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Table 2 Summary of studies

From: Use, adoption, and effectiveness of tippy-tap handwashing station in promoting hand hygiene practices in resource-limited settings: a systematic review

Author & yearPopulationSample sizeStudy design & methods Objectives/aims
ParticipantsAgeSettingCountryStudy purpose/
Objective
OutcomesResults
Abass (2018) [16]WomenAdults
(Age not provided)
CommunityNigeria500 women in 10 communitiesQualitative and quantitative cross sectional survey.
Data was collected through a questionnaire and observational checklist.
To improve livelihoods and promote safe sanitation, water and healthy living at home and communityUse and benefits of tippy-tapsWomen who constructed tippy-taps at their place of business experienced a higher patronage of customers, which led to more sales. The customers were attracted to the business site because of safe sanitation and effective hand washing practices.
Aiemjoy et al., 2017 [17]Children
Heads of the
Households
0–5 years
Adults (age not provided)
CommunityEthiopia255 childrenInterviews, observationsTo describe the prevalence of soil-transmitted helminths and intestinal protozoa in preschool children 0–5 years of age in seven communities in the Amhara region of Ethiopia, and to investigate associations between infection, household water and sanitation characteristics, and child growthUse and adoption of tippy-tapsTippy-tap was observed in approximately one in five households
Soap was observed in over three-quarters of households
Biran (2011) [7]Household headsAdults Villagers (Age not provided)CommunityUganda44 interviewsQualitative case study: semi-structured interviews.
Data were collected through nine key informant interviews, forty-seven interviews with householders from model and non-model villages, and twenty-two spot-check observations of handwashing facilities.
To learn about the promotion of specific handwashing enabling technology (the tippy-tap) through a particular approach (the use of visiting health workers and village-level volunteers to provide health education and carry out household inspections in model villages) in UgandaPromotion of hand hygiene practices (Increased hand washing)
Benefits and adoption of a tippy-taps
The tippy-taps probably increased handwashing after latrine use by providing convenient soap and water, and by acting as a salient cue to wash hands.
The tippy-taps were also attractive and easy for children to use and helped to foster the habit of handwashing among children.
Tippy-taps were common, though not universal in model villages.
Awareness of the tippy-taps did not necessarily translate into immediate action to obtain one.
Tippy-taps were acceptable to householders and were thought to have many advantages compared to using a jerry can.
Dissemination of information about the tippy-tap between villages and even between households within villages was limited.
While quantitative data on handwashing rates were not collected, households with tippy-taps believed that their post-latrine handwashing rates had increased as a result of the taps.
Respondents in non-model villages were largely unaware of tippy-taps.
Not all tippy-taps had water in them- might be that they were not in use or had run out of water
Researchers believed that participants adopted the tippy-tap technology because they were told to do so.
One participant said she constructed tippy-tap because she had seen one, which looked modern and she wanted visitors to use it.
Other participants built tippy-taps because they knew they would be visited by health assistants.
Some participants constructed tippy-taps because of the campaign and feared fines.
Participants were able to articulate genuine advantages of tippy-taps such as prevention of contamination and use of less water, but it was not clear whether this was just a repetition of the health message by health assistants or genuine motivation to build tippy-taps.
One participant suggested that tippy-taps did not look attractive.
Elderly participants said tippy-taps looked childish and unnecessary, people used to live longer before tippy-taps.
Some participants complained that they needed to replace some parts yearly.
Some participants had never heard about tippy-taps.
No data to quantify handwashing changes.
Bresee et al. (2016) [18]Children
39 female guardians
8–12 years
And adults over 18 years
Schools and householdsZambia5 schools were purposively selected. Teachers helped to purposively select students to participate in the studyQualitative methods
(Used open ended questions to ask guardians and pupils during focus group discussions)
Two focus groups discussion (FDGs) for pupils at each school during phase I & 2 with the same pupils and guardians
To assess the potential for children to be change agents in five schools in rural Zambia.Adoption of tippy-tapsPupils engaged parents and siblings in constructing tippy-taps in their homes despite some parents indicating that they did not know what it was.
Cantrell, 2013 [19]Households members37.7 years average ageCommunityHaitiHousehold (N = 1198) and a latrine (N = 167)
26 communities
182 households
Survey that recorded household use of laundry pads, bath houses, hand-pumped drilled wells, health and hygiene education sessions, and latrines as well as demographic dataTo examine and describe potential strengths, weaknesses, and opportunities within the intervention program as well provide recommendations for future WASH projects in Haiti and in other developing countries.Use of tippy-tapsUse of tippy-taps in many communities ranged from 0 to 40%.
Chisanga 2018 [20]Mother and caregivers of 0–23 months oldsAdults (Age not provided)CommunityTanzania161 mothers and caregiversQuestionnaire
Interviews and FGDs
To assess the
sustainability practices of Mwanzo Bora
Nutrition Program at Kilolo district
Use and adoption of tippy-taps80% of the participants had tippy taps.
80% of those who had tippy-taps were using them before and after using toilet (p ≤ 0.05).
55% reported that they were still using tippy-taps after the implementation of the program (p ≤ 0.05).
Chiziwisano et al., 2019 [21]Households with a child aged between 3 and 24 monthsAdults (Age not provided)Community and
Households
Malawi21 households
323 participants
Mixed methods.
Data collected through household survey
Household surveys (n = 323), checklists (n = 31), structured observations (n = 80), and microbiological food samples (n = 20)
(1) To identify practices and associated factors at household level related to food contamination, child mouthing, handwashing practices and kitchen utensils.Use of tippy-tapsA specific place for handwashing, mostly tippy taps was found in 51% of households.
Only 19% of handwashing facilities had soap and water. The majority (64%) of handwashing facilities were located near the latrine.
Christensen et al. (2015) [22]Caregivers of 4- to 16-month-old children in the first study area and pregnant women in their second or third trimester and caregivers of children under 3 months of age in the second study areaAdults
(Age not provided)
Households in 72 villagesWestern Kenya499 subjectsPilot cluster randomized trialThe study’s scientific objectives are to (1) determine if WASH interventions aid in early child development, (2) determine if the combination of WASH interventions is more beneficial than a single intervention alone, and (3) determine if the com- bination of WASH interventions plus nutrient supplements is more beneficial than any of the interventions or supplements alone.Use of tippy-tapsEnumerator-observed indicators of use of tippy taps (availability of both soap and water) ranged between 72 and 85%.
Contzen et al., 2015 [23]Primary caregivers of householdsAdults (Age not provided)CommunityEthiopia462Quasi-experiment with pre-post design and four arms
An intervention was administered in four arms of the study.
In arm 1, the control group, only education was implemented; arm 2 received education plus public commitment; arm 3 received education plus tippy-tap promotion; and arm 4 received education, public commitment and tippy-tap promotion
To test the hypothesis that evidence- and theory-based interventions, especially when matched to the target population’s needs, are expected to perform better than common practice.Use and adoption of tippy-tapsIn kebeles 3 and 4, nearly 100% of the households followed the promotion and invested material and time to construct for themselves a tippy- tap.
Three months after termination of the intervention, tippy-taps were in use with water and soap being present in up to 83% of the households (kebele 4).
Pre-post data analysis on self-reported handwashing revealed that the population-tailored interventions, and especially the tippy-tap-promotion, performed better than the standard education intervention.
94 to 99% of participants in the intervention arm built the tippy-taps and recognised tippy-tap as their designated place for handwashing.
Dajaan et al. (2018) [24]Children and HeadmastersChildren and adults (Age not provided)SchoolsGhana300 children and 10 headmasters in 10 selected schools.A cross sectional
Data were collected using questionnaires and observation checklist regarding socio-demographic characteristics, knowledge of hand washing, hand washing practices and availability of hand washing facilities in the selected schools.
To determine the availability of hand washing facilities, hand washing knowledge and practices among public primary schools in Kintampo Municipality.Promotion of hand hygiene practices (Increased hand washing)
Use of tippy-taps
37.67% of participants washed their hands in order to prevent diseases,
53.33% had never been educated on how to wash their hands,
23.33% of the children demonstrated correctly on how to wash hands,
over 15% washed -lean running water, while
23.33% wipe their hands using handkerchiefs.
40% indicated that it is necessary to wash hands after visiting toilet.
42.33% cited lack of water as the barrier to hand washing.
39.88% always washed their hands with soap after using the toilet.
60% of the schools had hand washing points.
30% of the schools had clean running water.
20% had one or more tippy-taps.
Hurtado (1994) [25]Mothers with children under three years of age who had water taps and latrines in their homesChildren (Age not provided)CommunityIndia300 mothers,
40 indepth interviews
QualitativeTo obtain in-depth information on beliefs, perceptions, and motivation with regard to water, and the behaviours related to the handling and use of waterUse and benefits of tippy-tapsThe perceived benefit of tippy-tap use was that it uses less water and soap than the usual method of hand washing because the soap is not placed where it gets wet and soggy but hangs up and dries.
It was not easy to wash hands of very young children with the tippy-tap. Another potential problem was that older children may play with the device, thus destroying it or wasting water.
Although mothers did not mention it, it is recognized that the device requires extra water, time, and work to install, use, and maintain.
Kamuteera et al. 2018 [26]Stakeholders, including: (i) households; (ii) institutions such as schools, churches, and police and prison barracks; and (iii) local government officials and non-governmental organisations (NGOs).Adults
Stakeholders (Age not provided)
CommunityUganda138 protected springs and ten gravity-flow schemes (GFSs) were surveyed.
Household-level data were collected from 150 households, and four NGOs provided insight into their experiences and practices.
Survey
Data collection occurred through direct visual observation, onsite dialogue with individuals and groups, telephone and electronic correspondence with stakeholders, and structured questionnaires.
Three types of questionnaires were developed to cater to various stakeholders, including: (i) households; (ii) institutions such as schools, churches, and police and prison barracks; and (iii) local government officials and NGOs.
To assess the roles that training and monitoring have played in WASH projects in Rukungiri District.
To examine the theoretical possibility of selling nutrients recovered from sanitation to support the ongoing monitoring and operating needs of local water systems
Promotion of hand hygiene practices (Increased hand washing)
Use of tippy-taps
Most households had dish drying racks, but hand-washing facilities were extremely uncommon, with only four households having tippy-taps.
At critical times (e.g., before eating, before handling food, after using the latrine), most households did not report washing hands either “all of the time” or “most of the time”.
One third of respondents stated that they used soap when washing hands. However, among the four households with tippy-taps, no soap was observed, and the jerry cans had not been filled with water for a long time.
Mbuya et al., 2015 [27]Children0–18 monthsCommunity and HouseholdsZimbabwe21 households4 phases of formative research, comprising in-depth interviews, focus group discussions, behavior trials, and a combination of observations and microbiological sampling methodsTo develop a water, sanitation, and hygiene (WASH) intervention to minimize fecal–oral transmission among children aged 0–18 months in the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial.Promotion of hand hygiene practices (Increased hand washing)
Use and adoption of tippy-taps
Within 2 weeks of counseling, all study households had built and were using a Tippy-tap,. After 1 year, 12 of the 15 (80%) households still had a Tippy-tap installed, with evidence of use (water in the container and on the ground around the device).
Musoke et al. 2018 [28]Household with children below 5 years
Community informants
Two Schools
Adults and primary school pupils
(Age not provided)
Community and schoolsUganda24 community informants
200 health club pupils
200 households
Interventions
- Special training
sessions on hand washing, specifically, the use of tippy-tap
technology were conducted in the community
survey and observations
FGDs
In-depth interviews
To improve the health status of the inhabitants through conducting community proactive and sustainable interventions targeting two priority problem areas of access to safe drinking
water and improved sanitation facilities
Promotion of hand hygiene practices (Increased hand washing)
Use of tippy taps
More than 200 household constructed their own tippy-taps.
Use of tippy taps improved hand washing practices among adults and children especially after using the toilet.
Mwakitalima (2018) [29]HouseholdsHeads of households
(age not provided)
CommunityTanzania2875 householdsInterviews, ObservationsTo evaluate the extent that the campaign has contributed to the overall coverage of improved sanitation in relation to areas that are not under the campaign?Use and adoption of tippy-tapsAbout 10% (n = 252) of the households had a tippy-tap while only 3% (n = 77) households had a sink with a tap.
Tippy-taps were available in 14.1% of the households in the intervention villages versus 4.1 in the control villages.
Many households adopted Tippy-tap was the most adopted hand washing station compared to fised basin, mobile basin/bucked, water source such as hand pump and sink with tap
Pietropaoli (2017) [30]HouseholdsAdults
(Age not provided)
CommunitySierra Leone24 householdsSurvey?
Formative research.
Counselled
Interventions: Construct a handwashing station (such as a
tippy-tap);
3. Prioritise soap for handwashing and keeping
soap by the handwashing station
Test mothers’ responses to recommendations for improving infant and young child feeding, WASH and other desired practices; and determine which practices were most feasible and acceptable
Investigate the constraints mothers face when trying to change feeding patterns, hygiene practices and other daily routines and determine their motivations for trying and sustaining new practices
Use and adoption of tippy-tapsTippy taps were accepted and used by many households.
The main reasons for constructing a tippy-tap were that it was simple to construct, and that it was made from
locally available materials.
Shukla (2018) [31]15 angamwandis and 116 childrenChildren 2–6 yearsCommunityIndia116 children
15 angamwandis
Quantitative: Survey -checklist for facility assessment.
-tippy-tap was introduced in the anganwadis
To identify the lack of facilities in the anganwadis and implement
innovative and sustainable solutions to tackle grass-root level problems at anganwadi centres
Promotion of hand hygiene practices (Increased hand washing)
Use of tippy-taps
None (0%) of the children in the anganwadis practiced
handwashing before the meals.
Intervention was instantly accepted in the anganwadis and children started with the habit of handwash before
every meals.
Singh et al. (2016) [32]Community Health Workers (CHWs)
Community Health Volunteers CHV
40 yrs.
mean age
(> 18 years)
Community and householdsUganda81 CHVIn-depth Interviews with 82 CHVs.
Each interview lasted from 1 to 1.5 h.
These informal face-to-face interviews were semi-structured with open-ended and some Likert scale questions.
To understand whether full-time professional CHWs can potentially work with volunteers in the community to widen their reach and scope and if so what motivators might be of key importance to the CHVs remaining active in the fieldUse and adoption of tippy-tapsCHVs put what they learnt into practice by building tippy-taps, having dish-racks and purifying water in their homes and acted as role models in the community.
A large number of tippy-taps were built in the community. About 4.7% of households had tippy-taps at baseline compared to 47% post intervention, P < 0.05).
The CHVs implemented what they learnt during the training and as such were role models to other members of the community with 84% of CHVs having tippy-taps themselves. This compares to 1% of CHVs who had a tippy-tap, prior to the commencement of the study.
Singh et al. (2016b) [33]CHWs, CHV, caregivers of the underfive childrenAdults (Age not provided)CommunityUganda4 paid supervisor (CHWs),
82 CHV
200 household
100 household intervention
100 household in control group
To compare training alone versus training and supportive supervision by paid CHWs (n = 4) on the effectiveness of CHVs (n = 82) to deliver
education about pregnancy, newborn care, family planning and hygiene.
Use and adoption of tippy-tapsAt 1 year follow-up there was a significantly higher
prevalence of installed and functioning tippy-taps for hand washing (p < 0.002) in the intervention villages (47%) than control villages (35%).
Zhang et al. (2013) [34]397 School children7–13 yearsSchoolsUganda398 children
(8 schools)
Pre−/postintervention surveys were fielded in eight schools.
Four intervention schools were given tippy-taps, soap and educational materials, while four control schools initially received only educational materials.
At each school, one classroom was selected at random (lottery draw), and 25 boys and 25 girls (Grades 2–5) were selected from that classroom to be given surveys using a systematic random sampling design (every third girl and boy)
To measure the efficacy of a tippy-tap-based handwashing programme in promoting handwashing rates in elementary schools in rural UgandaPromotion of hand hygiene practices (Increased hand washing and prevention of diarrhoea)After 1 month, the intervention schools reported a large increase in daily handwashing rates and absence of stomach pain episodes compared with the control schools.
After receiving the intervention, the control schools attained similar handwashing and stomach pain rates.
Both handwashing at school and after using the toilet increased after the introduction of tippy-taps.
The proportion of students reporting ‘always’ or ‘often’ washing their hands at school increased from 3.5% at baseline to 100.0% at follow-up {t = 19.54, P < 0.05, 95% confidence interval (CI) 1.21–1.68 in the intervention schools [replicated in control schools by Time 3 (t = 12.92, P < 0.05, 95% CI 1.48–2.45].
The proportion of students ‘always’ washing their hands after using the toilet increased from 5.5 to 65.0% (t = 14.61, P < 0.05, 95% CI 1.02–1.58) in the intervention schools [Washing hands after using the toilet among students in the control schools increased from 3.6 to 79.3% (t = 13.21, P < 0.05, 95% CI 1.16–1.90) by Time 3].
Use of soap in the intervention schools increased from 13.5 to 84.5% (t = 5.64, P < 0.05, 95% CI 0.29–1.04) with even higher proportions reported at control schools at Time 3 (t = 298.15, P < 0.05, 95% CI 0.86–0.88).
In the intervention schools, the proportion of students reporting washing their hands three or more times/day increased from 5.5 to 93.0% (t = 9.84, P < 0.05, 95% CI 0.98–1.91) after the installation of tippy-taps.
Furthermore, the control schools also attained the handwashing rates of the intervention schools (97.9%) by Time 3 (t = 18.47, P < 0.05, 95% CI 1.42–2.01). Proxy data on the incidence of diarrhoeal disease are indicated by the number of students reporting stomach pain episodes in the previous month. In the intervention schools, the percentage of students reporting no stomach pain episodes increased from 7.0 to 80.0% (t = 10.84, P < 0.05, 95% CI 0.92–1.68).