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Special Issue "Solutions for Improving Essential Environmental Conditions in Healthcare Facilities in Low- and Middle-Income Countries"

A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Environmental Health".

Deadline for manuscript submissions: closed (30 June 2021).

Special Issue Editors

Dr. Ryan Cronk
E-Mail Website
Guest Editor
1. ICF, Health Science Practice, 2635 Meridian Pkwy Suite 200, Durham, NC 27713, USA
2. The Water Institute at UNC and Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166 Rosenau Hall, CB, Chapel Hill, NC 27599-7431, USA
Interests: environmental health; public health engineering; water and sanitation
Prof. Irving Hoffman
E-Mail Website
Guest Editor
Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, United States
Interests: global public health; infectious diseases; health systems; public health surveillance systems;
Dr. Tisungane Mvalo
E-Mail Website
Guest Editor
School of Medicine, University of North Carolina, Chapel Hill, United States
Interests: global public health; health care improvement; infectious diseases

Special Issue Information

Dear Colleagues,

One of the most critical issues hampering health systems in low- and middle-income countries (LMICs) is the lack of essential environmental conditions in healthcare facilities (HCFs). Essential environmental conditions include adequate environmental health infrastructure (e.g., water supply, sanitation facilities, waste management), sufficient environmental hygiene items for infection prevention and control (IPC) (e.g., soap, gloves), clean surfaces, and appropriate hygienic behaviours. A lack of essential environmental conditions can impede the delivery of quality healthcare and contribute to healthcare-acquired infection (HAI). Rates of HAIs in LMICs are estimated to be 16% and contribute to an estimated 1 million maternal and neonatal deaths each year from unhygienic practices at or after birth. The 2019 report from the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation, and Hygiene (JMP) indicated that one in four HCFs in LMICs lack a basic water service, one in five has no sanitation facility, two in five have no hand hygiene at points of care, and two in five have no systems for waste segregation.

Since the launch of a landscape report in 2015, there has been tremendous mobilization of resources and support for improving water, sanitation, and hygiene in HCFs in LMICs. This is due largely to WHO and UNICEF’s leadership, the UN Secretary General’s 2018 call to action, and the 2019 World Health Assembly resolution. However, improving the situation requires new evidence describing potential solutions to improve essential environmental conditions, especially evidence demonstrating effective implementation that might be used to inform policy, programming, and practice at the local, national and global levels.

In this Special Issue, we are interested in papers that illuminate the scope of the problem, identify potential solutions and effective implementation approaches, and test novel technologies that could help to improve essential environmental conditions (e.g., infrastructure, hygienic items, clean surfaces, behaviours) in HCFs. Examples include:

  • formative research studies that identify and describe enablers of and barriers to essential environmental conditions in HCFs;
  • operational research studies that identify determinants of improved essential environmental conditions in HCFs;
  • implementation science approaches that demonstrate the acceptability, adoptability, appropriateness, and feasibility of implementing environmental health-related evidence-based practices in HCFs;
  • evaluations of new infrastructure interventions, service delivery models, and behavioural programs for environmental health in HCFs; and
  • evidence describing the costs of infrastructure, services, and programs in environmental health in HCFs.

Studies may address one or multiple essential environmental condition(s) in HCFs in LMICs. Solutions-oriented studies that address known research gaps, such as accessibility, gender, and patient satisfaction, or integrate these concepts, are encouraged.

Dr. Ryan Cronk
Prof. Irving Hoffman
Dr. Tisungane Mvalo
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All papers will be peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. International Journal of Environmental Research and Public Health is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2500 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • implementation science
  • healthcare-acquired infection
  • healthcare cleaning
  • hygienic healthcare behaviors
  • healthcare waste management
  • water, sanitation, and hygiene.

Published Papers (7 papers)

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Research

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Article
Barriers and Opportunities for Sustainable Hand Hygiene Interventions in Rural Liberian Hospitals
Int. J. Environ. Res. Public Health 2021, 18(16), 8588; https://doi.org/10.3390/ijerph18168588 - 14 Aug 2021
Cited by 1 | Viewed by 923
Abstract
Hand hygiene is central to hospital infection control. During the 2014–2016 West Africa Ebola virus disease epidemic in Liberia, gaps in hand hygiene infrastructure and health worker training contributed to hospital-based Ebola transmission. Hand hygiene interventions were undertaken post-Ebola, but many improvements were [...] Read more.
Hand hygiene is central to hospital infection control. During the 2014–2016 West Africa Ebola virus disease epidemic in Liberia, gaps in hand hygiene infrastructure and health worker training contributed to hospital-based Ebola transmission. Hand hygiene interventions were undertaken post-Ebola, but many improvements were not sustainable. This study characterizes barriers to, and facilitators of, hand hygiene in rural Liberian hospitals and evaluates readiness for sustainable, locally derived interventions to improve hand hygiene. Research enumerators collected data at all hospitals in Bong and Lofa counties, Liberia, in the period March–May 2020. Enumerators performed standardized spot checks of hand hygiene infrastructure and supplies, structured observations of hand hygiene behavior, and semi-structured key informant interviews for thematic analysis. During spot checks, hospital staff reported that handwashing container water was always available in 89% (n = 42) of hospital wards, piped running water in 23% (n = 11), and soap in 62% (n = 29). Enumerators observed 5% of wall-mounted hand sanitizer dispensers (n = 8) and 95% of pocket-size dispensers (n = 53) to be working. In interviews, hospital staff described willingness to purchase personal hand sanitizer dispensers when hospital-provided supplies were unavailable. Low-cost, sustainable interventions should address supply and infrastructure-related obstacles to hospital hand hygiene improvement. Full article
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Article
Using the Water and Sanitation for Health Facility Improvement Tool (WASH FIT) in Zimbabwe: A Cross-Sectional Study of Water, Sanitation and Hygiene Services in 50 COVID-19 Isolation Facilities
Int. J. Environ. Res. Public Health 2021, 18(11), 5641; https://doi.org/10.3390/ijerph18115641 - 25 May 2021
Viewed by 2246
Abstract
The availability of water, sanitation and hygiene (WASH) services is a key prerequisite for quality care and infection prevention and control in health care facilities (HCFs). In 2020, the COVID-19 pandemic highlighted the importance and urgency of enhancing WASH coverage to reduce the [...] Read more.
The availability of water, sanitation and hygiene (WASH) services is a key prerequisite for quality care and infection prevention and control in health care facilities (HCFs). In 2020, the COVID-19 pandemic highlighted the importance and urgency of enhancing WASH coverage to reduce the risk of COVID-19 transmission and other healthcare-associated infections. As a part of COVID-19 preparedness and response interventions, the Government of Zimbabwe, the United Nations Children’s Fund (UNICEF), and civil society organizations conducted WASH assessments in 50 HCFs designated as COVID-19 isolation facilities. Assessments were based on the Water and Sanitation for Health Facility Improvement Tool (WASH FIT), a multi-step framework to inform the continuous monitoring and improvement of WASH services. The WASH FIT assessments revealed that one in four HCFs did not have adequate services across the domains of water, sanitation, health care waste, hand hygiene, facility environment, cleanliness and disinfection, and management. The sanitation domain had the largest proportion of health care facilities with poor service coverage (42%). Some of the recommendations from this assessment include the provision of sufficient water for all users, Menstrual Hygiene Management (MHM)- and disability-friendly sanitation facilities, handwashing facilities, waste collection services, energy for incineration or waste treatment facilities, cleaning supplies, and financial resources for HCFs. WASH FIT may be a useful tool to inform WASH interventions during the COVID-19 pandemic and beyond. Full article
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Article
The Impact of Water Sanitation and Hygiene (WASH) Improvements on Hand Hygiene at Two Liberian Hospitals during the Recovery Phase of an Ebola Epidemic
Int. J. Environ. Res. Public Health 2021, 18(7), 3409; https://doi.org/10.3390/ijerph18073409 - 25 Mar 2021
Cited by 2 | Viewed by 1151
Abstract
Fourteen years of civil war left Liberia with crumbling infrastructure and one of the weakest health systems in the world. The 2014–2015 Ebola virus disease (EVD) outbreak exposed the vulnerabilities of the Liberian health system. Findings from the EVD outbreak highlighted the lack [...] Read more.
Fourteen years of civil war left Liberia with crumbling infrastructure and one of the weakest health systems in the world. The 2014–2015 Ebola virus disease (EVD) outbreak exposed the vulnerabilities of the Liberian health system. Findings from the EVD outbreak highlighted the lack of infection prevention and control (IPC) practices, exacerbated by a lack of essential services such as water, sanitation, and hygiene (WASH) in healthcare facilities. The objective of this intervention was to improve IPC practice through comprehensive WASH renovations conducted at two hospitals in Liberia, prioritized by the Ministry of Health (MOH). The completion of renovations was tracked along with the impact of improvements on hand hygiene (HH) practice audits of healthcare workers pre- and post-intervention. An occurrence of overall HH practice was defined as the healthcare worker practicing compliant HH before and after the care for a single patient encounter. Liberia Government Hospital Bomi (LGH Bomi) and St. Timothy Government Hospital (St. Timothy) achieved World Health Organization (WHO) minimum global standards for environmental health in healthcare facilities as well as Liberian national standards. Healthcare worker (HCW) overall hand hygiene compliance improved from 36% (2016) to 89% (2018) at LGH Bomi hospital and from 86% (2016) to 88% (2018) at St. Timothy hospital. Improved WASH services and IPC practices in resource-limited healthcare settings are possible if significant holistic WASH infrastructure investments are made in these settings. Full article
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Article
When It Is Not Measured, How Then Will It Be Planned for? WaSH a Critical Indicator for Universal Health Coverage in Kenya
Int. J. Environ. Res. Public Health 2020, 17(16), 5746; https://doi.org/10.3390/ijerph17165746 - 08 Aug 2020
Cited by 3 | Viewed by 1304
Abstract
The quality and safety of healthcare facility (HCF) services are critical to achieving universal health coverage (UHC) and yet the WHO/UNICEF joint monitoring program for water supply, sanitation and hygiene report indicates that only 51% and 23% of HCF in Sub-Saharan Africa have [...] Read more.
The quality and safety of healthcare facility (HCF) services are critical to achieving universal health coverage (UHC) and yet the WHO/UNICEF joint monitoring program for water supply, sanitation and hygiene report indicates that only 51% and 23% of HCF in Sub-Saharan Africa have basic access to water and sanitation, respectively. Global commitments on improving access to water, sanitation, hygiene, waste management and environmental cleaning (WaSH) in HCF as part of implementing UHC have surged since 2015. Guided by political ecology of health theory, we explored the country level commitment to ensuring access to WaSH in HCFs as part of piloting UHC in Kisumu, Kenya. Through content analysis, 17 relevant policy documents were systematically reviewed using NVIVO. None of the national documents mentioned all the component of WaSH in healthcare facilities. Furthermore, these WaSH components are not measured as part of the universal health coverage pilot. Comprehensively incorporating WaSH measurement and monitoring in HCFs in the context of UHC policies creates a foundation for achieving SDG 6. Full article

Review

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Review
Safe Healthcare Facilities: A Systematic Review on the Costs of Establishing and Maintaining Environmental Health in Facilities in Low- and Middle-Income Countries
Int. J. Environ. Res. Public Health 2021, 18(2), 817; https://doi.org/10.3390/ijerph18020817 - 19 Jan 2021
Cited by 3 | Viewed by 1627
Abstract
A hygienic environment is essential to provide quality patient care and prevent healthcare-acquired infections. Understanding costs is important to budget for service delivery, but costs evidence for environmental health services (EHS) in healthcare facilities (HCFs) is lacking. We present the first systematic review [...] Read more.
A hygienic environment is essential to provide quality patient care and prevent healthcare-acquired infections. Understanding costs is important to budget for service delivery, but costs evidence for environmental health services (EHS) in healthcare facilities (HCFs) is lacking. We present the first systematic review to evaluate the costs of establishing, operating, and maintaining EHS in HCFs in low- and middle-income countries (LMICs). We systematically searched for studies costing water, sanitation, hygiene, cleaning, waste management, personal protective equipment, vector control, laundry, and lighting in LMICs. Our search yielded 36 studies that reported costs for 51 EHS. There were 3 studies that reported costs for water, 3 for sanitation, 4 for hygiene, 13 for waste management, 16 for cleaning, 2 for personal protective equipment, 10 for laundry, and none for lighting or vector control. Quality of evidence was low. Reported costs were rarely representative of the total costs of EHS provision. Unit costs were infrequently reported. This review identifies opportunities to improve costing research through efforts to categorize and disaggregate EHS costs, greater dissemination of existing unpublished data, improvements to indicators to monitor EHS demand and quality necessary to contextualize costs, and development of frameworks to define EHS needs and essential inputs to guide future costing. Full article
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Review
Budgeting for Environmental Health Services in Healthcare Facilities: A Ten-Step Model for Planning and Costing
Int. J. Environ. Res. Public Health 2020, 17(6), 2075; https://doi.org/10.3390/ijerph17062075 - 20 Mar 2020
Cited by 8 | Viewed by 3299
Abstract
Environmental health services (EHS) in healthcare facilities (HCFs) are critical for safe care provision, yet their availability in low- and middle-income countries is low. A poor understanding of costs hinders progress towards adequate provision. Methods are inconsistent and poorly documented in costing literature, [...] Read more.
Environmental health services (EHS) in healthcare facilities (HCFs) are critical for safe care provision, yet their availability in low- and middle-income countries is low. A poor understanding of costs hinders progress towards adequate provision. Methods are inconsistent and poorly documented in costing literature, suggesting opportunities to improve evidence. The goal of this research was to develop a model to guide budgeting for EHS in HCFs. Based on 47 studies selected through a systematic review, we identified discrete budgeting steps, developed codes to define each step, and ordered steps into a model. We identified good practices based on a review of additional selected guidelines for costing EHS and HCFs. Our model comprises ten steps in three phases: planning, data collection, and synthesis. Costing-stakeholders define the costing purpose, relevant EHS, and cost scope; assess the EHS delivery context; develop a costing plan; and identify data sources (planning). Stakeholders then execute their costing plan and evaluate the data quality (data collection). Finally, stakeholders calculate costs and disseminate findings (synthesis). We present three hypothetical costing examples and discuss good practices, including using costing frameworks, selecting appropriate indicators to measure the quantity and quality of EHS, and iterating planning and data collection to select appropriate costing approaches and identify data gaps. Full article
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Other

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Systematic Review
Evidence Map and Systematic Review of Disinfection Efficacy on Environmental Surfaces in Healthcare Facilities
Int. J. Environ. Res. Public Health 2021, 18(21), 11100; https://doi.org/10.3390/ijerph182111100 - 22 Oct 2021
Viewed by 719
Abstract
Healthcare-associated infections (HAIs) contribute to patient morbidity and mortality with an estimated 1.7 million infections and 99,000 deaths costing USD $28–34 billion annually in the United States alone. There is little understanding as to if current environmental surface disinfection practices reduce pathogen load, [...] Read more.
Healthcare-associated infections (HAIs) contribute to patient morbidity and mortality with an estimated 1.7 million infections and 99,000 deaths costing USD $28–34 billion annually in the United States alone. There is little understanding as to if current environmental surface disinfection practices reduce pathogen load, and subsequently HAIs, in critical care settings. This evidence map includes a systematic review on the efficacy of disinfecting environmental surfaces in healthcare facilities. We screened 17,064 abstracts, 635 full texts, and included 181 articles for data extraction and study quality assessment. We reviewed ten disinfectant types and compared disinfectants with respect to study design, outcome organism, and fourteen indictors of study quality. We found important areas for improvement and gaps in the research related to study design, implementation, and analysis. Implementation of disinfection, a determinant of disinfection outcomes, was not measured in most studies and few studies assessed fungi or viruses. Assessing and comparing disinfection efficacy was impeded by study heterogeneity; however, we catalogued the outcomes and results for each disinfection type. We concluded that guidelines for disinfectant use are primarily based on laboratory data rather than a systematic review of in situ disinfection efficacy. It is critically important for practitioners and researchers to consider system-level efficacy and not just the efficacy of the disinfectant. Full article
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