WASH FIT: manual for trainers

WASH FIT MANUAL FOR TRAINERS

WASH FIT MANUAL FOR TRAINERS Water and sanitation for health facility improvement tool (WASH FIT): manual for trainers ISBN 978-92-4-004773-0 (electronic version) ISBN 978-92-4-004774-7 (print version) © World Health Organization 2022 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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W A SH F IT M an ua l f or T ra in er s iii Annex 1 Sample pre-training/post-training test 23 Annex 2 WASH links with health – module outline 26 Annex 3 WASH FIT methodology – module outline 28 Annex 4 Managing safe water supplies – module outline 31 Annex 5 Sanitation – module outline 34 Annex 6 Hand hygiene – module outline 38 Annex 7 Health care waste – module outline 41 Annex 8 Environmental cleaning – module outline 44 Annex 9 Climate resilience – module outline 47 Annex 10 Gender equality, disability and social inclusion – module outline 50 Annex 11 Example agenda focused on introductory WASH FIT training (face to face) 53 Annex 12 Example agenda for training (virtual) 57 Annex 13 Post-training action plan (facility level) 60 Annex 14 Example training evaluation form 62 Annex 15 Example certificate of completion 64 About the manual 1 Delivering the recommended modular approach2 14 Preparing to deliver successful WASH FIT training1 6 Evaluating the training3 19 CONTENTS W A SH F IT M an ua l f or T ra in er s iv ACKNOWLEDGEMENTS The development of the manual was led by the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) under the strategic direction of Maggie Montgomery (WHO) and Silvia Gaya (UNICEF). Claire Kilpatrick (WHO) and Julie Storr (WHO) coordinated the development of the manual and led the writing. Arabella Hayter (WHO), Irene Amongin (UNICEF) and Fabrice Fotso (UNICEF) provided input into content development and review of the document. WHO and UNICEF gratefully acknowledge review and feedback from Anand Balachandran (WHO), Molly Patrick (United States Centers for Disease Control and Prevention – CDC) and Carrie Ripkey (CDC) during the review process. WHO and UNICEF also note and acknowledge the work of Professor Wendy Graham of the London School of Hygiene and Tropical Medicine (LSHTM) – in particular, the TEACH CLEAN package (https://www.lshtm.ac.uk/research/ centres/march-centre/soapbox-collaborative/teach-clean) developed by the Soapbox Collaborative, in partnership with NHS Grampian and LSHTM. This package helped to stimulate the design of this training manual. W A SH F IT M an ua l f or T ra in er s v ABBREVIATIONS AND ACRONYMS IPC infection prevention and control IT information technology NGO nongovernmental organization UNICEF United Nations Children’s Fund WASH water, sanitation and hygiene WASH FIT Water and Sanitation for Health Facility Improvement Tool WHO World Health Organization

W A SH F IT M an ua l f or T ra in er s 1 ABOUT THE MANUAL W A SH F IT M an ua l f or T ra in er s 2 INTRODUCTION The Water and Sanitation for Health Facility Improvement Tool (WASH FIT) presents a framework and acts as a guide to support multisectoral action to improve water, sanitation and hygiene (WASH) in health care. Central to the WASH FIT methodology is training and incremental improvements. Implementation of WASH FIT requires six preparatory steps at the national level, one of which is conducting national sensitization and training of trainers, followed by facility-level training. At the facility level, step 1 (of five) involves establishing and training a WASH FIT team. The WASH FIT methodology is outlined in WASH FIT: A practical guide for improving quality of care through water, sanitation and hygiene in health care facilities. Second edition. (the WASH FIT guide), which includes a set of templates designed to help users with each phase of the improvement cycle (see figure 1). Fig. 1 Summary of all elements of WASH FIT READ THIS FIRST WASH FIT: a practical guide Second ed. 100 pages 50-minute read 3-5 pages 5-minute read each 30-minute read Templates Assessment, hazard and risk analysis tools (support development and implementation of improvemnt plan and ongoing monitoring) Fact sheets 5 fact sheets (within the WASH FIT Practical Guide) WASH FIT manual for trainers All the materials for training in one place (slides, speaker notes, assessment & evaluation tools, sample agenda etc.) WASH FIT portal www.washinhcf.org/wash- fit Country examples, case studies and opportunity to share experience WASH FIT helpdesk washinhcf@who.int W A SH F IT M an ua l f or T ra in er s 3 PURPOSE This manual for trainers outlines the information and materials required to undertake training in line with the WASH FIT guide, including background documents, the content of the recommended training modules and training evaluation approaches. The modular approach outlined enables trainers to decide on the topics that are most useful to support delivery of targeted training at the local level. AIM The training manual provides information to build capacity in a cadre of trainers, enabling them to prepare for, deliver and evaluate WASH FIT training. TARGET AUDIENCE The manual is a resource for use by trainers (i.e. those who will be delivering the training), those involved in supporting delivery of training (i.e. those responsible for resource allocation necessary for running training), and those involved in preparing training courses at the national or facility level (Table 1). Table 1 Target audiences Ministries of health Other ministries with responsibilities for WASH in health care facilities Quality improvement teams Focal points for WASH, waste, and infection prevention and control Community WASH and health committee members Local government officials District health officers Managers of health care facilities Other members of senior management in health care facilities Relevant nongovernmental organizations (NGO) and partners, including United Nations agencies Civil society organizations W A SH F IT M an ua l f or T ra in er s 4 The manual can also be used to prepare to deliver training-of-trainers sessions, to develop “master trainers” and to support the development of a roster of in- country trainers. • Master trainers: A WASH FIT master trainer is an individual who has a background in environmental or civil engineering, public health or infection prevention and control (IPC); has been deemed competent in WASH FIT and to deliver WASH FIT training; has several years of experience in training; and is committed to supporting facilities to improve WASH services for better quality of care. • Roster of trainers: Some countries (e.g. Liberia) have trained county health teams and established a roster of certified country trainers to provide training on an ongoing basis. Although this manual can support the establishment of a roster of trainers, it is not intended to be a formal or accredited certification resource. The expected recipients of WASH FIT training may differ, depending on local circumstances and the approach taken. They will usually be health care workers and others working at the health care facility, including those at management level, non- clinical staff (e.g. cleaners, wasteworkers) and relevant community members (e.g. plumbers, water and sanitation technicians, women, disabled people, indigenous group members) who support action on WASH in health care facilities (see also section 1.2). The recipients may be identified through local fact-finding assignments (see section 1.1). AT-A-GLANCE SUMMARY OF THE MANUAL The manual is structured around three sections to support the user in 1) preparing for, 2) delivering and 3) evaluating training. This is outlined in Fig. 2. Each section describes information, actions and activities that support users to be ready to implement their training plan effectively. Section Section Section PREPARING DELIVERING EVALUATING • An outline of the usefulness of training needs assessments and local fact- finding missions • A list of considerations related to the people required to run a successful training • An overview of the considerations for face-to- face and virtual training • Some examples of country efforts • Some prompts to consider when addressing resources and budgets for training • An outline of the training modules that comprise WASH FIT with reference to an overview of each of the modules (found in the annexes) • Reference to example training agendas, face-to-face or virtual (found in the annexes) • Some additional prompts to consider as you start to deliver the training • Prompts to address adaptation of WASH FIT module • Lessons identified from countries - potential barriers and mitigations • Test and evaluation suggestions (sample pre/ post test and evaluation forms found in annexes) • How to use a certificate of completion (example found in the annexes) • An outline of how to address sustainability post-training • A list of summary action checks Fig. 2. Summary of this training manual 1 2 3 W A SH F IT M an ua l f or T ra in er s 5 HOW TO USE THE MANUAL Those who have never been involved in WASH FIT previously, including training, may find it useful to work through this manual in a linear fashion. Those who are at a more mature stage (e.g. have already completed WASH FIT training and assessments) may find the manual and its contents useful as a refresher and can go directly to certain modules or associated resources to support their current work. To help the user navigate between different sections and different templates, click on the hyperlinks found throughout each section in blue underlined text. W A SH F IT M an ua l f or T ra in er s 6 PREPARING TO DELIVER SUCCESSFUL WASH FIT TRAINING 1 7W A SH F IT M an ua l f or T ra in er s 1.1 TRAINING NEEDS ASSESSMENTS AND LOCAL FACT-FINDING ASSIGNMENTS In a perfect world, a full baseline assessment and analysis would ensure that the local situation is fully understood before any training. This would include existing roles and responsibilities, policies and procedures, and resources. All of this would help with understanding factors that influence the practical aspects of the training. Gaps in this understanding can in part be addressed by the local fact-finding assigments described here. Importantly, the training approach taken may differ depending on local needs. A training needs assessment, either formal or informal, usually consists of a questionnaire or interviews to understand the knowledge and perceptions of those who the training is intended for. The questions should focus on the content of the WASH FIT training modules to understand where the content will provide most benefit. Local fact-finding assignments have provided important information in some countries, to guide preparation for, and delivery of, training. Health care facilities can be visited by trainers and training facilitators to enable them to understand the on-the-ground WASH situation. A fact-finding assignment should enable you to identify and understand the perceived challenges, and to capitalize on lessons learned to support roll-out of WASH FIT training in a way that will be sustained after training. This may involve reviewing what training already exists and how it has been used, and local quality improvement approaches that could be built on for successful training delivery and practical implementation. During this preparation period, it is recommended that a review of all WASH FIT tools and templates, including the WASH FIT assessment, is undertaken. Most importantly, the WASH FIT assessment tool will need to be adapted to the country context (see the WASH FIT guide). This allows for training to be delivered in a way that can be sustained (see section 3). In summary, as you start, consider the following key questions. • Competence: Do you know the existing competence (behaviours, skills, attitudes) of those who will attend the training? Will there be a mix of skills? • The local situation: Overall, what is known about the infrastructure and resources? • Learning from the past: Are you aware of previous training relevant to WASH that has been delivered? Who delivered it? Was it evaluated? What lessons have been learned to inform future training? • Evaluation: How are you planning to evaluate this training (e.g. pre- and post-test assessment, follow- up assessment)? (See also section 3.) 8W A SH F IT M an ua l f or T ra in er s 1.2 PEOPLE Consider the following questions in preparing the training sessions. • Training “organization”: Which entity will be involved in organizing, delivering and supporting the training, if any? How can the government (national or local) be engaged in the training and, where possible, deliver some content (this might help to legitimize and give credibility to the training)? • Delivery, trainers and training facilitators: Who will deliver the training? Will the training be run jointly with other programmes (e.g. IPC or quality of care programme)? Trainers or training facilitators may include existing WASH FIT experts, such as WASH engineers and IPC focal points. Numbers of trainers for virtual and in-person sessions are addressed in section 1.3. • Trainees: Who will be trained? How will nominations be sought (e.g. health facility managers approached to nominate trainees)? It is important to understand your trainees: what competencies do they have and are there gaps in these (refer to the results of the needs assessment)? The following groups may be targeted (different groups of workers can attend the training together): ‒ facility-based clinical and non-clinical staff (e.g. doctors, IPC nurses, waste management focal points, environmental health officers, engineers, sanitation workers, those who clean); ‒ health facility managers; and ‒ community members (e.g. plumbers), including those serving on local WASH or health committees and other community groups (e.g. women’s groups, representatives from local nongovernmental organization – NGOs, representatives and leaders of faith-based organizations, civil society). • Logistics and resources: How will the right people be engaged to ensure that the necessary infrastructure and supplies are financed to support not only ongoing training but the incremental improvements required to address all aspects of WASH in health care? Training alone will not change the situation if other gaps are not also addressed (see the WASH FIT guide and section 3.3). For the logistics of training delivery, see section 1.3. 1.3 TRAINING FORMAT AND APPROACH The format and approach for training will depend on whether the training will be directly delivered to a range of participants at the facility level or a training-of-trainers session at the facility level, and whether it is face to face or virtual. The format may also depend on what stage the participants are at with regard to existing knowledge and competence. “Throughout the assessment, we have realized that the sustainability and continuity of WASH FIT relies on the understanding of the decision-makers and it is imperative to provide training to the managers of the targeted health care facilities.” (Lessons from Bangladesh WASH FIT training, 2019) 9W A SH F IT M an ua l f or T ra in er s 1.3.1 Face-to-face training To help you prepare to deliver effective face-to-face training in the right format, address the following considerations. • Setting objectives: Be clear on the objective and the expected learning outcomes. An example objective or learning outcome is: “This training will engage facility managers in an ongoing cycle of WASH improvement and equip them to use WASH FIT effectively and sustainably”. • Participant (and trainer) peparation: Consider the need for pre-training preparation, including pre-reading. Each module has its own logistical preparation (see section 2, which describes the recommended modular approach, and Annexes 2–10). Some example preparatory considerations are provided in Box 1. Box 1. Preparatory considerations Pre-training tests and other preparatory exercises (at least 1 week before training starts) • Undertake a participant pre-training test through an online platform such as Google forms, if possible (taking account of internet reliability). This will make data collection and analysis easier. Undertake the following: • Review the sample pre-training test questions in Annex 1. • At local level, consider amending or adding additional questions (but ensure that the answers are evidence based and relate to WASH FIT). World Health Organization (WHO) and other materials are available to help achieve this, if necessary (see resources listed in Annexes 2–10). • Consider asking additional questions to gauge participants’ expectations. • Consider asking questions relating to job roles and technical experience. • Invite participants to pose questions they would like answered during the training, via email or other platform, or by writing them down and delivering them to the trainer. • Provide instructions for other pre-training tasks (e.g. printing requirements; see relevant modules in Annexes 2–10). Pre-reading • Encourage participants to familiarize themselves with the WHO and United Nations Children’s Fund (UNICEF) WASH FIT web portal (www.washinhcf.org/wash-fit), which contains general WASH FIT background materials. • If possible, participants should familiarize themselves with the WASH FIT guide, assessment form (adapted to the local context, if applicable) and training agenda. Alternatively, review of visual posters may be adequate pre-reading (e.g. waste images, hand hygiene posters). This pre-reading may need to be delivered to participants electronically or on paper, according to training resources and budget. • The trainer should be familiar with the WASH FIT guide, tools and templates (especially the assessment tool), and all training module content in advance. • Timing and duration: WASH FIT training – which comprises the WASH FIT methodology and a range of technical modules – usually takes approximately 3 days for face-to-face training. The technical modules address water, waste, sanitation, environmental cleaning, hand hygiene, climate, and gender and equity (see section 2). Importantly, the timing is designed to encourage participation and interaction. 10 W A SH F IT M an ua l f or T ra in er s • Agenda: Develop an agenda, informed by local assessments and fact-finding assigments, where available. Example agendas are provided in Annexes 11 and 12. • Topics to be covered: Review all the WASH FIT modules (see section 2 and Annexes 2–10). The assessment and fact-finding assignments will help you decide which topics to cover. The WASH FIT methodology module is considered essential. • Ensuring interactivity: Each module uses a mix of theoretical and practical approaches, including group work, presentations, and questions and answers. You may wish to consider adding other approaches, such as quizzes, energizers, discussions, case studies, assignments and additional presentations. • Venue: Consider costs and ease of access when securing a venue. Often the best place is a health care facility, or a hotel very close to a health care facility, to enable facility visits and for ease of access for attendees. Delivering WASH FIT training in a health care facilty makes it easier to observe real-life experiences (permission will be required to undertake walk-arounds) and can enhance learning. However, if training takes place outside the facility, field visits can provide a similar experience (see “Field visits”, below). • IT support: Consider what IT support will be required (e.g. data projector and laptop, wifi) and how it will be secured. • Timing of training: There is no set recommendation for when to deliver training, but coordinating training with other WASH or health training efforts could reinforce messages and make best use of time away from day-to-day work of the trainees. Note that refresher training and ongoing mentoring will be necessary. Even when other seemingly urgent matters arise (e.g. disease outbreaks in the health care facility), WASH FIT training is still critical for improvements. • Numbers of trainees: Consider whether the training will be conducted with participants from one or more health care facilities or other settings. This includes considering the optimum number of participants, taking account of the intended interactivity of the training sessions and the potential for different skill mixes among trainees, and the number of facilitators available (e.g. a group of more than 20 will make it harder to ensure one-to-one engagement and interactivity with all participants). • Trainers: A training-of-trainers session could be considered to build training capacity and enable future scale-up. The trainer of trainers should have: ‒ subject matter expertise, including knowledge, skills and experience in relation to WASH FIT methodology (e.g. WASH engineer), and WASH links to health (e.g. IPC or quality of care focal point); ‒ experience in training and facilitation skills, including ability to communicate and engage with the audience; ‒ interpersonal skills; and ‒ willingness to listen to and learn from participants. • External support: Consider what additional support is needed (e.g. from governments, WHO, UNICEF, other partners). External stakeholders may also support the delivery of training. Make a list of potential sources (e.g. active NGOs in the region who can support WHO/UNICEF WASH FIT improvement approaches). • Translation: Where not all the participants understand or speak the same language, consider the feasibility of translation of written materials, and interpretation of oral presentations and discussions. • Literacy: Some of the attendees may not be fully literate (e.g. those who clean, wasteworkers) and/or may not be fluent in national language(s). Consider how to incorporate as many photographs and hands-on learning experiences as possible. • Field visits: Consider the feasibility of field visits as part of the training. These usually require government-level approval. Take into account security and safety, including 11 W A SH F IT M an ua l f or T ra in er s travel restrictions in the context of COVID-19. Which sites will be appropriate for field visits during the training? How and when will you seek necessary government permission to visit the health care facility? How will you communicate with colleagues in the health care facility to ensure smooth running of the field visits? How will logistics be addressed (e.g. transportation, refreshments, security)? How will you feed back information to the facility after the field visit? How will you link the training in the modules to the field visit activities and observations? • Post-training action planning: Time should be allocated to use the post-training action plan (Annex 13) during training sessions to plan what will happen next, after delivery of the training. This plan should specifically focus on targeted post-training actions, rather than specific, facility-level WASH FIT improvement actions. Therefore, it might relate to training follow-up or to specific technical actions that have been identified during training session discussions with participants. An example is the hand hygiene slide set, which might lead to a number of questions to inspire next steps in practice. These questions might be incorporated into the action planning session; they should also fit in with any planned local assessments and actions already in place, and overall WASH FIT improvement efforts. • Virtual delivery option: As a contingency, consider whether you are prepared to switch to virtual delivery of the training. Section 1.3.2 (see below) outlines the specific considerations for running virtual training. • Follow-up: Plan to include the post-training test (Annex 1) at the end of the training. A follow-up session 2–3 weeks after the training is complete is beneficial. It can be an informal virtual question-and-answer session to provide clarification from the training and address concerns that have arisen. A short agenda might be helpful, based on aspects of the training modules that the trainer feels might need reinforcement (also see section 3.3). • Roll-out plans: Consider how you will prepare to engage different stakeholders in the roll-out of further training, if necessary (including government representatives). Will master trainers be used to train a cadre of health care facility staff? How will you ensure and incentivize continued involvement of necessary stakeholders for sustained roll-out of training? • Reporting: Prepare to deliver a short report on the overall training experience. Also see section 2.2 on adaptation of the WASH FIT training modules. Training of trainers: Democratic Republic of the Congo advocated at the national level for implementation of WASH FIT and established a group of master trainers in the Hygiene Section of the Ministry of Health. The training was then cascaded to six members of each “Zone de Santé” (district), who in turn trained the head nurse and head of the maternity department in each health centre. In Liberia, the Ministry of Health trained 94 master trainers, covering all eight counties, who then cascaded training to facilities throughout the country. 1.3.2 Virtual training Virtual training has advantages and has been used effectively to deliver WASH FIT training, particularly where COVID-19 restrictions have prevented face-to-face training. Many of the considerations that should be addressed are similar to those for in-person training, and are listed here. • Setting objectives: Be clear on the objective and the expected learning outcomes. An example objective is: “This training will engage facility managers in an ongoing cycle of WASH improvement and equip them to use WASH FIT effectively as part of a sustainable effort”. 12 W A SH F IT M an ua l f or T ra in er s • Participant and trainer preparation: Consider performing a training needs assessment and conduct pre-training preparation, as described in section 1.3.1, in order to be organized and engage participants. Consider any potential suggestions for participant pre-reading and conduct relevant trainer pre-reading. Each module has its own logistical preparation (refer to section 2, which describes the recommended modular approach, and Annexes 2–10). Some participant engagement considerations are also provided in Box 1. Importantly, because it may not be possible to deliver all modules using virtual training, it may be useful to recommend that participants read all the technical modules (i.e. undertake some self-directed learning); key questions can then be addressed as part of the virtual training programme. • Timing and duration: Consider the length of the training sessions. It is important to have regular breaks. Online training sessions work best with shorter sessions (maximum 45 minutes is considered effective) over a period of days or weeks and with multiple facilitators. Ideally, the trainer should change every 15 minutes to keep participants engaged. Consider how many sessions are feasible per week and the number of days between sessions. • Agenda: Develop an agenda, informed by local fact-finding assigments and needs assessments, where available. An example virtual agenda is provided in Annex 12. • Topics to be covered: Review all WASH FIT modules (see section 2 and Annexes 2–10). Will you focus only on certain modules, informed by needs assessments, or all the modules? The WASH FIT methodology module is considered essential. • Ensuring interactivity: Each of the modules uses a mix of theoretical and practical approaches, including group work, presentations, and questions and answers. With virtual training, maximum engagement and interaction with participants are particularly important. The modules contain exercises to facilitate interactivity – consider how these can be used online. A blended approach using a mixture of “live” training, pre-recorded sessions and self-learning can be useful. Use of the right platforms to ensure interactivity is important (e.g. Zoom whiteboard function and breakout rooms, Slido, Google Jamboard). For group work, in particular, Google Jamboard is a useful tool. Polling software is available on Zoom, Mentimeter and Slack. All can be used for asking questions and facilitating group discussion. • IT support: Consider who will provide IT and logistical support, and how it will be provided. Does your target audience have access to laptops, computers and good internet connection to make virtual training possible? Additional support may be needed for virtual training – for example, to ensure that breakout rooms can be easily accessed and run during live training (each breakout room will require its own facilitator). It is recommended to have one dedicated IT support person for the duration of the training. • Numbers of trainees: Consider whether the training will be conducted with participants from one or more health care facilities or other settings. This includes considering the optimum number of participants, taking account of the intended interactivity of the training sessions and the potential for different skill mixes among trainees, and the number of facilitators available (e.g. a group of more than 20 will make it harder to ensure engagement and interactivity with all participants). • Trainers: Online training can be particularly challenging for the presenter, so consider a miminum of two trainers per session. The voice should changed every 15 minutes to keep sessions engaging and interesting. • External support: Consider what additional support is needed (e.g. from WHO or UNICEF country, regional and headquarters offices). External stakeholders may also support the delivery of training. Make a list of potential sources (e.g. local NGOs). • Translation: Aim to deliver the training in the language of the participants. If the 13 W A SH F IT M an ua l f or T ra in er s participants do not all speak the same language, explore capabilities for simultaneous interpretation. Some online platforms support this note, although interpretation is not generally available in breakout rooms. • Literacy: Some of the attendees may not be fully literate (e.g. those who clean, wasteworkers) and/or may not be fluent in national language(s). Consider how to incorporate as many photographs and hands-on learning experiences as possible during the virtual experience. Literacy may pose more of a challenge for virtual training than for face-to-face training • Virtual field visits: Consider the use of videos (e.g. secure a video recording of a tour of a health care facility) to simulate a virtual, mini WASH FIT assessment. Walk around the facility and video record each area of the facility. In addition, interview the head of the facility and encourage them to describe the general situation, major problems and some of the elements that cannot be seen by walking around a facility with a camera. These video files should be shared in advance with participants, where possible, since it can be difficult to stream videos over online platforms with low bandwidth. Where videos are not possible, consider static photographs of different areas of the facility, to bring the situation to life during a virtual session. A sample WASH FIT field visit assessment virtual video is available (filmed in Indonesia - https://www.youtube.com/watch?v=Ab4BC1IwVS8). • Post-training action planning: There may be time to use Annex 13 during virtual training sessions to plan what will happen next, after delivery of the technical modules. This plan should specifically focus on targeted post-training actions, rather than overall WASH FIT improvement actions (as featured in the WASH FIT guide). • Follow-up: Plan to include the post-training test (Annex 1) at the end of the training. A follow-up session 2–3 weeks after the training is complete is beneficial. It can be an informal virtual question-and-answer session to provide clarification from the training, if participants have not fully absorbed the information. A short agenda might be helpful, based on aspects of the training modules that the trainer feels might need reinforcement (also see section 3.3). • Roll-out plans: Consider how you will prepare to engage different stakeholders in the roll-out of further training, if necessary (including government representatives). Will master trainers be used to train a cadre of health care facility staff? How will you ensure and incentivize continued involvement of necessary stakeholders for sustained roll-out of training? • Reporting: Prepare to deliver a short report on the overall training experience. Also see section 2.2 on adaptation of the WASH FIT training modules. 1.4 RESOURCES AND BUDGET The availability of human and financial resources to deliver training is an important consideration – for example, for printing, translation and interpretation, venue hire, IT, recording of videos, trainers’ time and daily allowances, and field visits for trainers. Decide on the budget needed to deliver the training and ensure that it is available in advance. The WASH FIT guide presents some example costs associated with WASH FIT training. Table 3 in section 2.3 addresses how some of the resource constraints might be overcome. 14 W A SH F IT M an ua l f or T ra in er s 2 DELIVERING THE RECOMMENDED MODULAR APPROACH 15 W A SH F IT M an ua l f or T ra in er s 2.1 WASH FIT TRAINING MODULES WASH FIT training comprises a series of modules (Fig. 3). These take the format of PowerPoint slides, speakers notes and exercises, which can be download from www.washinhcf.org. Trainers should become familiar with the modules in the preparation phase and have all speakers notes to hand for delivery. Fig. 3. The WASH FIT modules Water Sanitation Climate Resilience Gender Equality, Disability & Social Inclusion Health Care Waste Hand Hygiene Environmental Cleaning WASH links with health: introductory module WASH FIT methodology2 16 W A SH F IT M an ua l f or T ra in er s An outline of each module, including how to prepare and deliver them, is available in Annexes 2–10. As a minimum, the WASH FIT methodology module must be delivered. Other modules may be delivered as necessary, informed by the local situation and assessments described in section 1. Remaining modules can also be made available to participants to look at in their own time, especially if not all modules are being formally delivered. Although there is no specific module on follow-up actions, an interactive session (described in Annex 13) is included in the sample agendas (Annexes 11 and 12) and can be part of training delivery to ultimately ensure greater impact and sustainability. Importantly, as you are starting to deliver the training: • undertake tests and checks just before starting to ensure that all IT, internet and other materials are available and ready to use, whether conducting face-to-face or virtual training; • ensure that any printed materials are available, as outlined in the module outline tables (Annexes 2-10) for breakout group exercises; • ensure that participants are allocated to breakout groups, if relevant; and • ensure that all trainers involved in a session have familiarized themselves with, and have have access to, slides; have practised their presentations, including using the explanatory notes that accompany the slides; have handouts and group exercises ready; and have available additional necessary reading material to answer questions. Each module follows the same approach (see Table 2). Table 2. Module approach Name of module Topic to be addressed Pre-training preparation Lists any special preparation required before delivery of the training, including printing requirements, source materials, IT and pre-reading requirements Learning objectives A list of objectives that the learner is expected to achieve on completion of the module Module duration Approximate length of time to deliver the module Languages All modules are in English (availability of other languages will be listed) Module information Short summary of the module and each of its subsections Format A summary of how the module is constructed; all modules are slide based, and include trainer notes and discussion points to guide the trainer Supporting materials and resources Lists all supporting materials and resources to be used, including flip charts, pens, post-it notes, photographs and handouts, and when to use them Group exercises Instructions for group exercises, where applicable 17 W A SH F IT M an ua l f or T ra in er s 2.2 ADAPTATION OF WASH FIT TRAINING MODULES The training modules (slide sets) are provided as a guide and should be adapted to the local context. Examples of adaptation include: • replacing photographs with more relevant examples (e.g. photographs and/or drawings) to reflect the regional or country context; • adding references to technical guidance containing local standards, where applicable; • translating materials into local or national languages; and • removing slides that are not relevant or adding extra slides; some modules have supplementary slides that may be moved to the main part of the module if time allows. In adapting WASH FIT training modules, it is important not to lose the essence of the evidence-based content of WASH FIT and the training modules. The principles of adult learning should be maintained when undertaking any adaptation, such as incorporating many of the approaches and formats outlined here – for example, pauses and breaks, and questions and exercises. 2.3 POTENTIAL BARRIERS TO SUCCESSFUL TRAINING AND SOLUTIONS In countries implementing WASH FIT training, a number of common barriers have been encountered. These are listed in Table 3 with some potential solutions. Table 3. Common training barriers and potential solutions Barriers Potential solutions Time: perceived work pressures preventing staff attending training • Engage the right decision-makers to ensure that staff are free to attend training. • Be creative with how training can be delivered to make use of even short periods that participants have available. Make training relevant to staff so time away is well spent and perceived as beneficial. For example, training could be held in the evening after work or for 2–3 days rather than an entire week. Workforce: staff turnover and the need for ongoing training • Consider human resources needed for ongoing WASH FIT training (accept that staff turnover will always be an issue and new staff will need to be trained). • Explore ways for staff to do self-directed learning (e.g. using OpenWHO.org and other available online training or recordings of previous trainings). 18 W A SH F IT M an ua l f or T ra in er s Barriers Potential solutions Language: having materials translated and having skilled experts to deliver in each language  • Plan and budget for translation and interpretation. Literacy: some participants (e.g. those who clean) having lower literacy • Use photos/pictorials as much as possible during delivery and interactive exercises, and “hands-on” examples, where relevant. External factors: e.g. not being able to undertake field visits because of COVID-19, security concerns, drop-out of external speakers at the last minute • Explore virtual options for field visits and pre-recorded messages from external speakers. • Be prepared to switch to full virtual training, if necessary. • Host training in “safe zones” and ensure that participants can travel safely to reach training. • In areas that may be difficult for national or international staff to reach, train local community members remotely to deliver hands-on training. Consolidating skills: insufficient information on existing competencies before training (to allow the most effective training approach); insufficient follow-up of trainees (knowing if they are using the skills they have been taught and continuing to support them to implement these skills); or insufficient time to complete all necessary material • Conduct a short pre-training test to understand knowledge and what participants would like to learn. • Prioritize key topics and provide options for self-learning where time spent together is limited. Financial resources for training, and for implementation of the WASH and health aspects presented during training: insufficient planning before training, insufficient thought given to future implementation, and insufficient budget for WASH FIT improvements (also see section 3.3) • Keep training simple; to support delivery, use existing resources. Integrate follow-up into district health officials’ responsibilities; “add on” a short WASH FIT training session to other training on safe childbirth, quality of care, IPC, vaccines, etc. • Combine post-training supportive supervision with existing mentoring efforts on quality and/or IPC to save time and money. • Consider using a meeting room at WHO, UNICEF or government offices. • Keep refreshments simple. • Include trainers who speak local languages. Human resources: insufficient master trainers to carry out training in the long term • Involve key WASH and health partners at national and local levels; provide motivated staff with the necessary technical expertise and leadership skills to sustain improvements. Provide technical backstopping from WASH FIT master trainers, the district health office or implementing partners. Ensure that those supporting training from different levels always understand and appreciate the local culture. Resources are needed to provide ongoing supportive supervision to facilities implementing WASH FIT. In Lao People’s Democratic Republic, investment was made in regular supportive supervisory visits to facilities, which offered an opportunity to provide technical support to WASH FIT implementers. This was found to be a crucial factor in maintaining progress. 19 W A SH F IT M an ua l f or T ra in er s 3 EVALUATING THE TRAINING 20 W A SH F IT M an ua l f or T ra in er s 3.1 TESTING AND EVALUATION SUGGESTIONS Training evaluation can range from a simple pre-training/post-training test to a more comprehensive assessment. A pre-training/post-training test can be used at the beginning and end of the training to determine how participants’ knowledge has improved (see Annex 1). Evaluation of the training session (i.e. feedback from participants) is important to ensure continuous learning and improvement. Was the training useful? Did it meet participant expectations? Use a short feedback survey to add to the post- training test if deemed necessary (see Annex 14). Think how you will achieve a good response rate; this is important for the impact of future trainings. 3.2 CERTIFICATE OF COMPLETION A certificate of completion may be prepared and presented to participants, depending on the local context. Certificates may be delivered for individual modules. This can make participants feel valued and can acknowledge their commitment. It should not imply accreditation, unless a trainer of trainers has been validated (e.g. by government, experts in leading organizations, academia). A sample certificate of completion is available in Annex 15. 3.3 ADDRESSING SUSTAINABILITY POST-TRAINING It is important to consider how new practices and behaviours will be sustained over time and the factors required for long-term success post-training. Plan how you will follow up from the training, including future sessions (and their timing), and monitoring and supportive supervision of WASH FIT implementation. Every trainee should leave the training with a set of actions, follow-up items or responsibilities. Trainees, and others, should be held to account and followed up to ensure that they implement their tasks and required actions. A sample facility-level action plan is in Annex 13. Overall improvement of WASH in health care facilities is dependent on a number of factors, including infrastructure, resources and facility manager support for action. Although training is important, it is not enough to make and sustain improvements by itself – a multimodal improvement approach or strategy is required that addresses infrastructure and resources, monitoring and feedback, effective communications and advocacy, and a culture of safety and quality improvement (including leadership, mentorship and role modelling) to influence and sustain behaviours and practices. Refer to the WASH FIT hand hygiene fact sheet (Annex 6 In the WASH FIT guide) for a detailed outline of a multimodal approach. 21 W A SH F IT M an ua l f or T ra in er s After training, participants will benefit from regular supportive supervision and mentoring to ensure consolidation of learning. This may include ongoing role modelling, coaching, mentoring and facility visits. On completion of the training, a report, including lessons learned and recommendations, should be prepared and shared with relevant stakeholders (e.g. government, partner organizations, trainees). Additionally, refer to the WASH FIT guide for a description of the facility- and national-level factors for success. 3.4 SUMMARY ACTION CHECKS To effectively deliver and evaluate WASH FIT training, finally work through the action checks listed in Table 4. Table 4. Summary action checks Action checks • The training needs of the target audience have been identified and considered □ • The overall objectives of the training have been developed (to address local needs) □ • A fact-finding assignment has been undertaken □ • Lessons from previous WASH FIT training have been reviewed (if appropriate) □ • A review of WASH FIT tools and templates, including any assessments, has been undertaken □ • Previous and sample agendas have been reviewed, and an agenda for the training has been developed and approved □ • Evaluation of the training has been planned □ • Roles and responsibilities for preparing and delivering training have been assigned, and external stakeholders have been engaged, where necessary □ • The right decision-makers (e.g. those that control budgets, those that make decisions on health facility staffing) have been engaged to ensure the best chances of success for the training □ • A decision has been made on face-to-face versus virtual training, or a hybrid approach □ • The decision on which modules to use has been agreed (note that the WASH FIT methodology module must be completed) □ • The venue has been secured (for in-person training) □ • IT logistics have been confirmed, and IT support has been secured, if needed □ • Any other external support has been secured (where relevant) □ • Translation of materials has been completed, and literacy has been considered □ 22 W A SH F IT M an ua l f or T ra in er s Action checks • Preparation for in-person field visits has been completed with necessary clearances; where appropriate, a member of the facility has been invited to attend the training □ • Virtual field visits (video or photo) have been planned, where possible □ • Necessary resources and budgets are available □ • Training materials have been adapted as needed □ • Printing requirements have been addressed (for in-person training) □ • Barriers and potential solutions have been considered and addressed □ • Certificates of completion have been prepared locally (if required) □ • Continued mentoring and supervision, and support for implementation of practices outlined through the training have been planned and budgeted for □ • Plans are in place to write a report of the training, including lessons learned and recommendations. □ YOU ARE NOW READY TO DELIVER WASH FIT TRAINING! W A SH F IT M an ua l f or T ra in er s 23 SAMPLE PRE-TRAINING/ POST-TRAINING TEST QUESTIONS Answers are provided on a separate sheet. Questions may be added to or changed as appropriate. A facility’s water supply is considered sufficient if it is off-site but within 500 metres of the facility. a. True b. False A facility should have water storage sufficient for how long? a. 12 hours b. 24 hours c. 48 hours d. 72 hours Chlorination is effective in inactivating the cholera bacterium and Ebola virus. a. True b. False How often should toilets be cleaned? a. At least once a day b. 2–3 times per week c. Once a week d. When a cleaner is available How many bins should be available at points of care for sorting waste? a. 1 b. 2 a. 3 b. 4 General waste in a health care facility constitutes about ____% of all waste. a. 75% b. 65% c. 55% d. 45% e. 35% f. 25% Which of these sanitation technologies are most resilient to climate change? a. Conventional sewerage b. High-volume on-site systems c. Low-flush on-site systems d. Pit latrines Energy is needed in which of the following areas of a health care facility? a. Water supply b. Latrines c. Incineration d. Refrigeration of vaccines e. None of the above f. All of the above 1 2 3 4 5 6 7 8 ANNEX 1 W A SH F IT M an ua l f or T ra in er s 24 Which of the following activities are involved in developing WASH FIT? a. Assemble a WASH FIT team b. Conduct a thorough assessment of the health care facility c. Identify and prioritize areas for improvement d. Develop and implement an incremental improvement plan e. Continuously monitor the effectiveness of the plan and make revisions f. All of the above Hand hygiene in health care facilities does not need to be performed by health workers if they are using gloves. a. True b. False How often should ward-based audits of hand hygiene materials be undertaken? a. Once a week b. Once a month c. Once every 3 months d. Once a year The WASH FIT team should include which of the following? a. Facility managers b. Cleaners c. Nurses d. WASH technicians e. All of the above WASH FIT is a risk management tool aimed at providing a holistic approach to protecting patient and staff health through the assessment and management of risks. a. True b. False WASH FIT is only used in the interior of a facility building. a. True b. False Greywater and/or stormwater can be captured and reused for washing, cleaning, watering plants, toilet flushing and drinking, to conserve water. a. True b. False Which two of the following are not considered climate-smart improvements? a. Using a low-cost incinerator to treat medical waste b. Using an autoclave to treat medical waste c. Conducting training and awareness raising to reduce quantities of waste generated at source d. Segregating recyclable nonhazardous waste and sending it to municipal recycling plants e. Requiring all health care workers administering vaccinations to wear gloves In health care settings, an area for cleaning supplies should not include: a. Storage of equipment b. Space to prepare cleaning materials for use c. A dedicated sign as to the nature of the area d. Nursing supplies (e.g. for wound dressings) Which of these are accessibility and safety features of WASH FIT? a. Latrines are adequately lit, including at night b. At least one toilet needs to have menstrual hygiene facilities  c. At least one toilet meets the needs of people with reduced mobility d. Hand hygiene promotion materials clearly visible and understandable at key places e. All of the above 9 10 11 12 13 14 15 16 17 18 W A SH F IT M an ua l f or T ra in er s 25 WASH FIT: Pre-training and post-training test answers 1 B 2 C 3 A 4 A 5 C 6 A 7 D 8 F 9 F 10 B 11 C 12 E 13 A 14 B 15 B 16 A and E 17 D 18 E W A SH F IT M an ua l f or T ra in er s 26 WASH LINKS WITH HEALTH – MODULE OUTLINE Name of module Introductory presentation: How WASH in health care facilities is linked to other health initiatives Pre-training preparation • Face to face: ‒ Computer, projector, module slides ‒ Adaptation of the module with local information and local photos, if possible and relevant ‒ Accessibility requirements (ensure that the venue is physically accessible) • Virtual: ‒ Presentation platform (e.g. Zoom – requires link and access) and functions to be used ‒ Adaptation of the module with local information and local photos, if possible and relevant • Understanding of competence (starting point of knowledge and perceptions) of those attending the training Learning objectives On completion of this module learners, will be able to: • understand the latest global data and monitoring mechanisms for WASH in health care facilities • describe how WASH is addressed in quality, maternal and child health, IPC and antimicrobial resistance guidance and tools, and how to engage with health partners • define key elements of the 2019 World Health Assembly resolution on WASH in health care facilities, how progress is being tracked and efforts to strengthen accountability • understand the global targets and metrics of success for advancing WASH in health care facilities • understand the latest WHO technical evidence on COVID-19 and WASH • know where to get more information from WHO and UNICEF on WASH in health care facilities. Module duration Approximate time to deliver all aspects of the module: 40 minutes Languages English Module information This module is an introductory presentation, designed to set the scene for the other modules and, more generally, any national work on WASH in health care facilities. It is based on the latest WHO global guidance, and data and will periodically be updated as new evidence emerges. The module includes: • an overview of the latest global data on WASH in health care facilities • instructions for accessing relevant national or regional data on WASH in health care facilities • guidance on COVID-19 as it relates to WASH and waste in health care facilities • a summary of relevant global guidance and frameworks to address WASH in health care facilities • a description of each of the eight WHO/UNICEF “practical steps” • a related reading list. Format The module comprises: • approximately 50 slides with speaker notes (for the trainer to read before and during the session) • a group exericse, indicated by the group work exercise icon • time estimates for group work and key questions – indicated by a clock Group work Time Discussion... ANNEX 2 W A SH F IT M an ua l f or T ra in er s 27 Name of module Introductory presentation: How WASH in health care facilities is linked to other health initiatives Supporting materials and resources • Face to face: ‒ Laptop and data projector • Virtual: ‒ Laptop, with internet access • Copy of the PowerPoint slide set to be shared with all participants (by USB or email) • List of additional reading (for trainer preparation and participants post-training) Group exercises One group exercise that ask questions about the relationship between WASH and infection prevention and control (5 minutes) Further reading and resources General • WHO (2022). Water and Sanitation for Health Facility Improvement Tool (WASH FIT): a practical guide for improving quality of care through water, sanitation and hygiene in health care facilities, second edition. https://washinhcf.org/wash-fit/ • WHO (2008). Essential environmental health standards in health care. https:// www.who.int/publications/i/item/9789241547239 Water • WHO (2022). Guidelines for drinking-water quality: Fourth edition incorporating the first and second addenda. https://www.who.int/publications/i/ item/9789240045064 • WHO (2019). Results of round II of the WHO international scheme to evaluate household water treatment technologies. https://apps.who.int/iris/ handle/10665/325896 Sanitation • WHO (2018). Guidelines on sanitation and health. https://www.who.int/ publications/i/item/9789241514705 Waste • WHO (2014). Safe management of wastes from health-care activities, second edition. https://www.who.int/publications/i/item/9789241548564 • WHO (2017). Safe management of wastes from health-care activities: a summary. https://apps.who.int/iris/handle/10665/259491 • WHO (2019). Overview of technologies for the treatment of infectious and sharp waste from health care facilities. https://apps.who.int/iris/handle/10665/328146 Environmental cleaning • United States Centers for Disease Control and Prevention (2019). Best practices for environmental cleaning in healthcare facilities: in resource limited settings. https://www.cdc.gov/hai/prevent/resource-limited/index.html COVID-19 • WHO (2020). Water, sanitation, hygiene, and waste management for SARS- CoV-2, the virus that causes COVID-19. https://www.who.int/publications/i/ item/WHO-2019-nCoV-IPC-WASH-2020.4 • WHO (2020). Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. https://www.who.int/publications/i/ item/10665-331495 Emergencies • WHO/WEDC (2013). Technical notes on WASH in emergencies (set of 15). https://www.who.int/teams/environment-climate-change-and-health/water- sanitation-and-health/environmental-health-in-emergencies/technical-notes- on-wash-in-emergencies Quality of care, and infection prevention and control • WHO (2016). Standards for improving quality of maternal and newborn care in health facilities. https://www.who.int/publications/i/item/9789241511216 • WHO (2016). Global guidelines for the prevention of surgical site infection. https://www.who.int/publications/i/item/global-guidelines-for-the-prevention- of-surgical-site-infection-2nd-ed W A SH F IT M an ua l f or T ra in er s 28 WASH FIT METHODOLOGY – MODULE OUTLINE Name of module WASH FIT methodology Pre-training preparation • Face to face: ‒ Computer, projector, module slides ‒ Printing – WASH FIT guide, or at least a list of WASH FIT indicators and WASH FIT tools ‒ Adaptation of the module to the local context with local photos ‒ Permission to visit a local facility to conduct an assessment, and logistics (e.g. transport, meals) ‒ Accessibility requirements (ensure that the venue is physically accessible) • Virtual: ‒ Presentation platform (e.g. Zoom – requires link and access) and functions to be used ‒ Slack, Google Jamboard or other platform to allow interactivity between participants ‒ Plan for breakout rooms for group work if the group is too large for a single group ‒ Allocation of participants to breakout rooms, and allocation of facilitators and note takers for each breakout room ‒ Adaptation of the module to the local context with local photos ‒ Preparation of a virtual facility visit using a video or photos of a local health care facility to undertake a sample WASH FIT assessment (optional) • Understanding of competence (starting point of knowledge and perceptions) of those attending the training Learning objectives On completion of this module, learners will be able to: • describe what WASH FIT is, where and how it is used, and the expected impacts and outcomes • describe the five phases of the WASH FIT cycle and how to carry them out • understand how to adapt and use WASH FIT in a range of different settings • understand the enabling factors and possible barriers for implementing WASH FIT successfully. Module duration Approximate time to deliver all aspects and allow discussion of the module: 2–3 hours, depending on how many group exercises are used Languages English Module information This module is the core WASH FIT training module, and sufficient time should be allocated to it. It is essential for anyone wishing to use WASH FIT. The module includes: • setting the scene – what is WASH FIT and what is it used for? • the five WASH FIT steps – tasks, outputs and country examples • country examples of WASH FIT implementation • an explanation of the WASH FIT process from preparation and initial implementation to sustaining and scaling up • a related reading list. Group work Time Discussion... ANNEX 3 W A SH F IT M an ua l f or T ra in er s 29 Name of module WASH FIT methodology Format The module comprises: • approximately 85 slides with speaker notes (for the trainer to read before and during the session); the module is very comprehensive, and trainers may wish to select a subset of slides that are most relevant to their context • a warm-up/ice-breaker exercise to begin • group exercises, brainstorming exercises and discussions throughout the module to keep participants interested and engaged; these should be modified according to the local context and time available, and are indicated by the group work symbol • two role-play exercises to help consolidate trainee knowledge • time estimates for group work and key questions – indicated by a clock • country examples that explain where and how WASH FIT has been used. Supporting materials and resources • Face to face: ‒ Laptop and data projector ‒ Flip chart paper and pens to summarize group work and exercise feedback ‒ Copy of the WASH FIT guide, or at least the assessment form and other WASH FIT tools • Virtual: ‒ Laptop, with internet access ‒ Consider a shared folder and documents (Google Docs) to collate real- time feedback and/or use of a shared whiteboard (e.g. in Zoom), so that all participants can see feedback ‒ Video tour of a local health care facility to conduct a virtual WASH FIT assessment (optional) • Copy of the PowerPoint slide set to be shared with all participants (by USB or email) • List of additional reading (for trainer preparation and participants post- training) Group exercises Nine interactive exercises, role play and discussion topics (timings are approximate and will depend on the number of participants and trainer discretion): • Ice-breaker: Just a minute (3–5 minutes) • Group discussion: Which parts of a facility does WASH FIT address? (5 minutes) • Group discussion: What problems have you experienced that are linked to WASH in health care facilities? (8–10 minutes) • Group exercise: Who is responsible for WASH FIT? (10 minutes) • Group discussion: What challenges might the WASH FIT team face? (3 minutes) • Group exercise: Does this picture meet the standards? (5 minutes) • Group exercise: Conduct a risk assessment (15 minutes) • Role play: Can you convince your colleagues of the benefits of WASH FIT? (10 minutes) • Role play: Can you convince senior management why WASH is important? (10 minutes) W A SH F IT M an ua l f or T ra in er s 30 Further reading and resources WHO (2008). Essential environmental health standards in health care. https://www.who.int/publications/i/item/9789241547239 WHO (2014). Safe management of wastes from health-care activities, second edition. https://www.who.int/publications/i/item/9789241548564 WHO (2017). Safe management of wastes from health-care activities: a summary. https://apps.who.int/iris/handle/10665/259491 WHO (2019). Overview of technologies for the treatment of infectious and sharp waste from health care facilities. https://apps.who.int/iris/handle/10665/328146 WHO (2016). Standards for improving quality of maternal and newborn care in health facilities. https://www.who.int/publications/i/item/9789241511216 WHO (2016). Global guidelines for the prevention of surgical site infection https:// www.who.int/publications/i/item/global-guidelines-for-the-prevention-of-surgical- site-infection-2nd-ed WHO. SAVE LIVES: Clean Your Hands. https://www.who.int/campaigns/world- hand-hygiene-day WHO (2008). Essential environmental health standards in health care. https://www. who.int/publications/i/item/9789241547239 WHO (2022). Guidelines for drinking-water quality: Fourth edition incorporating the first and second addenda. https://www.who.int/publications/i/item/9789240045064 WHO (2018). Guidelines on sanitation and health. https://www.who.int/ publications/i/item/9789241514705 WHO (2016). Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. https://apps.who. int/iris/handle/10665/251730 WHO (2019). Minimum requirements for infection prevention and control programmes. https://www.who.int/publications/i/item/9789241516945 WHO (2009). Guidelines on hand hygiene in health care. https://www.who.int/publications/i/item/9789241597906 United States Centers for Disease Control and Prevention (2019). Best practices for environmental cleaning in healthcare facilities: in resource limited settings. https:// www.cdc.gov/hai/prevent/resource-limited/index.html WHO (2021). Strengthening infection prevention and control in primary care. https://www.who.int/publications/i/item/9789240035249 WHO (2018). Standards for improving the quality of care for children and young adolescents in health facilities. https://www.who.int/publications/i/ item/9789241565554 WHO (2020). Guidance for climate-resilient and environmentally sustainable health care facilities . https://www.who.int/publications/i/item/9789240012226 WHO (2014). Access to modern energy services for health facilities in resource- constrained settings. a review of status, signi ficance, challenges and measurement. https://apps.who.int/iris/handle/10665/156847 Links to all documents can be found at: https://washinhcf.org/resource/summary-of-all-who-and-related-resources-on- wash-in-hcf/ W A SH F IT M an ua l f or T ra in er s 31 MANAGING SAFE WATER SUPPLIES – MODULE OUTLINE Name of module Managing safe water supplies Pre-training preparation • Face to face: ‒ Computer, projector, module slides ‒ Printing for the group work exercise ‒ Adaptation of the module to the local context with local photos, if possible and relevant ‒ Permission to visit a local facility to conduct an assessment, and logistics (e.g. transport, meals) ‒ Allocation of participants to breakout groups, and allocation of breakout group facilitators and note takers ‒ Accessibility requirements (ensure that the venue is physically accessible) • Virtual: ‒ Presentation platform (e.g. Zoom – requires link and access) and functions to be used ‒ Slack, Google Jamboard or other platform to allow interactivity between participants ‒ Plan for breakout rooms for group work if the group is too large for a single group) ‒ Allocation of participants to breakout rooms, and allocation of facilitators and note takers for each breakout room ‒ Adaptation of the module to the local context with local photos ‒ Preparation of a virtual facility visit using a video or photos of a local health care facility to undertake a sample WASH FIT assessment (optional) • Understanding of competence (starting point of knowledge and perceptions) of those attending the training • Plan for introducing each participant, within the time allocation for the module Learning objectives On completion of this module, learners will be able to: • describe the minimum requirements for safe and sufficient water in health care facilities • describe the impacts of inadequate water supplies • outline the tools available to monitor and improve water quality and quantity • describe common plumbing problems and simple improvements that can be made • understand the causes of Legionella outbreaks and how to address them • understand how climate change can affect a facility’s water supply and some simple, low-cost improvements to address this. Module duration Approximate time to deliver all aspects and allow discussion of the module: 1 hour 45 minutes Languages English Group work Time Discussion... ANNEX 4 W A SH F IT M an ua l f or T ra in er s 32 Name of module Managing safe water supplies Module information This module addresses managing safe water supplies in support of WASH in health care facilities. The module includes: • a review of minimum water requirements • a review of water quality for health care • water requirements and COVID-19 • an outline of a water safety plan • the content of a sanitary inspection form • a review of water treatments • a description of common plumbing problems and solutions • the issue of climate change and some solutions • key takeaway messages • supplementary information • further reading. Format The module comprises: • 47 slides, including opening and closing slides, and supplementary slides (if required) • speaker notes within each slide (for the trainer to read before and during the session) • an ice-breaker exercise in the form of a generic water question (slide 5) • seven quiz questions, to provide an opportunity for all participants to contribute • an exercise with a handout • time estimates for quizzes and exercises – indicated by a clock • a list of relevant WASH FIT indicators • a summary of key takeaway messages • time for final questions and review of resources for further reading. Supporting materials and resources • Face to face: ‒ Laptop and data projector ‒ Internet access ‒ Flip chart paper and pens to summarize whole-group questions and discussions, and potentially exercise feedback (if this will not be collected in another platform) • Virtual: ‒ Laptop, with internet access ‒ Consider a shared folder and documents (Google Docs) to collate real- time feedback and/or use of a shared whiteboard (e.g. in Zoom), so that all participants can see feedback ‒ Video tour of a local health care facility to conduct a virtual WASH FIT assessment (optional) • Copy of the PowerPoint slide set to be shared with all participants (by USB or email) • List of additional reading resources (for trainer preparation and participants post-training) Group exercises One formal exercise (estimated 30 minutes) with a handout: an opportunity to complete a sanitary inspection form, comprising 10 questions ... W A SH F IT M an ua l f or T ra in er s 33 Further reading and resources General • WHO (2008). Essential environmental health standards in health care. https:// www.who.int/publications/i/item/9789241547239 • WHO (2022). Guidelines for drinking-water quality: Fourth edition incorporating the first and second addenda. https://www.who.int/publications/i/ item/9789240045064 • WHO (2018). Developing drinking-water quality regulations and standards. https://www.who.int/publications/i/item/9789241513944 Emergencies • WHO (2011). Technical notes on drinking water, sanitation and hygiene in emergencies. http://www.who.int/water_sanitation_health/publications/2011/ tn9_how_much_water_en.pdf • WHO/WEDC (2013). Technical Notes on WASH in Emergencies https://www.who.int/teams/environment-climate-change-and-health/water- sanitation-and-health/environmental-health-in-emergencies/technical-notes- on-wash-in-emergencies • WHO (2007). Legionella and the prevention of legionellosis. https://apps.who. int/iris/handle/10665/43233 • WHO/UNICEF (2020). Water, sanitation, hygiene, and waste management for SARS-CoV-2, the virus that causes COVID-19. https://www.who.int/publications- detail-redirect/WHO-2019-nCoV-IPC-WASH-2020.4 Climate • WHO (2017). Climate-resilient water safety plans: managing health risks associated with climate variability and change. https://apps.who.int/iris/ handle/10665/258722 • WHO (2020). WHO guidance for climate resilient and environmentally sustainable health care facilities. https://www.who.int/publications/i/ item/9789240012226 Water quality and treatment • WHO (2021). Sanitation inspection packages for drinking-water. https://www.who. int/teams/environment-climate-change-and-health/water-sanitation-and-health/ water-safety-and-quality/water-safety-planning/sanitary-inspection-packages • WHO (2019). Results of round II of the WHO international scheme to evaluate household water treatment technologies. https://apps.who.int/iris/ handle/10665/325896 Plumbing • WHO, World Plumbing Council (2006). Health aspects of plumbing. https:// apps.who.int/iris/bitstream/handle/10665/43423/9241563184_eng. pdf?sequence=1&isAllowed=y • Netherlands Water Partnership (2006). Smart water solutions: examples of innovative, low-cost technologies for wells, pumps, storage, irrigation and water treatment. https://www.joinforwater.ngo/sites/default/files/library_assets/330_ NWP_E9_smart_water.pdf WHO webpages • Water safety and quality. https://www.who.int/teams/environment-climate- change-and-health/water-sanitation-and-health/water-safety-and-quality • International Scheme to Evaluate Household Water Treatment Technologies. https://www.who.int/tools/international-scheme-to-evaluate-household- water-treatment-technologies W A SH F IT M an ua l f or T ra in er s 34 SANITATION – MODULE OUTLINE Name of module Safely managed sanitation in health care facilities Pre-training preparation • Face to face: ‒ Computer, projector, module slides ‒ Adaptation of the module to the local context with local photos, if possible and relevant ‒ Permission to visit a local facility to conduct an assessment, and logistics (e.g. transport, meals) ‒ Allocation of participants to breakout groups, and allocation of breakout group facilitators and note takers (with flip chart paper and pens) ‒ Accessibility requirements (ensure that the venue is physically accessible) • Virtual: ‒ Presentation platform (e.g. Zoom – requires link and access) and functions to be used ‒ Slack, Google Jamboard or other platform to allow interactivity between participants ‒ Plan for breakout rooms for group work ‒ Allocation of participants to breakout rooms, and allocation of facilitators and note takers ‒ Adaptation of the module to the local context with local photos ‒ Preparation of a virtual facility visit using a video or photos of a local health care facility to undertake a sample WASH FIT assessment (optional) • Understanding of competence (starting point of knowledge and perceptions) of those attending the training • Plan for introducing each participant, within the time allocation for the module Learning objectives On completion of this module, learners will be able to: • describe the minimum requirements for sanitation in health care facilities • understand what “safely managed sanitation” is, and why it is important for human health and providing safe care • understand the links between antimicrobial resistance and sanitation in health care facilities, and what can be done to address the problem • describe the different sanitation technology options and the effects of climate change on technologies • understand how to make sanitation facilities user-friendly, gender-inclusive and climate-resilient. Module duration Approximate time to deliver all aspects and allow discussion of the module: 90 minutes Languages English Group work Time Discussion... ANNEX 5 W A SH F IT M an ua l f or T ra in er s 35 Name of module Safely managed sanitation in health care facilities Module information This module addresses health care waste management in the context of WASH and waste. It is made of up 10 sections. The module includes: • minimum requirements • why safe sanitation is important • antimicrobial resistance in health care facilities • sanitation technologies, including toilet options and treatment options • sanitation inspections • minimizing risks to waste handlers • climate change/resilience and sanitation systems • improving and maintaining services, including for equitable access • key takeaway messages • further reading. Format The module comprises: • 43 slides, including opening and closing slides, plus one supplementary slide • speaker notes within each slide (for the trainer to read before and during the session) • a 5-minute (breakout) quiz (with answers on the next slide) • a 2-minute brainstorming exercise with prompt questions • another 5-minute (breakout) quiz (with answers on the next slide) • a 3-minute quiz/discussion • time for questions • time estimates for group work, key questions and videos – indicated by a clock. Supporting materials and resources • Face to face: ‒ Laptop and data projector ‒ Internet access ‒ Flip chart paper and pens to collate notes from discussions ‒ Consider posters/photos for the walls, if relevant, to highlight and bring to life sanitation situations in different settings • Virtual: ‒ Laptop, with internet access ‒ Consider a shared folder and documents (Google Docs) to collate real- time feedback and/or use of a shared whiteboard (e.g. in Zoom), so that all participants can see feedback ‒ Video tour of a local health care facility to conduct a virtual WASH FIT assessment (optional) • Copy of the PowerPoint slideset to be shared with all participants (by USB or email) • List of additional reading (for trainer preparation and participants post- training) Group exercises Four exercises: • A 5-minute (breakout) quiz (with answers on the next slide), aiming to have participants focus on the broad aspects of what constitutes sanitation. • A 2-minute brainstorming exercise with prompt questions focused on the sanitation chain and defining a sanitation system. • Another 5-minute (breakout) quiz (with answers on the next slide), addressing types of sanitation services, measures to make systems climate- resilient and numbers of toilets. • A 3-minute quiz/discussion focused on toilet requirements including GEDSI (gender equality, disability and social inclusion), with notes for the trainer to discuss during feedback. ... W A SH F IT M an ua l f or T ra in er s 36 Further reading and resources General • WHO (2008). Essential environmental health standards in health care. https:// www.who.int/publications/i/item/9789241547239 • WHO (2018). Guidelines on sanitation and health. https://www.who.int/ publications/i/item/9789241514705 (Also available in Arabic, French, Russian and Spanish) • WHO (2020). State of the world’s sanitation: an urgent call to transform sanitation for better health, environments, economies and societies. https:// www.who.int/publications/i/item/9789240014473 • World Bank, International Labour Organization, WaterAid, WHO (2019). Health, safety and dignity of sanitation workers: an initial assessment. https://documents.worldbank.org/en/publication/documents-reports/ documentdetail/316451573511660715/health-safety-and-dignity-of-sanitation- workers-an-initial-assessment • International Organization for Standardization (2011). ISO 21542:2011 (Building construction – Accessibility and usability of the built environment) http://www. iso.org/iso/home/store/catalogue_tc/catalogue_detail.htm?csnumber=50498 Technologies • Eawag (2014). Compendium of sanitation systems and technologies, second revised edition. https://www.eawag.ch/en/department/sandec/publications/ compendium/ • WHO (2015). Sanitation safety planning: manual for safe use and disposal of wastewater, greywater and excreta. https://apps.who.int/iris/ handle/10665/171753 (second edition is due for publication in 2022) • Water Supply & Sanitation Collaborative Council (2010). Hygiene and sanitation software: an overview of approaches. https://sswm.info/sites/default/files/ reference_attachments/PEAL%202010%20Hygiene%20and%20Sanitation%20 Software.%20An%20overview%20of%20approaches.pdf • Health Habitat Australia. How does a septic tank work? https://www.youtube. com/watch?v=uuORuwb4cfs&t=3s • Smart Sanitation Solutions. Examples of innovative, low-cost technologies for toilets, collection, transportation, treatment and use of sanitation products. ttps://www.joinforwater.ngo/sites/default/files/library_assets/360_NWP_E2_ Smart_Sanitation.pdf Antimicrobial resistance • WHO (2020). Technical brief on water, sanitation, hygiene (WASH) and wastewater management to prevent infections and reduce the spread of antimicrobial resistance (AMR). https://www.who.int/publications/i/ item/9789240006416 • WHO (2019). Turning plans into action for antimicrobial resistance (AMR): Working Paper 2.0: Implementation and coordination. https://www.who.int/ publications/i/item/turning-plans-into-action-for-antimicrobial-resistance-(- amr)-working-paper-2.0-implementation-and-coordination • WHO, Food and Agriculture Organization of the United Nations, World Organisation for Animal Health (OIE). Global Database for the Tripartite Antimicrobial Resistance (AMR) Country Self-Assessment Survey. https:// amrcountryprogress.org/ • WHO, Food and Agriculture Organization of the United Nations, World Organisation for Animal Health (OIE) (2019). Monitoring and evaluation of the global action plan on antimicrobial resistance: framework and recommended indicators. https://apps.who.int/iris/handle/10665/325006 W A SH F IT M an ua l f or T ra in er s 37 Emergencies • WHO (2011). Technical notes on drinking water, sanitation and hygiene in emergencies. http://www.who.int/water_sanitation_health/publications/2011/ tn9_how_much_water_en.pdf • WHO/WEDC (2013). Technical Notes on WASH in Emergencies https://www.who.int/teams/environment-climate-change-and-health/water- sanitation-and-health/environmental-health-in-emergencies/technical-notes- on-wash-in-emergencies • WHO/WEDC (2013). Updated technical notes on WASH in emergencies (set of 15). https://www.who.int/teams/environment-climate-change-and-health/water- sanitation-and-health/environmental-health-in-emergencies/technical-notes- on-wash-in-emergencies • WHO/UNICEF (2020). Water, sanitation, hygiene and waste management for SARS-CoV-2, the virus that causes COVID-19. https://www.who.int/publications- detail-redirect/WHO-2019-nCoV-IPC-WASH-2020.4 Infographics • WHO, WATERAID (2019) Combatting AMR through WASH and IPC in healthcare https://washinhcf.org/wp-content/uploads/2021/07/WASH_IPC_AMR_ techbriefOct2020.pdf • WHO (2019). AMR. A major public threat. https://cdn.who.int/media/ docs/default-source/integrated-health-services-(ihs)/amr/ipc_amr_ a4.pdf?sfvrsn=ede4a5cd_7 W A SH F IT M an ua l f or T ra in er s 38 HAND HYGIENE – MODULE OUTLINE Name of module Hand hygiene Pre-training preparation • Face to face: • Computer, projector, module slides ‒ The two videos embedded within the slides – test before delivering training (will require a built-in or external speaker) ‒ Printing – group work exercise (one page); numbers of copies will depend on number of breakout groups and participants ‒ Adaptation of the module to the local context with local photos, if possible and relevant ‒ Permission to visit a local facility to conduct an assessment, and logistics (e.g. transport, meals) ‒ Allocation of participants to breakout groups, and allocation of breakout group facilitators and note takers ‒ Accessibility requirements (ensure that the venue is physically accessible) • Virtual: ‒ Presentation platform (e.g. Zoom – requires link and access) and functions to be used ‒ Slack, Google Jamboard or other platform to allow interactivity between participants ‒ Two videos embedded within the slides – test before delivering training ‒ Plan for breakout rooms for group work 1 (and group work 2 if the group is too large for a single group) ‒ Allocation of participants to breakout rooms, and allocation of facilitators and note takers for each breakout room ‒ Adaptation of the module to the local context with local photos ‒ Preparation of a virtual facility visit using a video or photos of a local health care facility to undertake a sample WASH FIT assessment (optional) • Understanding of competence (starting point of knowledge and perceptions) of those attending the training • Plan for introducing each participant, within the time allocation for the module Learning objectives On completion of this module, learners will be able to: • understand how WASH supports the five golden rules for hand hygiene • describe the importance of using a multimodal improvement strategy and where WASH fits within this • describe the importance of health workers and managers being trained in, and reminded about, the right moments and technique for hand hygiene • state how WASH FIT indicators overall support IPC and hand hygiene efforts to stop the spread of healthcare-associated infections and antimicrobial resistance, including the infrastructure and resources necessary to support hand hygiene improvement Module duration Approximate time to deliver all aspects and allow discussion of the module: 90 minutes Languages English Group work Time Discussion... ANNEX 6 W A SH F IT M an ua l f or T ra in er s 39 Name of module Hand hygiene Module information This module addresses hand hygiene improvement within the context of WASH. It is made of up five broad sections. The module includes: • setting the scene – what we know about the problem • five golden rules for hand hygiene • understanding the point of care, in different settings • understanding an evidence-based, effective formula for improving hand hygiene – the multimodal improvement strategy (five elements with definitions, what to ask/look for, how improving hand hygiene using the multimodal strategy maps to the WASH FIT indicators) • key takeaway messsages • further reading list. Format The module comprises: • 35 slides, including opening and closing slides, two slides with embedded videos (see below), and three slides of additional reading/references • speaker notes for all slides (for the trainer to read before and during the session) • an ice-breaker exercise in the form of a question • use of two videos to ‒ engage participants and help the five elements of the multimodal improvement strategy to “stick” in their minds (an up-beat, simple introduction to the WHO strategy) (video 1) ‒ describe how the moments for hand hygiene in health care are important in relation to workflow (video 2) • a symbol embedded within slides to prompt the trainer to ask questions while reading out information • a 10-minute group work exercise on hand hygiene and the multimodal strategy (slide 16) – to be used in breakout rooms or groups • a 5-minute group work exercise on engagement of management in hand hygiene improvement (slide 28) – this requires the same breakout rooms or groups • time estimates for group work and key questions – indicated by a clock • reference to existing WASH FIT indicators (text presented in pink boxes – slides 18, 20, 22, 24, 26) • time to review available resources for further reading. Supporting materials and resources • Face to face: ‒ Laptop and data projector ‒ Internet access ‒ Flip chart paper and pens to summarize feedback from group work exercises ‒ Consider having posters of the WHO 5 Moments of Hand Hygiene and bottles of alcohol-based hand santizer, if possible • Virtual: ‒ Laptop, with internet access ‒ Consider a shared folder and documents (Google Docs) to collate real- time feedback and/or use of a shared whiteboard (e.g. in Zoom), so that all participants can see feedback ‒ Video tour of a local health care facility to conduct a virtual WASH FIT assessment (optional) • Copy of the PowerPoint slide set to be shared with all participants (by USB or email) • List of additional reading (for trainer preparation and participants post-training) Group exercises Two group exercises: • Address hand hygiene and the multimodal approach using a 5-point scenario with two prompt questions to stimulate discussion. Questions are: Do you think anything is lacking in the current approach to hand hygiene improvement? Can you think of any examples you have seen that might be useful in achieving a multimodal approach to clean hands at the right times? Recommend 15 minutes to complete. • Stimulate participants to consider “How might you better engage hospital or clinic managers in hand hygiene improvement?” to support a culture of safety that supports and values hand hygiene by reconsidering the 5-point scenario. Recommend 5 minutes to discuss. ... W A SH F IT M an ua l f or T ra in er s 40 Further reading and resources General • WHO hand hygiene tools and resources ‒ Implementation tools: https://www.who.int/teams/integrated-health- services/infection-prevention-control/hand-hygiene/tools-and-resources ‒ Training tools: https://www.who.int/teams/integrated-health-services/ infection-prevention-control/hand-hygiene/training-tools ‒ Monitoring tools: https://www.who.int/teams/integrated-health-services/ infection-prevention-control/hand-hygiene/monitoring-tools • WHO (2021). Resource considerations for investing in hand hygiene improvement in health care facilities. https://www.who.int/publications/i/ item/9789240025882 • New England Journal of Medicine hand hygiene video article: ‒ English: https://www.nejm.org/doi/full/10.1056/nejmvcm0903599 ‒ Official UN languages plus other languages: https://www.who.int/ campaigns/world-hand-hygiene-day • Hand hygiene: a handbook for medical professionals. https://www.wiley.com/en-gb/ Hand+Hygiene:+A+Handbook+for+Medical+Professionals-p-9781118846865 • OpenWHO Standard precautions: hand hygiene module. https://openwho.org/ courses/IPC-HH-en • WHO (2010). Hand Hygiene Self Assessment Framework. https://cdn.who.int/ media/docs/default-source/integrated-health-services-(ihs)/hand-hygiene/ monitoring/hhsa-framework-october-2010.pdf?sfvrsn=41ba0450_6 Alcohol-based handrub • WHO (2010). Alcohol-based Handrub Planning and Costing Tool. https://www. who.int/teams/integrated-health-services/infection-prevention-control/hand- hygiene/tools-and-resources • WHO (2010). Guide to local production: WHO-recommended handrub formulations. https://www.who.int/publications/i/item/WHO-IER-PSP-2010.5 Five moments in a range of care settings • WHO (2012). Hand hygiene in outpatient and home-based care and long-term care facilities: a guide to the application of the WHO multimodal hand hygiene improvement strategy and the “My 5 Moments for Hand Hygiene” approach. https://apps.who.int/iris/handle/10665/78060 Additional training materials • WHO infection prevention and control training package (e-learning): ‘Standard precautions: hand hygiene’, and ‘Standard precautions: environmental cleaning’. https://openwho.org/courses/IPC-HH-en Infection prevention and control • WHO (2019). Minimum Requirements for infection prevention and control programmes. https://apps.who.int/iris/handle/10665/330080 • WHO (2016). Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. https://apps. who.int/iris/handle/10665/251730 • WHO (2021). Aide-memoire: respiratory and hand hygiene. In: Infection prevention and control: guidance to action tools. https://apps.who.int/iris/ handle/10665/341418 Antimicrobial resistance • WHO antimicrobial resistance webpages. https://www.who.int/health-topics/ antimicrobial-resistance W A SH F IT M an ua l f or T ra in er s 41 HEALTH CARE WASTE – MODULE OUTLINE Name of module Health care waste management Pre-training preparation • Face to face: ‒ Computer, projector, module slides ‒ Adaptation of the module to the local context with local photos, if possible and relevant ‒ Permission to visit a local facility to conduct an assessment, and logistics (e.g. transport, meals) ‒ Allocation of participants to breakout groups, and allocation of breakout group facilitators and note takers (with flip chart paper and pens) ‒ Accessibility requirements (ensure that the venue is physically accessible) • Virtual: ‒ Presentation platform (e.g. Zoom – requires link and access) and functions to be used ‒ Slack, Google Jamboard or other platform to allow interactivity between participants ‒ Plan for breakout rooms for group work ‒ Allocation of participants to breakout rooms, and allocation of facilitators and note takers ‒ Adaptation of the module to the local context with local photos ‒ Preparation of a virtual facility visit using a video or photos of a local health care facility to undertake a sample WASH FIT assessment (optional) • Understanding of competence (starting point of knowledge and perceptions) of those attending the training • Plan for introducing each participant, within the time allocation for the module Learning objectives On completion of this module, learners will be able to: • understand the risks caused by unsafe health care waste management practices in health care facilities • understand the process of health care waste management from generation to safe treatment and disposal • outline waste management guidelines in the context of COVID-19 • understand which waste treatment options are the most environmentally friendly and be aware of measures to mitigate impacts of climate change • apply an incremental improvement approach. Module duration Approximate time to deliver all aspects and allow discussion of the module: 90 minutes Languages English Module information This module addresses health care waste management in the context of WASH and waste. It is made of up 10 sections. The module includes: • the nature of the problem • waste generation rates and steps • common examples of waste found in health care facilities • responsibilities for health care waste management • waste segregation, collection, transport and storage • waste treatment and disposal options • occupational safety and documentation • health care waste indicators for WASH FIT • sustainability of waste practices and climate change impacts • key takeaway messsages • further reading. Group work Time Discussion... ANNEX 7 W A SH F IT M an ua l f or T ra in er s 42 Name of module Health care waste management Format The module comprises: • 46 slides, including opening and closing slides, plus supplementary slides on selection criteria for treatment technologies, treatment of waste during emergency situations and biodigestion of food/pathology waste, to be used depending on the setting and time • speaker notes within each slide (for the trainer to read before and during the session) • five opportunities for interactive questions/discussions, shown by the group activity icon • a short video on waste treatment by autoclaving • a 5-minute breakout group exercise • a 10-minute breakout group exercise • time for questions • time estimates for group work, key questions and videos – indicated by a clock. Supporting materials and resources • Face to face: ‒ Laptop and data projector ‒ Internet access ‒ Flip chart paper and pens to collate notes from discussions ‒ Consider posters/photos for the walls, if relevant, to highlight and bring to life waste situations in different settings • Virtual: ‒ Laptop, with internet access ‒ Consider a shared folder and documents (Google Docs) to collate real- time feedback and/or use of a shared whiteboard (e.g. in Zoom), so that all participants can see feedback ‒ Video tour of a local health care facility to conduct a virtual WASH FIT assessment (optional) • Copy of the PowerPoint slideset to be shared with all participants (by USB or email) • List of additional reading (for trainer preparation and participants post- training) Group exercises Seven exercises: • A whole-group discussion on what is wrong with the picture of waste (slide 5) – 2 minutes • A whole-group exercise to take a three-question quiz (consider an on- screen poll) – 2 minutes (slide 7, then move to the next slide with answers) • A whole-group exercise to ask about the requirement for bins (slide 11) • A whole-group exercise to ask about rational use of personal protective equipment (slide 16) • A breakout group exercise (2–5 people per group) to consider some key questions. During COVID-19, volumes of waste have dramatically increased. What are the reasons for this? How much waste would a hospital with 200 beds and an occupancy rate of 80% generate in one day? One month? One year? How much would typically be hazardous? Total of 5 minutes for discussion and feedback. • A whole-group exercise to identify examples that cause higher volumes of waste (slide 22). • A breakout group exercise (2–5 people per group), asking the groups to consider what they would do if they were responsible for waste management at a facility by posing a scenario and three questions to be discussed, with anwers recorded for feedback. ... W A SH F IT M an ua l f or T ra in er s 43 Further reading and resources • United Nations Environment Programme (2003). Technical guidelines on the environmentally sound management of biomedical and healthcare wastes. http://archive.basel.int/pub/techguid/tech-biomedical.pdf • United Nations Environment Programme (2007). Guidelines on best available techniques and guidance on best environmental practices relevant to Article 5 and Annex C of the Stockholm Convention on Persistent Organic Pollutants. http://chm.pops.int/Implementation/BATandBEP/BATBEPGuidelinesArticle5/ tabid/187/Default.aspx • WHO (2003). Aide-memoire for a strategy to protect health workers from infection with bloodborne viruses. https://apps.who.int/iris/handle/10665/68354 • WHO (2014). Safe management of wastes from health-care activities, second edition. https://www.who.int/publications/i/item/9789241548564 • WHO (2017). Safe management of wastes from health-care activities: a summary. https://apps.who.int/iris/handle/10665/259491 • WHO (2019). Overview of treatment technologies for infectious and sharp waste from health care facilities. https://apps.who.int/iris/handle/10665/328146 • United Nations Development Programme. Green Healthcare Waste. https:// greenhealthcarewaste.org/ • WHO (2020). Water, sanitation, hygiene, and waste management for SARS- CoV-2, the virus that causes COVID-19. Interim guidance. https://www.who.int/ publications/i/item/WHO-2019-nCoV-IPC-WASH-2020.4 • WHO (2018). Fact sheet on health care waste: https://www.who.int/news-room/ fact-sheets/detail/health-care-waste • WHO (2022). Global analysis of health care waste in the context of COVID-19 https://www.who.int/publications/i/item/9789240039612 • UNEP (2012). Compendium of Technologies for Treatment / Destruction of Healthcare Waste https://wedocs.unep.org/bitstream/ handle/20.500.11822/8628/IETC_Compendium_Technologies_Treatment_ Destruction_Healthcare_Waste.pdf?sequence=3&isAllowed=y • USAID/PATH (2008). Small scale autoclaves to managed medical waste https:// pdf.usaid.gov/pdf_docs/Pnado504.pdf W A SH F IT M an ua l f or T ra in er s 44 ENVIRONMENTAL CLEANING – MODULE OUTLINE Name of module Environmental cleaning Pre-training preparation • Face to face: ‒ Computer, projector, module slides ‒ Printing ‒ Allocation of participants to breakout groups, and allocation of breakout group facilitators and note takers ‒ Adaptation of the module to local context with local photos, if possible and relevant ‒ Permission to visit a local facility to conduct an assessment, and logistics (e.g. transport, meals) ‒ Accessibility requirements (ensure that the venue is physically accessible) • Virtual: ‒ Presentation platform (e.g. Zoom – requires link and access) and functions to be used ‒ Recommend either › completing OpenWHO module “Standard precautions: environmental cleaning and disinfection” (https://openwho.org/courses/IPC-EC-EN; languages: English, Tetun); or › watching YouTube video “Environmental cleaning in the context of COVID-19” (https://www.youtube.com/ watch?v=fz46qUS58CM&t=20s); recorded in April 2020 – some data (e.g. COVID cases) are now out of date ‒ Slack, Google Jamboard or other platform to allow interactivity between participants ‒ Plan for breakout rooms for group work if the group is too large for a single group) ‒ Allocation of participants to breakout rooms, and allocation of facilitators and note takers for each breakout room ‒ Adaptation of the module to the local context with local photos, if relevant ‒ Preparation of a virtual facility visit using a video or photos of a local health care facility to undertake a sample WASH FIT assessment (optional) • Understanding of competence (starting point of knowledge and perceptions) of those attending the training. Participants to read or review the Centers for Disease Control and Prevention (CDC) Best practices for environmental cleaning in healthcare facilities: in resource-limited settings (https://www.cdc.gov/hai/prevent/resource-limited/index.html), if possible • Plan for introducing each participant, within the time allocation for the module Objectives On completion of this module, learners will be able to: • describe the importance of having an organized approach to cleaning to achieve a safe health care environment • understand why it is important to clean health care environments • describe the best institutional practices associated with cleaning • outline the association between cleaning best practices and WASH FIT indicators • recognize the most important products, resources, processes, supplies and equipment associated with effective and safe cleaning and disinfection. Group work Time Discussion... ANNEX 8 W A SH F IT M an ua l f or T ra in er s 45 Name of module Environmental cleaning Module duration Approximate time to deliver all aspects and allow discussion of the module: 90 minutes Languages English Module information This module addresses environmental cleaning in health care, focused on an organized approach and best organizational practices; underlying the information is the need for WASH. The module includes: • introduction – why it is important to clean • an organized approach to effective cleaning (summary of the key elements that constitute best practice) • an overview of organizational infrastructures and resources (staffing) • an overview of training and education requirements, and lessons from an in-country training approach for those who clean • an overview of the role of cleaning schedules and standard operating procedures • an overview of procedures, the role of reminders, monitoring, products, supplies and equipment management • an overview of safety and climate issues related to environmental cleaning • the role of water in environmental cleaning and its preservation • the use of dedicated personal protective equipment and hand hygiene for safe cleaning • relevant WASH FIT indicators • key takeaway messages • resources list. Format The module comprises: • 35 slides, including opening and closing slides • speaker notes within each slide (for the trainer to read before and during the session) • an ice-breaker question for all to discuss, denoted by a symbol (slide 4) • four slides (slides 10, 11, 15, 25) denoted by a question mark symbol to allow a short amount of discussion time for participant engagement on different topics • three group exercises, working in groups to discuss why it is important to clean (slide 6; 10 minutes); what cleaning schedules should include for particular situations (slide 17; 15 minutes); and the right personal protective equipment for different cleaning procedures (slide 30; 10 minutes) • time estimates for exercises – indicated by a clock • reference to relevant WASH FIT indicators (slides 12, 16, 19, 22, 24, 32) • time for final questions and review of resources for further reading. Supporting materials and resources • Face to face: ‒ Laptop and data projector ‒ Internet access ‒ Flip chart paper and pens to summarize whole-group questions and discussions, and potentially exercise feedback (if this will not be collected in another platform) • Virtual: ‒ Laptop, with internet access ‒ Consider a shared folder and documents (Google Docs) to collate real- time feedback and/or use of a shared whiteboard (e.g. in Zoom), so that all participants can see feedback ‒ Video tour of a local health care facility to conduct a virtual WASH FIT assessment (optional) • Copy of the PowerPoint slide set to be shared with all participants (by USB or email) • List of additional reading resources (for trainer preparation and participants post-training) • A Word document outlining one exercise, to be printed in advance (for face-to-face training) ... W A SH F IT M an ua l f or T ra in er s 46 Name of module Environmental cleaning Group exercises Three group exercises: • Discuss three key questions: Where might potentially harmful microorganisms live? What is the key way for potentially harmful microorganisms to move from where they live? Who might be at risk from potentially harmful microorganisms? Working group feedback is then encouraged. Recommend 10 minutes to complete. • Review cleaning schedules and methods, and what they achieve. Participants should be asked to look at the handout and review the information in groups, working through it for 10 minutes. Five minutes is allowed to gather feedback. This exercise relates to the detail contained in the CDC manual (listed in the resources). Recommend 15 minutes to complete. • Review the table (on the screen, slide 29) to allocate personal protective equipment to the cleaning tasks listed. Allow 5 minutes and then take rapid feedback. Review slide 30 where the correct answers are summarised (taken from the CDC manual, listed in the resources). Further reading and resources • United States Centers for Disease Control and Prevention (2019). Best practices for environmental cleaning in healthcare facilities: in resource limited settings. https://www.cdc.gov/hai/prevent/resource-limited/index.html • WHO (2019). Implementation manual to prevent and control the spread of carbapenem-resistant organisms at the national and health care facility level. https://apps.who.int/iris/bitstream/handle/10665/312226/WHO-UHC-SDS- 2019.6-eng.pdf • WHO/UNICEF (2020). Water, sanitation, hygiene, and waste management for SARS-CoV-2, the virus that causes COVID-19. https://apps.who.int/iris/ handle/10665/333560 • WHO (2008). Essential environmental health standards in health care. https:// www.who.int/publications/i/item/9789241547239 • London School of Hygiene and Tropical Medicine (2019). TEACH CLEAN. https://www.lshtm.ac.uk/research/centres/march-centre/soapbox- collaborative/teach-clean • WHO (2022). Water and Sanitation for Health Facility Improvement Tool (WASH FIT): a practical guide for improving quality of care through water, sanitation and hygiene in health care facilities, second edition. https://washinhcf.org/wash-fit/ W A SH F IT M an ua l f or T ra in er s 47 CLIMATE RESILIENCE – MODULE OUTLINE Name of module Climate resilience Pre-training preparation • Face to face: ‒ Computer, projector, module slides ‒ Adaptation of the module to the local context with local photos, if possible and relevant ‒ Permission to visit a local facility to conduct an assessment, and logistics (e.g. transport, meals) ‒ Allocation of participants to breakout groups, and allocation of breakout group facilitators and note takers (with flip chart paper and pens) ‒ Accessibility requirements (ensure that the venue is physically accessible) • Virtual: ‒ Presentation platform (e.g. Zoom – requires link and access) and functions to be used ‒ Slack, Google Jamboard or other platform to allow interactivity between participants ‒ Plan for breakout rooms for group work ‒ Allocation of participants to breakout rooms, and allocation of facilitators and note takers ‒ Adaptation of the module to the local context with local photos ‒ Preparation of a virtual facility visit using a video or photos of a local health care facility to undertake a sample WASH FIT assessment (optional) • Understanding of competence (starting point of knowledge and perceptions) of those attending the training • Plan for introducing each participant, within the time allocation for the module Learning objectives On completion of this module, learners will be able to: • understand climate change–related definitions and how climate change impacts health • identify different approaches that can be used to combat the impacts of climate change • identify global guidance that relates to climate change and WASH, specifically for health care facilities • explain approaches to address climate change in health care facilities in relation to ‒ water supply ‒ sanitation ‒ hygiene ‒ health care waste ‒ environmental cleaning. Module duration Approximate time to deliver all aspects and to allow discussion of the module: 60 minutes Languages English Group work Time Discussion... ANNEX 9 W A SH F IT M an ua l f or T ra in er s 48 Name of module Climate resilience Module information This module addresses climate resilience in the context of WASH and waste. It is made of up 10 sections. The module includes: • terminology • definitions • the impacts of climate change • approaches to combating climate change • global frameworks • climate resilience and water • climate resilience and sanitation • climate resilience and waste • climate resilience and environmental cleaning • key takeaway messages • further reading. Format The module comprises: • approximately 35 slides, including opening and closing slides, plus one supplementary slide • speaker notes within each slide (for the trainer to read before and during the session) • a whole-group quiz (with answers presented on the next slide) • time for questions Supporting materials and resources • Face to face: ‒ Laptop and data projector ‒ Internet access ‒ Flip chart paper and pens to collate notes from discussions ‒ Consider posters/photos for the walls, if relevant, to highlight and bring to life climate-related situations in different settings • Virtual: ‒ Laptop, with internet access ‒ Consider a shared folder and documents (Google Docs) to collate real- time feedback and/or use of a shared whiteboard (e.g. in Zoom), so that all participants can see feedback ‒ Video tour of a local health carefacility to conduct a virtual WASH FIT assessment (optional) • Copy of the PowerPoint slideset to be shared with all participants (by USB or email) • List of additional reading (for trainer preparation and participants post-training) Group exercises One exercise: • A quiz that focuses on statements that reflect increasing temperatures and the impact on diarrhoeal diseases. ... W A SH F IT M an ua l f or T ra in er s 49 Further reading and resources • WHO (2020). WHO global strategy on health, environment and climate change: the transformation needed to improve lives and wellbeing sustainably through healthy environments. https://apps.who.int/iris/handle/10665/331959 • Global Water Partnership, UNICEF (2017). Strategic framework for WASH climate resilience. https://www.gwp.org/en/WashClimateResilience/ • WHO (2020). WHO guidance for climate resilient and environmentally sustainable health care facilities. https://www.who.int/publications/i/ item/9789240012226 • WHO (2019). Discussion paper: climate change, sanitation and health. https:// https://www.who.int/publications/m/item/climate-sanitation-and-health • WHO (2009). Vision 2030: the resilience of water supply and sanitation in the face of climate change. https://apps.who.int/iris/handle/10665/70462 • Climatic drivers of diarrheagenic Escherichia coli incidence: a systematic review and meta-analysis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907410/ • WHO (2022). Global analysis of health care waste in the context of COVID-19. https://www.who.int/publications/i/item/9789240039612 W A SH F IT M an ua l f or T ra in er s 50 GEDSI – MODULE OUTLINE Name of module Gender equality, disability and social inclusion Pre-training preparation • Face to face: ‒ Computer, projector, module slides ‒ Two videos embedded within the slides – test before delivering training ‒ Printing – group work exercise (one page); numbers of copies to be printed will be based on number of breakout groups/numbers of participants ‒ Adaptation of the module to the local context with local photos, if possible and relevant ‒ Permission to visit a local facility to conduct an assessment, and logistics (e.g. transport, meals) ‒ Allocation of participants to breakout groups, and allocation of breakout group facilitators and note takers ‒ Accessibility requirements (ensure that the venue is physically accessible) • Virtual: ‒ Presentation platform (e.g. Zoom – requires link and access) and functions to be used ‒ Slack, Google Jamboard or other platform to allow interactivity between participants ‒ Two videos embedded within the slides – test before delivering training ‒ Plan for breakout rooms for group work if the group is too large for a single group) ‒ Allocation of participants to breakout rooms, and allocation of facilitators and note takers ‒ Adaptation of the module to the local context with local photos ‒ Preparation of a virtual facility visit using a video or photos of a local health care facility to undertake a sample WASH FIT assessment (optional) • For both face-to-face and virtual training, preparation to ensure that facilitation is accessible and inclusive: ‒ Ensure that PowerPoint slides meet accessibility standards (https:// support.microsoft.com/en-us/office/make-your-powerpoint- presentations-accessible-to-people-with-disabilities-6f7772b2-2f33- 4bd2-8ca7-dae3b2b3ef25). ‒ Provide electronic copies of slides in advance to participants who use accessibility software to read. ‒ Ask convenors or participants if they have accessibility requirements (e.g. local language, sign interpreter, support person), and prepare to support these if possible. ‒ When facilitating, be ready to describe the contents of each slide to support accessibility standards. ‒ Understand empowering facilitation techniques – review list of participants, and their positions and gender. Consider who has power and how you will ensure that all participants can contribute equally. • Understanding of competence (starting point of knowledge and perceptions) of those attending the training • Plan for introducing each participant, within the time allocation for the module. Group work Time Discussion... ANNEX 10 W A SH F IT M an ua l f or T ra in er s 51 Name of module Gender equality, disability and social inclusion Learning objectives On completion of this module, learners will be able to: • understand who experiences exclusion, marginalization and discrimination when using health care facilities and why • understand the barriers to WASH for diverse users of health care facilities • understand how to improve participation of women and people with disability when implementing WASHFIT • understand and describe accessible and inclusive WASH solutions in health care facilities within the WASHFIT model • state how WASH FIT indicators support inclusion and empowerment of people experiencing marginalization, including accessible infrastructure and participatory processes. Module duration Approximate time to deliver all aspects and allow discussion of the module: 90 minutes Languages English Module information This module addresses gender equality, disability and social inclusion within the context of WASH. It is made of up five broad sections. The module includes: • understanding exclusion – who is marginalized and why • “nothing about us without us” – how to ensure participation and empowerment • assessing the facility – participatory barriers and risk analysis in WASHFIT • taking action – practical solutions to develop and implement an improvement plan (mapped to WASH FIT indicators) • GEDSI as a journey – how to reflect, adapt and improve • further reading. Format The module comprises: • 35 slides, including opening and closing slides, and two slides with embedded videos (see below) • speaker notes within each slide (for the trainer to read before and during the session) • a 10-minute activity to get participants thinking about marginalization from different perspectives • a 15-minute group work exercise to understand the different types of barriers across gender and disability • a 5-minute reflection using the Participation Ladder tool • time for questions • time estimates for group work, key questions and videos – indicated by a clock • country examples. Supporting materials and resources • Face to face: ‒ Laptop and data projector ‒ Internet access ‒ Flip chart paper and pens to summarize group-work exercise feedback • Virtual: ‒ Laptop, with internet access ‒ Consider a shared folder and documents (Google Docs) to collate real- time feedback and/or use of a shared whiteboard (e.g. in Zoom), so that all participants can see feedback ‒ Video tour of a local health facility to conduct a virtual WASH FIT assessment (optional) • Copy of the PowerPoint slideset to be shared with all participants (by USB or email) • List of additional reading (for trainer preparation and participants post-training) W A SH F IT M an ua l f or T ra in er s 52 Name of module Gender equality, disability and social inclusion Group exercises Three exercises, which can be done either alone, in pairs or in small groups. One reflective exercise, which can be done either alone or in pairs: • Participants read three quotes and choose one to focus on. • Participants take 5 minutes to read and reflect on key questions ‒ If online, spend 5 minutes taking notes on three key questions. ‒ If face to face, sit in pairs and discuss one quote using three key questions. • In plenary, facilitator discusses responses to the reflection questions. One group exercise, to understand the common barriers people experience (15 minutes): • Groups focus on either gender or disability. • Groups use a template to map out barriers for their group of people across three categories. • Groups share their reflections with each other afterwards. • After all discussions, facilitator shares a completed barrier analysis tool to show some of the key barriers experienced by both groups. One reflective activity using a monitoring tool, in either pairs, small groups or plenary (5–10 minutes): • Participants imagine they are a cleaner in a WASH FIT meeting. • Participants use the Participation Ladder tool to reflect on their level of participation. Further reading and resources • WHO (2019). Delivered by women, led by men: a gender and equity analysis of the global health and social workforce. https://www.who. int/docs/default-source/nursing/delivered-by-women-led-by-men. pdf?sfvrsn=94be9959_2 • WaterAid Cambodia (2018). User-friendly WASH in healthcare facilities in Cambodia: developing a participatory management tool. https:// washmatters.wateraid.org/publications/user-friendly-wash-in-healthcare- facilities-in-cambodia • Australian Government AusAID (2013). Accessibility design guide: universal design principles for Australia’s aid program. https://www.dfat. gov.au/sites/default/files/accessibility-design-guide.pdf • WHO (2018). Standards for improving the quality of care for children and young adolescents in health facilities. https://apps.who.int/iris/ bitstream/handle/10665/272346/9789241565554-eng.pdf?ua=1 • WHO (2016). Standards for improving quality of maternal and newborn care in health facilities. https://www.who.int/publications/i/ item/9789241511216 • WHO (2012). Making health services adolescent friendly: developing national quality standards for adolescent friendly health services. https:// apps.who.int/iris/handle/10665/75217 • WaterAid. Female-friendly public and community toilets: a guide for planners and decision makers. https://washmatters.wateraid.org/ publications/female-friendly-public-and-community-toilets-a-guide-for- planners-and-decision-makers • UNICEF (2019). Guide to menstrual hygiene materials. https://www. unicef.org/documents/guide-menstrual-hygiene-materials • WHO/UNICEF (2019). Water, sanitation, and hygiene in health care facilities practical steps to achieve universal access to quality care. https://apps.who.int/iris/handle/10665/311618. W A SH F IT M an ua l f or T ra in er s 53 EXAMPLE AGENDA FOCUSED ON INTRODUCTORY WASH FIT TRAINING (FACE TO FACE) Introduction This agenda provides a general guide. The number of days, timings and topics should be modified according to the local situation, the number of participants, participants’ level of existing WASH expertise, and plans for implementing WASH FIT. Breaks are not included in the agenda but should be factored into timings. Each day is based on approximately 6 hours of training (3 hours each in the morning and afternoon), two 30-minute refreshment breaks and 1 hour for lunch. The order of modules may also be changed. The example agenda is for a 3-day training course, which is the most common length. Longer trainings allow more group exercises and in-depth discussions, but can be more expensive to run and require staff to be absent from work for longer. If the decision is to focus primarily on the WASH FIT methodology and field visit, go directly to day 2 and adapt those sections of the agenda; this would then require about one and a half days. Depending on the local situation, if all modules presented in the sample agenda are delivered in full, the length of the training/number of days will need to be extended. In the sample agenda below for example, multiple technical modules are listed on day 1 for illustration purposes. DAY 1 Time Activity/topic Notes Registration of participants 30 min • Opening remarks • Welcome and introduction of participants • Purpose and objectives of the workshop • Pre-training test and review of pre- reading material • Group photo Opening remarks may be given by ministry of health, WHO, UNICEF or other, as relevant. Undertake pre-training test if it has not been provided in advance of training. Session 1: Global and national overview of WASH/IPC in health care facilities 20 min • Overview of WASH, infection prevention and other related health topics in <country> This module is not included in the training package because it is country/ context-specific. 40 min • WASH links with health (Annex 2): general introduction to the topic and scene setting This may be adapted to include local content about how WASH fits within national health programmes. ANNEX 11 W A SH F IT M an ua l f or T ra in er s 54 Time Activity/topic Notes 15 min • Discussion/Q&A Time can be saved here if there are not many questions. Session 2: Technical modules – an overview of relevant WASH standards 1 hr 45 mins Water (Annex 4) These modules may require more time, depending on the existing level of WASH and IPC expertise. Interactive exercises are included within each module and should be used to deepen understanding and make the training more engaging. If all group activities are used, modules may take longer. 1 hr 30 mins Sanitation (Annex 5) 1 hr 30 mins Hand hygiene (Annex 6) 1 hr 30 mins Health care waste (Annex 7) 1 hr 30 mins Environmental cleaning (Annex 8) 25 min Discussion/Q&A Housekeeping for day 2 A group activity may again be useful here. Ask participants to share any topics or outstanding questions from the day and note them down, even if they cannot be addressed at the time. 5 min Close DAY 2 Time Activity/topic Notes 20 min Recap of day 1 and/or ice-breaker or group activity Consider a group activity or interactive exercise, rather than one presenter reading a summary of the previous day. Questions raised at the end of day 1 might be addressed. Participants could be asked to each share one learning point from the previous day. Session 3: Cross-cutting themes 1 hours Climate resilience (Annex 9) The time required for this module will depend on the level of expertise of participants, and the type and extent of climate-related challenges in the country. Interactive exercises are included and should be used to deepen understanding. 1 hr 30 mins Gender equality, disability and social inclusion (Annex 10) If all interactive exercises are used, this module may require more time. This module could also be delivered before the technical modules so that participants keep GEDSI principles in mind throughout the training. Session 4: WASH FIT methodology 2.5–3 hours WASH FIT methodology (Annex 3) This module contains numerous group activities and should have sufficient time dedicated to it. It is the most important module of the whole training package and should be the focus of any training. It may be broken up into sections (e.g. each step of the WASH FIT cycle delivered separately) and interspersed with the other modules to keep the attention of the audience. W A SH F IT M an ua l f or T ra in er s 55 Time Activity/topic Notes 15 min Introduction to field visit and logistics Not applicable if no field visit is being conducted. Session 5: Field visit – conducting a WASH FIT assessment 3 hours Participants are divided into groups to conduct an assessment of a health care facility. For bigger facilities, groups assess one or two domains. In smaller facilities, each group may be able to complete the full assessment in the allocated time. Based on the assessment, teams complete a risk assessment and come up with some suggested improvements to address the problems they have identified. Includes 30 minutes for feedback to facility management and staff. This could also be done the following day at the training venue. Travel time should be factored in. A training venue should be chosen that is as close as possible to the health care facility (or at the facility) to minimize travel time. Depending on the proximity of the facility to the training venue, packed breakfast or lunches may be needed. If a field visit is not possible, a virtual facility visit should be conducted. This could be based on a real-life example (e.g. a video of a facility walk-through) or an imaginary scenario (e.g. using pictures of common WASH problems). It may be based on a facility where participants work, even if the facility is not visited that day. Participants should share the results of their assessment with the facility: What were the main gaps they identified? What recommendations would they give to address these gaps? DAY 3 Time Activity/topic Notes Session 6: Next steps and WASH FIT implementation 30 min Reflections from field visit and morning group activity A representative from the facility should be invited to listen to the results of the assessment. The morning group activity can be decided to suit the local setting. 15–30 min Troubleshooting and clarification If time permits, discuss any outstanding issues or concerns from the previous days. 2 hours Developing an action plan to implement and scale up WASH FIT (see Annex 13) Issues to address at national level (not exhaustive): How many facilities, where and what size of facility will be involved in the initial implementation of WASH FIT? How will the training be cascaded? What resources and budget are needed? What other organizations should be involved? Issues to address at local/facility level (not exhaustive): When and how will the WASH FIT cycle start (e.g. forming the team, conducting the assessment)? What additional support and expertise will be needed to get started? Action plans at national or local level should be according to each participant, organization or facility. The overall aim is to establish how each organization or participant will put into practice the information learned. How will they cascade information to colleagues? Each participant should leave the training with a set of clear, measurable and time- bound next steps and action points. This activity may be done individually or in groups (colleagues from one facility or one organization work together). No specific template is provided for this activity. W A SH F IT M an ua l f or T ra in er s 56 Time Activity/topic Notes 15 mins Group presentations and discussion: presentation of plans by each group Session 7: Closing Any final presentations and discussion Time for any other relevant presentations or discussion 40 min • Post-training test (Annex 1) • Completion of training evaluation forms (Annex 14) and general feedback from participants • Presentation of certificates of completion (Annex 15) • Any other business 10 min Words of thanks and closing POST-TRAINING – ON COMPLETION OF TRAINING, OR WITHIN 3 DAYS, IF SUBMITTED ONLINE Activity Purpose Format Tools required Post-training test discussion (Annex 1) and training evaluation (Annex 14) To evaluate participants’ progress and experience of the training To outline suggested improvements to the training package and methodology for future trainings Google/online form; Zoom (or other platform) discussion Training evaluation form POST-TRAINING – WITHIN 3 MONTHS OF COMPLETION OF TRAINING Activity Purpose Format Tools required Follow-up session, to be held 2–3 months after training To review progress To troubleshoot ongoing problems or challenges faced Informal sessions with no presentations (in person, or via Zoom or other platform) Limited preparation needed W A SH F IT M an ua l f or T ra in er s 57 EXAMPLE AGENDA FOR TRAINING (VIRTUAL) Introduction This agenda is meant to provide a general guide. The number of days, timings and topics should be modified according to the local situation, the number of participants and participants’ level of existing WASH expertise. The length of virtual training courses will depend on the number of trainers available, the number of participants and how the training is structured. Because there is no travel time or venue hire, the training can be spaced out over a number of days or even weeks, with gaps to allow participants to take a break and consolidate their knowledge, and to secure maximum attention for the virtual sessions. The example agenda presented below is based on a series of sessions held over multiple weeks. Consider encouraging pre-reading of certain WASH technical modules a week before training starts. Where possible, add in additional technical modules to the virtual training agenda based on the local situation. If the decision is to focus primarily or initially on the WASH FIT methodology and field visit, the methodology module may need to spread over a number of sessions given its length. Activity/topic Objectives Description Notes General instructions (e.g. download Zoom, sign up to other sharing platforms such as Slack channel) To ensure that participants are familiar with online platforms Participants to be comfortable using Zoom and other interactive platforms, etc. Week 1 Introduction and scene setting (45 min) • Overview of the training plan (over a course of weeks); explanation of Zoom functions, etc. • Introduction of participants (verbally or in an online sharing platform) • Participant expectations • Review of pre-training test • Time for questions from self- directed learning • Overview of WASH, infection prevention and other related health programmes in <country> To set the scene for delivery of the training modules, outline participant interaction and engage participants Online platform (e.g. Zoom, MS Teams, Slack), depending on local technology This module is not included in the training package because it is country/ context specific. WASH links with health (Annex 2) See Annex 2 See Annex 2 See Annex 2 WASH FIT methodology (Annex 3) See Annex 3 See Annex 3 See Annex 3 ANNEX 12 W A SH F IT M an ua l f or T ra in er s 58 Activity/topic Objectives Description Notes Homework: Action planning (Annex 13) To develop a post-training plan May be done individually or in groups, depending on whether participants are able to meet/ work effectively together remotely using online platform functions Annex 13 provides a post- training action plan template and can be presented to start this part of the training. Cross-cutting themes Climate resilience (Annex 9) See Annex 9 See Annex 9 See Annex 9 Gender equality, disability and social inclusion (see Annex 10) See Annex 10 See Annex 10 See Annex 10 Week 2 (consider a break between weeks 1 and 2) Short Q&A To recap on topics discussed thus far to provide clarification, and to take questions on pre-reading (self-directed reading) of other technical modules not covered in the virtual training Questions and answers related to all technical modules and associated resource materials Trainers must be prepared and fully versed in the contents of all training modules and associated resource materials. Presentations of WASH FIT improvement plans (use this approach only if already in the WASH FIT process) To outline real-world improvement plans for use in practice Each group or selected individuals to present their WASH FIT improvement plan, using online platform (homework), to all participants See Annex 13 and WASH FIT guide Next steps and action plans To describe how training objectives will be put into practice, and how actions can be sustained to improve WASH services, practices and behaviours Online platform with breakout rooms for work planning; participants to have agreed list of activities with timelines Next steps will vary according to country context, and whether regional, national or facility training. See Annex 13. W A SH F IT M an ua l f or T ra in er s 59 Activity/topic Objectives Description Notes Post-training – within 3 days of completion of training Post-training test (Annex 1) and training evaluation (Annex 14) To evaluate participants’ progress To outline suggested improvements to the training package and methodology for future trainings Google/online form Training evaluation form Post-training – within 3 months of completion of training Follow-up session, to be held 2–3 months after training To review progress To troubleshoot ongoing problems with implementation of training knowlege Informal sessions with no presentations Limited preparation needed. To be organized by country office, where possible, or another authoritative agency. W A SH F IT M an ua l f or T ra in er s 60 POST-TRAINING ACTION PLAN (FACILITY LEVEL) WASH FIT training: facility-level planning tool This template is intended as an example to help plan WASH FIT activities within a facility. It can be used by a WASH FIT team or by district-level implementers. It will also help those monitoring WASH FIT to keep track of activities and ensure that the process is ongoing. Example activities and a blank template are provided below. “X” indicates when each activity is planned. Write the name of the month below the number – for example, if you are doing the training in December, month 1 will be January, month 2 will be February, and so on. Sample action plan (populated for illustration) Activity Month (M) – add more columns as required M1 M2 M3 M4 M5 M6 M7 M8 M9 1. Share the materials and lessons learned from WASH FIT training with the rest of the facility  X 2. All facility members to read the training materials and WASH FIT guide   X 3. Meeting to identify external partners to join the WASH FIT team   X 4. First weekly meeting of the core WASH FIT team   X 5. Present the WASH FIT methodology to the rest of the team   X 6. Complete baseline facility assessment with the whole team   X 7. First meeting with external partners   X 8. Make initial immediate improvements (e.g. install handwashing stations and start daily record of cleaning)   X 9. Conduct review of progress and discuss longer-term improvements with district officials   X 10. Implement improved water supply, including storage and piped water in examination rooms   X 11. Other activities identified   X ANNEX 13 W A SH F IT M an ua l f or T ra in er s 61 Sample action plan (blank) Activity Month (M) – add more columns as required M1 M2 M3 M4 M5 M6 M7 M8 M9 W A SH F IT M an ua l f or T ra in er s 62 EXAMPLE TRAINING EVALUATION FORM Evaluation sheet: WASH FIT training [Insert place, date] Please fill in the questionnaire at the end of the training. This will take approximately 10 minutes, and your answers are anonymous. Your feedback will help us to improve the training and respond to your future needs. Q1. What is your OVERALL opinion of the training? Not interesting 1 2 3 4 5 Very interesting Not useful 1 2 3 4 5 Very useful Q2. What did you think of the length of the training? Too short 1 2 3 4 5 Too long Q3. How useful was the training in relation to your needs? Not useful 1 2 3 4 5 Very useful Q4. How much have you learned from this training? Did not learn much 1 2 3 4 5 Learned a lot Q5. Were your objectives for the training met? Needs not met at all 1 2 3 4 5 Needs completely met Q6. Do you feel you understand the purpose of WASH FIT and how to implement it? Don’t understand it 1 2 3 4 5 Understand it well Q7. Do you feel confident that you are able to deliver training on WASH FIT? Not confident 1 2 3 4 5 Very confident Not applicable Q8. What was your impression of the trainer’s competence? Very poor 1 2 3 4 5 Very good Q9. Were the teaching methods suitable (e.g. amount of group work compared with theoretical sessions)? Not suitable 1 2 3 4 5 Very suitable Please continue over the page ANNEX 14 W A SH F IT M an ua l f or T ra in er s 63 I would like more information on the following subjects: Please provide any additional comments on the training (e.g. how it can be improved) Thank you for your comments and for attending the training course W A SH F IT M an ua l f or T ra in er s 64 EXAMPLE CERTIFICATE OF COMPLETION An example of an overall certificate of completion (relating to the entire course) is shown below. It can be modified according to the local context. CERTIFICATE OF COMPLETION This certificate is presented to For successful completion of Water and Sanitation for Health Facility Improvement Tool (WASH FIT) training based on WHO and UNICEF WASH FIT: A practical guide for improving quality of care through water, sanitation and hygiene in health care facilities. Second edition, which took place on ( ) Signature(s) Date ANNEX 15 W A SH F IT M an ua l f or T ra in er s lxviii Contact: Water, Sanitation, Hygiene and Health Unit Department of Environment, Climate Change and Health World Health Organization 20 Avenue Appia, 1211-Geneva 27 | Switzerland https://www.who.int/teams/environment-climate-change-and-health/water-sanitation-and-health