The effects of environmental health services on patient well-being and quality of care: A qualitative study in Malawi’s public healthcare facilities

Abstract

Healthcare facility environmental conditions – including water, sanitation, hygiene, waste management, cleaning, energy, and building design – contribute to safe and quality care delivery. However, how environmental conditions shape patient experiences have not been systematically assessed. We conducted a case study to examine the impacts of environmental conditions on patient well-being and quality of care through interviews with 56 patients and caregivers from all service delivery levels and geographic areas in public healthcare facilities in Malawi. We analyzed interview data to identify impacts of environmental conditions on multiple dimensions of well-being (physical, mental, social, and economic well-being) and quality of care (patient-centeredness, equity, safety, efficiency, and timeliness). Many participants reported poor environmental conditions and extensive impacts on well-being. Patients felt stress, fear of infection, and dissatisfaction with inadequate water, sanitation, and hygiene services. To cope with poor conditions, patients and family caregivers cleaned areas, fetched water, or spent money on supplies, leading to economic impacts. Facility conditions influenced perceptions of dignified and respectful care. Inadequate or overcrowded conditions led to negative encounters with other patients and healthcare workers. Patients felt more satisfied and respected when they observed healthcare workers performing hand hygiene or maintaining the facility. Findings demonstrate that environmental conditions influence numerous aspects of patient experience and well-being. The development of quantitative measures for well-being and quality of care would allow programs to routinely monitor these impacts and detect changes over time. Patient perspectives and priorities should be considered in future efforts to evaluate and improve environmental conditions in healthcare facilities.

1. Introduction

Environmental conditions in healthcare facilities include water, sanitation, hygiene, waste management, energy, and the goods, services, and practices that ensure a facility is safe, clean, and equipped to deliver healthcare (Adams et al., 2008). Safe and adequate environmental conditions have protective effects for individuals within the facility and in the local community. The role of environmental conditions in preventing healthcare-acquired infections and reducing the development of antimicrobial resistance is well-documented (Sehulster and Chinn, 2003; Allegranzi et al., 2011; Tomczyk et al., 2019; Storr et al., 2017; Nejad et al., 2011; Aleem et al., 2021). However, many healthcare facilities in low-resource settings lack adequate environmental conditions. Across least-developed countries in 2021, an estimated 53 % of healthcare facilities had basic water services, 21 % had basic sanitation services, 32 % had basic hygiene services, and 34 % had basic waste management services (Joint Monitoring Programme, 2022). These deficiencies undermine patient and healthcare worker safety (Watson et al., 2019).

Beyond infection prevention, environmental conditions shape experiences throughout the clinical encounter (Tu et al., 2022). Environmental conditions impact clinical and non-clinical staff, patients, caregivers, and the local community (Elling et al., 2022). Environmental conditions have been shown to influence healthcare workers’ ability to perform their jobs and deliver care while also affecting their physical, mental, and social well-being (Fejfar et al., 2021; Reuland et al., 2020). In qualitative research conducted in Malawi, healthcare workers reported barriers to delivering safe care and maintaining infection control due to poor infrastructure and overcrowding (Tu et al., 2022; Mangochi et al., 2023). Inadequate conditions impact healthcare workers economically by causing them to incur direct expenses (e.g., purchasing soap or cleaning supplies) and perform additional labor without additional compensation (Anderson et al., 2023; Ridge et al., 2021).

In addition to impacts on healthcare workers, prior research has indicated that environmental conditions influence patients’ safety, privacy, comfort, and willingness to seek care (Bouzid et al., 2018; Huisman et al., 2012). Prior studies have identified water, sanitation, and cleanliness as influencing patient satisfaction with healthcare facilities (Bouzid et al., 2018). However, many studies measure patient satisfaction with a single survey item and do not explore other types of potential impacts (Bouzid et al., 2018). In addition, family members are often involved in caring for patients in low-resource healthcare facility settings (Hogan et al., 2022). Poor environmental conditions may be detrimental to caregivers’ own well-being and ability to contribute to patient care (Hogan et al., 2022; Hoffman et al., 2012). Exploring the impacts of environmental conditions on patients and caregivers can inform discussions on the role of environmental health in care delivery, assess potential interventions, and shape strategies to better protect patients.

This study sought to identify and describe how environmental conditions impact patient experiences in a sample of healthcare facilities in Malawi. Our study had two specific objectives: (Adams et al., 2008) to assess the effects of environmental conditions in healthcare facilities on the quality of care rendered to patients and (Sehulster and Chinn, 2003) to assess the impact of environmental conditions in healthcare facilities on patients’ physical, mental, economic, and social well-being.

2. Methods

2.1. Study overview

We conducted a descriptive case study using qualitative interviews with patients and caregivers in Malawian healthcare facilities. We included participants who were seeking or receiving inpatient, outpatient, or maternity care for themselves as well as those at the healthcare facility accompanying someone seeking or receiving care, including patient caregivers, spouses, and guardians. Individuals present in other roles at the healthcare facility, such as staff, were excluded. We considered the following to be eligible environmental conditions: water, sanitation, hygiene, cleanliness, waste (garbage) management, energy (e.g., electrical lighting and heating and cooling mechanisms), and building design (e.g., facility size, ventilation, structural integrity, fencing). We included all healthcare facility-based environmental conditions in our analysis. Patients and caregivers may incur economic costs and experience mental effects from environmental conditions in the community and while in transit to the facility (Thaddeus and Maine, 1994). However, we excluded those impacts as outside the scope of this paper.

2.2. Conceptual framework

We investigated the effects of environmental conditions on patients’ health and economic well-being. We defined health effects in accordance with the World Health Organization’s (WHO) definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease.” Following the WHO definition, we categorized health effects as physical, mental, or social (World Health Organization, 1946). We also considered economic effects on patients and caregivers, as economic factors are a well-established social determinant of health (WHO Commission on Social Determinants of Health, 2008). Table 1 defines well-being effects as evaluated in this study.

Table 1.

Categories and definitions for well-being impacts.

Effect on well-being	Definition
Physical	Effects on the body resulting from exposure to biological, chemical, or mechanical hazards occurring either within the healthcare facility or on its grounds or through community-based exposure to hazards originating from the healthcare facility
Mental	Effects on one’s emotional or psychological well-being; effects are primarily non-physical, though physical sequelae may occur
Economic	Effects on one’s economic or financial well-being, including both direct costs (requiring one to expense money) and indirect costs (contributing one’s supplies or performing unpaid labor), as well as expenses and opportunity costs associated with complications or delays in treatment
Social	Effects on one’s relationships with staff, caregivers, or other patients, and impacts from social interactions while receiving healthcare, including implications to one’s social standing and perceptions of cultural sensitivity, fairness, and social isolation/rejection

We examined the impacts of environmental conditions on the quality of care using a framework from the Institute of Medicine (Institute of Medicine US Committee on Quality of Health Care in America, 2001), which was originally used to identify and analyze quality gaps in healthcare delivery in the United States. While it was developed for the context of the United States, the framework is applicable internationally, including a study to assess the impact of environmental conditions on quality of care from the healthcare worker perspective (Anderson et al., 2023). It identifies six aspects of quality healthcare: safety, patient-centeredness, timeliness, efficiency, equity, and effectiveness. We excluded effectiveness from our analysis, as it pertains to the appropriate provision of medical services based on scientific knowledge and is thus less likely to be influenced by the environmental conditions of the setting in which care is being administered. Table 2 provides our quality of care definitions (Institute of Medicine US Committee on Quality of Health Care in America, 2001).

Table 2.

Categories and definitions for quality-of-care impacts.

Quality of care measures	Definition
Patient-centeredness	The extent to which care conveys respectfulness, upholds privacy, affords dignity, and responds to patient preferences, needs, and values
Equity	The extent to which care does not vary in quality based on patient characteristics, including sex, race, age, ethnicity, religion, socioeconomic status, etc., as well as the extent to which challenges or benefits disproportionately impact patients based on their characteristics or demographics
Safety	Realization of the “do no harm” principle: preventing and mitigating harm to patients from care intended to help
Efficiency	The optimization of resources, including equipment, space, staffing, energy, and time, in the delivery of services to provide maximum benefits and avoid waste
Timeliness	The existence of wait times and delays in care, especially those that have the potential to cause harm to patients

2.3. Study setting and facility selection

Participant interviews were conducted in public healthcare facilities throughout Malawi from 14 June – 4 August 2017. These interviews were part of a larger project to analyze healthcare facilities’ environmental conditions and impacts on healthcare workers (Anderson et al., 2023). The study included facilities providing different levels of care (central hospitals, district hospitals, health centers, and health posts/dispensaries). The study sample was designed in collaboration with the Environmental Health Department of the Malawian Ministry of Health and Population. The sampling strategy has been described elsewhere (Anderson et al., 2023). Briefly, we first stratified into the regions of Malawi– Central, Northern, and Southern –to ensure a geographically representative sample and to allow for analysis of regional variability. Within each region, we selected one central hospital and several districts proportional to the region’s population. Within each district, we selected one district hospital and one health center. Finally, we selected the health post or dispensary most proximal to the health center in each district, as the health centers and health posts/dispensaries from each district were assessed on the same day.

Forty-five facilities were selected for the study. However, one was closed on the day of the study visit, and the research team was unable to recruit a participant for an interview in an additional four facilities. The final sample for this study therefore included forty healthcare facilities: three central hospitals, 14 district hospitals, 14 health centers, three health posts, and six dispensaries. These facilities served a median catchment population of 34,500 people; the smallest dispensary served 1000 people, whereas the largest central hospital served about 6 million. Table 3 summarizes healthcare facility characteristics, as they were observed by the research team on the day of the study visit.

Table 3.

Description of healthcare facilities’ characteristics, as observed by the research team at the time of the study visit.

Healthcare facility characteristics	Proportion (n)
The facility has multiple wards	75 % (30)
Improved water source is present onsite	95 % (38)
The water source is tested for microbial contamination	30 % (12)
All observed wards have at least one improved toilet*	8 % (3)
Hand hygiene stations are present at all observed points of care*	100 % (42)
Water and soap or alcohol-based handrub are available at all observed hand hygiene stations	55 % (22)
The facility has cleaning protocols	70 % (28)
The facility has a designated laundry area onsite	50 % (20)
Facility disposes of sharps waste safely†	70 % (28)
Facility disposes of non-sharps infectious waste safely†	55 % (22)

^*For facilities with multiple wards, sanitation, hygiene, and cleaning conditions were observed in the inpatient pediatric, maternity, and outpatient wards (as present in each facility)

^†Safe disposal methods comprised incineration, autoclave followed by disposal in a protected area, chemical disinfection followed by disposal in a protected area, or removal offsite to a protected storage area

2.4. Participant sampling and recruitment

We attempted to recruit 1–2 participants at each facility. Eligible participants were individuals aged 18 or older who were receiving or accompanying someone receiving care at the facility. Any individual receiving treatment—or serving as a caregiver to a patient receiving treatment—at the healthcare facility at the time of the study visit was eligible for inclusion, regardless of whether they had received any prior care at the facility. We excluded patients and caregivers under the age of 18.

In larger facilities with more than one ward, we recruited participants from the maternity, outpatient, inpatient, and/or pediatric wards. Participants were recruited by convenience based on their availability and willingness to speak with the research team at the time of the study visit.

2.5. Data collection

Data was collected through semi-structured interviews with patients and caregivers. Interviews sought to elicit patients’ expectations, observations, and perceptions of the environmental conditions of the healthcare facility they were visiting and how those conditions impacted their well-being and the quality of care administered at the facility. Caregivers were asked to reflect on these themes from the perspective of how environmental conditions impacted the patient they were accompanying.

We developed an interview guide to steer conversations with participants. The interview guide was initially developed in English, then translated into Chichewa. We did not conduct pilot pre-testing of the interview guide, but interview questions were revised for clarity and as thematic areas reached saturation throughout the study period based on participant responses (Sofaer, 1999).

Initial interview questions asked about the participant’s current visit to the healthcare facility, including their reason for seeking care, satisfaction with their visit, and their impression of the facility’s conditions, staff, and services. Questions then asked about patients’ experiences with and perspectives on specific environmental conditions of the facility. Finally, participants were asked to compare the facility with other public facilities they had visited before and to describe their past experiences receiving maternity care, if applicable.

Interviews were conducted in Chichewa at the healthcare facility, in a private room inside or within the yard or compound. With the written consent of the participant, interviews were audio-recorded, then transcribed in Chichewa. Transcriptions were translated to English for analysis.

2.6. Analysis

We conducted a thematic analysis of the transcripts. First, we developed deductive codes based on the definitions presented in Tables 1 and 2 (i.e., our conceptual frameworks for patient well-being and quality of care). Two authors then coded a subset of three interviews and convened to discuss how our codes aligned with the transcripts’ content. We revised the codebook to improve the fit of deductive codes and added inductive codes to reflect themes that were not captured by existing codes. A single author then coded the entire data set in Dedoose (Version 9.0.107) (SocioCultural Research Consultants, 2021). We analyzed the coded dataset to describe and synthesize participant perspectives within each well-being and quality of care domain.

2.7. Ethics

Ethical approval and all relevant research permits were received from the University of North Carolina at Chapel Hill’s Office of Human Research Ethics (approved non-biomedical research, project no. 16–1682) and the Malawi Health Sciences Research Committee (approval no. UNCPM 21908). We obtained permission from healthcare facility directors for all research activities conducted at each healthcare facility and written informed consent from all participants prior to interviews.

3. Results

3.1. Participant demographics

We conducted interviews with 56 participants across 40 healthcare facilities. Most participants (86 %) were female. Of participants who reported their age (n = 15), the mean reported age was 32 years. Nineteen participants (34 %) were receiving or accompanying a patient receiving inpatient care, while 36 (64 %) were receiving or accompanying someone receiving outpatient care. Approximately one-third of participants were caregivers for a patient, most commonly a child. Interviews took place at facilities across levels of care. Table 4 presents participant demographics.

Table 4.

Summary of the demographics and characteristics of the 56 participants interviewed.

Participant demographics	Proportion (n)
Gender
Female	86 % (48)
Male	9 % (5)
Not reported	5 % (3)
Relationship to patient
Self	68 % (38)
Caregiver	32 % (18)
Visit Type	Visit Type
Inpatient	34 % (19)
Outpatient	64 % (36)
Unknown/not reported	2 % (1)
Facility type visited
Central hospital	11 % (6)
District hospital	48 % (27)
Health center	25 % (14)
Health post/dispensary	16 % (9)
Level of care*
Primary	41 % (23)
Secondary	48 % (27)
Tertiary	11 % (6)
Geographic region
Northern	23 % (13)
Central	34 % (19)
Southern	43 % (24)

^*Primary care encompasses health posts, dispensaries, and health centers. Percentages are rounded to the nearest whole number and may not sum to 100 %

3.2. Effects on well-being

Patients reported that healthcare facilities’ environmental conditions impacted their physical, mental, economic, and social well-being. Poor or insufficient environmental conditions were common and typically produced adverse impacts. However, sufficient environmental conditions supported well-being.

Tertiary healthcare facilities in urban locations typically had better environmental conditions, therefore patients and caregivers sampled from these facilities typically reported more favorable experiences. However, where urban, tertiary healthcare facilities had poor environmental conditions, we found their effects on patient wellbeing to be similar to the effects of poor environmental conditions on patients in other locations and healthcare facility types. For simplicity, we therefore report our findings in aggregate across the entire study sample. Table 5 summarizes the primary findings. Supplementary File 1 contains additional results.

Table 5.

Summary of impacts from the environmental conditions studied on different dimensions of patient well-being.

	Impact on Well-being
Environmental Condition	Physical	Mental	Economic	Social
Water	Exposure to pathogens in unsafe drinking water; dehydration	Satisfaction from accessible, clean water; dissatisfaction in challenges accessing water; stress and worry about water access and quality	Purchasing water; unpaid labor for fetching or treating water	Caregivers fetching and/or treating water for patients; fetching water for facility staff
Sanitation	Exposure to pathogens from contaminated sanitation facilities; relieving oneself outside or not going due to insufficient clean toilets	Dissatisfaction and lack of dignity from dirty toilets; stress over infection risks, privacy, and physical safety	Unpaid labor helping clean sanitation facilities	Staff educating patients on using facilities; patients blaming other patients for dirty facilities
Hygiene	Exposure to pathogens from inability to wash hands; contact with staff who do not wash hands or wear gloves	Dissatisfaction and stress over inability to wash hands; dissatisfaction, stress, and lack of dignity from bathing in unclean/non-private washrooms	Purchasing or bringing own soap from home; unpaid labor fetching and heating water for hygiene	Staff educating patients on hygiene; patients having adverse perceptions of other patients’ and staff’s hygiene
Cleanliness	Exposure to pathogens from dirty surfaces and bedding; exposure to insects from lack of bed nets	Satisfaction from cleanliness and availability of bedding; dissatisfaction and stress if sleeping without bedding or bed nets	Unpaid labor helping clean the facility, bringing own bedding from home	Caregivers cleaning facilities and bringing bedding; patients pleased by staff cleaning, blame fellow patients for unclean facilities
Waste Management	Exposure to improperly discarded medical waste; inhalation of toxins or smoke from burning trash	Satisfaction with facilities having designated garbage areas; dissatisfaction with improperly discarded garbage	No substantial effects described	Staff educating patients on waste management; patients blame fellow patients for litter
Energy	Uncomfortable temperatures from lack of heating and cooling; electrical outages compromising water supply	Dissatisfaction with lack of heating and cooling; stress and dissatisfaction when energy compromised water supply	Bringing torches or buying candles; unpaid labor fetching water during outages	No substantial effects described
Building Design	Exposure to pathogens from overcrowded facilities; exposure to weather and elements from poor structural integrity	Dissatisfaction from crowds; lack of dignity from poor privacy; satisfaction and dignity from curtains and private areas	No substantial effects described	Negative interactions with staff due to crowds, care delays, and caregivers not having enough space to sleep and cook

3.2.1. Physical

Environmental conditions impacted patients’ physical well-being primarily through exposure to biological hazards such as infectious pathogens, disease vectors, medical waste, and bodily fluids. Soap was unavailable in many facilities, and thus, participants often could not perform proper hand hygiene, leading to fears of infection. Sanitation facilities were often unclean, exposing users to human excreta and bodily fluids, and medical waste was sometimes improperly discarded in sanitation facilities. Participants commonly expressed concerns about their risk of infections from unclean sanitation facilities. Cleanliness problems also led to biological exposures on wards: Many facilities did not provide clean bedding or functional bed nets, and some participants reported being bitten by mosquitoes during overnight stays at healthcare facilities.

Some participants experienced dehydration from inaccessible or scarce drinking water. Many facilities had an inconsistent water supply. When facing water shortages, some participants successfully sourced water from a facility’s secondary source (e.g., a borehole in the facility’s yard) or the community. Occasionally, patients reported that water was available but that patients shared the same drinking cup, potentially resulting in exposure to pathogens.

“When there is [an electricity] blackout there is no access to water, and we can stay for the whole day without water.”

– Outpatient, District Hospital

Chemical and mechanical impacts were uncommonly reported. Participants reported garbage burned at healthcare facilities and expressed concern that this could expose them to harmful chemical compounds. Some noted that used syringes were improperly discarded. Participants raised concerns about the risk of injury that could arise from contact with poorly-disposed sharps.

3.2.2. Mental

Environmental conditions impacted patients’ satisfaction, stress and worry, dignity, and care-seeking behavior. Satisfaction and dignity were frequently linked to experiences with sanitation facilities. Insufficient numbers of toilets, cleanliness problems, and a perceived lack of privacy or safety in sanitation facilities resulted in stress and dissatisfaction. Some participants said they avoided using toilets due to poor conditions. Similarly, women experienced stress and worry when using unclean or non-private washrooms to bathe themselves, especially after delivery. Sanitation facilities alleviated stress and upheld dignity when they were clean and structurally sound, had separate facilities designated for men and women, and had adequate doors with locks.

“The toilets are not good they are blocked, and we sometimes go to the men’s rooms, its challenging and I feel we could contract diseases there.”

- Inpatient, District Hospital

Patients observed healthcare facility cleaning practices, and some were pleased to see workers performing cleaning tasks, such as sweeping and mopping floors. Some participants highlighted the use of chemicals in cleaning, feeling that the use of chemicals contributed to a higher level of cleanliness. The aesthetics of a space, including whether it was littered and its apparent tidiness, influenced patients’ perception of an area’s cleanliness and subsequent satisfaction. One participant described their facility as clean and hygienic, making it “attractive.” Additional participants spoke of a facility’s grounds, connecting the external appearance of the facility to its perceived cleanliness.

Electricity and lighting were important for patients’ perceived safety and satisfaction, particularly those seeking care at night. The availability of electricity at healthcare facilities influenced some participants’ decisions to seek care from specific facilities. Participants suggested that a facility with electricity could better provide medical services. Some facilities’ water sources required an electricity supply. Inconsistent energy and episodic outages, therefore, presented challenges for accessing water. When outages occurred, patients and caregivers often had to travel further to fetch water or use water sources they deemed less safe or of poorer quality. Participants were frustrated and dissatisfied when a facility’s energy issues made it difficult to access water.

The building design and structural integrity of healthcare facilities contributed to perceptions of safety and dignity. Facilities were often overcrowded, making it challenging to maintain patients’ privacy. The quality of sleeping areas influenced stress, worry, and dignity; patients and caregivers were worried when bed nets were unavailable, and one participant expressed distress in expecting to sleep on the floor in a crowded facility. Some facilities’ layouts afforded privacy despite their small size. A maternity patient described appreciating having curtains surrounding her bed, which provided privacy and conveyed respect while she delivered. Building designs that provided acceptable areas for patients and caregivers to sleep were better able to foster dignity.

3.2.3. Economic

Healthcare facility environmental conditions had direct and indirect economic effects on participants. Direct effects arose when patients or their families purchased supplies or contributed money in response to poor environmental conditions or insufficient resources. Since soap was often unavailable at facilities, many participants purchased their own in the community. Some reported being asked to contribute money for candles or paraffin in settings without electricity or during blackouts. Some patients, unable to access drinking water from the facility, purchased their own at local markets.

Indirect economic effects occurred when patients and caregivers brought items from home or performed unpaid labor to improve environmental conditions. Participants reported bringing materials from home, including soap and hand-drying materials, bed linens, water cups and containers, and flashlights for seeking care at night. When running water was unavailable at the facility, patients and caregivers fetched water from other sources for themselves, other patients, and healthcare workers. Some also reported boiling or chemically treating water to make it safer.

“If there is no water [the healthcare workers] tell us that they will not open the hospital because for them to work they need to wash hands, so what should we do? So we go into the community to fetch water with drums at the borehole, then they start work”

– Outpatient, Dispensary

3.2.4. Social

Interactions at healthcare facilities impacted patients’ social well-being. Environmental conditions influenced perceptions of cultural consideration, social rejection or isolation, and interpersonal relationships.

Sanitation services and hygiene procedures impacted patients’ perceptions of cultural sensitivity. Participants conveyed culturally informed expectations for a facility’s sanitation services, including that men’s and women’s toilets should be separate, that patients’ and staff’s facilities should be separate, and a reluctance to be seen going to the toilet. These expectations were grounded in cultural norms and associated with desires for privacy and safety. Healthcare facilities that met such expectations conveyed a sense of cultural consideration.

Participants expected staff to contribute to the cleanliness of healthcare facilities and maintain satisfactory personal hygiene. Participants associated healthcare workers’ hand hygiene and infection prevention measures with health and respect and were satisfied when they saw them performing hand hygiene or cleaning the facility. Participants commonly reported that staff educated patients on hand hygiene, proper use of sanitation facilities, and infection prevention measures.

Negative interactions with staff were often associated with facilities’ insufficient building size and staff’s need to ration limited resources across large patient populations. Additionally, some participants felt socially isolated or rejected when healthcare workers reprimanded or intimidated them. Occasionally, these exchanges resulted from environmental effects; one participant described staff shouting at patients about improperly discarded garbage, and several patients expressed fear of discussing poor environmental conditions with staff.

“It’s difficult just to come to the hospital and start complaining to hospital staff on how unhygienic the hospital is; they will think you are a difficult person or trying to be smarter than everyone else, so even if you see something bad, you can’t talk.”

– Outpatient, Central Hospital

Environmental conditions shaped patients’ relationships with their caregivers and with other patients. Caregivers, especially of admitted patients, took on cleaning and water-fetching duties to help patients cope with the facilities’ poor environmental conditions, and sometimes helped perform duties for other patients or staff. Facilities were often overcrowded, which created challenges for maintaining cleanliness and led to negative interactions between patients. Participants sometimes disapproved of other patients’ actions regarding sanitation, cleaning, hygiene, and managing garbage.

“Because we are so many of us here there is no hygiene. Everyone does what she wants because we are all sorts of different people here.”

– Inpatient, District Hospital

3.3. Effects on quality of care

Environmental conditions of healthcare facilities impacted multiple dimensions of quality of care: patient-centeredness, equity, safety, efficiency, and timeliness. Supplementary File 1 contains additional results.

3.3.1. Patient-centeredness

Building design could enhance or degrade the patient-centeredness of care. The size of facilities, presence of security guards, and infrastructure affording privacy, including designated maternity wings, curtains around beds, and separate wards and sanitation facilities for men and women, were all relevant aspects of the buildings’ design. Having acceptable places to sleep conveyed respect to admitted patients and their caregivers. Facilities that were especially dirty or did not afford privacy or security to users conveyed disrespect. When patients arrived at healthcare facilities in the evening, facilities with energy, lighting, and staffing available overnight were better equipped to deliver services.

Patient-centeredness was especially relevant for maternity patients. Beds to sleep in overnight and kitchens to cook food in were essential but not consistently available for maternity patients arriving at facilities early to await labor. Using toilets and bathing in an acceptable environment was important to maternity patients and conveyed respect and dignity. The availability and condition of these sanitation and hygiene facilities varied.

“For the pregnant women, some of them come from very far, and they are told that they should come to await labor here at the facility despite there not being beds and a cooking area, so this brings up a lot of problems.”

– Outpatient, Health Center

3.3.2. Equity

Some patients were especially burdened by challenges stemming from poor environmental conditions, undermining equity of care. Many patients and families brought supplies from home to cope with poor environmental conditions; those with minimal financial resources or without supplies from home were disadvantaged.

“This place is cold, and not everyone brings bedding when coming here. Like the guardians, they go to sleep outside, and there it is cold.”

– Inpatient, Central Hospital

Some participants described challenges in accessing water sources and using garbage bins not located near the facility. Reports of fetching water from outside the facility were common. Patients without caregivers accompanying them to the water source (or retrieving water for them) and those with severe health conditions or mobility issues faced difficulty accessing water from these sources.

3.3.3. Patient Safety

Participants described exposure to pathogens from poor sanitation and lack of hygiene or cleanliness within facilities. They identified the increased risk of acquiring infections or other diseases while receiving care in the facility as impacting patient safety.

3.3.4. Efficiency and timeliness

Efficiency and timeliness of care were closely related. Shortages in healthcare staff and limited resources made providing care to large populations and maintaining facilities’ environmental conditions difficult. When resources like soap and gloves were unavailable, workers struggled to provide a clean facility and meet hygienic standards. Some facilities did not open until the facility had been cleaned. Therefore, the availability of water, cleaning supplies, and labor determined the timeliness of patient care.

“In the past, we used to stay long, maybe up to before 10 am before work would start. But because of these women volunteers that have joined here, they help with weighing, mopping, and helping with this and that, by 8 o’clock, the doctor has arrived at work. That itself I have seen and noticed should continue.”

– Outpatient, Health Center

Building design, energy, and water were the most influential environmental conditions for care efficiency. Healthcare facilities often operated in buildings too small for their patient populations, leading to overcrowding and undermining efficiency. However, some facilities were able to optimize their space and provide efficient and timely care despite limited resources. A consistent energy supply promoted efficient care, but inefficiencies and time delays arose when facilities experienced power outages. Patients seeking care at facilities that lacked lighting at night also experienced delays in receiving care.

Water was closely connected to efficiency. An adequate, consistent water supply promoted efficient care, while difficulties in accessing water introduced inefficiencies. Tasks associated with water could be time intensive. Many participants had to fetch water from sources external to the facility, including taps and boreholes in the community. When a facility’s primary water source was broken or unavailable, patients and caregivers had to identify alternative sources, which required unpaid labor and time.

4. Discussion

This study examined the impacts of environmental conditions on patient well-being and quality of care at 40 healthcare facilities in Malawi, finding that many patients experienced adverse impacts from inadequate environmental conditions. Participants connected poor environmental conditions with increased risks of acquiring infection or disease, and the resultant fear and stress of infection contributed to frustration with healthcare workers or other patients. To cope with poor conditions, patients and caregivers performed unpaid labor or spent their money on supplies, leading to economic impacts. Positive impacts on well-being arose when patients saw healthcare workers performing hand hygiene or cleaning the facility, indicating that infection control measures play a role in patient satisfaction and well-being and protecting physical health. The layout, visual aesthetics, and privacy of facilities were also determinants of satisfaction and perceived quality of care. Findings reveal opportunities to enhance well-being through the implementation of patient-centered interventions and the development of indicators for monitoring impacts. The impacts that we observed in a Malawian patient population may be similar to those occurring in other global low-resource settings where healthcare facilities lack safe environmental conditions (Joint Monitoring Programme, 2022).

We found that patients frequently encountered difficulties accessing safe water, sanitation, and hand hygiene services while at the healthcare facilities, leading to dissatisfaction, dehydration, and fear of infection. Prior studies in low-resource healthcare facility settings have similarly found that patients and caregivers experience poor sanitation and hygiene conditions, leading to frustration and undermining their ability to maintain personal hygiene (Hogan et al., 2022; Hoffman et al., 2012; Panulo et al., 2024). Research from Bangladesh has found that caregivers lack access to hand hygiene supplies despite being frequently exposed to patients’ bodily fluids, contributing to the risk of infection transmission (Horng et al., 2016; Islam et al., 2014). Strategies to improve patient and caregiver infection control behaviors could improve well-being and prevent the spread of infections (Srigley et al., 2016). An intervention to provide hand hygiene infrastructure, training, and reminders in maternal healthcare settings in Cambodia improved hand hygiene behavior among patient caregivers, although absolute levels of hand hygiene remained low (Nalule et al., 2022). A program to install drinking water and hand hygiene stations in Kenyan healthcare facilities found improvements in hand hygiene and water treatment in nearby households, indicating that patients and caregivers who adopt new hygiene behaviors in healthcare facilities may sustain and disseminate these practices in communities (Bennett et al., 2015). Programs to improve the accessibility of water, sanitation, and hygiene infrastructure for patients and caregivers could prevent infections and support well-being.

Beyond direct health impacts, poor environmental conditions lead to care delays and economic costs for patients and communities. Study participants experienced long waiting times for care when facilities were not cleaned, undermining quality of care. Prior research among maternal patients in Malawi has found that delays in receiving care after reaching a healthcare facility are common and that these delays contribute to increased risk of disease complications and mortality (Mgawadere et al., 2017). Patients in our study performed unpaid labor to clean healthcare facilities and fetch water, and purchased soap, water, and other essential resources when healthcare facility-provided supplies were unavailable. This spending may represent a large, under-recognized financial burden in low-resource healthcare facilities. Prior studies have found that informal payments are highly prevalent in healthcare facilities in sub-Saharan Africa and that patients often make these payments in hopes of receiving higher-quality care. However, little research has examined payments related to environmental conditions (Kabia et al., 2021). Research conducted in Kenya found that households spend considerable time and money to cope with poor access to water supplies (Cook et al., 2016), and our study suggests that similar dynamics exist in healthcare facilities. Poor operations and maintenance of water infrastructure also have economic impacts, as patients and healthcare workers may perform additional labor or pay for their water when healthcare facility infrastructure is non-functional (Tantum et al., 2024). Effective environmental infrastructure management and hiring additional cleaning and maintenance staff would reduce the need for patients and caregivers to contribute money or labor. Healthcare facility revenue-generation programs, such as programs to sell treated water to communities, could financially support environmental improvement and reduce informal payments (Huttinger et al., 2017).

While this study used qualitative methods to explore patient and caregiver perspectives, developing and applying quantitative indicators for well-being and quality of care would strengthen impact measurement and monitoring. Researchers in the community and household water, sanitation, and hygiene (WASH) sector have developed scales and indices to quantitatively measure water insecurity experiences, sanitation-related quality of life, and women’s WASH-related empowerment (Young et al., 2019; Ross et al., 2022; Sinharoy et al., 2023; Caruso et al., 2017). Prior research has also examined social benefits arising from improved water infrastructure in community settings, finding that access to piped water was associated with increased happiness and reduced worry in households (Winter et al., 2021). Impact measures developed in community settings could be adapted and applied to measure the impacts of environmental conditions in health-care facilities. In our study, patients frequently reported well-being impacts associated with the accessibility and quality of water and sanitation, suggesting that indicators from community WASH may translate to the facility context. Quantitative indicators could be integrated into evaluation studies or routine health system monitoring programs to evaluate impacts of interventions and advocate for increased funding.

4.1. Limitations

Most study participants (86 %) were female, so findings may not fully reflect the experiences of male patients in Malawian healthcare facilities. A majority of participants (64 %) had visited an outpatient ward at the healthcare facility, and outpatient experiences with environmental conditions may have differed from those of inpatients. Our methods relied upon participants’ descriptions of environmental conditions and their self-reported impacts. While we collected data on the characteristics of healthcare facilities in our study, we did not attempt to verify participants’ specific reports or experiences in individual facilities. Participants may have hesitated to identify deficiencies or describe negative impacts to avoid reputational loss, leading to underestimating the negative effects of poor environmental conditions. On the other hand, participants may have highlighted negative results in hopes that doing so would help their facility or community receive support for improvements.

Furthermore, we sampled 1–2 patients per facility, prioritizing including a wider range of facility types and geographies rather than sampling a smaller number of facilities but including more participants per facility. However, because of this, our opportunities to triangulate findings between multiple patients—or other individuals such as staff members—was limited. Future research that includes an in-depth sample of patients, staff members, and caregivers within a single facility would be valuable.

5. Conclusion

Environmental conditions in healthcare facilities influence patient well-being and perceived quality of care. Our study found that poor environmental conditions in low-resource healthcare facilities in Malawi led to dissatisfaction and fear of infection, contributed to delays in care, and generated economic costs for patients. Findings demonstrate that, while environmental conditions are conventionally linked to infection control and physical health, these conditions also confer a range of other impacts. Further study and quantification of the impacts of environmental conditions on well-being and quality of care could strengthen the investment case for infrastructure in healthcare facilities and ultimately lead to improvements in conditions. Strategies to enhance environmental conditions in healthcare facilities can increase patient dignity and well-being while also supporting the health system’s ability to deliver high-quality care.

Supplementary Material

Appendix A. Supporting information

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.ssmhs.2025.100064.