Environmental cleaning

and infection prevention

and control in health care
facilities in low- and
middle-income countries
Trainer’s guide
Environmental cleaning
and infection prevention
and control in health care
facilities in low- and
middle-income countries
Trainer’s guide
Environmental cleaning and infection prevention and control in health care facilities in low- and middle-income
countries: trainer’s guide
ISBN 978-92-4-005104-1 (electronic version)
ISBN 978-92-4-005105-8 (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. If you
create a translation of this work, you should add the following disclaimer along with the suggested citation: “This
translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or
accuracy of this translation. The original English edition shall be the binding and authentic edition”.
Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation
rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/).
Suggested citation. Environmental cleaning and infection prevention and control in health care facilities in low- and
middle-income countries: trainer’s guide. Geneva: World Health Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO.
Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.
Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests
for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing.
Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables,
figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain
permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned
component in the work rests solely with the user.
General disclaimers. The designations employed and the presentation of the material in this publication do not
imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country,
territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and
dashed lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed
or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions
excepted, the names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by WHO to verify the information contained in this publication.
However, the published material is being distributed without warranty of any kind, either expressed or implied.
The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable
for damages arising from its use.
Design and layout by 400 Communications.
Contents

Acknowledgements iv
Abbreviations and acronyms v
1. Introduction 1
1.1 Terminology 3
1.2 Purpose 3
1.3 Aim and intended use 3
1.4 Target audience 3
1.5 Expected recipients of the training 3
1.6 Structure of the training package 4
1.7 Adaptation 4
1.8 Topics outside the scope of the package 4
1.9 Related guidance and standards 6
2. Prepare 7
2.1 Preparing the delivery of the training – general considerations 8
2.2 Getting ready to deliver the training 17
3. Deliver 20
3.1 Modules and resources summary 21
3.2 Ready to deliver the training? 22
4. Sustain 23
4.1 Sustaining improved performance 24
4.2 Reviewing and planning for the future 25
Annexes 27
Annex 1 28
Annex 2 29
Annex 3 32
Annex 4 35
References 36
Acknowledgements

The TEACH CLEAN package, created for The Soapbox Coordination and writing
Collaborative in partnership with NHS Grampian,
Scotland, United Kingdom of Great Britain and Northern Stephen Nurse-Findlay coordinated the
Ireland, and the London School of Hygiene & Tropical development of the document, under the supervision
Medicine, United Kingdom, was used as the basis for of Silvia Bertagnolio (Department of Surveillance,
the development of this training package. Prevention and Control, AMR, WHO headquarters).
Claire Kilpatrick and Julie Storr (infection prevention
The World Health Organization (WHO) acknowledges and control consultants, United Kingdom) led the
the United States Centers for Disease Control and adaptation and writing of the document, with the
Prevention, United States of America (USA), and technical input of Wendy Graham (London School
the Infection Control Africa Network (ICAN) for the of Hygiene & Tropical Medicine, United Kingdom).
permission to use materials from the document Best
practices for environmental cleaning in healthcare
facilities in resource-limited settings.
Expert review
Benedetta Allegranzi (Department of
Integrated Health Services, WHO headquarters),
Mandy Deeves (Department of Integrated Health
Services, WHO headquarters), Margaret Montgomery
(Water, Sanitation and Hygiene, WHO headquarters),
Molly Patrick (United States Centers for Disease Control,
USA), Anthony Twyman (Department of Integrated
Health Services, WHO headquarters).

iv
Abbreviations and acronyms

AMR antimicrobial resistance

CDC United States Centers for Disease Control and Prevention
HAI health care-associated infection
ICAN Infection Control Africa Network
IPC infection prevention and control
IPCAF Infection Prevention and Control Assessment Framework
LMIC low- and middle-income countries
PPE personal protective equipment
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

v
1. Introduction
Introduction

• First, infections associated with unclean births

People who perform environmental account for 26% of neonatal deaths, 11% of maternal
cleaning in health care facilities are key mortality; together, these account for more than 1
personnel responsible for supporting million deaths each year. Of note, in some African
countries, up to 20% of women develop a wound
safe environmental health conditions
infection after a caesarean section (1).
for patients, visitors and staff.
• Second, maternity units have several features found
Those who clean help to prevent health care-associated in other wards, such as high turnover, surgical and
infections (HAIs), and support efforts to reduce non-surgical cases, both emergency and routine care,
antimicrobial resistance (AMR) and maternal and and multiple touch points.
newborn sepsis. Strengthening the training of this • Third, the training package builds upon an existing
important group can contribute to resolving many training resource for those who clean, with a specific
of today’s public health challenges. This is currently focus on maternity wards (2).
a pressing issue to be addressed as the cleaning
This combination of factors makes the maternity unit an
of both surfaces and hands is vital to control the
excellent choice of an exemplar to illustrate how to train
transmission of a number of HAIs.
those who clean as detailed in this training package. It is
Those who clean are a crucial link in the delivery of expected that this material be adapted for use by those
safe, high quality health care. They should be valued, responsible for training those who clean in other clinical
supported and trained to perform their roles effectively. areas of the health facility.
Sustained investment is therefore important in order to
train those who clean, to improve their knowledge and WHO’s Environmental cleaning and infection
practices and to ensure active involvement in developing prevention and control in health care facilities
improvement strategies with support from infection in low- and middle- income countries is a two-
prevention and control (IPC) teams alongside those who part training package that targets those who clean
clean and supervise cleaning. This is important, given heath care facilities. It is based on the Training in
that those who clean often have inadequate training on environmental hygiene and cleaning in healthcare
IPC, including the use of personal protective equipment (TEACH CLEAN) package (2) and includes the
(PPE) and optimal hand hygiene practices. In addition, perspectives of AMR, IPC, water, sanitation and
they may lack sufficient PPE and cleaning supplies and hygiene (WASH), and quality of care.
experience stigma from patients and staff.
The World Health Organization (WHO) developed this While the language used in this training package applies
two-part training package Environmental cleaning to maternity units, much of the content applies to
and infection prevention and control in health care all clinical areas and can be readily used with small
facilities in low- and middle- income countries using adaptations to language (for example, ‘beds’ rather
cleaning protocols developed for the maternity unit than ‘delivery beds’).
as an exemplar, for three reasons:

2
1. INTRODUCTION

1.1 Terminology 1.4 Target audience

There is no universal term to describe those who The package is intended for use in health care
clean in the health care environment. facilities by individuals or groups who develop,
deliver or are concerned with training programmes
The package uses the term ‘those who clean’ as
intended to improve environmental cleaning. Thus,
an alternative to common terms, such as cleaners
the target audience is those with a background in IPC
or cleaning staff, domestic services workers,
and/or environmental hygiene. This may include:
environmental services staff, domestic assistants,
orderlies, housekeepers, and ward boys. • ministries of health.
• nongovernmental organizations or international
organizations supporting IPC in health care facilities.
• academic institutions.
1.2 Purpose
• experts working in IPC and
The purpose of the training described in this package environmental cleaning/ WASH.
is to improve the competence of those who clean • IPC focal points and onsite supervisors
through a practical, educational approach for adult of those who clean.
learners in low- and middle-income countries (LMIC).
• individuals who have a role in improving
The training package’s resources are intended to lead
the quality of health care services.
to long-term improvement in competence through
supporting the target audience to put cleaning The section on preparing to deliver the package (section
approaches into practice, in the context of supportive 2.1.1) recommends establishing a steering group to bring
supervision and a multimodal improvement strategy. together key stakeholders to oversee all stages of the
training, including from adaptation to implementation.
An IPC committee, if in place, can fulfil this role.
At the Seventy-Second World Health Assembly
in May 2019, the resolution WHA72 on WASH in
health care facilities described the need to invest
in a sufficient and well-trained health workforce,
including cleaners (3). The WHO Core components
1.5 Expected recipients
of IPC programmes at the national and acute of the training
health care facility level also highlight the need for
There is a significant difference between the intended
a trained workforce (4). These aspects will help in
users of the package and the recipients of the training.
achieving the WHO Global Action Plan to combat
The users, as described in section 1.4 are those who train
AMR (5).
– i.e. those who develop or deliver training programmes
intended to improve environmental cleaning of health
care facilities.
The expected recipients are those who clean and their
1.3 Aim and intended use supervisors within a health care facility.

The training package aims to address critical gaps

in the training and empowerment of those who clean
in LMIC and to address gaps in the necessary support
to achieve this.
Although the training package was developed to
improve the competence of those who clean, its
contents and the associated training materials are
relevant to other health workers, including nurses and
midwives who may periodically undertake cleaning
as part of wider duties. The training package considers
the many factors that influence the successful
implementation of training programmes.

3
TRAINER’S GUIDE
IN HEALTH CARE FACILITIES IN LOW- AND MIDDLE-INCOME COUNTRIES
ENVIRONMENTAL CLEANING AND INFECTION PREVENTION AND CONTROL 1.6 Structure of the 1.7 Adaptation
training package The principles contained in the package are universally
Environmental cleaning and infection prevention applicable. However, the content may need to be
and control in health care facilities in low- and middle- adapted to ensure that the approaches are relevant to
income countries, herafter referred to as “the package” the local context and culture. Thus, those who train in
comprises two interconnected parts: the trainer’s guide regions, countries and at local level have the flexibility
(this document) and Modules and resources (Fig. 1.1). to inform their own approach, with the package
providing all the necessary information for building
• The trainer’s guide (this document) takes the user capacity among those who clean.
through how to prepare, deliver and sustain an
effective training for those who clean.
• In Modules and resources, learners can find training
materials (instructions, definitions, photographs, 1.8 Topics outside the scope
posters and other illustrated cleaning guides of the package
including specific illustrations that support
competence statements intended to improve Basic microbiology and IPC core competencies are
pratices). The written instructions can be be printed not included in this training package as these issues
or converted to slides as appropriate and other are not intended to be the responsibility of those who
necessary materials gathered and prepared in clean health care facilities. WHO IPC & WASH online
advance. training modules are available and a summary of these
– The materials can be used to train those who clean modules is presented in Annex 1 (for information); the
how to perform cleaning activities, to support recipients of these modules are not those who clean
them to visualise the correct steps to take and to health care facilities.
check environmental cleanliness standards while The package also does not include training on workforce
supporting the competences of those who clean. issues, although it may support a case for increasing the
– The IPC and environmental cleaning questionnaire numbers of those who clean, where necessary. Similarly,
in Modules and resources can be completed by the package does not cover the infrastructure required
participants before training to establish the to support optimal WASH as this aspect should be
extent of existing knowledge; after training, the addressed within other programmes of work.
questionnaire can be reapplied and used as a
Routine resource needs and budgets are not included
measure of learning.
as a specific module, but it is crucial that those who
– From the outset, literacy skill levels should clean have access to adequate supplies of cleaning
be considered by trainers while gathering materials and equipment as detailed in the package.
information from those who clean to complete
the questionnaire and it may have to be delivered Finally, the package assumes that those who clean
in an interview format. (whether in-house or contracted) have already been
identified and are in place within health care facilities.

4
1. INTRODUCTION

Fig. 1.1 Structure of the training package

TRAINER’S GUIDE MODULES AND RESOURCES

The trainer’s guide outlines the ‘how’. How to prepare, Modules and resources contains the materials
deliver and sustain training programmes to those who clean. required to deliver training programmes to those who clean.

Prepare Teach
Outlines all preparatory Provides learning objectives,
activities and considerations definitions, discussion prompts,
and introduces an outline of images and practical activities
the Modules and resources. to deliver each module.

Deliver Environmental cleaning Visualise

and infection prevention
Signposts the user and control in health Contains all of the figures,
to the Modules and care facilities in low- and posters and illustrated
resources document. middle-income countries guides to be used when
delivering the modules.

Sustain Check
Summarises the Contains all of the
factors to be considered assessments, evaluation
for sustainability. resources and training records
associated with the training.

5
 Successful implementation
TRAINER’S GUIDE
IN HEALTH CARE FACILITIES IN LOW- AND MIDDLE-INCOME COUNTRIES
ENVIRONMENTAL CLEANING AND INFECTION PREVENTION AND CONTROL 1.9 Related guidance
and standards of cleaning guidance
Training and empowerment of those who clean
is one part of implementation of IPC and AMR depends on those
recommendations, although this is not often
explicitly stated in guidance documents. who clean knowing
Implementation of relevant guidance documents
and standards also relies on those who clean being
and doing the right
recognized as an integral part of the health workforce,
and their responsibilities being taken seriously within
things, and being
a supportive culture. supervised and valued.
Annex 2 summarizes the most up-to-date guidance
and best practice documents relevant to environmental
cleaning including the training of those who clean.
The publication Best practices for environmental
cleaning in healthcare facilities: in resource-limited
setting (6), issued by the United States Centers for
Disease Control and Prevention and the Infection
Control Africa Network (CDC/ICAN), is a reference
document for environmental cleaning.

6
2. Prepare
Prepare

2.1 Preparing the delivery 2.1.1 People, resources and budgets

of the training – This section describes those involved in the process
general considerations (that is, those who clean, those who deliver the training,
and those in the steering group or IPC committee, if
Preparation will improve the chance in place, who oversee the process), resources (that is,
of success and sustainability in infrastructure and supplies) and budget.
implementing the training package.
A health care facility should be fully People
prepared to deliver the training. Those who clean
This section focuses on seven key As highlighted in section 1.8, the training package
considerations that will help to ensure assumes that those who clean (whether in-house or
sustainability from the start. contracted) are already identified and in place within
health care facilities.

Box 2.1 Key considerations when If contracted staff are in place and it is stated that they
have already received training, check training against
starting out the content of this package to ensure consistent
1. Consider people, resources and budgets standards for the health care facility.
for training (see section 2.1.1).
Information on externally contracted programmes and
2. Review relevant cleaning guidance the development of a service level agreement can be
(see section 2.1.2). found elsewhere (6). Of note, even for those already
3. Establish baseline information trained, this package can inform regular updates on
(see section 2.1.3). knowledge and competency.
4. Understand the training approach
(see section 2.1.4). Those who deliver the training
5. Consider adaptation to the local context Those who use this package to prepare and deliver the
(see section 2.1.5). training should have an appropriate level of knowledge
of how to train as well as technical knowledge (for
6. Consider potential barriers and opportunities
example, on transmission of microorganisms, IPC,
(see section 2.1.6).
environmental hygiene practices, and standards and
7. Consider a multimodal approach regulations, as included in the guidance and best
(see section 2.1.7). practice documents listed in Annex 2).
Knowledge and application of IPC and related issues
is important for trainers. Having the relevant technical
knowledge allows those delivering participatory training
sessions to simplify and explain complex concepts in
such a way that they can be fully understood by the
intended recipients (that is, those who clean).

8
 If trainers are competent in training, but do not have the
2. PREPARE

relevant background in IPC and environmental cleaning, Box 2.2 Example of the composition
training should be co-facilitated by an individual with of an IPC committee
relevant experience of both training methods and
relevant technical areas. The facility leadership team • Senior facility leadership (e.g. administrative
may need to build capacity to deliver training or use director, chief executive officer, medical director).
external providers who have the relevant expertise • Senior clinical staff (e.g. physician, nurse,
(for example, from an academic institution, another midwife, pharmacist).
country, or a professional society). • Designated cleaning programme manager
If the facility has a designated cleaning programme or focal person accountable for the delivery
manager responsible for managing and overseeing of the training programme.
environmental cleaning activities on a daily basis, this • Nursing and midwifery leaders.
person is best suited to lead the training programme. • Facility management representative
If this position does not exist, then the selected person (e.g. biosafety, waste, and those tasked with
should have the following profile: addressing water, sanitation, and hygiene).
• Knowledge of facility IPC activities: typically, a staff • Individuals responsible for routine cleaning
person who is already a member of the facility IPC supplies and procurement.
or hygiene committee should be selected for this
role. However, this role should not be allocated to
the existing IPC lead or focal point who already has Resources and budgets for training
many activities for which they are responsible.
An annual budget is essential to an effective
• Be an experienced staff member: ideally, with environmental cleaning programme (7). The major
leadership and management experience. During elements of such a budget include the costs of training
the implementation process, they will need to and the production and printing of checklists, logs,
communicate regularly with the IPC committee, and other materials. The training package comprises
facility management, and department or unit eight separate training modules as well as important
supervisors (for example, nurse or midwife in charge). annexes including a train the trainers module, and the
• Demonstrate a good understanding of the materials required to deliver these, which are described
facility in terms of organization/management/ in section 2.1.4 and the Modules and resources
services provided. document.

Leadership: steering groups & IPC committees Human resource costs are not covered in the generic
training delivery budget, but are a prerequisite for
The minimum requirements for health care facilty
delivery of the training programme as described above.
IPC programmes (7) call for the establishment of
The process of adapting this programme to the local
an IPC committee composed of dedicated, trained
context may also require a budget.
personnel that should be in place in each acute
health care facility for the purpose of preventing
HAI and combating AMR through good IPC practices
(including strong cleaning practices). Actions for people, resources and budgets
Where in place, the IPC committee oversees the • Designate a cleaning programme manager
execution of the processes within the clinical unit or focal person to be accountable for the
of the facility to ensure a successful, sustainable delivery of the training programme.
outcome. The IPC committee should bring together, • Check that trainers have the appropriate level
involve, and influence the main stakeholders as of knowledge of IPC and related issues.
a key implementation priority. An example of the
composition of this committee is shown in Box 2.2. • Collaborate with the IPC committee, if in place,
to ensure links with hospital leadership to
Where an IPC committee is not yet established, a support the training.
steering group is recommended. This may be at the
• Secure a budget for printing the
national, regional and district level or facility level.
modules’ contents and sourcing other
The Steering Group also brings together key necessary materials.
stakeholders including leaders and advocates.
Written and verbal commitment from leaders is
important. Involving, preparing and influencing
key stakeholders is key to success.

9
TRAINER’S GUIDE
IN HEALTH CARE FACILITIES IN LOW- AND MIDDLE-INCOME COUNTRIES
ENVIRONMENTAL CLEANING AND INFECTION PREVENTION AND CONTROL 2.1.2 Relevant cleaning guidance Actions for baseline information
Annex 2 summarizes international guidance • Gather relevant information and data
relevant to the cleaning of health care facilities. on the facility baseline situation.
• Use existing information.
Actions for relevant cleaning guidance • If no baseline information is available,
• Ensure that the designated cleaning programme use the Basic Needs Assessment Tool in
manager or focal person is familiar with the Modules and resources.
guidance listed in Annex 2 and any resources • If necessary, use one of the other valid IPC
required for implementation of the guidance. and/or WASH tools to help in monitoring
• Seek out national cleaning guidance for overall improvement (see Annex 3).
health care facilities, if available. • If using IPCAF, review the contents of
• Download and become familiar with the CDC/ the interim practical manual supporting
ICAN best practices document (6). the implementation of the IPC core
components (10).

2.1.3 Baseline information

2.1.4 Training approach rationale
In deciding which training modules should be delivered
to best suit the facility context, the steering group or IPC The proposed training approach reflects WHO
committee should consider the current situation in the recommendations and is intended to be practical
facility. During this preparatory phase, as much relevant and participatory (11).
information/data as possible should be gathered (under
the leadership of the designated cleaning programme The structure: eight modules
manager or focal point) to provide a useful baseline or
situational analysis. This will help to identify gaps and Eight essential topics are included in the Modules
shape a successful training programme. and resources document (Box 2.3). For ease of delivery,
each module is presented in the same format.
When gathering baseline data, it is useful to engage
with those being trained within the health care facility Each module includes the essential information and
and their supervisors as this will help in obtaining resources required to deliver training on a specific
the relevant permissions, such as dedicated time for topic (Fig. 2.1). An additional supplementary module
training, funding for training materials, and revised addresses Supportive supervision (Module 8).
supervision standards.
A basic needs assessment tooI (found in the separate Box 2.3 The modules
Modules and resources document) can be used before
Module 1 Introduction to IPC
the training to identify baseline gaps in existing training,
resource availability and staff, to review the cleaning Module 2 Respiratory and personal hygiene
responsibilities of the facility’s unit. Furthermore, it can
Module 3 Hand hygiene
be used to determine the existence of current policies
and protocols on cleaning and cleanliness, and compare Module 4 Personal Protective Equipment (PPE)
current versus best practice outlined within this training
Module 5 Cleaning of the environment
package. The information gathered from the basic
needs assessment tool can be used by the steering Module 6 Waste management
group or IPC committee to adapt the training package
Module 7 Linen management
for different medical unit settings and as a baseline
for later evaluation or monitoring. Module 8 Supportive supervision (supplementary)
Availability of baseline information on broader
aspects of IPC can also provide useful insights.
If such information is not available, there are several
other validated tools that can be used to elicit such
information. These include the WHO Infection
Prevention and Control Assessment Framework (IPCAF)
(8) and the WHO/UNICEF Water and Sanitation for Health
Facility Improvement Tool (WASH FIT) (9) (see Annex 3).

10
 Definitions
2. PREPARE

The modules include definitions of terms (for example,

HAI and standard precautions).
The content and definitions in the modules have been
developed to suit the participatory approach and the
recipients of the training (that is, those who clean).
Box 2.4 presents a brief summary of the focus
and objectives of each of the modules.

Focus and objectives of the modules

Box 2.4 Summary outline of each module

Module 1 Introduction to IPC Module 5 Cleaning of the environment

This foundation module is intended to highlight the This module explains the importance of
environmental transmission pathway and the roles housekeeping and cleaning of the environment.
and responsibilities that trainees have to intervene It focuses on general principles of environmental
in that pathway. It explains HAIs and their impact cleaning, including procedures for cleaning
and describes standard infection control precautions common areas such as sinks, floors and beds.
(what they are, their purpose, and who they concern).
Module 6 Waste management
Module 2 Respiratory and personal hygiene This module explains what health care waste
This module highlights the importance of good is and describes the distinct types of waste. The
personal hygiene and the actions required for aim is to help trainees to understand the hazards
proper respiratory hygiene and cough etiquette. associated with inappropriate handling of waste.
It addresses the importance of dressing This module also explains the methods used to
appropriately and the need for a professional handle contaminated and non-contaminated waste.
appearance to give trainees an understanding
that their dress facilitates good practice and Module 7 Linen management
minimizes risks to themselves and to patients. This module explains why careful handling of both
clean and used linen is important and describes
Module 3 Hand hygiene what PPE to wear when dealing with clean and used
This module describes the importance of hand linen. It also addresses storage and transportation,
hygiene and its role in breaking the environmental including how used or contaminated linen should
transmission pathway. It covers the ‘when’ and be collected, handled and transported.
‘how’ of hand hygiene and highlights common
practices in poor hand hygiene. Module 8 Supportive supervision (supplementary)
This module is intended to highlight the importance
Module 4 Personal Protective Equipment (PPE) of monitoring and supervision and the differences
This module highlights the need for PPE, and between supportive supervision and more punitive
explains how to select and use relevant PPE, forms. It describes how to apply competency-based
including how to safely put on and take off PPE. assessments as part of supportive supervision and
ongoing monitoring.

11
 that necessary copyright permissions are in place
TRAINER’S GUIDE
IN HEALTH CARE FACILITIES IN LOW- AND MIDDLE-INCOME COUNTRIES
ENVIRONMENTAL CLEANING AND INFECTION PREVENTION AND CONTROL Module contents and necessary materials before such materials are used) could be used to help
Fig. 2.2 summarizes the contents and materials that are adapt the contents. Of note, the use of locally taken
needed in each module to deliver training sessions on photographs that emphasize good and suboptimal
multiple topics to those who clean. practices helps to make the content more applicable
and relatable to the context and audience. Other training
Modules used will depend on the baseline materials (for example, videos of cleaning procedures
information gathered (section 2.1.3). and demonstrations of good and bad practice) can also
Once it is clear which modules are relevant: be produced locally and can be effective as a training
resource.
• The materials for these modules should be printed
for use by the trainers and the resources secured for In addition to the module materials, Modules and
demonstrations and practical exercises (Fig. 2.3). resources contains illustrated cleaning guides that focus
on, for example, how to fold a cleaning cloth, how to
• Photographs, posters and illustrated cleaning prepare chlorine-based disinfectant solution, and how
guides should ideally be A3 in size. They can also to clean a handwash basin, a squat toilet, a standard
be presented using slides if the relevant technology toilet and a delivery bed, or a blood spillage.
is available and if this suits the setting where the
participatory training is being delivered.
• Printed materials can be laminated for durability. Actions for the training approach
A non‑permanent marker pen can be used to write • Become familiar with the modules
on or mark laminated documents to highlight key described in the accompanying publication
messages during training, as appropriate. Modules and resources.
• Training items to be included in the modules • Decide which module(s) will be used for
can be obtained from various sources, such as training, based on the facility baseline situation.
the health care facilities undergoing training
(depending on resource availability), hardware • Print the contents of the relevant modules.
stores and local markets. • Gather all the materials needed for
Adaptation is covered below in section 2.1.5. Here, we the demonstrations.
highlight that the photographs and posters supplied
• Place all the materials in one box
within the package can be replaced or supplemented
or in separate boxes.
for local adaptation. For example, photographs sourced
from databases such as Photoshare or Flickr (ensuring

Fig. 2.1 Format of the modules

Objectives Module A list of the Trainer Definitions/

sections module contents background description
information

Practical Discussion time/ Case studies

activities and prompts
demonstrations

12
2. PREPARE

Fig. 2.2 Summary of the modules

At-a-glance guide to module contents (All materials can be found in the Modules and resources document
complementing this training guide).

Contents Extra material for training

demonstration purposes
• Instructions, discussion questions
and general principles.
• Photograph(s) of a hospital
• Materials for practical activity.
Module 1 environment.
Introduction • Baby powder.
• Environmental transmission
to IPC pathway illustration.
• Case studies. • Illustrated guides.

Module 2 • Materials for hand hygiene practical activity.

Respiratory • Instructions, discussion questions
and general principles. • Soap (liquid, bar, leaf, powdered).
and personal
• Photograph of unsuitable footwear. • Disposable material for drying.
hygiene
• Poster for practical demonstration. • Alcohol-based handrub.

• Case study. • Illustrated guides.

• Examples of PPE as worn by those who clean,

• Instructions, discussion questions for example, single-use gloves, disposable
Module 3 and general principles. apron, disposable mask, reusable heavy-duty
Hand hygiene (chemical-resistant) gloves.
• Poster for practical demonstration.
• Additional PPE as appropriate.
• Materials for hand hygiene practical activity.

• Instructions, discussion questions • Illustrated guides.

and general principles.
Module 4 • Posters for practical demonstration. • Examples of cleaning materials, for example,
PPE • Photograph of good practice. mop, bucket, single-use gloves, reusable heavy-
duty (chemical-resistant) gloves, cleaning
• Case study.
cloths, soap, detergent.
• Materials for cleaning blood spillage
(if applicable to participant group).
Module 5 • Instructions, discussion questions • Warning/hazard signs.
Cleaning of the and general principles. • Illustrated cleaning guides.
environment • Photographs of high-touch
surfaces and good practices.
• Sharps box, (colour coded) waste bags,
examples of PPE worn by those who clean
to dispose of waste, for example, single-use
gloves or reusable heavy-duty (chemical-
Module 6 • Instructions, discussion questions resistant) gloves, disposable apron.
Waste and general principles.
management • Photograph of poor practice.
• Examples of PPE as worn by those who clean
• Case study.
for handling of linen, for example, single-use
gloves, reusable heavy-duty (chemical-
resistant) gloves, disposable apron.
• Instructions, discussion questions • Bucket (to carry ‘contaminated linen’ to the
Module 7
and general principles. washroom).
Linen
management • Photograph of poor linen storage. • Examples of bed linen plus a ‘soiled’ sheet
• Case study. (add red food colouring or paint to the centre
of a sheet to indicate ‘blood or body fluid’).

Module 8 • Instructions, discussion questions

• Example of competency assessments.
Supportive and general principles.
supervision
(supplementary)

13
TRAINER’S GUIDE
IN HEALTH CARE FACILITIES IN LOW- AND MIDDLE-INCOME COUNTRIES
ENVIRONMENTAL CLEANING AND INFECTION PREVENTION AND CONTROL Fig. 2.3 Actions to be undertaken before training starts

1. Print all 2. Prepare source 3. Provide laminate 4. Place all 5. Ready to start!
Module contents materials for and source materials in
demontrations/ marker pens separate or
practical activities same box(es)

As discussed earlier, people who deliver training should

2.1.5 Adaptation to the local context also be involved in the following adaptation tasks,
Adaptation is a prerequisite for successful training. together with the steering group or IPC committee:
The information and materials within Modules and • review of training materials (including illustrations,
resources are designed to be adapted to the local photographs and case studies) to assess whether
context. All information is supplied as Microsoft Word the level of technical detail should be adjusted for
files to facilitate editing and local adaptation. those being trained, based on their literacy skills,
Three of the modules (Introduction to IPC, module 1, knowledge and expertise.
hand hygiene, module 3 and PPE, module 4) are generic • identification or creation of local photographs
modules that should not require significant adaptation. or images (including videos), if applicable.
The remaining modules should be reviewed, checked • decisions on the need to use the illustrated guides
and adapted to reflect local or national policies or most and other training materials as is, or if they should
recent best practice recommendations and/or guidance, be translated into the local language(s).
if available. • incorporation of changes where appropriate.
Once these local or national norms are understood, • review and sign-off of final revisions.
local adaptation requires the involvement of one or
more individuals with the following specific skills
to adapt the training package to the local context: Actions for adaptation to the local context
• working knowledge of the health care facility • Clarify roles and responsibilities.
environment and resource availability • Use the baseline information to
(for example, a practising clinician, midwife, inform adaptation.
hospital administrator or nurse).
• Review materials for suitability and source
• knowledge of (or a background in) IPC and
more appropriate content where necessary.
environmental hygiene to inform the adaptation.
• an understanding of (or a background in) • Secure sign-off for all adaptations in line
participatory training. with best practice guidance.
• comprehensive knowledge of local language(s)
and/or dialect(s) spoken by those who clean.

14
2. PREPARE

2.1.6 Potential barriers and opportunities 2.1.7 Multimodal approach

It is helpful to consider potential barriers to the training Training is critical for equipping people with the
programme. Some commonly encountered barriers knowledge and skills required to do their job well.
relate to local culture and context and the availability
However, it is just one part of influencing performance
of technical expertise and leadership support to drive
and outcomes – on its own, training is not sufficient
the training forward. Actions taken to address local
to result in a clean, safe health care facility.
adaptation (section 2.1.5) will help to address cultural
and contextual barriers, including those related to Many varied factors within the work environment
literacy. Incorporating the training plan as part of the influence performance and need to be considered
IPC committee’s plans, where in place, can help to when working towards overall improvement,
achieve leadership support and delivery. particularly to sustain any changes made following
training. These factors include:
Obtaining equipment and supplies that are fit for
purpose may also present a barrier. Such issues will be • an enabling environment, that is, the infrastructure,
identified through the collection of baseline information supplies and other ‘hardware’ that needs to be in
and these findings should be presented to the steering place to support and enable cleaning.
group or IPC committee. • mechanisms to monitor progress and
Despite the barriers, preparing to start a new training provide feedback.
programme presents opportunities. For example, it • the existence and application of reminders
may show how training could be strengthened more and communication aids.
generally and how the training can integrate and align • organizational support, including the
with existing campaigns, such as WHO’s ‘World Hand current safety climate.
Hygiene Day’ every 5 May and other local improvement
• leaders who know and value a safe
initiatives (for example, quality improvement), and help
clean environment.
to address other barriers.
• an understanding that environmental cleaning
is part of overall quality improvement.
Actions for potential barriers Addressing these factors requires a multimodal
and opportunities approach that goes beyond training. Such an
approach supports sustainability. Annex 4 provides
• Consider potential barriers and mitigations, some prompt questions about the multimodal
drawing on previous experiences of change approach and examples of factors to be considered.
being introduced; the Basic Needs Assessment
Tool, in Modules and resources, is often useful
for this exercise. Actions for the multimodal approach
• Start to think about whether the training can • Consider actions in the following areas
be ‘bolted on’ to or incorporated within existing from Annex 4.
mandatory training (for example, on health and
safety, patient safety or IPC), where available. – Infrastructure, supplies and hardware.
– Training and education.
– Monitoring, assessment and feedback.
– Reminders and communication aids.
– Organizational support and leadership.

15
TRAINER’S GUIDE
IN HEALTH CARE FACILITIES IN LOW- AND MIDDLE-INCOME COUNTRIES
ENVIRONMENTAL CLEANING AND INFECTION PREVENTION AND CONTROL 2.1.8 Ready to continue?
Before moving on to section 2.2, the person
accountable for implementing this training
should review the action checks below to determine
whether each point has been addressed.

Action checks 1. Initial key considerations

# Action Checks Yes No

1 We have assessed the people, resources and budgets needed to deliver the training X
2 We have reviewed the available, relevant guidance presented in Annex 2 X
3 We have considered our current baseline using basic needs assessment and other
X
available tools (WASH FIT, IPCAF)
4 We have familiarized ourselves with the modules in Modules and resources X
5 We have collated all of the materials needed for each of the modules X
6 We have examined who needs to be involved, including leaders and stakeholders X
7 We have adapted materials, where necessary, based on baseline information X
8 We have considered how to integrate the training into existing courses
X
and initiatives
9 We have listed the barriers and discussed how to overcome them X
10 We have considered sustainable improvement X

16
2. PREPARE

2.2 Getting ready to deliver Box 2.5 Actions and considerations

the training for the accountable cleaning programme
manager or focal person before delivery
The format used to deliver training will of the training
depend on who is delivering the training
1. Identify the trainers.
and for what purpose, and the target
2. Develop workshop timetables.
audience. The appropriate format for
3. Review the modular approach.
the health care facility will depend on the
4. Understand the pros and cons of direct
baseline information acquired, a review delivery of training from an external provider.
of the training, identification of priorities, 5. Understand the rationale and benefits
and consideration of resources. of including other staff members in a
A training of trainers approach is the focus of this participatory approach to training.
section. However, direct delivery by an experienced 6. Deliver safe training when physical
and informed external provider or the use of master distancing is required.
trainers can be considered. 7. Plan for the pre- and post-training knowledge
questionnaires, including training evaluation.
Training of trainers and direct delivery 8. Prepare certificates of completion.

‘Training of Trainers’ (ToT)

• This approach is facilitated by individuals with 2.2.1 Suitable trainers
a background in training and IPC/environmental
hygiene, for example an educational or training To successfully complete this phase, all trainers
institute (e.g. the School of Nursing & Midwifery should have an appropriate level of knowledge of the
or the Ministry of Health). transmission of microorganisms, IPC, environmental
• Trainers should be selected from selected health hygiene practices, standards and regulations.
care facilities e.g. nurses, midwifes, public health Ideally, the steering group or IPC committee will
officers (ideally supervisors of those who clean) designate or assign an individual (such as an on-site
to attend a ToT workshop and subsequently deliver supervisor) with relevant experience of both training
training to those who clean within their own facilities. and IPC to be accountable for the training.
Direct delivery
• Direct delivery of training to those who clean can
take a variety of formats, including for example 2.2.2 Workshop timetables
delivery of training by master trainers (i.e. selected,
trained individuals from academic settings or The total time required to deliver all eight modules
working at a regional level for the Ministry of Health is approximately 12 hours, with an additional 2 hours
who deliver training directly to those who clean required for module 8: Supportive supervision
within facilities). (supplementary).
Selected individual(s) within facilities may It is up to those accountable for implementing the
also deliver training. training, in consultation with the health care facilities
Whichever approach is used, this section concerns the from which the trainees will be drawn, to determine
final preparations to be undertaken before delivering the the best timetable for training. All efforts should be
training using Modules and resources. It outlines eight made to ensure that the training does not disrupt
actions and considerations (summarized in Box 2.5) that the facility function by taking those who clean away
will help to ensure sustainability from the start. from their work for extended periods of time. Thus, a
30- to 60-minute session over 3–5 days (for example)
may work better than a longer session once a week.
Examples of workshop timetables, modules and
delivery formats for delivering a ToT course can be
found in Modules and resources.

17
TRAINER’S GUIDE
IN HEALTH CARE FACILITIES IN LOW- AND MIDDLE-INCOME COUNTRIES
ENVIRONMENTAL CLEANING AND INFECTION PREVENTION AND CONTROL 2.2.3 ‘Train-the-trainers’ approach 2.2.5 Participatory approach to training
The training of trainers approach offers several benefits The training approach is rooted in participatory methods
in terms of delivery, uptake of training, and sustainability of training; the rationale for this approach is summarized
of changes made within facilities. in Box 2.6, Annex 1 in Modules and resources, and further
explained elsewhere (11).
• In many settings, this will be the first formal
training ever delivered to those who clean;
lack of familiarity with the process may therefore Box 2.6 Rationale for using
affect the confidence of those who clean and
the participatory approach
their willingness to participate.
• Training those who clean as well as their supervisors • Individuals learn in diverse ways with
may aid delivery, based on the already established different learning styles.
working relationship. • Some prefer the use of pictures, images,
• Individuals can be selected for the training and diagrams to organize and communicate
workshop based on leadership roles within their information; others prefer language and text.
respective facilities (for example, monitoring and • Different training styles can be more effective
supervision of those who clean) or familiarity with for one kind of learner than the other; some
the local work context, thus allowing appropriate styles appeal to both.
adaptation of training. • Training courses that recognize unique
• By involving these individuals, longer term training styles and use different methods of training,
can be repeated within the facility (for example, while considering the literary skill of
with a wider group of people, new staff, and as an participants, are much more successful
update or reminder of best practices following the in achieving objectives than courses using
initial training). one method of training delivery.
• The health care facility can take ownership • Participatory approaches are considered most
of the training programme going forward. effective in terms of knowledge acquisition,
Application of training within facilities and associated retention and subsequent performance.
barriers should be discussed with participants
throughout the workshop. Mock training sessions may
The modules in Modules and resources include many
be undertaken to practise participatory methods and
examples and suggestions for active participation,
to familiarize trainers with the materials. The format
mostly through practical exercises.
used to deliver training will depend on the baseline,
a review of the training, identification of priorities, Participatory training normally comprises four
and consideration of resources. Modules and resources elements: instruction; demonstration; questioning;
includes a module that outlines the information needed and observation of performance. These elements
to deliver a train-the-trainer course (Train-the-trainer should be repeated until a satisfactory performance
course: how to train module). is consistently achieved.
How training is delivered should take into consideration
budget, time, resources, sustainability, and the desired
scope and reach of training.
2.2.4 Direct delivery of training
by an external provider Training should be delivered in the local language,
with training materials translated into that language,
Direct delivery of training to those who clean from where appropriate.
an external provider has several advantages and
disadvantages that need to be considered. The
advantages of using an external provider include:
• short-term cost and time-savings by delivering
training directly to those who clean (and their
supervisors) without the additional step of
train‑the‑trainer.
The disadvantages of using an external provider are:
• external trainers may not be familiar with the local
context or the specific participants and their abilities,
language(s) and/or dialect(s).
• potential benefits of longer term monitoring and
supervision, ownership of the training process, and
the ability to repeat in-house training may be lost.

18
2. PREPARE

2.2.6 Precautions when delivering 2.2.7 Pre- and post-training questionnaires

the training Modules and resources contain a sample questionnaire
Although it is important to ensure engagement and that can be used before and after training. Asking
successful outcomes from training sessions, ensuring participants to complete the questionnaire before
the safety of participants is a major consideration. delivering the training will establish baseline knowledge.
Facilitated participant completion of the questionnaire
This may mean: can then be used as a measure of learning.
• Considering the contents of the modules, how When asking participants to complete the questionnaire,
practical demonstrations can be delivered safely, consider levels of literacy, for example, the questions
for example at distance when necessary, and how may have to be delivered in an interview format.
any equipment used in the training can be cleaned
Modules and resources also contain sample
afterwards.
evaluation forms to be completed by trainers and
• Considering the ventilation required, based on the recipients of the training including an assessment
number of people being trained in a physical space of cleaning competency.
at any one time.
• Finding creative ways to demonstrate and observe
practices during training (for example, using videos).
Online training is an option. However, it does not 2.2.8 Preparing certificates of completion
readily fulfil the goal of this training, which applies
a practical approach that is suitable for those with A sample certificate of completion to be presented to
low literacy. This package focuses on standard face-to- those who clean upon successful completion of the
face training and thus should be adapted to consider relevant training is provided in Modules and resources.
precautions required if physical distancing is an issue
when delivering training.

2.2.9 Ready to continue?

Before moving on to section 3, the person designated
for implementing this training should review the action
checks below to determine whether each point has
been addressed.

Action checks 2. The cleaning programme manager or focal person

# Action Checks Yes No

1 We have reviewed the training-of-trainers and direct delivery training formats X
2 We have identified potential trainers X
3 We have reviewed and modified the workshop timetable X
4 We have reviewed the participatory training approach and its rationale X
5 We have considered safety precautions when delivering the training X
6 We have considered providing a pre-training knowledge questionnaire X
7 We have agreed on how we will evaluate the training X
8 We have prepared certificates of completion X

19
3. Deliver
Deliver

3.1 Modules and resources The contents of Modules and resources

summary are shown in Fig. 3.1 for reference.

This section summarises all of the

information and materials in Modules
and resources that are available to
deliver the training.

Fig. 3.1 Summary of the contents of the document Modules and resources

MODULES AND RESOURCES CONTENTS

TEACH • Module 1: Introduction to IPC. • Module 6: Waste management.

• Module 2: Respiratory and • Module 7: Linen management.
personal hygiene. • Module 8: Supportive supervision
• Module 3: Hand hygiene. (supplementary).
• Module 4: PPE.
• Module 5: Cleaning
of the environment.

VISUALISE • How to fold a cleaning cloth. • How to prepare a chlorine-based

• Hand rubbing. disinfectant solution.
• How to wash your hands. • How to clean a blood spillage.
• How to put on single use, • Damp mopping.
disposable gloves. • High-touch cleaning.
• How to remove single use, • Cleaning paintwork, walls,
disposable gloves. and doors.
• How to put on reusable heavy-duty • How to clean a handwash basin.
(chemical-resistant) gloves. • How to clean a standard (Western-
• How to remove reusable heavy- style) toilet.
duty (chemical-resistant) gloves. • How to clean a squat toilet.
• How to put on a disposable apron. • How to clean a shower.
• How to remove a disposable apron. • How to clean a delivery bed.
• How to prepare a detergent • How to clean a ward bed mattress.
solution.

21
TRAINER’S GUIDE
IN HEALTH CARE FACILITIES IN LOW- AND MIDDLE-INCOME COUNTRIES
ENVIRONMENTAL CLEANING AND INFECTION PREVENTION AND CONTROL

Fig. 3.1 Summary of the contents of the document Modules and resources (continued)

MODULES AND RESOURCES CONTENTS

CHECK • Training on baseline needs • Competency assessments.

assessment tool. • Training course evaluation.
• IPC and environmental hygiene pre- • Example of a training record.
and post‑training questionnaire.

ANNEXES • Annex 1: Training workshop • Annex 3: Competency assessment

– how to train. referral procedure.
• Annex 2: Example of • Annex 4: Example of a certificate
workshop timetables. of completion for adaptation.

3.2 Ready to deliver the training?

Having completed the preparations in section 2,
the steering group or IPC committee is now ready to
implement the training package and deliver the training.
Before moving on to section 4, the person designated
for implementing this training should review the action
checks below to determine whether each point has
been addressed.

Action checks 3. Sustaining improved performance

# Action Checks Yes No

1 We have addressed all of the action checks outlined in section 2 X
2 We are familiar with all of the materials in Modules and resources X
3 We have agreed which of the materials in Modules and resources will be used
X
for the training
4 We are ready to deliver the training! X

22
4. Sustain
Sustain

4.1 Sustaining improved 4.1.1 Supportive supervision, monitoring

performance and feedback
Supportive supervision focuses on supporting staff to
Several factors can improve the performance
improve their own performance. It takes a joint problem-
of those who clean – supportive supervision, solving approach, with open communication between
monitoring and feedback, non-monetary supervisors and those being supervised.
incentives, clear expectations, and resource Performance is monitored and results are fed back
availability. Together, these factors combine to staff in a constructive manner and used to improve
to establish an ‘enabling environment’. staff skills and knowledge.

• Central to an enabling environment is recognizing Monitoring and feedback are used to sustain change
the importance of IPC and valuing the role of those and improve performance and motivation among staff.
who clean in establishing and maintaining IPC Providing feedback allows open dialogue between
standards. staff and their supervisors; feedback can celebrate
superior performance and be constructive for inferior
• An enabling environment encompasses not just
performance. It can also be used as a tool for continued
training, but also ongoing professional support at
learning (for example, following competency-based
all levels, including adequate infrastructure and
assessments, as described in the Supportive supervision
resource availability (see Annex 4 that outlines
module). Recent developments in the use of simple
multimodal factors to support sustainability).
technology (gel dots) (12) for assessing the adequacy
• It includes developing, implementing and enforcing of cleaning surfaces, such as bed rails, may also be
supportive policies; strengthening institutions considered as part of a continuous process of quality
through effective coordination of personnel, assessment.
resources and activities; and creating clear outlines of
roles and responsibilities, with effective mechanisms
of accountability throughout.
• The WHO Guidelines on the core components of 4.1.2 Non-monetary incentives
IPC programmes (4) notes that a good programme
needs to work throughout the system and involve Non-monetary incentives (for example, verbal
organizational and cultural change. recognition and respect by supervisors, colleagues and
patients) can strongly improve workers’ performance.
An overview of some of these factors is provided
This is particularly relevant for those working in
below and addressed in more detail in the supportive
environmental cleaning. In some contexts, those who
supervision module in Modules and resources.
clean are not recognized as integral to the overall health
workforce. This lack of recognition, combined with
those who clean having little control over job roles,
responsibilities and the work environment, can affect
job satisfaction, motivation and performance.

24
4. SUSTAIN

4.1.3 Clear expectations 4.1.5 Assessing impact

Clear expectations of what is required of each Tools used during baseline data collection (IPCAF,
staff member in their respective roles includes WASH FIT or basic needs assessment) can be used
discussing roles and responsibilities with employees to understand where progress has been made and
and making job descriptions available. A job where gaps remain for decision-making, sustainability
description typically outlines an employee’s required and future planning.
skills, training and background. It should also list the
The findings of these assessments should be presented
duties and responsibilities of the job and reporting
to the IPC Committee or steering group. This committee/
and organizational structures. Job descriptions can
group should establish ongoing review and engagement
be used in orientating employees to their role and
cycles to embed this training in existing processes across
in the evaluation of job performance.
the health care facility, thus contributing to its overall
impact and sustainability.
In addition to the use of structural and process
4.1.4 Resource availability indicators, the IPC committee or steering group
can advise on the use of environmental indicators
If those who clean do not have adequate resources for to monitor cleaning practices (for example,
cleaning, including access to water, or satisfaction with fluorescent marker systems, or other mechanisms
the way their work is organized, it can be difficult for to monitor the bio-burden before and after cleaning
them to perform their role to the required standard. (12)). These environmental indicators have their own
Provision of resources required for maintaining elevated advantages and disadvantages.
levels of environmental cleaning depends on factors IPC committee members where in place are best placed
such as budgets, reporting and audit. In addition, the to advise on the use of indicators to assess the impact
state of the WASH infrastructure in the health institution, of environmental cleaning.
including ready access to water and the condition of
sanitation facilities, is key to maintaining standards
of environmental cleaning in the daily work of those
who clean. Health managers need to be engaged to 4.1.6 Ongoing leadership and
ensure that these resource requirements are met and
organizational support
it is important to gauge the state of the wider WASH
environment, as well as the specific needs of those who Sustainability requires ongoing leadership and
clean, during the baseline assessment before training. support for environmental cleaning, including an
Financial constraints can also oblige trainers to organizational safety climate that values cleaning.
search for feasible or creative adaptations to the An understanding of environmental cleaning as part
modules that require little or no financial outlay of overall quality improvement and an integration
(for example, materials from the health care facility, of training within existing approaches to quality
hardware stores or local markets). However, if the improvement are also useful.
contents of this package are to be effective, the
health care facility needs to agree to meet a baseline
level of financial investment for the training of those
who clean in order to maintain the environmental 4.2 Reviewing and planning
standards that will lead to the target outcomes. for the future
Having come to the end of the last step in the process,
it is time to reflect on what has happened and consider
longer term plans. The designated focal point should
discuss the idea of setting up an annual review cycle
with the IPC committee or steering group.
The focal point (on behalf of the IPC committee
or steering group) should thank all those involved
and celebrate and publicize their commitment
and successes.
Finally, the person accountable for implementing this
training should review the action checks below and
consider whether each point has been addressed.

25
TRAINER’S GUIDE
IN HEALTH CARE FACILITIES IN LOW- AND MIDDLE-INCOME COUNTRIES
ENVIRONMENTAL CLEANING AND INFECTION PREVENTION AND CONTROL Action checks 4. Sustaining improved performance

# Action Checks Yes No

1 We have considered the enabling environment that supports cleaning X
2 We have considered approaches to sustain improved performance X
3 We have conducted a follow-up assessment to determine the success of the training X
4 We have developed a long-term plan X

26
Annexes
Annex 1

Summary of existing training modules in IPC and WASH

IPC modules aimed at IPC focal points
Name of training course Source

Introduction to IPC https://openwho.org/courses/IPC-INTRO-EN

IPC core components https://openwho.org/courses/IPC-CC-MMIS-EN
and multimodal strategies
Standard precautions: https://openwho.org/courses/IPC-HH-en
hand hygiene
Standard precautions: https://openwho.org/courses/IPC-SP-PPE-EN
The role of personal
protective equipment
Standard precautions: https://openwho.org/courses/IPC-WM-EN
waste management
Standard precautions: https://openwho.org/courses/IPC-EC-EN
environmental
cleaning and disinfection
Basic microbiology https://openwho.org/courses/IPC-MICRO-EN
Standard precautions: https://openwho.org/courses/IPC-IS-EN
injection safety and needlestick
injury management
Infection Prevention and Control https://openwho.org/courses/COVID-19-IPC-EN
(IPC) in the context of COVID-19
Infection Prevention and Control https://openwho.org/courses/care-pregnant-woman-antenatal-clinic-en
in Maternal and Neonatal Care

WASH modules aimed at WASH focal points

Name of training course/resource Source

WASH FIT: manual for trainers https://apps.who.int/iris/handle/10665/353805

WASH FIT Training Modules: https://washinhcf.org/wash-fit-training-modules/
WASH links with health; WASH
FIT methodology; Managing
safe water supplies; Sanitation;
Hand hygiene; Health care waste;
Environmental cleaning; Climate
resilience; Gender equality,
disability & social inclusion

28
Annex 2

Summary of guidance, tools and best practice documents relevant to environmental

cleaning including the training of those who clean

Document Purpose Links

Best practice document

Best practices for environmental To improve and standardize the https://www.cdc.gov/hai/pdfs/

cleaning in healthcare facilities: implementation of environmental resource-limited/environmental-
in resource-limited settings. cleaning in patient care areas in all cleaning-RLS-H.pdf
CDC/ICAN (2020) (6) health care facilities in resource-
limited settings.

Relevant Implementation tools and guidance on IPC and WASH

Improving infection prevention and Designed to support health care https://apps.who.int/iris/
control at the facility level. Interim facilities to effectively implement handle/10665/279788
practical manual supporting their IPC programmes according
implementation of the WHO to the relevant WHO guidelines.
guidelines on core components
of infection prevention and
control programmes.
WHO (2018) (14)
Infection prevention and A structured questionnaire with https://apps.who.int/iris/
control assessment framework a closed format and an associated handle/10665/330072
at the facility level. scoring system that is primarily
WHO (2018) (8) intended to be self-administered,
to assess the current facility
IPC situation.
Minimum requirements To present and promote the https://apps.who.int/
for infection prevention minimum requirements for iris/bitstream/hand
and control programmes. IPC programmes at the national le/10665/330080/9789241516945-
WHO (2019) (7) and health care facility level eng.pdf?sequence=1&isAllowed=y
(requirements identified by expert
consensus according to available
evidence and in the context of
the WHO core components).
Hand Hygiene: Why, How Brochure that addresses the https://www.who.int/
and When? why, when and how of hand publications/m/item/hand-
WHO (2009) (15) hygiene, and includes step- hygiene-why-how-when
by-step instructions on how to
handrub and how to handwash.
Also includes the ‘Your 5 moments
for hand hygiene’ image and the
glove use pyramid to aid decision-
making on when to wear (and
when to not wear) gloves.

29
TRAINER’S GUIDE
IN HEALTH CARE FACILITIES IN LOW- AND MIDDLE-INCOME COUNTRIES
ENVIRONMENTAL CLEANING AND INFECTION PREVENTION AND CONTROL Summary of guidance, tools and best practice documents relevant to environmental
cleaning including the training of those who clean (continued...)

Document Purpose Links

Water, sanitation, and hygiene Presents eight practical steps https://apps.who.int/iris/

in health care facilities: practical that Member States can take at handle/10665/311618
steps to achieve universal access the national and sub-national
to quality care. level to improve WASH in health
WHO/UNICEF (2019) (16) care facilities and summarizes
the global response to the United
Nations Secretary-General’s Call
to Action on WASH in health care
facilities.
Water and sanitation for health A risk-based management tool https://apps.who.int/iris/
facility improvement tool (WASH for health care facilities, covering handle/10665/353411
FIT): a practical guide for improving key aspects of WASH services:
quality of care through water, water; sanitation; hand hygiene;
sanitation and hygiene in health environmental cleaning; health
care facilities, 2nd ed 2022 (9) care waste management; and
selected aspects of energy,
building and facility management.
Essential environmental health Provides essential environmental https://apps.who.int/iris/bitstream
standards in health care. health standards required for /handle/10665/43767/97892415472
WHO (2008) (13) health care settings in medium- 39_eng.pdf?sequence=1
and low-resource countries to
support assessment and planning,
development of standards, and
to support the development and
application of national policies.
Implementation manual to Designed to support national https://apps.who.int/iris/
prevent and control the spread IPC programmes and health handle/10665/312226
of carbapenem-resistant care facilities to effectively
organisms at the national implement the WHO guidelines
and health care facility level. for the prevention and control
Interim practical manual of carbapenem-resistant
WHO (2019) (17) Enterobacterales, Acinetobacter
baumannii and Pseudomonas
aeruginosa in health care facilities.
Antimicrobial stewardship Aims to support countries in https://apps.who.int/iris/
programmes in health-care implementing objective 4 of the handle/10665/329404
facilities in low and middle income Global Action Plan – ‘optimize the
countries. A WHO practical toolkit. use of antimicrobial medicines’ –
WHO (2019) (18) by providing practical guidance
on how to implement antimicrobial
stewardship programmes in
the human health sector at the
national and health care facility
level in LMIC.

30
TO ENVIRONMENTAL CLEANING INCLUDING THE TRAINING OF THOSE WHO CLEAN
ANNEX 2 – SUMMARY OF GUIDANCE, TOOLS AND BEST PRACTICE DOCUMENTS RELEVANT
Summary of guidance, tools and best practice documents relevant to environmental
cleaning including the training of those who clean (continued...)

Document Purpose Links

Standards for improving quality Aims to support preparation https://apps.who.int/iris/

of maternal and newborn care of national standards of care handle/10665/249155
in health care facilities. and measures for improving,
WHO (2016) (19) assessing and monitoring the
quality of care provided to
mothers and newborns in health
care facilities, and as a basis for
quality improvement strategies.
Can be used as a resource in
medical training institutions.
Emphasis throughout on
clean environments.
Cleaning and disinfection Aims to provide guidance on https://apps.who.int/iris/
of environmental surfaces in the cleaning and disinfection of handle/10665/332096
the context of COVID-19. environmental surfaces in the
WHO (2020) (20) context of COVID-19 – outlines
products to be used and the
importance of cleaning.
Standard precautions for Standard precautions aim https://apps.who.int/iris/
the prevention and control to protect both health workers handle/10665/356855
of infections: aide-memoire. and patients by reducing
WHO (2022) (21) the risk of transmission of
microorganisms from both
recognized and unrecognized
sources. This aide-memoire
presents a concise overview
of important advice for
implementation and key
elements at a glance.

31
Annex 3

Summary of IPCAF, WASH FIT and a Basic

Needs Assessment tool
This annex summarizes the characteristics of three
different available assessment tools:
• Infection Prevention and Control Assessment
Framework (IPCAF) (8).
• Water and Sanitation for Health Facility
Improvement Tool (WASH FIT) (9).
• A basic needs assessment (featured in Modules
and resources).

32
AND A BASIC NEEDS ASSESSMENT TOOL
ANNEX 3 – SUMMARY OF IPCAF, WASH FIT
Summary of IPCAF, WASH FIT and a Basic Needs Assessment tool

Assessment IPCAF WASH FIT Basic needs assessment

tools
Website https://www.who.int/publications/i/item/ https://apps.who.int/iris/ See Basic Needs Assessment Tool
WHO-HIS-SDS-2018.9 handle/10665/353411 in “Modules and resources”
Aim of • The IPCAF is a structured, closed- • WASH FIT is a risk- based approach • The Basic Needs Assessment Tool
the tool formatted questionnaire with an for improving and sustaining water, evaluates the current status of the
and what associated scoring system. sanitation and hygiene and health care management of environmental
it measures • The framework is intended for acute waste management infrastructure and cleaning in the maternity unit.
health care facilities, but it can be used services in health care facilities in low-
in other inpatient health care settings. and middle-income countries.
• IPCAF can assess existing IPC activities/ • Use of WASH FIT in health care
resources; identify strengths and facilities can help reduce maternal
gaps to inform future plans, and and newborn mortality and improves
detect problems or shortcomings the quality of care so that women can
that require improvement to meet deliver with dignity, further benefiting
international standards. holistic health aims.

Applicability • Acute health care facilities, • Health care facilities in • Maternity units, but can be applied
but can be used in other inpatient low‑resource settings. to other health care facility units.
health care settings.

Outline • Eight sections reflecting the eight • Assessment tool that includes indicators • Personnel responsible for cleaning
WHO IPC core components: associated with environmental cleaning and supervision of cleaning.
1. IPC programme. (supplies, policies, personnel). • Role responsibilities.
2. IPC guidelines. • Supervision and monitoring.
3. IPC education and training. • Provision of training.
4. health care-associate infection • Training topics.
surveillance. • Resources.
5. multimodal strategies. • IPC committee.
6. monitoring/audit. • Policies, protocols and guidelines.
7. workload, staffing and bed occupancy.
8. built environment, materials and
equipment for IPC at the facility level.
• A total of 81 indicators.
33
TRAINER’S GUIDE
IN HEALTH CARE FACILITIES IN LOW- AND MIDDLE-INCOME COUNTRIES
ENVIRONMENTAL CLEANING AND INFECTION PREVENTION AND CONTROL Summary of IPCAF, WASH FIT and a Basic Needs Assessment tool (continued...)

Assessment IPCAF WASH FIT Basic needs assessment

tools

Time to • Approximately 2–3 hours. • If information is readily available: • If information is readily available:
complete 3–6 hours. 30–45 minutes.
• If there is a need to gather information, • If there is a need to gather information,
may take substantially longer. may take 1.5 hours.
Who • Health care professionals and teams • Health care facility managers and staff • A senior member of staff from the
completes responsible for organizing and (for example, chief medical officer, maternity unit (for example, matron,
implementing IPC activities. financial administrator, doctors, nurses head nurse or lead physician).
• If these do not exist or there is no IPC and persons in charge of managing water
programme, senior facility managers and waste).
complete the tool.
Manual or • For manual completion using • Manual and online via an application. • For manual completion using
online a paper form. a paper form.

Length • 15 pages. • 128 pages. • 9 pages.

Analysis • Scoring system to guide development • Table available for recording the • Self-review of information gathered.
and data of action plans. percentage score of each section. • No scoring system.
visualization • Scores range from inadequate through
to basic, intermediate and advanced.
• Template slides available to present data
(https://www.who.int/publications/m/
item/ipc-assessment-framework-
presentation-template).
Frequency • For local decision, but potentially • A full facility assessment should ideally • Before training.
as an annual cycle. be conducted every 6–12 months,
depending on the size of the facility.

34
Annex 4

Multimodal factors to support sustainability of the improvements

Multimodal factor Prompt questions Examples

Infrastructure, • What resources, • The resources needed to do the job,
supplies and hardware infrastructure or supplies including those related to WASH.
are required for success? • An instruction document.
• Trainer or supervisor guide.
• Cleaning procedures – in a range of formats
to suit the target audience and including
a synthesis of current evidence (found in
Modules and resources).
• Availability of job descriptions outlining clear
expectations of the role of those who clean.
Training and education • How can training success • Use training principles and governance
be assured? described in this document.
Monitoring, assessment • How have you become • Cleanliness monitoring approaches.
and feedback aware that cleaning • Assessments (found in Modules
practices need to be and Resources document).
improved? How will you
• Supportive supervision
know that a improvement
(found in Modules and Resources document).
has taken place?

Reminders and • How will you publicize • Reminders to prompt ongoing good practices
communication aids action on specific (Modules and resources).
measures and promote • Advocacy for cleaning at different levels:
improvement and
– promote the value of cleaning.
best practice in this area?
– support the need for training as part
of an improvement strategy.
– address gender and equity issues.
– advocate to help sell the value of a clean
culture, especially with health care managers.
Organizational support • How will you make and • Development of leaders and champions
and leadership maintain cleaning as a who empower those who clean.
health care facility priority • Use of non-monetary incentives.
and engage senior leaders,
managers, champions and
opinion leaders over time?

35
References
References

1. Water, sanitation, hygiene and health: a primer for 8. Infection Prevention and Control Assessment
health professionals. WHO/CED/PHE/WSH/19.149. Framework at the facility level. Geneva:
Geneva: World Health Organization; 2019 (https:// World Health Organization; 2018 (https://www.who.
apps.who.int/iris/handle/10665/330100, accessed int/publications/i/item/WHO-HIS-SDS-2018.9,
5 November 2021). accessed 5 November 2021).
2. TEACH CLEAN. London, UK: London School of 9. Water and sanitation for health facility improvement
Hygiene & Tropical Medicine; 2021 (https://www. tool (WASH FIT): a practical guide for improving
lshtm. ac.uk/research/centres/march-centre/ quality of care through water, sanitation and hygiene
soapbox-collaborative/teach-clean, accessed 5 in health care facilities, 2nd ed. World Health
November 2021). Organization; 2022 (https://apps.who.int/iris/
3. Resolution WHA72.7. Water, sanitation and hygiene handle/10665/353411, accessed 3 October 2022)
in health care facilities. In: Seventy-second World 10. Interim practical manual supporting national
Health Assembly, 28 May 2019. Geneva: World implementation of the WHO guidelines on
Health Organization; 2019 (https://apps. who. core components of infection prevention and
int/gb/ebwha/pdf_files/WHA72/A72_R7-en. pdf, control programmes. Geneva: World Health
accessed 5 November 2021) Organization; 2017 (https://apps.who.int/iris/
4. Guidelines on core components of infection handle/10665/279788, accessed 5 November 2021).
prevention and control programmes at the 11. Malone S. Characteristics of adult learners.
national and acute health care facility level. Training & Development. 2014:41; 10–13.
Geneva: World Health Organization; 2015 (https:// 12. Gon G, Kabanywanyi AM, Blinkhoff P, et al. The Clean
apps.who.int/iris/handle/10665/251730, pilot study: evaluation of an environmental hygiene
accessed 5 November 2021). intervention bundle in three Tanzanian hospitals.
5. Global action plan on antimicrobial resistance. Antimicrob Resist Infect Control 2021; 10: 8.
Geneva: World Health Organization; 2015 13. Essential environmental health standards for
(https://apps.who.int/iris/bitstream/ health care. Adams J, Bartram J, Chartier Y,
handle/10665/193736/9789241509763_eng. eds. Geneva: World Health Organization; 2008
pdf?sequence=1, accessed 5 November 2021). (https:// apps.who.int/iris/handle/10665/43767,
6. Best practices for environmental cleaning in accessed 25 November 2021).
healthcare facilities in resource-limited settings. 14. Improving infection prevention and control
Atlanta, GA: United States Centers for Disease at the facility level. Interim practical manual
Control and Prevention; Cape Town, South supporting implementation of the WHO guidelines
Africa: Infection Control Africa Network (ICAN); on core components of infection prevention
2019 (https://www.cdc.gov/hai/prevent/ and control programmes. Geneva: World Health
resource- limited/index.html and http://www. Organization; 2018 (https://apps.who.int/iris/
icanetwork. co.za/icanguideline2019, accessed handle/10665/279788, accessed 5 November 2021).
5 November 2021).
15. Hand hygiene: why, how and when? Geneva: World
7. Minimum requirements for infection prevention Health Organization; 2009 (https://www.who.int/
and control programmes. Geneva: World Health publications/m/item/hand-hygiene-why-how-
Organization; 2019 (https://apps.who.int/iris/ when, accessed 3 October 2022).)
bitstream/handle/10665/330080/9789241516945-
eng.pdf,accessed 5 November 2021).

37
 16. Water, sanitation, and hygiene in health care
TRAINER’S GUIDE
IN HEALTH CARE FACILITIES IN LOW- AND MIDDLE-INCOME COUNTRIES
ENVIRONMENTAL CLEANING AND INFECTION PREVENTION AND CONTROL facilities: practical steps to achieve universal access
to quality care. Geneva: World Health Organization
and United Nations Children’s Fund; 2019 (https://
apps.who.int/iris/ handle/10665/311618, accessed
5 November 2021).
17. Implementation manual to prevent and control
the spread of carbapenem-resistant organisms at
the national and health care facility level. Interim
practical manual. WHO/UHC/SDS/2019.6. Geneva:
World Health Organization; 2019 (https://apps.
who.int/iris/handle/10665/312226, accessed 5
November 2021).
18. Antimicrobial stewardship programmes in health-
care facilities in low- and middle-income countries.
A WHO practical toolkit. Geneva: World Health
Organization; 2019 (https://apps.who.int/iris/
bitstream/handle/10665/329404/9789241515481-
eng.pdf?sequence=1&isAllowed=y, accessed 5
November 2021).
19. Standards for improving quality of maternal
and newborn care in health facilities.
Geneva: World Health Organization; 2016
(https://apps.who.int/iris/bitstream/han
dle/10665/249155/9789241511216-eng.
pdf?sequence=1, accessed 5 November 2021).
20. Cleaning and disinfection of environmental
surfaces in the context of COVID-19. Geneva: World
Health Organization; 2020 (https://www. who.int/
publications/i/item/cleaning-and- disinfection-
of-environmental-surfaces-inthe- context-of-
covid-19, accessed 5 November 2021).
21. Standard precautions for the prevention and
control of infections: aide-memoire. World Health
Organization; 2022 (https://apps.who.int/iris/
handle/10665/356855, accessed 19 October 2022)

38
WHO Antimicrobial Resistance Division
World Health Organization
20 Avenue Appia
1211 Geneva 27
Switzerland
Website: https://www.who.int/health-topics/antimicrobial-resistance