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

Background: Water, sanitation, and hygiene are essential for public health in healthcare facilities, with many lacking basic services, especially in rural sub-Saharan Africa, including Uganda. WASH impacts health security, staff morale, quality of care, and gender equality. Although the WASHFIT has been tested and recommended for enhancing WASH and IPC practices, it has not been extensively evaluated in various healthcare settings. We, therefore, employed a qualitative case study design to explore the fidelity of the WASHFIT process, as well as the barriers and facilitators to its application in HCFs in Northern Uganda. Methodology: The study was conducted in the districts of Amuru and Nwoya in Northern Uganda. We used a combination of snowball and purposive sampling techniques to select 20 key informants and 36 focus group discussants associated with the eight healthcare facilities that implemented the WASHFIT intervention. We used Atlas. Version 24 to code the data and the RE-AIM framework to guide our analysis. Results: The WASHFIT intervention, implemented by knowledgeable trainers, distinguished itself from others by incorporating a structured risk assessment and rating, stakeholder participation, and an emphasis on the governance, operation, and maintenance of WASH/IPC facilities. Through weekly CMEs and regular status meetings, the participants acquired knowledge which they used to implement WASH/IPC interventions. A lack of customised assessment tools, a heavy workload, a negative attitude among staff, a shortage of human resources competent in using WASHFIT, inadequate inter-departmental collaboration, and insufficient technical support from implementing partners and district healthcare managers hindered the use of the WASHFIT methodology. Healthcare providers' awareness of the challenges posed by WASH in healthcare facilities, as well as expectations related to reporting and accountability. Conclusions: Based on these findings, addressing challenges with the customisation and localisation of the WASHFIT, managing the healthcare provider workload, and defining task boundaries, as well as addressing governance, are likely to stimulate the implementation of the WASHFIT intervention.