Table 2

Impact of WASH in healthcare facilities on patient satisfaction and care seeking behaviour

Reference	Title	Location	Type of study	Context	Intervention	Findings	Further comments
Water and sanitation
Woldeyohanes et al25	Perceived patient satisfaction with in-patient services at Jimma University Specialized Hospital, Southwest Ethiopia	Ethiopia	Cross-sectional	This study aims to measure and describe the level of patient satisfaction within in-patient healthcare services		Toilet cleanliness: 18.5% (35/189) were satisfied while 81.5% (154/189) were dissatisfied. 76.6% (145/189) were satisfied with cleanliness of the ward.	Research clearly identified a link between patient outcomes and patient satisfaction scores.
Tessema and Adnae26	Assessment of antiretroviral treatment (ART) care service provision in Tigray Region health centers, North Ethiopia	Ethiopia	Cross-sectional	Perceived levels of clients’ satisfaction with health services at ART clinic level in health centres		High scores of satisfaction were reported for courtesy and respect 95.80% (684/714) and privacy 93.28% (666/714). Access and cleanliness to latrines were not always assessed. Toilet cleanliness was unsatisfactory for 35.32% (243/688).	Adjusted OR for satisfaction was 2.22 (95% CI 1.62 to 6.32) for toilet cleanliness. Measures such as increasing access to ART service, availing clean toilet and ART drugs may further increase client satisfaction. Clean toilets are required especially for HIV/AIDS patients to prevent opportunistic and non-opportunistic coinfections.
Tumlinson et al33	Quality of care and contraceptive use in urban Kenya	Kenya	Cross-sectional	The study hypothesis is that poor quality of family planning service provision is a barrier to contraceptive use		78.5% of facilities (204/260) have running water.	Facility infrastructure and most aspects of client satisfaction—including privacy issues, amount of information given, waiting time and overall satisfaction—were unrelated to contraceptive use.
Galukande et al43	Developing hospital accreditation standards in Uganda	Uganda	Cross-sectional	Accreditation is not well established in most developing countries for several reasons, including insufficient incentives, insufficient training and a shortage of human and material resources	Self-assessment hospital accreditation tool developed for a resource-limited context.	Among accreditation items (1) physical infrastructure and (2) infection control and waste management are relevant to WASH. 27.5% (11/40) hospitals were not tracking infection rates and 32.5% (13/40) had functional sterilisation equipment.	Good performance was measured in availability of equipment and running water, 24 hours staff calls systems, clinical guidelines and waste segregation. Poor performance was measured in care for the vulnerable, staff living quarters, physician performance reviews, patient satisfaction surveys and sterilising equipment.
Okwaro et al44	Challenging logics of complex intervention trials: community perspectives of a health care improvement intervention in rural Uganda	Uganda	Cross-sectional	Attract patients to health centres through improved services and attitudes of staff and better management of fevers	The intervention aims to enhance quality of care at public health centres and by extension improve malaria-related health indicators in community children	Many health centres lacked running water and electricity. Improvements in antimalarial drug availability were noted but community members were disappointed with the quality of care received. Patients continued to seek care at health centres they considered inadequate.	The intervention targeted malaria control to the exclusion of other diseases or basic infrastructure such as in-patient facilities or clean water. Requests by patients to increase the number of health workers, expand buildings and space within facilities, provide clean water and electricity, in-patient services, and clean toilets were reported.
Ezegwui et al27	Patients’ satisfaction with eye care services in a Nigerian teaching hospital	Nigeria	Cross–sectional	Evaluate patients’ satisfaction with the care received		71.7% (220/307) were not satisfied with toilet facilities. There is only one toilet for patients and there is no running tap.	The main areas of dissatisfaction were the cost of service and toilet facilities.
Khamis and Njau30	Patients’ level of satisfaction on quality of health care at Mwananyamala hospital in Dar es Salaam, Tanzania	Tanzania	Cross-sectional	Determine patients’ level of satisfaction on the quality of healthcare delivered at the out-patient department		422 patients were enrolled. Mean gap score was (−2.88±3.1) indicating overall dissatisfaction with the quality of care. Respondents were dissatisfied with general cleanliness (−0.50; p<0.001), and sufficient chairs and toilets (−0.67; p<0.001).	The questionnaire is divided into five dimensions (tangibles, reliability, responsiveness, assurance and empathy) to determine patients’ level of satisfaction. The mean gap score is calculated as the difference between mean perception score and mean expectation score.
Mohammed et al31	Assessing responsiveness of health care services within a health insurance scheme in Nigeria: users’ perspectives	Nigeria	Retrospective, cross-sectional survey	Insured users’ perspectives of their healthcare services’ responsiveness		42.8% (341/796) of users were satisfied with the quality of facilities. This included having enough space, seating places and fresh air in rooms and wards as well as a clean facility and clean toilets in the hospital. Low-income insured users reported better quality of facilities than high-income users (p<0.001).	Responsiveness is included in patient satisfaction and quality of care literature, and refers to the way individuals are treated and the environment in which they are treated. ‘Quality of basic facilities’ (clean waiting rooms, toilet facilities, examination rooms and surroundings) is important to patients in their experience of responsiveness.
Ray et al28	An assessment of rural health care delivery system in some areas of West Bengal-an overview	India	Cross-sectional observational study	Identify extent of utilisation of healthcare facilities and understand healthcare seeking behaviour in the community		13.97% (63/451) were dissatisfied with care quality. 27% and 23% clients reported that toilets were ‘not at all usable’ and ‘dirty needing cleaning’, respectively (n=174). Safe drinking water was available in 55% of the facilities (n=18). Restrooms were either of poor quality or the clients did not use them, while they were not available in 3% of health facilities.	Cleanliness of the premises, face-lift (of public health centres), and clean toilet with privacy and availability of safe drinking water could improve client satisfaction in rural healthcare delivery systems.
Sudhan et al29	Patient satisfaction regarding eye care services at tertiary hospital of central India	India	Descriptive study	To evaluate patients' satisfaction regarding eye care services		The majority of respondents were highly satisfied with toilet 83.2% (133/160), water facilities 99.4% (159/160) and cleanliness (159/160). 16.9% (27/160) did not answer the toilet question and one each for water and cleanliness question.
Westaway et al32	Interpersonal and organizational dimensions of patient satisfaction: the moderating effects of health status	South Africa	A cross-sectional analytical study design	To identify the underlying dimensions of patient satisfaction in diabetic clinic for black patients		263 patients were surveyed. The most important items for satisfaction were availability of a seat in the waiting area (0.73), availability of a toilet in the waiting area (0.70) and cleanliness (0.70).	Amenities and attributes of care were central to the organisational dimension of patient satisfaction. Given lengthy waiting times in South Africa’s public health facilities, it is not surprising that the availability of a seat and toilet in the waiting area featured so prominently. Cleanliness was also perceived as an important satisfaction area.
Glick34	How reliable are surveys of client satisfaction with healthcare services? Evidence from matched facility and household data in Madagascar	Madagascar	Cross-sectional	Investigation of the reliability of exit surveys by comparing patient satisfaction outcomes to population-based household surveys		An appearance index (mean of binary indicators for dirtiness, humidity damage, decay of walls, floors and ceilings, evidence of insects and condition of toilet facilities (presence and cleanliness)) was calculated. The appearance index was 0.84 in household surveys and 0.91 in exit surveys for the same facilities. The number of respondents were 262 and 770, respectively.	The findings suggest that reported satisfaction in exit surveys is biased strongly upward for subjective questions regarding treatment by staff and consultation quality, but not for relatively objective questions about facility condition and supplies.
Water, sanitation and hygiene in maternity services
Srivastava et al35	Determinants of women’s satisfaction with maternal health care: a review of literature from developing countries	Developing countries	Systematic review	Identify determinants of women’s satisfaction with maternity care in developing countries		Good physical environment was significant in women’s positive assessment of the health facility and maternal care services. In Bangladesh, mothers who rated the availability of services at the facility (a composite of waiting area, drinking water, clean toilet and waiting time) as ‘good’ were significantly more satisfied with care than those who rated the services as ‘poor’. Cleanliness, good housekeeping services and maintenance of hygiene were reported as determinants of satisfaction in Bangladesh, Gambia, Thailand, India and Iran.	Determinants of maternal satisfaction covered all three dimensions of care: structure, process and outcome. Structural elements included good physical environment, cleanliness, and availability of adequate human resources, medicines and supplies. Access, cost, socioeconomic status and reproductive history also influenced perceived maternal satisfaction. Process of care dominated the determinants of maternal satisfaction. Interpersonal behaviour was the most widely reported determinant, particularly around provider behaviour in terms of courtesy and non-abuse.
Steinmann et al36	Availability and satisfactoriness of latrines and hand washing stations in health facilities, and role in health seeking behavior of women: evidence from rural Pune district, India	India	Cross-sectional/questionnaire-based	Investigation of the WASH infrastructure in small health facilities and survey of expectations and satisfaction among women		12 health facilities were assessed (6 private and 6 public). The mean number of latrines per healthcare facility was 2.4 (range 0–8), but was lower in public (mean 1.3; range 0–2) than in private facilities (mean 3.5; range 1–8). One facility had no latrine and one had an unimproved latrine. Generally, one hand washing station (tap) was available per latrine but two public facilities did not have any hand washing stations. The mean number of hand washing stations was 0.8 (range 0–2) in public facilities and 3.7 (range: 1–8) in private facilities. Soap was often missing from hand washing stations (6/12). Dedicated latrines for women were rare.	WASH installations in health facilities are generally acceptable in private facilitieswhile improvements are needed in some government facilities. Women expect WASH provision in health facilities, and view their quality in a broader framework of ‘cleanliness’, which they consider when choosing facilities. Key WASH features important to women are: number of latrines, their cleanliness and availability of water and accessories (such as dustbins). Other factors, such as a good reputation, well-respected and competent doctors were considered more important than WASH status. For ambulatory visits, including child birth, WASH status was seen as less critical than for prolonged hospitalisation.
Philibert et al42	No effect of user fee exemption on perceived quality of delivery care in Burkina Faso: a case-control study	Burkina Faso	A quasi-experimental design with both intervention and control groups	Assessing whether women’s satisfaction with delivery care is influenced by a total fee exemption	In the intervention group, delivery care is free of charge at health centres	870 women were interviewed. 600 in intervention group and 270 in control group. 90% were satisfied with delivery care in both intervention and control groups. The poorest women were more highly satisfied with delivery environment than the wealthiest ones, especially concerning hygiene and comfort.	Quality of care was assessed using three components: care provider-patient interaction, nursing care and delivery environment. Patients are often inclined by courtesy to respond positively to questions on satisfaction with care quality. This level of courtesy is higher for interpersonal relationships between care providers and patients. Other biases: intimidation by male interviewer and non-sampling of remote households.
Mbwele et al37	Quality of neonatal healthcare in Kilimanjaro region, northeast Tanzania: learning from mothers’ experiences	Tanzania	Cross-sectional study using qualitative and quantitative approaches	Assess mothers’ experiences, perception and satisfaction with neonatal care in the hospitals		80 mothers were interviewed from 13 peripheral facilities and 32 from a referral hospital. Only 2% discussed issues of hygiene. One mother mentioned that the facility should ‘increase the level of hygiene’. The state of toilets at referral hospital were as expected for 59% respondents while, in peripheral hospitals 28% were as expected. Toilets were worse than expected for 7% and 26% in referral and peripheral hospitals, respectively.	The most common reasons for primary delays: quality of treatment at the facility 55.1% (27/49) and cost of medical care 32.6% (16/49). Parameters for secondary delays were distance from home (11.1%) and combined distance and transport (7.4%).
Tetui et al38	Quality of Antenatal care services in eastern Uganda: implications for interventions	Uganda	Cross-sectional	Assessment of quality of ANC (Antenatal care) services in eastern Uganda with a goal of benchmarking		74.6% (217/291) respondents rated the ANC service as satisfactory. Infection control was available in 73.4% (11/15) facilities. Cleanliness was dissatisfactory for 4.1% (12/291), fairly satisfactory for 25.8% (75/291) and satisfactory in 70.1% (204/291).	Data collected to gauge infection control: existence of piped running water, water buckets or basins, hand washing soap, disposable hand drying towels, waste bins, sharps containers, disposable latex gloves and disinfection solution. The variables associated with high satisfaction were provider’s attitude (87.6%) and examination room privacy (83.5%). However, availability of medicines (32.3%) and waiting time (25.1%) had the highest dissatisfaction rates.
Gabrysch and Campbell40	Still too far to walk: literature review of the determinants of delivery service use	Low or middle income countries	Literature review (of review articles)	Identification of various factors related to delivery service use		Shortcomings in medical care are often coupled with shortcomings in hygiene. Women criticise dirty toilet facilities, lack of water and aseptic practices as well as lack of drugs or too early caesarean sections.	Perceived quality of care has an important influence on care seeking behaviour. Poor personal and medical quality of care, clash with culture and fear of procedures may decrease use.
Kongnyuy et al45	Criteria-based audit to improve women-friendly care in maternity units in Malawi	Malawi	Cross-sectional/interviews	To assess and improve women-friendly care in maternity units in Malawi	280 women were interviewed about care quality. The audit results were presented, and recommendations made. A re-audit (367 women) was conducted 3 months later and performance compared.	Significant improvement was recorded for cleanliness of maternity wards (89.6 vs 97.0%; p<0.001). However, there were no significant changes in provision of clean bathroom and toilet (83.6 vs 80.4%; p=0.282).	Each health facility should assess the availability and functioning of toilets and bathrooms. Where available, they should be functional and kept clean. If lacking, they should be requested. One health centre requested and had a new toilet but no report on the impact of this improvement was presented.
MacKeith et al39	Zambian women’s experiences of urban maternity care: results from a community survey in Lusaka	Zambia	Cross-sectional/community survey questionnaires	Examine access, coverage and quality of care in midwives run maternity service		845 were interviewed. 74% would like to see improvements overall and 18.23% would like to see better hygiene in toilets and bathrooms at health facilities.
Griffiths and Stephenson41	Understanding users’ perspectives of barriers to maternal health care use in Maharashtra, India	India	Cross-sectional/interviews	Identification of key social, economic and cultural factors influencing women’s decisions to use maternal healthcare		45 women were interviewed. Respondents identified poor-quality of services offered at government institutions to be a motivating factor for delivering at home: ‘It was safe in the house and the nurse was present to do the delivery. In government hospital, delivery room is not there. Toilet and water facilities are not there. So I felt safe to give birth in the house’.	Socioeconomic status was not found to be a barrier to service use when women perceived the benefits of the service to outweigh the cost, and when the service was within reasonable distance.

The table summarises the characteristics of included studies and their main findings.
WASH components are presented in bold.
WASH, water, sanitation and hygiene.