Assessment of infection prevention and control in public hospitals in the post war Tigray region of Ethiopia using the WHO Infection Prevention and Control Assessment Framework (IPCAF)

Abstract

Background

Strengthening infection prevention and control (IPC) is crucial for mitigating the risks of infections and antimicrobial resistance in healthcare facilities. The conflict in Tigray has had serious repercussions on the health system. This study aimed to assess the implementation of the IPC core components of (CC) public health facilities in post-war Tigray, Ethiopia, using the World Health Organization (WHO) IPC Assessment Framework (IPCAF) and hand hygiene self-assessment framework (HHSAF) standard tools.

Methods

A cross-sectional study was conducted across 35 public health facilities comprising referral, general, and primary hospitals in Tigray state from June to July 2024. Data were collected by interviews of the IPC focal or managers at the accessible hospitals, using standardized WHO IPCAF and HHSAF tools. Descriptive statistics, including mean, median, interquartile range (IQR) and standard deviation, were utilized to summarize the data. Pearson correlation analysis was performed to examine the relationship between IPCAF and HHSAF scores. An independent t-test was employed to compare mean IPCAF scores by type of healthcare facility.

Results

From a total of 35 eligible healthcare facilities invited, 33 participated in the survey, resulting in a 94% response rate. The mean age of respondents was 36 years (SD = 8), with an average of 10 service years (SD = 7). Most respondents were IPC focal persons (48.5%), followed by chief executive officers (27.3%). The median IPCAF score was 348 (IQR: 258–439), indicating a basic IPC level. Three facilities (9%) exhibited an inadequate IPC level, which means scores below 200. Twenty-one facilities (63.6%) demonstrated basic IPC levels, 8 facilities (24.2%) had intermediate IPC levels and only 1 facility (3%) achieved an advanced IPC level. A statistically significant positive correlation was identified between IPCAF and HHSAF scores (r = 0.765, p < 0.001).

Conclusions

The levels of implementation of the WHO CC in post-war health facilities in Tigray were found to be unsatisfactory, with limitations evident across all zones and types of facilities. This situation increases the risk of healthcare-associated infections for healthcare personnel, patients, and visitors. A significant positive correlation was observed between IPCAF and HHSAF scores. Addressing the identified gaps through enhancements of IPC core components and capacity building is essential for preventing healthcare-associated infections. Longitudinal studies to monitor IPC implementations are recommended for ongoing assessment and improvement.

Supplementary Information

The online version supplementary material available at 10.1186/s13756-026-01746-3.

Background

There is a high prevalence of infectious disease agents that contribute to healthcare-associated infections (HAIs) in healthcare settings [1]. On average, the prevalence of HAIs at any given time ranges from 7% in high income countries to 10% in low- and middle-income countries (LMICs). Approximately 10% of HAIs results in death [2]. Strengthening infection prevention and control (IPC) measures offers effective strategies to mitigate the risks of infections and combat antimicrobial resistance (AMR) within healthcare environments [3–5].

Despite its importance, many health systems around the world do not allocate resources for the implementation and monitoring of IPC programmes, particularly in low-income settings [3–5]. In order to prevent present and future threats from infectious diseases, strengthen health service resilience, aid in the fight against antimicrobial resistance (AMR), and enhance the general quality of health care delivery, it is critical to monitor the IPC programs [6]. The World Health Organization (WHO) introduced the Infection Prevention and Control Assessment Framework (IPCAF) at National and Acute Health Care Facility Level in 2016 [2]. The purpose of the tool is to evaluate the IPC programmes which are effective at monitoring IPC compliance in healthcare facilities [2, 7]. However, little is known about its application in resource constrained settings, such as Sub-Saharan Africa [8, 9]. According to earlier research, there is a direct correlation between IPC level and hand hygiene compliance [10, 11], which points to hand hygiene practice being explained by IPCAF status, and vice versa.

The war in Tigray, which begun in November 2020 [12], has severely impacted civilian structures, targeting hospitals, schools, factories, and businesses. Many facilities have been shelled, looted, or destroyed by Ethiopian federal forces, Amhara regional militias, and Eritrean armed forces [13, 14]. Conflict-affected settings face specific barriers to the effective implementations of IPC programmes, especially in secondary and tertiary care. Inadequate infrastructure, shortages of resources including water, sanitizer and soap, enough health workforce, insufficient staff education, lack of in-service IPC training and supervision as well as high numbers of visitors have been identified barriers to the effective implementation of IPC programmes in conflict affected healthcare facilities [15]. However, there is a notable lack of scientific literature addressing IPC implementations within war zones. Insights into these situations are essential for future planning regarding healthcare workers in similar situations. This is especially true of Tigray, where few studies with sufficient data have been published [16]. This study describes the implementation of the IPC core components of public health facilities in post-war Tigray, Ethiopia, utilizing the IPCAF tool and its implications. It also examines the relationship between IPC levels and the level of hand hygiene implementation.

Method

Study setting description

The Tigray region, located in northern Ethiopia which consists of seven zones and 93 districts, with a population of approximately six million people [17]. The study was conducted across all accessible public health facilities in Tigray regional state, including referral (n = 2), general (n = 13), and primary hospitals (n = 24), from June to July 2024. These facilities provide promotive, preventive, curative, and rehabilitative care. The research encompassed six zones of Tigray: Southern, Southeast, Mekelle, Eastern, Central, and Northwest. The Western zone, which contains two primary hospitals and two general hospitals, was deemed inaccessible and therefore not included in the study. In total, 35 facilities were invited to participate in the study. (Fig. 1)

Fig. 1.

Map of study area

Study design & population

A cross-sectional study design was applied to describe the level of implementation of IPC programmes in the facilities. Eligible facilities with the category of referral, general and primary hospitals were identified from a list of all public health facilities in the Tigray region. However, hospitals located in Western Tigray were inaccessible due to insecurity concerns and were therefore excluded from the study. Health centres and health posts were also excluded due to the low patient load when compared to hospitals. All included health facilities and their leadership were visited and presented with a support letter written by the Tigray Regional Health Bureau to ask for permission to conduct. The study was conducted from June to July 2024 by environmental health professionals under the direct supervision of the principal investigator. IPC focal persons and managers were the respondents of the study. The manager could either be the head of the health facility (medical director, chief executive officer), or the head of nursing (matron). One person was interviewed per hospital using the electronic tool Kobo. Respondents were selected based on the roles and their involvement in infection prevention and control activities within the facility. The data was stored in a server accessible only for the researcher and data manager..

Questionnaire description

A standardized, English-language, interview-based IPC assessment was conducted, using the WHO IPCAF questionnaire [2] (See supplementary material). The primary outcome of this study is IPCAF level in post war settings of Tigray regional state, Ethiopia and IPCAF results were the primary outcome of this study. At the same time, the level of hand hygiene implementation was assessed utilizing the WHO Hand Hygiene Self-Assessment Framework (HHSAF) tool [18] published elsewhere [19]. The IPCAF questionnaire is a structured, validated closed-format instrument divided into eight sections that correspond to the eight core components of IPC as outlined by WHO: IPC program (CC1) 10 items; IPC guidelines (CC2) 8 items; IPC education and training (CC3) 10 items; Health care-associated infection (HAI) surveillance (CC4) 15 items; Multimodal strategies for implementation of IPC interventions (CC5) 5 items; Monitoring/audit of IPC practices and feedback (CC6) 8 items; Workload, staffing and bed occupancy (CC7) 8 items; and Built environment, materials and equipment for IPC at the facility level (CC8) 17 items of yes/no questions or multiple-choice options with corresponding values. Each core component is assigned a maximum score of 100 points, resulting in a total possible score of 800 points, where higher scores indicate better IPC performance [2]. The level of adherence to the IPC core components of each facility is classified into four categories based on the average weighted score, as detailed in Table 1.

Table 1.

Infection Prevention and Control Assessment Framework (IPCAF) score level categories and the interpretation

IPCAF score	Category	Interpretation
0–200 points	Inadequate IPC level	IPC core components implementation is deficient with a significant improvement required
201–400 points	Basic IPC level	Only some aspects of the IPC core components are in place without sufficient implementation. Additional improvement is needed
401–600 points	Intermediate IPC level	Most aspects of the IPC core components are properly implemented. The facility should continue to improve the scope, implementation, and quality and focus on the development of long-term plans to sustain and promote the existing IPC program activities
601–800 points	Advanced IPC level	The IPC core components are fully implemented according to the WHO recommendations and appropriate to the facility’s needs

In addition, the HHSAF questionnaire is a validated tool divided into five sections with 27 indicators [18]. The components are system change (6 questions); training and education (5 questions); evaluation and feedback (5 questions); reminders in the workplace (5 questions); and institutional safety climate for hand hygiene (6 questions). Each section has a maximum score of 100 points, with a total maximum of 500, where higher scores are best. The hand hygiene score was categorized as follows: 0–125 points: Inadequate performance; 126–250: Basic performance; 251–375: Intermediate (or consolidation) performance; and 376–500: Advanced (or embedding) performance.

Data management

Data collected using ODK, which was then extracted from the server and checked for completeness and any inconsistencies before the actual analysis.

Data analysis

Statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS), version 25. Descriptive statistics, including the median and interquartile range (IQR), were calculated to summarize the data. The Shapiro-Wilk test of normality was conducted to evaluate the distribution of the data, revealing that the data followed a normal distribution (p > 0.05). Independent t-tests were performed to compare IPCAF scores across different types of health facilities. Furthermore, Pearson correlation tests were utilized to explore the relationship between IPCAF levels and HHSAF levels. A significance level of p < 0.05 was established for all analyses.

Results

Demographic information

Out of 35 eligible public health facilities invited, 33 participated in this survey, resulting in a response rate of 94%. Two facilities, Maytsebri primary hospital and Alamata general hospital, which are part of the accessible zones, were excluded due to transportation challenges and service disruptions because of regional insecurity. Additionally, four facilities in the western zone of Tigray were excluded because the area is currently occupied by non-Tigray forces. The participating facilities included 2 referral, 10 general, and 21 primary hospitals from six accessible zones in Tigray.

The mean age of the respondents was 36 years (SD = 7.5), with an average of 10 years of service (SD = 7). Most respondents were male (n = 28, or 84.8%). Most participants were the IPC focal person (48.5%), followed by Chief Executive Officers (27.3%). The rest includes medical directors, matrons/heads of nursing, and other delegates accounted 24.2% of the total.

Total IPCAF scores

All questions of the IPCAF tool were fully completed, with no missing data. The overall median IPCAF score summarized for the 33 public health facilities was 348 (IQR: 258–439) which is an indicative of a basic IPC level. Of the 33 facilities assessed, three (9%) facilities had an inadequate IPC level, 21 (64%) facilities had a basic IPC level, 8 (24%) facilities had an intermediate IPC level, and 1(3%) facility had an advanced IPC level (Fig. 2). The lowest IPC score was found in IPC education and training (CC3) followed by multimodal strategies (CC5) and monitoring and audit of IPC practices and feedback (CC6). The details of the findings related to each core component are described below.

Fig. 2.

IPC level in 33 public hospitals across Tigray, Ethiopia

CC1: IPC programme

The calculated median IPCAF score for CC1 across the 33 assessed health facilities was 55, with an interquartile range (IQR) of 40–73. This is the highest value compared to the other core components. Of these 33 facilities, 15 had established IPC programmes with clearly defined objectives and annual activity plans; 16 facilities had IPC programmes without clearly articulated objectives; and 2 facilities did not have an IPC programme in place. Additionally, half of the facilities lacked an IPC committee that actively supported the IPC team. Only 7 had allocated a budget specifically for the IPC programme, which covered IPC activities, including staff salaries.

CC2: IPC guidelines

The median and IQR IPCAF score for CC2 was 53 (25–73) points. In 13 of these facilities, frontline healthcare workers participated in both the planning and execution of IPC guideline implementation alongside IPC personnel. Relevant stakeholders, including leading doctors, nurses, hospital managers, and quality management officials, were involved in the development and adaptation of IPC guidelines in these 13 facilities. In 14 facilities, healthcare workers receive targeted training related to new or updated IPC guidelines introduced within their respective facilities. Moreover, 13 facilities regularly monitor the implementation of at least some IPC guidelines.

CC3: IPC education and training

The median and IQR IPCAF score for CC3 was 25 (10–50). Twenty-two facilities had personnel with expertise in IPC and/or infectious diseases who are qualified to lead IPC training sessions. However, only two facilities provided both new employee orientation and regular mandatory IPC training for all healthcare workers, conducted at least annually. Six facilities offered new employee orientation and annual IPC training, but it was not mandatory. Two facilities provided orientation exclusively for new healthcare workers. Alarmingly, 23 facilities reported that healthcare workers received IPC training either rarely or never. Additionally, there was no periodic evaluation of the effectiveness of training programmes such as hand hygiene audits or knowledge assessments in 21 facilities. While 12 facilities conducted periodic evaluations, these are not performed regularly. Furthermore, 24 facilities have reported no integration of IPC training into clinical practice. Four facilities indicated that IPC training is fully integrated across all disciplines, while five facilities noted integration in some disciplines. Lastly, only 10 facilities offered ongoing professional development or education for IPC staff, such as attending conferences or courses, whereas the remaining 23 facilities do not provide such opportunities.

CC4: HAI surveillance

The median and IQR IPCAF score for CC4 was 45 (36–66). Nineteen facilities reported that surveillance is a defined component of their IPC programme. However, five facilities do not have personnel assigned to oversee surveillance activities. Overall, there are limited surveillance activities taking place in these health facilities, and twelve of them do not regularly assess whether their surveillance efforts align with the current needs and priorities of their institution.

CC5: multimodal strategies

The median IPCAF score for CC5 was 30, with an IQR of 5 to 70. Fourteen facilities reported using multimodal strategies to implement IPC interventions. Seventeen facilities indicated that a multidisciplinary team is involved in executing these IPC multimodal strategies. Additionally, twelve facilities regularly collaborated with colleagues from quality improvement and patient safety initiatives to develop and promote IPC multimodal strategies.

CC6: monitoring and audit of IPC practices and feedback

The CC6 had a median and IQR IPCAF score of 38 (28–56). Eighteen facilities employed trained personnel specifically responsible for the monitoring and auditing of IPC practices and providing feedback. Eleven facilities have established a well-defined monitoring plan that includes clear goals, targets, and activities, along with systematic tools for data collection. Eighteen facilities monitor hand hygiene compliance using the WHO Hand Hygiene Observation Tool or an equivalent. Five facilities conduct the WHO Hand Hygiene Self-Assessment Framework Survey at least annually, while thirteen perform it periodically but without a regular schedule. Sixteen facilities have never undertaken a hand hygiene self-assessment. In addition, eighteen facilities monitored the disinfection and sterilization of medical equipment and instruments, while ten facilities tracked the consumption and usage of alcohol-based hand rub or soap. However, there was no reporting of feedback on auditing reports such as data on hand hygiene compliance or other IPC processes related to the performance and state of IPC activities in thirteen facilities.

CC7: workload, staffing, and bed occupancy

The median and IQR IPCAF score for CC7 was 45 (25–63). Appropriate staffing levels are evaluated based on patient workload, utilizing national standards or a standard staffing needs assessment tool, such as the WHO Workload Indicators of Staffing Need method [20], in twelve facilities. Only nineteen facilities maintain a bed occupancy rate of one patient per bed.

CC8: the built environment, and materials and equipment for IPC

Twenty-two facilities lacked reliable water services that are available at all times and in sufficient quantities for various uses, including handwashing, drinking, personal hygiene, medical activities, sterilization, decontamination, cleaning, and laundry. Only four facilities provided accessible safe drinking water stations for staff, patients, and families at all times and in all locations/wards. Additionally, nine facilities do not have functioning hand hygiene stations equipped with either alcohol-based hand rub solutions or soap and water, along with clean single-use towels, available at all points of care. While hand hygiene stations are present in twenty-four facilities, supplies were not consistently available. Personal protective equipment (PPE) was not available at all times and in sufficient quantities for all healthcare workers in five facilities. In twenty-five facilities, PPE was available, but not continuously and not in adequate quantities. Fourteen facilities have functional waste collection containers for non-infectious general waste, infectious waste, and sharps waste located in close proximity to all points of waste generation. However, only sixteen facilities have a dedicated decontamination area and/or sterile supply department either onsite or operated by a licensed decontamination management service for the decontamination and sterilization of medical devices and other items or equipment. The median and IQR IPCAF score for CC8 was 48 (35–50). (Fig. 3)

Fig. 3.

IPCAF score of each core components in 33 public hospitals across Tigray, Ethiopia

Comparing facilities

No statistically significant difference was found in the IPCAF scores when comparing referral hospital, general hospital and primary hospitals (Table 2).

Table 2.

Infection Prevention and Control Assessment Framework (IPCAF) in public health facilities of post war Tigray, Ethiopia (n = 33)

Core component (CC)	Median IPCAF Score and IQR				p value2
	Referral hospital (n = 2)1	General hospital (n = 10)	Primary hospital (n = 21)	Total (n = 33)	RH versus GH	RH versus PH	GH versus PH
CC1	51	53(39–73)	58(38–75)	55(40–73)	0.901	0.781	0.732
CC2	73	48(24–89)	53(25–69)	53(25–73)	0.439	0.232	0.634
CC3	23	25(9–50)	25(10–53)	25(10–50)	0.711	0.653	0.824
CC4	44	44(0–64)	50(40–69)	45(36–66)	0.847	0.547	0.160
CC5	23	53(13–70)	25(5–70)	30(5–70)	0.414	0.568	0.730
CC6	59	41(34–77)	38(19–46)	38(28–56)	0.639	0.247	0.177
CC7	60	40(20–51)	45(25–65)	45(25–63)	0.106	0.490	0.318
CC8	43	50(43–58)	45(34–50)	48(35–50)	0.421	0.894	0.215
Total	374	334(269–452)	343(222–453)	348(258–439)	0.825	0.840	0.964

CC1, IPC programme; CC2, IPC guidelines; CC3, IPC education and training; CC4, HAI surveillance; CC5, Multimodal strategies; CC6, Monitoring and audit of IPC practices and feedback; CC7, Workload, staffing, and bed occupancy; CC8, The built environment, and materials and equipment for IPC; RH, Referral Hospital; GH, General Hospital; PH, Primary Hospital; IQR, Inter Quartile Range

¹No IQR calculated as sample size is 2

²Comparison of groups using independent t-test

In the referral hospitals the lowest IPC score was found in IPC education and training (CC3) and multimodal strategies (CC5) followed by the built environment, and materials and equipment for IPC (CC8) and HAI surveillance (CC4).

The minimum IPC score in general hospital was found in IPC education and training (CC3) followed by HAI surveillance (CC4), Workload, staffing, and bed occupancy (CC7) and multimodal strategies (CC5). However, the majority of the core components were found to be deficient scoring below 50, except IPC programme (CC1) and HAI surveillance in primary hospitals (CC4).

Comparing zones

When the IPCAF score was analysed by zones, a basic IPC level was found in Southern, Eastern, Central, Northwest, and Mekelle zone while Southeast zone found to have intermediate IPC level. The median IPCAF score was 349 (301–421) for southern zone, 433 (163–433) for southeast zone, 400 (271–499) for Mekelle zone, 315 (190–374) for eastern zone, 290 (237–584) for central zone and 342 (274–436) for Northwest zone (Fig. 4). There was no statistically significant difference in IPC levels among the different zones (p > 0.05).

Fig. 4.

Infection Prevention and Control Assessment Framework (IPCAF) median scores of public health facilities in six geographical zones of Tigray, Ethiopia The red broken line indicates a cut point i.e. 200 below which indicates inadequate IPC level

Hand hygiene level

The overall mean hand hygiene score for all facilities was found to be 127 (SD = 81) which is categorized as a basic hand hygiene level. A details of this study is stated elsewhere [19].

Correlation between IPCAF score and HHSAF score

There was a positive correlation between IPCAF level and HHSAF level, which was statistically significant (r = 0.765, n = 33, p < 0.001). Hand hygiene levels were higher in facilities with a higher IPCAF score. The equation can be expressed as y = 1.99E² + 1.2 x, where y = IPCAF Score, x = HHSAF Score (Fig. 5).

Fig. 5.

Correlation between Infection Prevention and Control Assessment Framework (IPCAF) and Hand Hygiene Self-Assessment Framework (HHSAF) score in public health facilities of Tigray, Ethiopia

Discussion

The overall median score for the IPCAF was 348, reflecting a basic level of IPC, which indicates that only some aspects of the IPC core components are in place but, without sufficient implementation. Only one institution achieved an advanced score (range: 601–800). Furthermore, there was a positive correlation between IPCAF scores and HHSAF scores, suggesting that the level of hand hygiene is indicative of the overall status of IPC within healthcare facilities and vice versa.

This low IPC status of our finding aligns with studies conducted in other conflict-affected settings, such as Syria, where it was found that most facilities presented significant deficiencies in their IPC levels [11]. Both studies utilized a similar sample size, although they had different categories of healthcare facilities. However, it was conducted in a conflict setting, it offers comparable IPC levels.

There is a notable absence of studies conducted in conflict or post-conflict settings, making it difficult to identify comparable results. As a result, we are compelled to rely on studies carried out in non-conflict environments (Table 3), which may introduce certain limitations. We observe parallels with neighboring countries such as Uganda, which reported an IPC median value of 225 [21], and Cote d’Ivoire, with a score of 242.5 [9]. Although Bangladesh is not in the same region, it exhibited a lower IPCAF score of 355 [27]. Notably, all these contexts have recorded a basic IPC level, even during peacetime, and they might share a history marked by social conflict or possess similar healthcare resources. Research indicates that high-income countries are more likely to meet the minimum IPC requirements compared to their less affluent counterparts [33, 34]. A global report on IPC published in 2024 highlights significant disparities in the implementation of core IPC components across various WHO regions, revealing that the African Region has demonstrated the lowest level of adherence [35]. This underscores that financial resources and commitment of individual countries significantly influence the overall implementation of IPC programmes [36].However, our findings diverge from those observed in neighbouring countries such as Malawi and Rwanda who reported 445 [22] and 545 [23] respectively. Looking at other settings in south Asia, Pakistan also recorded a similar score, with 405 [28]. The studies we are using for discussing our results were carried out in peaceful context with findings categorized as intermediate IPC level. These studies represent low-income settings, and we might have expected the IPC implementation to be lower. However, in Malawi, the Ministry of Health had developed IPC guidelines for the country in 2020, five years before the survey [22], and this may have influenced the IPC implementation positively. In Rwanda, the implementation of IPC guidelines has led to the availability of IPC program staff in the majority of healthcare facilities [23]. Similarly, in Pakistan, the establishment of IPC programs across most facilities has contributed to improved IPC standards [28].

Table 3.

Summary of IPCAF Scores (out of 800 points) by Countries

Region	Country	Sample size	Main findings/ median IPCAF score	IPCAF category	Reference
Global	Africa,	4440	605 out of 800	Advanced	[10]
	Eastern Mediterranean
	Europe
	Americas
	South East Asia
	Western Pacific
Africa	Uganda	1	225 out of 800	Basic	[21]
	Malawi	40	445 out of 800	Intermediate	[22]
	Rwanda	25	545 out of 800	Intermediate	[23]
	Cote d’Ivoire	30	242.5 out of 800	Basic	[9]
Asia	India	32	620 out of 800	Advanced	[24]
	Indonesia	355	620 out of 800	Advanced	[25]
	Turkey	68	668 out of 800	Advanced	[26]
	Bangladesh	11	355 out of 800	Basic	[27]
	Pakistan	12	405 out of 800	Intermediate	[28]
	Pakistan	5	117.5 out of 800	Inadequate	[29]
	China	222	682 out of 800	Advanced	[30]
Europe	Austria	65	620 out of 800	Advanced	[31]
	Germany	736	690 out of 800	Advanced	[32]

When the individual core components were examined, relatively higher median IPCAF scores were observed for the IPC programme (score = 55) and IPC guidelines (score = 50), followed by HAI surveillance (score = 48). However, despite the availability of an IPC programme and established guidelines, the lowest and critically concerning median IPCAF score was recorded for IPC education and training (score = 25).This was followed by multimodal strategies (score = 30) and monitoring, audit of IPC practices, and feedback (score = 38). These findings highlight substantial gaps in IPC capacity building and underscore the urgent need for strengthened education and training, implementation of coordinated multimodal interventions to promote sustainable behavioural change, and robust monitoring, evaluation and feedback mechanisms to support effective IPC implementation in post-war Tigray, Ethiopia. In comparison, findings from Malawi reported the highest scores for IPC guidelines (87.5) and IPC programme (72.5), whereas monitoring and audit of IPC practices with feedback (15) and HAI surveillance (40) received the lowest scores, indicating varying levels of implementation across the core components [22].

The low IPC scores observed in our study may be attributable to limited emphasis on IPC programmes. In addition, these low scores are likely influenced by the targeted attacks on health facilities during the war in Tigray, Ethiopia. As a result, many healthcare facilities have suffered damage to their infrastructure [37], as documented in the 2022 regional healthcare facilities damage assessment report. This leads to severely limited or non-existent IPC activities. According to the Health Resources and Services Availability Monitoring System (HeRAMS) assessment by the WHO, half of the 754 facilities evaluated lacked adequate water and sanitation services, three-quarters did not have waste segregation practices in place, and three-fifths had no hand hygiene services [38]. A 2024 study conducted in primary healthcare facilities in post war Tigray also reported poor access to water, sanitation and hygiene (WASH) services and limited IPC practices [16]. These deficiencies significantly compromise the effectiveness of IPC measures in war-torn Tigray, Ethiopia. Community-based studies have indicated that access to WASH services was notably low and varied across different zones in Tigray [39, 40]. This lack of access may help explain the low levels of IPC score observed in health facilities within these different zones.

It is crucial to address the poor IPC status, as research shows that targeted IPC interventions can lead to substantial improvements and significantly contribute to the reduction of HAIs [41]. Studies have also shown that the prevalence of HAIs is higher in war affected countries such as Ukraine [42]. Enhanced WASH facilities and targeted interventions have been proven to increase hand hygiene compliance [43], which is inversely related to the incidence of HAIs, potentially reducing rates by up to 60% [44, 45]. A study from China also demonstrated that hospitals with higher IPCAF scores experienced lower rates of HAIs [38], underscoring the critical importance of robust IPC activities.

There was a strong positive correlation between the IPCAF scores and HHSAF scores, indicating that the overall poor IPC standards were associated with low hand hygiene compliance and vice versa. Our findings on the strong correlation between IPCAF and HHSAF scores are consistent with a global study conducted across 81 countries [10] as well as a study carried out in Syria [11], highlighting that the effectiveness of existing IPC measures may influence hand hygiene practices within healthcare facilities. The inadequate IPC levels in these facilities adversely impact the quality of care provided. This underscores the urgent need for robust policy implementation and capacity-building initiatives focused on enhancing IPC in healthcare facilities of post war across Ethiopia.

This study has several limitations. The cross-sectional design provides only a snapshot of the IPC levels, making it difficult to capture the complete status over time. Additionally, we lacked data on the level of implementation of the WHO Core Components for IPC in the study area prior to the conflict. This hampered our ability to make comparisons between pre-war and post-war conditions. On the other hand, one notable strength of this study is the inclusion of all accessible public health facilities in war-torn Tigray, which enhances the generalizability of the results for the entire region except Western zone of Tigray. Furthermore, we utilized the WHO’s standardized and validated IPCAF tool for data collection [2], which bolsters the reliability of our findings. It is likely that similar findings can be seen in other post-war areas, and it is important to be aware of the IPC challenges demonstrated in the study.

It is important to note that the data were self-reported, and no objective measurements or direct observations were conducted. This limitation raises the possibility of bias, as we cannot ascertain whether the reports accurately reflect the actual situation. Also, the information was obtained from one source either IPC focal person or manager at each hospital, and these persons might not always reflect the opinions from the other employees. This might have caused bias, which we could not document in this study. Respondents were selected based on the roles and their involvement in infection prevention and control activities within the facility. However, variation in knowledge and expertise among the respondents may have influenced the responses. Despite these limitations, the results of this study will inform for resource planning in similar contexts, both now and in the future.

The findings from this study provide critical evidence to guide post-conflict health system recovery efforts in Tigray. The overall basic level of IPC performance, combined with notable gaps across all core components, highlights an urgent need for targeted interventions to strengthen facility-level safety systems. Health authorities, implementing partners, and facility managers can use these results to prioritize resource allocation particularly toward training and mentorship of IPC focal persons, establishment of functional IPC committees, consistent availability of essential supplies, and improvements in infrastructure for hand hygiene and waste management.

The demonstrated positive correlation between IPCAF and HHSAF scores underscores that improvements in hand hygiene systems are likely to reinforce broader IPC capacity. Therefore, strengthening hand hygiene programs including building staff competencies, securing continuous supply of alcohol-based hand rub, and promoting a culture of safety may serve as an effective entry point for elevating IPC standards across facilities.

Moreover, the study provides a baseline for post-war IPC performance in Tigray. These results can be used by policymakers to design evidence-based recovery strategies, integrate IPC improvements into routine supervision, and monitor progress over time. Humanitarian organizations and donors may also use the findings to align support with the most critical needs identified in the assessment.

Finally, establishing periodic IPC assessments using standardized WHO tools is essential for ensuring sustained improvements. Incorporating regular IPCAF and HHSAF evaluations into the regional health system will enable early detection of emerging gaps, facilitate accountability, and promote a culture of continuous quality improvement.

Conclusion

The IPC levels in post-war public health facilities in Tigray were found to be unsatisfactory, with deficiencies evident across all zones and types of facilities. This situation is likely to pose an increased risk of HAIs for healthcare personnel, patients, and visitors alike.

To mitigate these risks, it is crucial to enhance IPC practices and infrastructures invest in capacity building for IPC in post-war Tigray. Additionally, longitudinal research focused on monitoring the implementation of the IPC Core Components using the IPCAF tool is recommended to track changes in IPC status over time. Similar situations may occur also in other post-war areas, and resources should be given to support the IPC practices in health facilities during such situations.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

WHO

World Health Organization

IPC

Infection prevention and control

IPCAF

Infection prevention and control assessment framework

IQR

Interquartile range

HHSAF

Hand hygiene self-assessment framework

SD

Standard deviation

HAI

Healthcare associated infections

CC

Core components

SPSS

Statistical package for the social sciences

PPE

Personal protective equipment

PH

Primary hospital

GH

General hospital

RH

Referral hospital

HeRAMS

Health resources and services availability monitoring system

WASH

Water, sanitation, and hygiene

Author contributions

AAA designed the study and collected the data. AAA, ALR and BEM analysed and interpreted the data, and wrote the manuscript. All authors read and approved the final manuscript.

Funding

This study was funded by the Norwegian Program for Capacity Building in Higher Education and Research for Development (NORHED-II Safeworkers Project), grant number: 69181.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical clearance was obtained from College of Health Sciences, Institutional Review Board of Mekelle University (Ref. No: MU-IRB 2068/2023). A support letter from Tigray Health Bureau was obtained and given to the management of the facilities. Written consent from the health facility management was assured before the actual data collection. All research methods were performed in accordance with the ethical principles of the Declaration of Helsinki that assures beneficence, non-maleficence, autonomy, and justice.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.