Hand hygiene infrastructure and point-of-care resource availability in public hospitals in Sierra Leone: a national multicentre cross-sectional study.

Abstract

Introduction: This study explores hospital hand hygiene (HH) infrastructure and point-of-care (POC) resource availability in Sierra Leone's public hospitals.

Methods: A multicentre cross-sectional survey was conducted in 19 public hospitals between February to March 2025. Using the World Health Organization (WHO) Ward Infrastructure Survey tool (WIS), 155 wards were assessed. Outcomes included ward-level availability of water, soap, alcohol-based handrub (ABHR), towels, posters, and audits, plus POC indicators such as sink/dispenser density and bedside ABHR access. Analyses were descriptive, with hospital comparisons and modified Poisson regression for selected binary outcomes. Sensitivity analyses used strict and lenient definitions and best-/worst-case assumptions to assess missing data impact. Denominators vary by indicator due to item‑level missingness and skip‑logic inherent to the WHO‑WIS tool.

Results: In total, 109 wards with complete hospital-level data were analysed. Ward-level availability was uneven: running water available in 61/105 (58.1%) of wards, soap at all sinks in 64/103 (62.1%), and disposable towels at all sinks in 15/103 (14.6%); 73.4% relied on hand-operated taps. ABHR was reported in 87/107 (81.3%) of wards under strict criteria (lenient criteria = 98.1%), while HH audits and posters were common (> 60%). POC readiness was very low: only 73/1,762 (4.1%) beds had ABHR within reach, 14/145 (9.7%) sinks had the full triad (water, soap, and towels), and median sink density was 0.67 per 10 beds (1/15 beds), below WHO recommendations. Tertiary hospitals had higher adjusted ward-level ABHR availability than secondary (PR = 1.26, p = 0.043). Sensitivity analyses supported the robustness of findings, with prevalence ratios for ABHR (1.22-1.28), running water (0.93-1.02), and soap (1.25-1.30) aligning with adjusted estimates.

Conclusion: This first national multicentre survey of hospital HH infrastructure found major systemic gaps, especially in bedside access to essential HH facilities. Despite ward-level ABHR availability, shortages of water, soap, towel, and limited POC access fell below standards. Strengthening HH in similar settings requires investment in basic infrastructure/supplies, strategic resource placement, audits, and behavioural reinforcement.