**3. Methods**

A national assessment of WASH and IPC in primary healthcare facilities, including primary health centres and comprehensive health centres, was conducted in Jordan during the period October–November 2020. A multistage clustersampling technique proportional to the size of the facility was used for the selection of health centres. A sampling frame of all MoH health centres was obtained from the MoH and stratified according to region (North, Middle, and South), facility type (primary health centres and comprehensive centres). A random sample of health centres was selected from each stratum. A total of 11 primary healthcare centres and 22 comprehensive centres were selected.

A comprehsnive assessment tool was developed for healthcare centres a based on the review and adaptation of several tools, mainly the Water and Sanitation for Health Facility Improvement Tool (WASH FIT) [32]. WASH FIT covers four broad domains and comprises 65 indicators, aiming to achieve minimum standards for maintaining a safe and clean environment. WASH FIT is primarily designed for use in primary healthcare facilities that provide outpatient services. The assessment tools developed included more indicators and standards from other tools such as: 'The Infection Prevention and Control Assessment Framework' (IPCAF) [33]; the Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care [34]; The Systems for Improved Access to Pharmaceuticals and Services (SIAPS) tool, and the coronavirus disease (COVID-19) technical guidance by WHO [8].

The health centre assessment tool covered eight broad areas (Domains): (1) Water, (2) Medical waste and sanitation facilities, (3) Hygiene, (4) Management, (5) Infection prevention and control programme, (6) Training and education, (7) Evaluation and feedback, and (8) COVID-19 precautionary measures. The Hygiene domain covered areas related to hand hygiene and facility environment, cleanliness and disinfection. The Infection prevention and control programme area was divided into subareas including (a) Basic indicators, (b) Guidelines in IPC unit, (c) Training and education for the Infection Prevention and Control Unit, (d) Healthcare associated infection monitoring, (e) Monitoring/auditing of infection control practices and outcomes, (f) Personal protective equipment, and (g) Availability of hygiene materials. Evaluation and feedback covered subareas including (a) Basic Indicators, (b) Respiratory safety, (c) Environmental cleaning, and (d) Sterilization of Reusable Devices.

Each area/subarea included indicators and targets for achieving minimum standards for maintaining a safe and clean environment. These standards are based on global standards as set out in the WHO Essential environmental health standards in health care [35] and the WHO Guidelines on core components of infection prevention and control programmes at the national and acute healthcare facility level [33]. The assessment tool included WASH-FIT indicators in addition to other indicators identified from available tools. Indicators were adapted to Jordan's needs and local priorities and/or national standards in order to meet quality improvement cycles and mechanisms implemented to improve quality of care. Indicators that are not relevant were removed. Additional indicators were added as necessary to represent levels of services.

A committed team with leadership skills and who are familiar with and trained on WASH and IPC was formed. The assessment team was composed of 12 assessors who were divided into three teams; one team for each region. The team had support from the MoH leadership and from facility's administration. A training workshop was held to train the assessment team on the assessment process, data collection, and use of assessment tools. During the workshop, the assessment team members were made aware of the assessment tools and their roles and responsibilities.

The assessment teams planed their visits to the health centres with the senior facility manager. During the facility visit, the assessment team worked the with facility team including those who have in-depth understanding and knowledge of WASH and IPC activities at the facility level to fill the assessment tool. If there were no professionals in charge of WASH and IPC or there was not yet an IPC programme established, the tool was completed by the team with the consultation with the senior facility manager. The IPC team consulted with other relevant teams in the facility to respond to questions accurately.

A comprehensive assessment of the facility was conducted using the agreed list of indicators and each indicator was recorded as whether it meets, partially meets, or does not meet, the minimum standards. The assessment forms were reviewed by supervisors to ensure all information is clear and correct and all members of the team agree on the findings of each assessment. As part of the assessment, hygiene promotion materials, WASH and IPC guidelines and budget were reviewed and observed.

The percentage of indicators, which meet or partially meet the standards, was calculated for each facility. The overall facility score (the percentage of all indicators meetings the standards) was calculated to make comparisons over time when future assessments are conducted. The mean percentages over all facilities were calculated. Data were described using means and percentages.
