requires participatory involvement to increase their utilisation [\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e]. HCFs should be involved in mapping the population distribution of their catchment area and jurisdiction to ensure the inclusiveness of all people groups when designing IEC materials. Healthcare facilities and the communities they serve should be involved in the process of creating and distributing these materials to ensure that they are culturally appropriate, linguistically accessible, and responsive to the specific needs of the target population, thereby having a greater impact on improving WASH practices.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDespite the poor WASH conditions, healthcare facilities lacked IEC materials, especially on water safety, hand washing, environmental cleaning and waste management. HCFs found it challenging to access IEC materials in the language read and understood by the target community, and those catering for individuals with special needs, such as the blind, individuals with limited mobility, and illiterates. The available IEC materials were mainly found in the maternity, theatre, and outpatient departments, although they were not weather-resistant. The local experts played a crucial role in suggesting that the priority messages should target attitudinal change for patients, attendants, and healthcare providers, water safety practices, proper use of latrines, including operation and maintenance activities, waste segregation, and environmental cleaning, such as HCF cleanliness and safety, cleaning methods, dusting and disinfection of contaminated surfaces. As suggested by the local experts, the IEC materials ought to be in the local language or with translations where English is used, should cater for the health education needs of individuals with special needs, such as the blind, and the illiterate, and needed to be displayed in prominent locations, including facility entrances, sanitation facilities, compound areas, ward walls, waste containers, and notice boards. The findings from this study highlight the critical role played by the local experts in defining priority topics for messaging and the key considerations for the development and dissemination of IEC materials on water, sanitation and hygiene in healthcare facilities.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFGD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFocus group discussion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHealth Centre\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHCFs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHealthcare Facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIEC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInformation, Education, and Communication\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInfection Prevention and Control\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKIIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKey Informant Interviews\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLMICs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLow-and middle-income countries\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWASH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWater, Sanitation and Hygiene\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePFP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrivate for Profit\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePNFP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrivate Not for Profit\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVHTs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVillage Health Teams\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted following the Declaration of Helsinki. Ethics approval was obtained from the AIDS Support Organisation (TASO) Research and Ethics Committee (Protocol TASO-2022-131) and was registered by the Uganda National Council for Science and Technology. Before data collection, the investigators obtained administrative clearance from the Amuru and Nwoya district local governments, as well as the leadership of the respective healthcare facilities. All the respondents provided informed written consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe transcripts analysed in this manuscript are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe GIZ Sanitation for Millions Programme funded this study through its collaboration with Makerere University School of Public Health to promote water, sanitation and hygiene and infection prevention and control in Apac and Nwoya districts. The study protocol was independently peer-reviewed by the funding body; however, any opinions, conclusions, or recommendations expressed in this article are those of the authors alone and do not necessarily reflect the views of the funding agencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJBI and TS conceptualised and obtained the funding for this study. JBI, PT, RKM, STW, TA, JG, RN, GA, DN, EO, SM, RN, MN, IFA, FN, MN, MMM, and TS participated in the analysis and drafting of the manuscript. All authors read and approved this manuscript before submission to this journal.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the administration of the Amuru and Nwoya district local governments for granting clearance to undertake the study. We remain indebted to the leadership of the healthcare facilities for allowing us to collect data. Finally, we thank our diligent team of research assistants (Sandra Babirye, Geofrey Bwire, Ronald Tenywa, and Kassim Kaddu Mukasa) who made this study a success.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO and UNICEF. \u003cem\u003eWater, sanitation, hygiene, environmental cleaning and waste management in health care facilities: 2023 data update and special focus on primary health care\u003c/em\u003e (World Health Organization, 2025).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO and UNICEF. \u003cem\u003eWater, sanitation, hygiene, waste and electricity services in health care facilities: progress on the fundamentals. 2023 global report\u003c/em\u003e (World Health Organization, 2023).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKayiwa, D. et al. 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(2023).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"IEC, Local expertise, WASH communication, stakeholders","lastPublishedDoi":"10.21203/rs.3.rs-7546174/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7546174/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eInformation, Education, and Communication (IEC) materials relay information crucial for improving WASH behaviours in healthcare settings. However, due to a limited in-depth understanding of the status and the involvement of local experts in the IEC material development process, improvements in WASH in HCF remain suboptimal. This qualitative descriptive study employed seven focus groups and nine key informant interviews with local experts to enhance our understanding of WASH status, assess the availability of IEC materials, identify priority topics for messaging, and highlight considerations for optimising their use. This study revealed that HCFs faced numerous challenges, including intermittent supply, low-yield water supply, poor water quality, congestion, inadequate operation and maintenance of water sources, open defecation, limited hand hygiene infrastructure, poor environmental hygiene, and weak healthcare waste management practices. The absence of appropriate IEC materials to promote desired WASH behaviours further compounded the suboptimal status. To address the suboptimal status, local experts recommended that the messages on IEC materials should tackle the attitudes and practices of patients, caregivers, and healthcare providers, as well as water safety, sanitation, and hygiene, healthcare waste management, and environmental cleaning, while being inclusive and considering the display and language used by the target community. The study highlights the crucial role of local experts in guiding the development and utilisation of IEC materials to promote WASH behaviours and enhance conditions in healthcare facilities.\u003c/p\u003e","manuscriptTitle":"Informing Water, Sanitation and Hygiene (WASH) communication through local expertise: a qualitative study with healthcare providers in Northern Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-19 16:54:11","doi":"10.21203/rs.3.rs-7546174/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-20T20:09:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-08T19:13:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-24T16:29:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325661732786847148968356526582878895557","date":"2025-11-13T16:15:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102174099193322656679376382807034434510","date":"2025-11-13T07:46:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106423363416994352560683955400399252268","date":"2025-11-11T14:45:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-07T05:47:12+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-16T15:24:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-08T12:25:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-06T06:36:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-09-05T16:59:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6c983728-ab7a-4b29-863a-268d029904fc","owner":[],"postedDate":"October 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":56001230,"name":"Earth and environmental sciences/Environmental sciences"},{"id":56001231,"name":"Health sciences/Health care"}],"tags":[],"updatedAt":"2026-03-30T07:25:49+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-19 16:54:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7546174","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7546174","identity":"rs-7546174","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}