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A simple dressing change is often one of the more straightforward nursing tasks.
It requires skills in observation and process, but is a common nursing practice performed millions of times each day, most of the time without incident. It does, however, also represent a moment of risk in the patient’s recovery, a moment when a wound could be exposed to unpleasant bacteria that can wreak havoc once inside.
Hygiene is therefore essential, and if you cast your eye around any health-care facility in any corner of the world, you will likely see posters imploring staff to wash their hands. Whilst there has been some recent interesting work in a UK NHS trust which has moved away from traditional wash basins and sinks towards alcohol gel and waterless systems, as part of a wider system design to reduce superbugs, this approach is likely to remain an interesting outlier for a long time to come, largely because the approach has a high initial cost.
A brief literature review will draw data from a range of clinical settings to demonstrate the importance of high-quality hygiene to patient outcomes. To pull just one study from neonatal care, an improvement in hand hygiene compliance amongst health-care staff from 46% to 69% against WHO’s 6 moments was accompanied by a fall in nosocomial sepsis from 96 to 47 per 1,000 patient-days.
So having made a case that water, sanitation and hygiene are vital to effective health services it may come as a surprise when you see how badly the global health system is meeting even basic targets a WHO/UNICEF report ‘Progress on water, sanitation, hygiene, environmental cleaning and waste management in health care facilities 2015–2025’ found In 2025, 15% of health-care facilities did not have basic water services, 28% did not have basic hygiene services, 60% did not meet the reports benchmark for basic sanitation standard, 41% did not meet the basic environmental-cleaning standard, and 29% did not have basic health-care waste management services. More seriously, more than one in ten facilities had no water service at all, and the same proportion had no sanitation service.
It will come as no surprise that evidence shows that this lack of access to the basics is felt more acutely in lower-resourced settings. A study of 1,547 facilities providing maternity care across 14 low- and middle-income countries found that 73% did not meet WHO requirements for the “six cleans” needed for hygienic childbirth.
The posters on the wall and repeated initiatives designed to promote hand hygiene don’t really count for anything if there is no wash basin.
But now comes the bit that may be a surprise: the evidence on water quality, quantity, or sanitation in low- and middle-income countries within healthcare facilities is barely there at all. Given its importance and the apparent lethality of the link between poor hygiene practices and infections and mortality, evidence should be far more comprehensive.
A 2019 systematic review on the topic found just three relevant articles, and the years since have shown growing evidence of infrastructure challenges and challenges to practice, but almost nothing focused on outcomes.
So where does that leave us?
We have good reason to believe that poor hygiene increases infection risk, and increasingly strong data show where basic services are missing vital infrastructure; the WHO/UNICEF report clearly shows how widespread the problems are.
What we have far less of is rigorous evidence showing what happens to infection, sepsis and mortality when those services are improved. This is particularly true in low- and middle-income countries, arguably where it matters most, as these are the very places where responding to infections is most difficult for health staff to treat effectively.
Evidence gaps have real-world consequences; without a clear understanding of the scale of the problem, we are unable to fully articulate the impact on health workers’ ability to care safely and the knock-on effects on patient outcomes.
Consider, for a moment, the millions invested in WASH education, repeated training for health workers, awareness campaigns, and posters. What is now becoming painfully obvious is how much further the infrastructure has to go to catch up with what every health care worker clearly understands.
Knowledge may well be power, but systems (and cisterns!) are vital too.