use, adoption, and effectiveness of tippy-tap handwashing

RESEARCH ARTICLE Open Access

Use, adoption, and effectiveness of tippy-tap handwashing station in promotinghand hygiene practices in resource-limitedsettings: a systematic reviewBalwani Chingatichifwe Mbakaya1* , Fatch Welcome Kalembo2 and Maggie Zgambo1

Abstract

Background: Tippy-taps are locally made devices for washing hands with running water. They are simple and low-cost, enabling technology that provides adequate water sources, handwashing stations and motivation for peopleto prioritise handwashing. This systematic review aimed to establish the use, benefits, adoption and effectiveness ofenabling technology; tippy-tap handwashing station, in resource-limited settings.

Methods: We systematically searched for articles in the PubMed, EMBASE, PsycINFO, AMED, CINAHL, DOAJ andGoogle Scholar databases guided by the acceptable best practice developed by the PROSPERO and COCHRANE forsystematic search and selection of articles. Search terms such as tippy-taps, enabling technology, hand-washingstation, hand-washing behaviour, diarrhoea, respiratory infection, increase handwashing behaviour were used. Inaddition, a PRISMA flow diagram was used to elaborate on the number of articles retrieved, retained, excluded andreasons for every action. Studies that used tippy-tap hand washing station as a handwashing facility regardless ofthe design were included in this review. A mixed method appraisal tool was used to appraise studies.

Results: Twenty articles met the eligibility criteria. The use of tippy-taps for handwashing by household membersor school children was reported by authors of 16 studies, and it ranged from 2.7 to 80%. The availability of tippy-taps increased handwashing and use of soap among participants. Furthermore, the majority of people who wereoriented to tippy-taps or recruited to tippy-tap studies built their tippy-tap stations even after the promotionalactivities or programs had ended. In one study, tippy-taps were reported by participant to be effective inpreventing episodes of stomach pain among participants.

Conclusion: Tippy-tap handwashing station could help in promoting handwashing practice in resource constraintsettings. Future studies are needed to evaluate the effectiveness of tippy-tap hand washing station on preventingwater and hygiene-related infections.

Keywords: Tippy-tap, Handwashing station, Adoption, Effectiveness, Hand hygiene practice

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: [email protected] John’s Institute for Health, P.O. Box 18, Mzuzu, MalawiFull list of author information is available at the end of the article

Mbakaya et al. BMC Public Health (2020) 20:1005 https://doi.org/10.1186/s12889-020-09101-w

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BackgroundThe United Nations International Children’s EmergencyFund (UNICEF) estimate that 884 million people in theworld lack access to basic drinking water supply services[1]. The majority of these people live in rural areas oflow and middle-income countries [1]. Lack of improvedwater sources in these areas is problematic not only tothe households but also to the public facilities such ashospitals and schools [2]. The World Health Organisa-tion (WHO) states that 38% of healthcare facilities lackan improved water source, 19% lack improved sanitation,and 35% lack water and soap for handwashing in devel-oping countries [2]. In addition, more than half of allprimary schools in developing countries do not have ad-equate water facilities and nearly two-thirds lack ad-equate sanitation [1]. Where water or water stations arenot readily available, neglecting hand washing is not un-common. Failure to wash hands after visiting the toilet,before eating or feeding a child, before and after prepar-ing food, and after changing and cleaning up a childwho has used a toilet, increases the risk of contractingor spreading diarrheal and respiratory-related diseases[2, 3]). The inadequacy of water supply, sanitation andhygiene cause the death of a child every minute, 80% ofchildhood diseases, 272 million days of school absentee-ism and other health conditions such as diarrhoea andrespiratory disorders in the general population [4, 5].Although lack of resources and modern technology

are commonly associated with the inadequate handwash-ing stations, low cost and simple handwashing and tech-nology such as tippy-taps may provide adequate watersources, stations and motivation for people to prioritisehandwashing [6]. Tippy-taps are simple and economichandwashing stations, made with locally available mate-rials including plastic containers, jerry cans or gourds,and do not depend on a piped water supply [6]. Biran[7] describes a tippy-tap as ‘a device consisting of a small(three or five-litre) jerry can be filled with water and sus-pended from a wooden frame. A string is attached to theneck of the jerry can that can be tied to a piece of woodat ground level. Pressing on this piece of wood with thefoot, tips the jerry can to release a stream of waterthrough a small hole. Soap is suspended from the framebeside the jerry can’ (See Figs. 1 and 2). Furthermore,tippy-taps are easy to construct, use very little water,easier to use and only soap is touched, thereby makinghandwashing very hygienic because it avoids contamin-ation of the jerry can, unlike the real tap [7]. Tippy-tapscould be a technology of choice for reducing diarrhealand respiratory disorders and deaths that are associatedwith lack of water, inadequate handwashing stations andpractices through controlling factors that hinder hand-washing practice such as unavailability of handwashingstation, water and soap [10]. Following this, it should,

therefore, be noted that reducing infectious diseases thatoccur due to unhygienic hand practices takes more thathandwashing education, the handwashing stations, waterand soap equally play a major role in reducing.The first tippy-tap was constructed by Dr. Jim Watt

and Jackson Masawi of the Salvation Army in Chiweshe,Zimbabwe, and was called the Mukombe in the 1980s.

Fig. 1 A boy washing hands using tippy-tap. Source:UNICEF/Zambia/2012/Asindua [8]

Fig. 2 An examples of a tippy-tap. Source: Mark Tiele Westra [9]

Mbakaya et al. BMC Public Health (2020) 20:1005 of 25

The Mukombe is a type of gourd or calabash, which isused as the can [11]. Since then, many different versionsof tippy-taps have emerged in different parts of theworld, depending on the accessibility and types of avail-able local materials. Tippy-taps, although simply con-structed from locally affordable and accessible materials,could be the suitable handwashing stations for under-developed settings that often lack adequate water forhandwashing. The average amount of water used forhandwashing using tippy-taps is far much less comparedto ordinary handwashing stations such as taps. Com-paratively, a good hand wash using tippy-tap could useonly 50 mls of water, while washing hands using tapwater may utilise up to 500 mls of water [11]. Further-more, tippy-taps could help to increase handwashing be-haviour in schools because it is appealing to childrensince it is humorous and easy to use, consequently cut-ting the number of deaths in children that occur due tohealth conditions associated with hand hygiene practices[7]. Enabling technology is one of the factors that exter-nally influence individual’s probability to accomplish abehaviour [7]. The UNICEF and WaterAid recommendthe use of tippy-taps in schools and family houses nextto the latrines [12, 13]. Tippy-tap is possibly the bestknown low cost enabling technology for handwashing[7] and currently, tippy-taps are commonly used in Eastand Southern Africa in countries like Uganda, Rwanda,and Zambia [13].The aim of this systematic review, therefore, was to

gather, consolidate and quantify the evidence of the use,benefits, adoption and effectiveness of tippy-tap hand-washing station in promoting hand hygiene practices inresource-limited settings. Promotion of handwashing be-haviour was the main outcome in this systematic review.The secondary outcomes were use, adoption, benefitsand effectiveness of tippy-taps. The questions that wereaddressed by this review are: 1) How does the use oftippy-tap handwashing stations promote hand hygienepractices in a resource-limited setting? 2) How effectiveare tippy-taps in promoting hand hygiene and reducingwater and hygiene-related infections?

MethodsProtocolThis review was guided by the acceptable best practicedeveloped by the PROSPERO and COCHRANE for sys-tematic search and selection of articles. The protocolwas published in the PROSPERO database with registra-tion number CRD42017074331 [14].

Inclusion criteriaAll studies that used tippy-tap handwashing station as ahandwashing facility regardless of the design were in-cluded in this systematic review.

Exclusion criteriaPapers written in languages other than English and arti-cles with studies conducted in developed countries wereexcluded.

Information source /search strategyThe following database sources were used to gather therequired information; Medline, EMBASE, PsycINFO,AMED, CINAHL, DOAJ and Google Scholar. MeSHterms such as hand hygiene, hand disinfection, handwashing, handwashing, hand washings, washings, handscrubbing, scrubbing, infection, cross-infection, water-borne, waterborne disease, water related diseases, waterdiseases and diarrhoea were used during searching forthe articles to ensure accuracy. Besides MeSH terms,keywords were also combined using Boolean operatorsOR and AND. The following key terms and MeSH termswere used: Tippy-taps, OR Enabling technology ORHand-washing station OR Hand washing interventionsOR Hand washing strategies OR Hand washing pro-grams AND Hand wash OR Hand washing OR Handwashings OR Handwashing OR Hand washing behav-iour, OR Hand washing techniques OR Hand hygieneOR Hand disinfection OR Hand or Washings OR Handscrubbing AND Use OR Usefulness OR Utilisation ORBenefit OR Advantages OR Effectiveness OR evaluationAND Promotion OR Sustainability OR Adoption ORAppropriateness AND Prevention OR Control OR LimitAND diarrhoea, OR dysentery OR waterborne diseaseOR bloody stool OR Loose stool OR Respiratory Infec-tion OR Infection OR Cross infection (see Table 1). Key-words were also used to search for articles in GoogleScholar. Efforts were made to identify both publishedand unpublished interventional studies by manuallychecking the reference list of the articles that met the in-clusion criteria. Several strategies were used to identifyunpublished studies. First, we reviewed the methodologyand reference list of the included studies to assess if theyidentified any unpublished research related to the reviewquestion. Second, we manually searched conference pro-ceedings such as Development International Conference,Water Engineering and Development Centre and theUniversity of North Caroline Water and Health Confer-ence for any suitable studies. Further searches were con-ducted in clinical trial website such as ClinicalTrials.govwebsite (https://clinicaltrials.gov/). Efforts were alsomade to contact the authors of the unpublished studies.Reference lists of the included studies were checked andhand searching in the key journals was also done. Thesearch period for the research articles in the mentioneddatabases was from the inception of the databases to July2019. The search for the eligible studies in the databasewas conducted between September 2017 to July 2019.


http://clinicaltrials.gov

https://clinicaltrials.gov/

Table 1 Search strategy

Databases Search Search words/terms Results

CINAHL Title & abstract Tippy-taps, OR Enabling technology OR Hand-washing station OR Hand washing interventions ORHand washing strategies OR Hand washing programs AND Hand wash OR Hand washing OR Handwashings OR Handwashing OR Hand washing behaviour, OR Hand washing techniques OR Handhygiene OR Hand disinfection OR Hand or Washings OR Hand scrubbing AND Use OR UsefulnessOR Utilisation OR Benefit OR Advantages OR Effectiveness OR evaluation AND Promotion ORSustainability Or Adoption OR Appropriateness AND Prevention OR Control OR Limit AND diarrhoea,OR dysentery OR waterborne disease OR bloody stool OR Loose stool OR Respiratory Infection ORInfection OR Cross infection

4

MEDLINE Title & abstract Tippy-taps, OR Enabling technology OR Hand-washing station OR Hand washing interventions ORHand washing strategies OR Hand washing programs AND Hand wash OR Hand washing OR Handwashings OR Handwashing OR Hand washing behaviour, OR Hand washing techniques OR Handhygiene OR Hand disinfection OR Hand or Washings OR Hand scrubbing AND Use OR UsefulnessOR Utilisation OR Benefit OR Advantages OR Effectiveness OR evaluation AND Promotion ORSustainability Or Adoption OR Appropriateness AND Prevention OR Control OR Limit ANDdiarrhoea, OR dysentery OR waterborne disease OR bloody stool OR Loose stool OR RespiratoryInfection OR Infection OR Cross infection

7

AMED Title & abstract Tippy-taps, OR Enabling technology OR Hand-washing station OR Hand washing interventions ORHand washing strategies OR Hand washing programs AND Hand wash OR Hand washing OR Handwashings OR Handwashing OR Hand washing behaviour, OR Hand washing techniques OR Handhygiene OR Hand disinfection OR Hand or Washings OR Hand scrubbing AND Use OR UsefulnessOR Utilisation OR Benefit OR Advantages OR Effectiveness OR evaluation AND Promotion ORSustainability Or Adoption OR Appropriateness AND Prevention OR Control OR Limit AND diarrhoea,OR dysentery OR waterborne disease OR bloody stool OR Loose stool OR Respiratory Infection ORInfection OR Cross infection

14

PsychINFO Title, abstract &full article

Tippy-taps, OR Enabling technology OR Hand-washing station OR Hand washing interventions ORHand washing strategies OR Hand washing programs AND Hand wash OR Hand washing OR Handwashings OR Handwashing OR Hand washing behaviour, OR Hand washing techniques OR Handhygiene OR Hand disinfection OR Hand or Washings OR Hand scrubbing AND Use OR UsefulnessOR Utilisation OR Benefit OR Advantages OR Effectiveness OR evaluation AND Promotion ORSustainability Or Adoption OR Appropriateness AND Prevention OR Control OR Limit AND diarrhoea,OR dysentery OR waterborne disease OR bloody stool OR Loose stool OR Respiratory Infection ORInfection OR Cross infection

3

DOAJ Title, abstract &full article


8

Google Scholar Title & abstract Tippy-taps and handwashing 4040

EMBASE Title, abstract &full article


12

Reference search fromother sources

Title, abstract &full article


3

Total recordssearched

4091

Total articlesincluded

20


Study selectionIdentified titles from the databases were extracted andimported to Endnote X7 Reference Management System.Thereafter, duplicates were removed. The abstracts ofthe retained titles were retrieved and manually assessedfor potential eligibility. Full articles were retrieved forthe retained abstracts and these were thoroughlyassessed manually for eligibility. Assessing eligibility forthe articles was done independently by two reviewersusing the predefined inclusion and exclusion criteria.Any disagreement between the two reviewers over theeligibility of particular studies were resolved through dis-cussion with a third reviewer.

Data collection processThe process of data extraction started with databasesearch of relevant articles using search terms while fol-lowing the Preferred Reporting Items for Systematic Re-views and Meta-Analyses (PRISMA) [15] guidelines (seeFig. 3). A standardised form was used to extract datafrom the included studies for assessment of the studyquality and evidence synthesis. The details included:

author, year of study, type of participants, age, setting,country, sample size, study design, and methods, studypurpose and objectives, intervention description, studyoutcome measures (see Supplementary material A). Allrelevant information was extracted from each article,summarised and documented (see Table 2). Two re-viewers extracted data independently; discrepancies wereidentified and resolved through discussion with a thirdauthor. Missing data were requested from the corre-sponding authors of the study.

Search outcomeThe search yielded a total of 4091 titles of articles ofwhich 1696 were retained in a preliminary assessmentstage after removing duplicates. Of the retained arti-cles1623 were further excluded from the analysis be-cause they were based on different study areas or wereabstracts only. Seventy-three titles were retained, andtheir full articles were retrieved and assessed by two au-thors for eligibility. The third author validated the eligi-bility of the articles for inclusion in the review. Fromthis assessment, only 20 articles met the inclusion

Fig. 3 PRISMA Flow Diagram [15]


Table

2Summaryof

stud

ies

Autho

r&year

Popu

latio

nSamplesize

Stud

yde

sign

&metho

dsObjectives/aim

s

Participants

Age

Setting

Cou

ntry

Stud

ypu

rpose/

Objective

Outcomes

Results

Abass

(2018)

[16]

Wom

enAdu

lts(Age

not

provided

)

Com

mun

ityNigeria

500wom

enin

10commun

ities

Qualitativeand

quantitativecross

sectionalsurvey.

Datawas

collected

throug

ha

questio

nnaire

and

observational

checklist.

Toim

provelivelihoo

dsandprom

otesafe

sanitatio

n,water

and

healthylivingat

home

andcommun

ity

Use

and

bene

fitsof

tippy-taps

Wom

enwho

constructed

tippy-tapsat

theirplace

ofbu

sine

ssexpe

rienced

ahigh

erpatron

ageof

custom

ers,which

led

tomoresales.The

custom

erswereattracted

tothebu

sine

sssite

becauseof

safe

sanitatio

nandeffectivehand

washing

practices.

Aiemjoyet

al.,

2017

[17]

Children

Heads

ofthe

Hou

seho

lds

0–5years

Adu

lts(age

notprovided

)

Com

mun

ityEthiop

ia255children

Interviews,

observations

Tode

scrib

ethe

prevalen

ceof

soil-

transm

itted

helm

inths

andintestinalprotozoa

inpreschoo

lchildren0–5

yearsof

agein

seven

commun

ities

intheAm

hara

region

ofEthiop

ia,

andto

investigate

associations

betw

een

infection,ho

useh

old

water

andsanitatio

ncharacteristics,and

child

grow

th

Use

and

adop

tionof

tippy-taps

Tipp

y-tapwas

observed

inapproxim

atelyon

ein

fiveho

useh

olds

Soap

was

observed

inover

three-qu

artersof

househ

olds

Biran(2011)

[7]

Hou

seho

ldhe

ads

Adu

ltsVillage

rs(Age

notprovided

)

Com

mun

ityUgand

a44

interviews

Qualitativecase

stud

y:semi-structured

interviews.

Datawerecollected

throug

hnine

key

inform

antinterviews,

forty-seveninterviews

with

househ

olde

rsfro

mmod

elandno

n-mod

elvillage

s,and

twen

ty-twospot-

checkob

servations

ofhand

washing

facilities.

Tolearnabou

tthe

prom

otionof

specific

hand

washing

enabling

techno

logy

(the

tippy-

tap)

throug

haparticular

approach

(the

useof

visit

inghe

alth

workersand

village

-levelvolun

teersto

providehe

alth

education

andcarryou

tho

useh

old

inspectio

nsin

mod

elvil

lage

s)in

Ugand

a

Prom

otionof

hand

hygien

epractices

(Increased

hand

washing

)Bene

fitsand

adop

tionof

atip

py-taps

Thetip

py-tapsprob

ably

increasedhand

washing

afterlatrineuseby

providingconven

ient

soap

andwater,and

byactin

gas

asalient

cue

towashhand

s.Thetip

py-tapswerealso

attractiveandeasy

for

childrento

useand

helped

tofoster

thehabit

ofhand

washing

amon

gchildren.

Tipp

y-taps

werecommon

,thou

ghno

tun

iversalin

mod

elvillage

s.Awaren

essof

thetip

py-

taps

didno

tne

cessarily

translateinto

immed

iate

actio

nto

obtain

one.

Tipp

y-taps

were

acceptableto

househ

olde

rsandwere

thou

ghtto

have

many

advantages

comparedto


Table

2Summaryof

stud

ies(Con

tinued)

Autho

r&year

Popu

latio

nSamplesize

Stud

yde

sign

&metho

dsObjectives/aim

s

Participants

Age

Setting

Cou

ntry

Stud

ypu

rpose/

Objective

Outcomes

Results

usingajerrycan.

Disseminationof

inform

ationabou

tthe

tippy-tap

betw

een

village

sandeven

betw

eenho

useh

olds

with

invillage

swas

limited.

Whilequ

antitativedata

onhand

washing

rates

wereno

tcollected

,ho

useh

olds

with

tippy-

taps

believedthat

their

post-latrinehand

washing

rateshadincreasedas

aresultof

thetaps.

Respon

dentsin

non-

mod

elvillage

swere

largelyun

awareof

tippy-taps.

Not

alltippy-tapshad

water

inthem

-might

bethat

they

wereno

tin

use

orhadrunou

tof

water

Researchersbe

lievedthat

participantsadop

tedthe

tippy-tap

techno

logy

becausethey

were

told

todo

so.

One

participantsaid

she

constructedtip

py-tap

becauseshehadseen

one,

which

looked

mod

ern

andshewantedvisitors

touseit.

Other

participantsbu

ilttip

py-tapsbe

causethey

knew

they

wou

ldbe

visitedby

health

assistants.

Someparticipants

constructedtip

py-taps

becauseof

thecampaign

andfeared

fines.

Participantswereableto

articulatege

nuine

advantages

oftip

py-taps

such

aspreven

tionof

contam

inationanduseof

less

water,b

utitwas

not

clearwhe

ther

thiswas


Table

2Summaryof

stud

ies(Con

tinued)

Autho

r&year

Popu

latio

nSamplesize

Stud

yde

sign

&metho

dsObjectives/aim

s

Participants

Age

Setting

Cou

ntry

Stud

ypu

rpose/

Objective

Outcomes

Results

justarepe

titionof

the

health

message

byhe

alth

assistantsor

genu

inemo

tivationto

build

tippy-

taps.

One

participant

sugg

estedthat

tippy-taps

didno

tlook

attractive.

Elde

rlyparticipantssaid

tippy-tapslooked

childish

andun

necessary,pe

ople

used

tolivelong

erbe

fore

tippy-taps.

Someparticipants

complaine

dthat

they

need

edto

replacesome

partsyearly.

Someparticipantshad

neverhe

ardabou

ttip

py-

taps.

Nodata

toqu

antify

hand

washing

change

s.

Bresee

etal.

(2016)

[18]

Children

39female

guardians

8–12

years

And

adults

over

18years

Scho

olsand

househ

olds

Zambia

5scho

olswere

purposively

selected

.Teachers

helped

topu

rposivelyselect

stud

entsto

participatein

the

stud

y

Qualitativemetho

ds(Usedop

enen

ded

questio

nsto

ask

guardiansandpu

pils

durin

gfocusgrou

pdiscussion

s)Tw

ofocusgrou

psdiscussion

(FDGs)for

pupilsat

each

scho

oldu

ringph

aseI&

2with

thesamepu

pils

andgu

ardians

Toassess

thepo

tential

forchildrento

bechange

agen

tsin

fivescho

olsin

ruralZ

ambia.

Ado

ptionof

tippy-taps

Pupilsen

gage

dparents

andsiblings

inconstructin

gtip

py-tapsin

theirho

mes

despite

someparentsindicatin

gthat

they

didno

tknow

whatitwas.

Cantrell,2013

[19]

Hou

seho

lds

mem

bers

37.7years

averageage

Com

mun

ityHaiti

Hou

seho

ld(N

=1198)andalatrine

(N=167)

26commun

ities

182ho

useh

olds

Survey

that

recorded

househ

olduseof

laun

drypads,b

ath

houses,hand-

pumpe

ddrilled

wells,

health

andhygien

eed

ucationsessions,

andlatrines

aswellas

demog

raph

icdata

Toexam

ineandde

scrib

epo

tentialstren

gths,

weaknesses,and

oppo

rtun

ities

with

inthe

interven

tionprog

ram

aswellp

rovide

recommen

datio

nsfor

future

WASH

projectsin

Haitiandin

othe

rde

veloping

coun

tries.

Use

oftip

py-

taps

Use

oftip

py-tapsin

many

commun

ities

rang

edfro

m0to

40%.

Chisang

a2018

[20]

Mothe

rand

caregiversof

0–23

mon

ths

olds

Adu

lts(Age

notprovided

)Com

mun

ityTanzania

161mothe

rsand

caregivers

Questionn

aire

InterviewsandFG

Ds

Toassess

the

sustainability

practices

ofMwanzo

Bora

Use

and

adop

tionof

tippy-taps

80%

oftheparticipants

hadtip

pytaps.

80%

ofthosewho

had

tippy-tapswereusing

them

before

andafter


Table

2Summaryof

stud

ies(Con

tinued)

Autho

r&year

Popu

latio

nSamplesize

Stud

yde

sign

&metho

dsObjectives/aim

s

Participants

Age

Setting

Cou

ntry

Stud

ypu

rpose/

Objective

Outcomes

Results

NutritionProg

ram

atKilolo

district

usingtoilet(p≤0.05).

55%

repo

rted

that

they

werestillusingtip

py-taps

aftertheim

plem

entatio

nof

theprog

ram

(p≤0.05).

Chiziwisano

etal.,2019

[21]

Hou

seho

lds

with

achild

aged

betw

een

3and24

mon

ths

Adu

lts(Age

notprovided

)Com

mun

ityand

Hou

seho

lds

Malaw

i21

househ

olds

323participants

Mixed

metho

ds.

Datacollected

throug

hho

useh

old

survey

Hou

seho

ldsurveys

(n=323),che

cklists

(n=31),structured

observations

(n=80),

andmicrobiolog

ical

food

samples

(n=20)

(1)To

iden

tifypractices

andassociated

factorsat

househ

oldlevelrelated

tofood

contam

ination,

child

mou

thing,

hand

washing

practices

andkitche

nuten

sils.

Use

oftip

py-

taps

Aspecificplacefor

hand

washing

,mostly

tippy

taps

was

foun

din

51%

ofho

useh

olds.

Only19%

ofhand

washing

facilities

hadsoap

andwater.The

majority

(64%

)of

hand

washing

facilities

werelocatedne

arthe

latrine.

Christensen

etal.

(2015)

[22]

Careg

iversof

4-to

16-m

onth-old

childrenin

the

firststud

yarea

andpreg

nant

wom

enin

theirsecond

orthird

trim

esterandcare

giversof

chil

dren

unde

r3

mon

thsof

age

inthesecond

stud

yarea

Adu

lts(Age

not

provided

)

Hou

seho

ldsin

72village

sWestern

Kenya

499subjects

Pilotcluster

rand

omized

trial

Thestud

y’sscientific

objectives

areto

(1)

determ

ineifWASH

interven

tions

aidin

early

child

developm

ent,(2)

determ

ineifthe

combinatio

nof

WASH

interven

tions

ismore

bene

ficialthanasing

leinterven

tionalon

e,and

(3)de

term

ineifthecom-

binatio

nof

WASH

interven

tions

plus

nutrient

supp

lemen

tsis

morebe

neficialthanany

oftheinterven

tions

orsupp

lemen

tsalon

e.

Use

oftip

py-

taps

Enum

erator-observed

indicatorsof

useof

tippy

taps

(availabilityof

both

soap

andwater)rang

edbe

tween72

and85%.

Con

tzen

etal.,

2015

[23]

Prim

ary

caregiversof

househ

olds

Adu

lts(Age

notprovided

)Com

mun

ityEthiop

ia462

Quasi-experim

ent

with

pre-po

stde

sign

andfour

arms

Aninterven

tionwas

administeredin

four

armsof

thestud

y.In

arm

1,thecontrol

grou

p,on

lyed

ucation

was

implem

ented;

arm

2received

educationplus

public

commitm

ent;arm

3received

education

plus

tippy-tap

prom

otion;

andarm

4received

education,

Totestthehypo

thesis

that

eviden

ce-and

theo

ry-based

interven

tions,especially

whe

nmatched

tothetarget

popu

latio

n’sne

eds,are

expe

cted

tope

rform

bet

terthan

common

practice.

Use

and

adop

tionof

tippy-taps

Inkebe

les3and4,ne

arly

100%

oftheho

useh

olds

followed

theprom

otion

andinvested

materialand

timeto

constructfor

them

selves

atip

py-tap.

Threemon

thsafter

term

inationof

the

interven

tion,

tippy-taps

werein

usewith

water

andsoap

beingpresen

tin

upto

83%

ofthe

househ

olds

(keb

ele4).

Pre-po

stdata

analysison

self-repo

rted

hand

washing

revealed


Table

2Summaryof

stud

ies(Con

tinued)

Autho

r&year

Popu

latio

nSamplesize

Stud

yde

sign

&metho

dsObjectives/aim

s

Participants

Age

Setting

Cou

ntry

Stud

ypu

rpose/

Objective

Outcomes

Results

publiccommitm

ent

andtip

py-tap

prom

otion

that

thepo

pulatio

n-tailoredinterven

tions,and

espe

ciallythetip

py-tap-

prom

otion,

perfo

rmed

better

than

thestandard

education

interven

tion.

94to

99%

ofparticipants

intheinterven

tionarm

built

thetip

py-tapsand

recogn

ised

tippy-tap

astheirde

sign

ated

placefor

hand

washing

.

Dajaanet

al.

(2018)

[24]

Childrenand

Headm

asters

Childrenand

adults(Age

notprovided

)

Scho

ols

Ghana

300childrenand

10he

admastersin

10selected

scho

ols.

Acrosssectional

Datawerecollected

usingqu

estio

nnaires

andob

servation

checklistregarding

socio-de

mog

raph

iccharacteristics,know

ledg

eof

hand

washing

,hand

washing

practices

and

availabilityof

hand

washing

facilitiesin

theselected

scho

ols.

Tode

term

inethe

availabilityof

hand

washing

facilities,hand

washing

know

ledg

eand

practices

amon

gpu

blic

prim

aryscho

olsin

Kintam

poMun

icipality.

Prom

otionof

hand

hygien

epractices

(Increased

hand

washing

)Use

oftip

py-

taps

37.67%

ofparticipants

washe

dtheirhand

sin

orde

rto

preven

tdiseases,

53.33%

hadne

verbe

ened

ucated

onho

wto

washtheirhand

s,23.33%

ofthechildren

demon

stratedcorrectly

onho

wto

washhand

s,over

15%

washe

d-lean

runn

ingwater,w

hile

23.33%

wipetheirhand

susinghand

kerchiefs.

40%

indicatedthat

itis

necessaryto

washhand

saftervisitin

gtoilet.

42.33%

citedlack

ofwater

asthebarrierto

hand

washing

.39.88%

alwayswashe

dtheirhand

swith

soap

afterusingthetoilet.

60%

ofthescho

olshad

hand

washing

points.

30%

ofthescho

olshad

cleanrunn

ingwater.

20%

hadon

eor

more

tippy-taps.

Hurtado

(1994)

[25]

Mothe

rswith

childrenun

der

threeyearsof

agewho

had

water

taps

and

latrines

intheir

homes

Children(Age

notprovided

)Com

mun

ityIndia

300mothe

rs,

40inde

pth

interviews

Qualitative

Toob

tain

in-dep

thinfor

mationon

beliefs,p

erceptions,and

motivation

with

regard

towater,and

thebe

haviou

rsrelatedto

thehand

linganduseof

water

Use

and

bene

fitsof

tippy-taps

Thepe

rceivedbe

nefit

oftip

py-tap

usewas

that

ituses

less

water

andsoap

than

theusualm

etho

dof

hand

washing

because

thesoap

isno

tplaced

whe

reitge

tswet

and

sogg

ybu

thang

sup

and

dries.


Table

2Summaryof

stud

ies(Con

tinued)

Autho

r&year

Popu

latio

nSamplesize

Stud

yde

sign

&metho

dsObjectives/aim

s

Participants

Age

Setting

Cou

ntry

Stud

ypu

rpose/

Objective

Outcomes

Results

Itwas

noteasy

towash

hand

sof

very

youn

gchildrenwith

thetip

py-

tap.

Ano

ther

potential

prob

lem

was

that

olde

rchildrenmay

play

with

thede

vice,thu

sde

stroying

itor

wastin

gwater.

Alth

ough

mothe

rsdid

notmen

tionit,itis

recogn

ized

that

the

device

requ

iresextra

water,tim

e,andworkto

install,use,andmaintain.

Kamuteera

etal.

2018

[26]

Stakeh

olde

rs,

includ

ing:

(i)ho

useh

olds;(ii)

institu

tions

such

asscho

ols,

churches,and

policeand

prison

barracks;and

(iii)local

governmen

tofficialsand

non-go

vernmen

tal

organisatio

ns(NGOs).

Adu

lts

Stakeh

olde

rs(Age

not

provided

)

Com

mun

ityUgand

a138protected

sprin

gsandten

gravity-flow

sche

mes

(GFSs)

weresurveyed

.Hou

seho

ld-level

data

were

collected

from

150ho

useh

olds,

andfour

NGOs

provided

insigh

tinto

their

expe

riences

and

practices.

Survey

Datacollection

occurred

throug

hdirect

visual

observation,

onsite

dialog

uewith

individu

alsand

grou

ps,telep

hone

andelectron

iccorrespo

nden

cewith

stakeh

olde

rs,and

structured

questio

nnaires.

Threetype

sof

questio

nnaireswere

develope

dto

caterto

vario

usstakeh

olde

rs,

includ

ing:

(i)ho

useh

olds;(ii)

institu

tions

such

asscho

ols,churches,and

policeandprison

barracks;and

(iii)local

governmen

tofficials

andNGOs.

Toassess

therolesthat

training

andmon

itorin

ghave

played

inWASH

projectsin

Rukung

iriDistrict.

Toexam

inethe

theo

reticalpo

ssibility

ofselling

nutrients

recoveredfro

msanitatio

nto

supp

orttheon

going

mon

itorin

gandop

erating

need

sof

localw

ater

system

s

Prom

otionof

hand

hygien

epractices

(Increased

hand

washing

)Use

oftip

py-

taps

Mostho

useh

olds

had

dish

drying

racks,bu

thand

-washing

facilities

wereextrem

elyun

com

mon

,with

onlyfour

househ

olds

having

tippy-taps.

Atcriticaltim

es(e.g.,

before

eatin

g,be

fore

hand

lingfood

,after

using

thelatrine),m

ost

househ

olds

didno

trepo

rtwashing

hand

seither

“allof

thetim

e”or

“mostof

thetim

e”.

One

third

ofrespon

dents

stated

that

they

used

soap

whe

nwashing

hand

s.How

ever,amon

gthefour

househ

olds

with

tippy-taps,no

soap

was

observed

,and

thejerry

cans

hadno

tbe

enfilled

with

water

foralong

time.

Mbu

yaet

al.,

2015

[27]

Children

0–18

mon

ths

Com

mun

ityandHou

seho

lds

Zimbabw

e21

househ

olds

4ph

ases

ofform

ative

research,com

prising

in-dep

thinterviews,

focusgrou

pdiscussion

s,be

havior

trials,and

acombinatio

nof

observations

and

microbiolog

ical

samplingmetho

ds

Tode

velopawater,

sanitatio

n,andhygien

e(W

ASH

)interven

tionto

minim

izefecal–oral

transm

ission

amon

gchildrenaged

0–18

mon

thsin

theSanitatio

nHygiene

Infant

Nutrition

Efficacy(SHINE)

trial.

Prom

otionof

hand

hygien

epractices

(Increased

hand

washing

)Use

and

adop

tionof

tippy-taps

With

in2weeks

ofcoun

seling,

allstudy

househ

olds

hadbu

iltand

wereusingaTipp

y-tap,.

After

1year,12of

the15

(80%

)ho

useh

olds

stillhad

aTipp

y-tapinstalled,

with

eviden

ceof

use(water

inthecontaine

randon

the

grou

ndarou

ndthe


Table

2Summaryof

stud

ies(Con

tinued)

Autho

r&year

Popu

latio

nSamplesize

Stud

yde

sign

&metho

dsObjectives/aim

s

Participants

Age

Setting

Cou

ntry

Stud

ypu

rpose/

Objective

Outcomes

Results

device).

Musokeet

al.

2018

[28]

Hou

seho

ldwith

children

below

5years

Com

mun

ityinform

ants

TwoScho

ols

Adu

ltsand

prim

ary

scho

olpu

pils

(Age

not

provided

)

Com

mun

ityandscho

ols

Ugand

a24

commun

ityinform

ants

200he

alth

club

pupils

200ho

useh

olds

Interven

tions

-Specialtraining

sessions

onhand

washing

,spe

cifically,

theuseof

tippy-tap

techno

logy

were

cond

uctedin

the

commun

itysurvey

and

observations

FGDs

In-dep

thinterviews

Toim

provethehe

alth

status

oftheinhabitants

throug

hcond

uctin

gcommun

ityproactiveand

sustainableinterven

tions

targetingtw

opriority

prob

lem

areasof

access

tosafe

drinking

water

andim

proved

sanitatio

nfacilities

Prom

otionof

hand

hygien

epractices

(Increased

hand

washing

)Use

oftip

pytaps

Morethan

200ho

useh

old

constructedtheirow

ntip

py-taps.

Use

oftip

pytaps

improved

hand

washing

practices

amon

gadults

andchildrenespe

cially

afterusingthetoilet.

Mwakitalim

a(2018)

[29]

Hou

seho

lds

Heads

ofho

useh

olds

(age

not

provided

)

Com

mun

ityTanzania

2875

househ

olds

Interviews,

Observatio

nsTo

evaluate

theextent

that

thecampaignhas

contrib

uted

tothe

overallcoverageof

improved

sanitatio

nin

relatio

nto

areasthat

are

notun

derthecampaign?

Use

and

adop

tionof

tippy-taps

Abo

ut10%

(n=252)

oftheho

useh

olds

hada

tippy-tap

whileon

ly3%

(n=77)ho

useh

olds

hada

sink

with

atap.

Tipp

y-taps

wereavailable

in14.1%

ofthe

househ

olds

inthe

interven

tionvillage

sversus

4.1in

the

controlvillages.

Manyho

useh

olds

adop

tedTipp

y-tapwas

themostadop

tedhand

washing

stationcom

paredto

fised

basin,

mo

bilebasin/bu

cked

,water

source

such

ashand

pumpandsink

with

tap

Pietropaoli

(2017)

[30]

Hou

seho

lds

Adu

lts(Age

not

provided

)

Com

mun

itySierra

Leon

e24

househ

olds

Survey?

Form

ativeresearch.

Cou

nselled

Interven

tions:

Con

struct

ahand

washing

station

(suchas

atip

py-tap);

3.Prioritisesoap

for

hand

washing

and

keep

ing

soap

bythe

hand

washing

station

Testmothe

rs’respo

nses

torecommen

datio

nsfor

improvinginfant

and

youn

gchild

feed

ing,

WASH

andothe

rde

sired

practices;and

determ

ine

which

practices

were

mostfeasibleand

acceptable

Investigatethe

constraintsmothe

rsface

whe

ntrying

tochange

feed

ingpatterns,h

ygiene

practices

andothe

rdaily

routines

andde

term

ine

theirmotivations

for

trying

andsustaining

Use

and

adop

tionof

tippy-taps

Tipp

ytaps

wereaccepted

andused

bymany

househ

olds.

Themainreason

sfor

constructin

gatip

py-tap

werethat

itwas

simple

toconstruct,andthat

itwas

madefro

m

locally

availablematerials.


Table

2Summaryof

stud

ies(Con

tinued)

Autho

r&year

Popu

latio

nSamplesize

Stud

yde

sign

&metho

dsObjectives/aim

s

Participants

Age

Setting

Cou

ntry

Stud

ypu

rpose/

Objective

Outcomes

Results

new

practices

Shukla

(2018)

[31]

15angamwandis

and116

children

Children2–6

years

Com

mun

ityIndia

116children

15angamwandis

Quantitative:Survey

-che

cklistforfacility

assessmen

t.-tippy-tap

was

introd

uced

inthe

anganw

adis

Toiden

tifythelack

offacilitiesin

the

anganw

adisand

implem

ent

inno

vativeand

sustainablesolutio

nsto

tacklegrass-root

level

prob

lemsat

anganw

adi

centres

Prom

otionof

hand

hygien

epractices

(Increased

hand

washing

)Use

oftip

py-

taps

Non

e(0%)of

thechildren

intheanganw

adis

practiced

hand

washing

before

themeals.

Interven

tionwas

instantly

accepted

inthe

anganw

adisandchildren

startedwith

thehabitof

hand

washbe

fore

everymeals.

Sing

het

al.

(2016)

[32]

Com

mun

ityHealth

Workers

(CHWs)

Com

mun

ityHealth

Volunteers

CHV

40yrs.

meanage

(>18

years)

Com

mun

ityandho

useh

olds

Ugand

a81

CHV

In-dep

thInterviews

with

82CHVs.

Each

interview

lasted

from

1to

1.5h.

Theseinform

alface-

to-face

interviews

weresemi-structured

with

open

-end

edand

someLikertscale

questio

ns.

Toun

derstand

whe

ther

full-tim

eprofession

alCHWscanpo

tentially

workwith

volunteersin

thecommun

ityto

widen

theirreachandscop

eandifso

whatmotivators

might

beof

keyim

port

ance

totheCHVs

remaining

activein

the

field

Use

and

adop

tionof

tippy-taps

CHVs

putwhatthey

learnt

into

practiceby

buildingtip

py-taps,hav

ingdish-racks

andpu

rify

ingwater

intheirho

mes

andactedas

rolemod

els

inthecommun

ity.

Alargenu

mbe

rof

tippy-

taps

werebu

iltin

the

commun

ity.A

bout

4.7%

ofho

useh

olds

hadtip

py-

taps

atbaselinecom

paredto

47%

post

interven

tion,

P<0.05).

TheCHVs

implem

ented

whatthey

learnt

durin

gthetraining

andas

such

wererolemod

elsto

othe

rmem

bersof

the

commun

itywith

84%

ofCHVs

having

tippy-taps

them

selves.Thiscom

paresto

1%of

CHVs

who

hadatip

py-tap,p

riorto

thecommen

cemen

tof

thestud

y.

Sing

het

al.

(2016b

)[33]

CHWs,CHV,

caregivers

ofthe

unde

rfive

children

Adu

lts(Age

notprovided

)Com

mun

ityUgand

a4paid

supe

rvisor

(CHWs),

82CHV

200ho

useh

old

100ho

useh

old

interven

tion

100ho

useh

old

incontrolg

roup

Tocompare

training

alon

eversus

training

and

supp

ortivesupe

rvisionby

paid

CHWs(n=4)

onthe

effectiven

essof

CHVs

(n=82)to

deliver

educationabou

tpreg

nancy,ne

wbo

rncare,

family

planning

and

hygien

e.

Use

and

adop

tionof

tippy-taps

At1year

follow-upthere

was

asign

ificantlyhigh

er

prevalen

ceof

installed

andfunctio

ning

tippy-

taps

forhand

washing

(p<0.002)

intheinter

ventionvillage

s(47%

)than

controlvillages

(35%

).


Table

2Summaryof

stud

ies(Con

tinued)

Autho

r&year

Popu

latio

nSamplesize

Stud

yde

sign

&metho

dsObjectives/aim

s

Participants

Age

Setting

Cou

ntry

Stud

ypu

rpose/

Objective

Outcomes

Results

Zhanget

al.

(2013)

[34]

397Scho

olchildren

7–13

years

Scho

ols

Ugand

a398children

(8scho

ols)

Pre−

/postin

terven

tion

surveyswerefielded

ineigh

tscho

ols.

Four

interven

tion

scho

olsweregiven

tippy-taps,soap

and

educationalm

aterials,

whilefour

control

scho

olsinitially

received

only

educationalm

aterials.

Ateach

scho

ol,o

neclassroo

mwas

selected

atrand

om(lotterydraw

),and25

boys

and25

girls

(Grade

s2–5)

were

selected

from

that

classroo

mto

begiven

surveysusinga

system

aticrand

omsamplingde

sign

(every

third

girland

boy)

Tomeasure

theefficacy

ofatip

py-tap-based

hand

washing

prog

ramme

inprom

oting

hand

washing

ratesin

elem

entary

scho

olsin

ruralU

gand

a

Prom

otionof

hand

hygien

epractices

(Increased

hand

washing

and

preven

tionof

diarrhoe

a)

After

1mon

th,the

interven

tionscho

ols

repo

rted

alargeincrease

indaily

hand

washing

ratesandabsenceof

stom

achpain

episod

escomparedwith

the

controlschoo

ls.

After

receivingthe

interven

tion,

thecontrol

scho

olsattained

similar

hand

washing

and

stom

achpain

rates.

Both

hand

washing

atscho

olandafterusing

thetoiletincreasedafter

theintrod

uctio

nof

tippy-taps.

Theprop

ortio

nof

stud

entsrepo

rting

‘always’or

‘often

’washing

theirhand

sat

scho

olincreasedfro

m3.5%

atbaselineto

100.0%

atfollow-up{t=19.54,P<

0.05,95%

confiden

ceinterval(CI)1.21–1.68in

theinterven

tionscho

ols

[replicated

incontrol

scho

olsby

Time3(t=

12.92,P<0.05,95%

CI

1.48–2.45].

Theprop

ortio

nof

stud

ents‘always’washing

theirhand

safterusing

thetoiletincreasedfro

m5.5to

65.0%

(t=14.61,

P<0.05,95%

CI1.02–

1.58)in

theinterven

tion

scho

ols[W

ashing

hand

safterusingthetoilet

amon

gstud

entsin

the

controlschoo

lsincreased

from

3.6to

79.3%

(t=

13.21,P<0.05,95%

CI

1.16–1.90)

byTime3].

Use

ofsoap

inthe

interven

tionscho

ols

increasedfro

m13.5to

84.5%

(t=5.64,P

<0.05,

95%

CI0.29–1.04)with


Table

2Summaryof

stud

ies(Con

tinued)

Autho

r&year

Popu

latio

nSamplesize

Stud

yde

sign

&metho

dsObjectives/aim

s

Participants

Age

Setting

Cou

ntry

Stud

ypu

rpose/

Objective

Outcomes

Results

even

high

erprop

ortio

nsrepo

rted

atcontrol

scho

olsat

Time3(t=

298.15,P

<0.05,95%

CI

0.86–0.88).

Intheinterven

tion

scho

ols,theprop

ortio

nof

stud

entsrepo

rting

washing

theirhand

sthreeor

moretim

es/day

increasedfro

m5.5to

93.0%

(t=9.84,P

<0.05,

95%

CI0.98–1.91)after

theinstallatio

nof

tippy-

taps.

Furthe

rmore,thecontrol

scho

olsalso

attained

the

hand

washing

ratesof

the

interven

tionscho

ols

(97.9%

)by

Time3(t=

18.47,P<0.05,95%

CI

1.42–2.01).Proxy

data

ontheincide

nceof

diarrhoe

aldiseaseare

indicatedby

thenu

mbe

rof

stud

entsrepo

rting

stom

achpain

episod

esin

theprevious

mon

th.In

theinterven

tionscho

ols,

thepe

rcen

tage

ofstud

entsrepo

rtingno

stom

achpain

episod

esincreasedfro

m7.0to

80.0%

(t=10.84,P<0.05,

95%

CI0.92–1.68).


criteria. Fifty-three articles were excluded from this sys-tematic review because they did not meet the eligibilitycriteria (see Fig. 3).

Risk of bias/quality appraisalQuality of the design and reporting system were themain focus at this stage. Three review authors independ-ently assessed the risk of bias in the included studies.The MMAT [35] was used to appraise the twenty stud-ies included in the review critically. MMAT is a vali-dated checklist used to appraise the quality of studiesincluded in any systematic review with a quantitative,qualitative and mixed methods approach [36–38]. TheMMAT has two general screening questions applicableto all study designs: 1) Are there clear qualitative andquantitative research questions or objectives, or is therea clear mixed-methods’ question or objective? 2) Do thecollected data address the research question or object-ive? The MMAT appraises the following study method-ologies and designs: qualitative, quantitative randomisedcontrolled, quantitative non-randomized, quantitativedescriptive and mixed methods study designs. The toolis divided into five components and each component isdesigned to assess the quality of a specific study design.These components are qualitative, quantitative rando-mised controlled, quantitative non-randomized, quanti-tative descriptive, and mixed methods studies. Allcomponents are numbered, and each section has threeto four assessment criteria. For example, assessment cri-teria for assessing for randomised controlled trial studiesincluded: 1) Is there a clear description of therandomization? 2) Is there a clear description of the allo-cation concealment? 3) Are there complete outcomedata [80% or above]? 4) Is there low withdrawal/drop-out (below 20%)? Each criterion equals 25% if the assess-ment response is ‘Yes’, and zero if the response is ‘No’.A summation of the responses is the total score of thequality of the study in per cent and the maximum scoreper study is 100% (see Table 3). In the assessment com-ponent for mixed methods, 25% is given by default andis summed up with other scores from the criteria underthis component. Overall, the higher the score, the betterthe quality of the study. MMAT was chosen to appraisestudies in this review because it can simultaneously ap-praise studies of different designs, which suits differentstudy methodologies included in this systematic review.

Data synthesisA narrative approach was used to synthesise data. Narra-tive synthesis in systematic reviews is recommendedwhen there is a great variation in variables such as out-comes, interventions, population, and methods acrossstudies [39]. We integrated the findings from the quali-tative and quantitative findings [40]. This design involves

either turning qualitative data into quantitative (quanti-tising) or quantitative findings are turned into qualitative(qualitising) to facilitate their integration [40]. This de-sign has been widely used in mixed methods systematicreviews [41, 42]. We used study outcomes as themes tosynthesise data. A narrative approach was also used tosynthesis the quality of study and characteristics of thestudy characteristics.. The main category of the analysiswas based on the promotion of handwashing behaviourby using tippy-tap. Under this category, the reviewerscame up with three subcategories, namely: the use andbenefit of tippy-tap in promoting hand hygiene; adoptionof tippy-tap and its associated hand hygiene resources,and the effectiveness of tippy-tap. In this systematic re-view, “use” of tippy-tap refers to the situation wherebythe participant merely used tippy-tap to wash handsand/or increased their handwashing during their respect-ive project implementation. On the other hand, “adop-tion” of tippy-tap refers to a situation whereby theparticipant continued using tippy-taps even after theirrespective research projects or programs had stopped orconstructed new tippy-taps after completion of the pro-ject. Effectiveness of tippy-tap in this study refers toproxy data of reducing infectious diseases. Content ana-lysis was carried out to synthesise the extracted data andsimilar information was grouped (see Table 2). Findingswere presented in narrative form as shown below. Theinterventions were also classified according the settingswhere they were implemented. The settings of the studywere classified as households (peoples’ houses), primaryschools, and communities. Community based interven-tion in this study refers to interventions implemented ata public place (village level, church, and neighbour-hoods). Statistical meta-analysis was not possible as thestudies varied considerably on how the study outcomeswere analysed by the researchers.

ResultsQuality appraisalBased on MMAT, nine studies scored 100% [17–22, 24,29, 32]. Of these, two were qualitative, five were quantita-tive descriptive, and one was a mixed-methods study. Ninestudies scored 75% [16, 23, 25–28, 31, 33, 34] amongthese, three were experimental studies that had no infor-mation on blinding [23, 33, 34]; three were qualitativestudies with no clear description regarding the influenceof the researcher on study findings [25, 27, 31]; two weremixed methods studies that did not highlight the limita-tions to integration of qualitative and quantitative findings[16, 28]; and one was a non-randomised study with a lowresponse rate [26]. Two qualitative studies scored 50%each because they lacked information about how datawere analysed and description on whether a special con-sideration was given to how findings related to the


Table 3 MMAT

Name of studyauthor

Type of study Methodological quality criteria Yes Comments Score

Abass (2018) [16] Mixed methods 5.1. Is the mixed methods research design relevant to address thequalitative and quantitative research questions (or objectives), orthe qualitative and quantitative aspects of the mixed methodsquestion (or objective)?

Y not clear 75%

5.2. Is the integration of qualitative and quantitative data (orresults*) relevant to address the research question (objective)?

Y

5.3. Is appropriate consideration given to the limitations associatedwith this integration, e.g., the divergence of qualitative andquantitative data (or results*) in a triangulation design?

N

Aiemjoy et al.2017 [17]

Quantitativecross sectional

4.1. Is the sampling strategy relevant to address the quantitativeresearch question (quantitative aspect of the mixed methodsquestion)?

Y 100%

4.2. Is the sample representative of the population understudy? Y

4.3. Are measurements appropriate (clear origin, or validity known,or standard instrument)?

Y

4.4. Is there an acceptable response rate (60% or above)? Y

Biran (2011) [7] Qualitative 1.1. Are the sources of qualitative data (archives, documents,informants, observations) relevant to address the research question(objective)?

Y Nothing on analysis 50%

1.2. Is the process for analysing qualitative data relevant to addressthe research question (objective)?

N

1.3. Is appropriate consideration given to how findings relate tothe context, e.g., the setting, in which the data were collected?

Y

1.4. Is appropriate consideration given to how findings relate toresearchers’ influence, e.g., through their interactions withparticipants?

N

Breese et al.,(2016)

Qualitative 1.1. Are the sources of qualitative data (archives, documents,informants, observations) relevant to address the research question(objective)?

Y 100%

1.2. Is the process for analyzing qualitative data relevant to addressthe research question (objective)?

Y


Y


Y

Cantrell,(2013) [19]

Quantitativedescriptive Survey


Y 100%



Y

4.4. Is there an acceptable response rate (60% or above)?applicable, an acceptable response rate (60% or above), or anacceptable

Y

Chisanga et al.2018 [20]

Quantitative crosssectional


Y 100%



Y

4.4. Is there an acceptable response rate (60% or above)? Y

Chiziwisanoet al., 2019

Mixed methods 5.1. Is the mixed methods research design relevant to address thequalitative and quantitative research questions (or objectives), or

Y 100%


Table 3 MMAT (Continued)

Name of studyauthor


the qualitative and quantitative aspects of the mixed methodsquestion (or objective)?


Y


Y

Christensen et al.(2015) [22]

Randomizedcontrolled trial

2.1. Is there a clear description of the randomization (or anappropriate sequence generation)?

Y 100%

2.2. Is there a clear description of the allocation concealment (orblinding when applicable)?

Y

2.3. Are there complete outcome data (80% or above)? Y

2.4. Is there low withdrawal/drop-out (below 20%)? Y

Contzen et al.(2015) [23]

Quasi-experiment 2.1. Is there a clear description of the randomization (or anappropriate sequence generation)?

Y 75%


N



Dajaan et al.(2018) [24]

Quantitative

cross sectional


Y 100%



Y


Y

Hurtado(1994) [25]

Qualitative 1. Are the sources of qualitative data (archives, documents,informants, observations) relevant to address the research question(objective)?

Y not clear 75%


Y


Y


N

Kamuteera et al.2018 [26]

Quantitative crosssectional survey


Y not clear 75%



Y


N

Mbuya et al.,(2015) [27]


Y 75%


Y

1.3. Is appropriate consideration given to how findings relate to Y



Name of studyauthor


the context, e.g., the setting, in which the data were collected?


N

Musoke et all.2018 [28]

Mixed methods 5.1. Is the mixed methods research design relevant to address thequalitative and quantitative research questions (or objectives), orthe qualitative and quantitative aspects of the mixed methodsquestion (or objective)?

Y Superficial analysisprocedures reported

75%


Y


N

Mwakitalima(2018) [29]

Quantitative crosssectional

3.1. Are participants (organizations) recruited in a way thatminimizes selection bias?

Y 5KM apart 100%

3.2. Are measurements appropriate (clear origin, or validity known,or standard instrument; and absence of contamination betweengroups when appropriate) regarding the exposure/interventionand outcomes?

Y

3.3. In the groups being compared (exposed vs. non-exposed; withintervention vs. without; cases vs. controls), are the participantscomparable, or do researchers take into account (control for) thedifference between these groups?

Y

3.4. Are there complete outcome data (80% or above), and, whenapplicable, an acceptable response rate (60% or above), or anacceptable follow-up rate for cohort studies (depending on theduration of follow-up)?

Y

Pietropaoli(2017) [30]


Y Nothing on analysis 50%


N


Y


N

Shukla (2018)[31]

Quantitativedescriptive


Y Info not given 75%



Y

4.4. Is there an acceptable response rate (60% or above)? N

Singh et al.(2016) [32]


Y 100%


Y


Y


Y

Singh et al.(2016b) [33]

Randomisedcontrolled trial


Y 75%


researcher’s influence [7, 30]. MMAT has no cut-off pointfor the quality of studies, but we considered ‘less than50%’ score as low quality. However, none of our selectedstudies scored below 50%. With an average MMAT scoreof 82.5% across the included studies, the studies are con-sidered to be of high quality.

Study characteristicsTwenty studies met the eligible criteria. Of these, sixwere conducted in Uganda [7, 26, 28, 32–34], two inEthiopia [17, 23], and two in Tanzania [20, 29]. Further-more, one study was conducted in each of the followingcountries: Zambia [18], Zimbabwe [27], Kenya [22],Nigeria [16], Haiti [19], Malawi [21], Ghana [24] and Si-erra Leone ([30] (See Table 2). In terms of study design,six qualitative studies [7, 18, 25, 27, 30, 32], 11 quantita-tive studies [17, 19, 20, 22–24, 26, 29, 31, 32, 34], andthree mixed methods studies [16, 21, 28] were evaluated.Data collection in the qualitative studies was throughfocus group interviews, semi-structured questionnaireand in-depth interviews. The quantitative studies utilisedquasi-experiment, pre-post survey, cross-sectional surveyand cluster randomised trials study approaches (seeTable 2).A total of 11 studies were conducted in the commu-

nity [7, 16, 17, 19–23, 25–30] and four were conductedin schools [18, 24, 28, 34]. The study population in sixstudies were children while 16 studies were conductedwith adults. The youngest participants were infants lessthan 8 months old [27] and the oldest was 40 years [32]The number of participants in each study varied from 21[18] to 2875 [29].

Summary of the findingsStudies included in this review were analysed based onthe following three outcomes: the use and benefit oftippy-tap in promoting hand hygiene; adoption of tippy-tap and its associated hand hygiene resources, and theeffectiveness of tippy-tap. These sub-categories were

generated from the objective of the study. The presenta-tion and interpretation of the results follow these cat-egories as narrated below.

Use and benefits of tippy-tap in promoting hand hygieneThe use of tippy-taps for handwashing among householdmembers or school children was reported by authors of16 studies conducted in Nigeria, Haiti, Malawi, Ghana,India, Tanzania, Uganda, Sierra Leone, Kenya andEthiopia [7, 16, 17, 19–26, 28–31, 34]. The use of tippy-tap among the participants in the 16 studies ranged from2.7% [26] to 80% [20].Concerning the benefits of using tippy-taps, authors of

three studies [7, 23, 34] reported an increase in hand-washing practice by participants after being exposed totippy-tap. In a randomised controlled trial in Ugandafour intervention and four control schools were re-cruited into the study [34]. At each school, one class-room was selected randomly (lottery draw), and 25 boysand 25 girls (Grades 2–5) were selected from that class-room using a systematic random sampling design (everythird girl and boy). Data were collected at three waves of1 month apart intervals. The first wave was a baselinesurvey that was followed by the provision of soap andhandwashing education to four intervention schools.The second wave was followed by the introduction oftippy-taps and provision of soap to the interventiongroup. Lastly, the post-intervention survey was carriedout at the last wave. The four control schools receivedhealth education only through-out the experiment andwere provided with tippy-taps post-study interventions.The researchers reported an increased estimate in theproportion of students reporting ‘always’ or ‘often’ wash-ing their hands at school from 3.5% at baseline to100.0% at follow-up (t = 19.54, P < 0.05, 95% CI 1.21–1.68) in the intervention schools. When the similarintervention was replicated in the control schools byTime 3, there was an increase in handwashing (t = 12.92,P < 0.05, 95% CI 1.48–2.45] [34]. In the same study, it


Name of studyauthor



N



Zhang et al.(2013) [34]

Randomizedcontrolled trial


Y 75%


N



*Both qualitative and quantitative results


was observed that the proportion of students ‘always’washing their hands after using the toilet increased from5.5 to 65.0% (t = 14.61, P < 0.05, 95% CI 1.02–1.58) inthe intervention schools, while in the control schools itonly increased from 3.6 to 79.3% (t = 13.21, P < 0.05, 95%CI 1.16–1.90) by Time 3 when the same interventionwas replicated [34].In addition, compared to control schools, introduction

of tippy-taps increased the use of soap by students in theintervention schools in an experiential study from 13.5to 84.5% (t = 5.64, P < 0.05, 95% CI 0.29–1.04); hand-washing from 5.5 to 93.0% (t = 9.84, P < 0.05, 95% CI0.98–1.91) and handwashing after using the toilet from5.5 to 65.0% (t = 14.61, P < 0.05, 95% CI 1.02–1.58) [34].Similarly, another study [7] found that tippy-taps in-creased handwashing after latrine use by providing con-venient soap and water, and by acting as a salient cue tohandwashing. Although quantitative data on handwash-ing rates were not collected, participants in householdswith tippy-taps believed that their post-latrine hand-washing rates had increased as a result of the tippy-taps[7]. Pre- and post-data analysis on self-reported hand-washing revealed that the population-tailored interven-tions, especially the tippy-tap-promotion, performedbetter than the standard education intervention (educa-tion intervention, the f-diagram exercise, an often ap-plied intervention tool) [18]. In a study conducted byChristensen and colleagues [22], the use of tippy-tap wasmeasured through the availability of handwashing re-sources (soap and water) at the tippy-tap station. Theseresearchers found that enumerator-observed indicatorsof use were still high (72–85% for having both soap andwater present at the tippy-tap station) [22]. In an Indianqualitative study, most participants reported using tippy-tap because of its benefits [25]. The participants re-ported that handwashing using tippy-tap requires lesswater and soap compared to the usual method of hand-washing [25]. However, in the same study [25] partici-pants indicated the following as challenges of the tippy-tap handwashing technology: it was not easy to washhands of very young children with the tippy-tap; therewas a potential problem that older children may playwith the device, thus destroying it or wasting water; itwas also recognized that the device required extra water,time, and work to install, use, and maintain. In addition,a study by Biran [7], one participant suggested thattippy-taps did not look attractive, elderly participantssaid tippy-taps looked childish and unnecessary, and thatpeople used to live longer even before tippy-taps weredeveloped.On the other hand, the economic benefits of tippy-

taps were reported by the authors of a Nigerian study[16]. The installation of tippy-taps in small scale busi-ness facilities by women who were involved in selling

food items led to an increase in the number of cus-tomers, which resulted in more sales and profits.

Adoption of tippy-tap and its associated hand hygieneresourcesAuthors of six studies assessed the adoption of tippy-taps by households [7, 18, 22, 23, 32, 33]. In a study con-ducted by Christensen [22], the intervention householdswere significantly more likely to have a place for hand-washing (71–85 percentage point increases) with soapavailable (49–66 percentage point increases) than con-trols. These authors also noted an increase of 86% inhaving a dedicated location for tippy-taps. Similarly, inanother study, teachers educated school going childrenon tippy-tap as a handwashing station [18]. Althoughthese children were not directly asked to constructtippy-tap, they all managed to attempt building one orinfluence their parents to assist them. Their parentstrusted the information received from their children.The tippy-taps were also found to be attractive, easy touse and helpful in fostering the habit of handwashingamong children [18].Signh et al. [33] engaged the community in a hand hy-

giene promotion program. At 1 year follow-up, the re-searchers noted a 47% installation of functioning tippy-taps in the intervention villages compared to 35% in thecontrol villages (p < 0.002) [33]. There was a significantincrease in tippy-tap installation by community mem-bers from 4.7% of households at baseline to 47% ofhomes after the intervention, following the demonstra-tions to construct the device by community health vol-unteers (CHVs). The CHVs were trained on the tippytap construction and acted as role models to other com-munity members. Furthermore, there was a great im-provement in owning tippy-taps by CHVs from 1% atbaseline to 84% after interventions [33]. Another signifi-cant evidence of adoption of tippy-taps was observed ina study where all study households built tippy-tapswithin 2 weeks of counselling [27]. After 1 year of tippy-tap promotion, 80% of the households still had a tippy-tap installed, with evidence of use (water in the con-tainer and on the ground around the device). Similar re-sults were observed in a study by Contzen andcolleagues [23] in which, close to 100% of the house-holds followed the promotion and invested material andtime to construct their tippy-tap. In the same study, allparticipants in the intervention group constructed tippy-taps and about 83% of these were still operational 3months after termination of the interventions.Although there is limited awareness on tippy-tap, hav-

ing knowledge about tippy-tap did not result in immedi-ate construction of the station [7, 18]. The researcherthought that study participants constructed a tippy-tapsbecause they were asked to do so, or they anticipated


that the researcher would be visiting them regularly toevaluate the adoption of the technology [7]. Some partic-ipants constructed tippy-tap as a result of campaignsand fear of fines from community leaders [7].

Effectiveness of tippy-tapOut of twenty articles under review, only one study [34]had an incidence of diarrhoea as an outcome measure.The study was conducted in a school setting in Ugandaand aimed at measuring the efficacy of a tippy-tap-basedhandwashing programme in promoting handwashingrates in elementary schools in rural Uganda. Zhang andcolleagues [34] used the pre-and post-intervention sur-veys in which four intervention schools were giventippy-taps, soap and educational materials, while fourcontrol schools initially received only educational mate-rials. Proxy data for assessing the effectiveness of tippy-taps in reducing diarrhoeal disease was indicated by thenumber of students reporting stomach pain episodes inthe previous month. The authors of the study found thatin the intervention schools, the percentage of studentsreporting no stomach pain episodes increased from 7%at baseline to 80% after the intervention (t = 10.84, P <0.05, 95% CI 0.92–1.68) [34]. However, no proxy datawas provided on the trend of diarrhoea in the controlgroup.

DiscussionThe aim of this systematic review was to assess the use,benefits, adoption and effectiveness of tippy-tap hand-washing station in resource-limited settings. A total oftwenty articles were identified and reviewed. The find-ings of our systematic review show that the availabilityof tippy-taps increased handwashing and use of soapamong participants. Furthermore, the majority of peoplewho were oriented to tippy-taps or recruited to tippy-tap studies built their tippy-tap stations even after theend of promotional activities or programs. In one study,tippy-taps were found to be effective in preventing stom-ach pain episodes among participants [34].There is sufficient evidence that hand washing is a sin-

gle most important intervention for preventing diar-rhoeal and respiratory infections, yet the rate ofhandwashing in resource-limited settings is very low [3,43–45]. Indeed, with frequent global outbreaks of infec-tious diseases such as COVID-19, and Ebola, the import-ance of identifying a cost-effective hand handwashingenabling technologies cannot be overemphasized. Thefindings of this review suggest that tippy-taps have agreat potential to improve the health outcomes of peopleas it increases handwashing and use of soap, which arecrucial in breaking the transmission cycle of infections.The findings of our study point to many advantages oftippy-taps over other hand washing station technologies.

These advantages include inexpensive to construct as ituses local materials, easy to construct, entertaining forchildren, water economical and convenient to use as it isusually constructed near the toilet so that people caneasily wash their hands after using the toilet.In addition, the findings of this study indicate that

tippy-taps have a higher likelihood of being adopted byparticipants. Our study findings show that the majorityof participants who constructed their tippy-taps werestill using them even after the end of interventions orpromotional programs [7, 23, 27, 32, 34]. This is not sur-prising given that tippy-taps are cost-effective and aremade from locally available resources [6, 46]. Evidencepoints to the following as facilitators of adoption of pub-lic health interventions by users: perceived importanceof the intervention, availability of resources, affordability,culturally appropriate, easy to use, availability of tech-nical and financial support [47].Furthermore, although more than three decades have

passed since the first tippy-tap was constructed, the find-ings of our systematic review demonstrate that there isstill limited data regarding its use and effectiveness. Onlya few studies have specifically evaluated tippy-tap as anintervention. Out of the 20 studies included in thisstudy, only three were experimental studies [22, 23, 34].Out of these three experimental studies, only one [34]specifically evaluated the effectiveness of the tippy-tap inpreventing stomach pain episodes. In the other twostudies [22, 23], tippy-taps were part of a combinedwater and hygiene interventions that were evaluated to-gether. While Zhang and colleagues [34] reported thattippy-taps were effective in reducing stomach pains epi-sodes among the participants in the treatment group,the study lacked information regarding blinding of par-ticipants and measures of fidelity which put to questionthe validity and reliability of the findings.The findings of this review suggest that there is a

dearth of literature on tippy-tap enabling technology es-pecially on the promotion of handwashing practices. Thehistory of tippy-tap dates to 1980s, but the first peer-reviewed article was published in 1994 [25] . Thereafter,a gap ensued until 2011 when Biran and colleagues pub-lished the next paper on tippy-tap [7]. Our search strat-egy indicated that the latest articles in this field werepublished in 2019 [21, 31] while the remaining studieswere conducted between 2011 and 2019.

Limitations of the studyThis review is not without limitations. First, our system-atic review only included studies that were conducted inEnglish. This may have introduced bias to the findingsof the study as some studies published in other lan-guages may have had information that could be useful inanswering the research question. Second, the study was


limited to poor resource countries limiting the general-isation of the findings to other settings. Notwithstandingthese limitations, all the studies except two, scored high(≥75%) on quality appraisal using MMAT with eight ar-ticles scoring 100%. This entails that the majority of thestudies included in this review were of moderate orstrong quality.

Implications of the study findings for practice, researchand policyThe findings of this systematic review of literature informpractitioners, policy makers and researchers about the use,adoption, benefits, and effectiveness of tippy-taps in re-source limited countries. The tippy-tap technology is one ofthe interventions that people working in the field shouldpromote in resource-limited settings where the majority ofpeople fetch water from community boreholes or wellswhich are far from their houses. Tippy-taps are cheap, easyto construct, entertaining to children, and easy to adoptwhich make them suitable hand washing promotion inter-vention in resource poor countries where the prevalence ofwaterborne and other infectious diseases is high. Publichealth care workers, Governments, non-governmental or-ganisations, and other stakeholders are encouraged to takea leading role in promoting the use of tippy-taps to peoplethrough public campaigns. The campaigns may targetschools, churches, communities, and hospitals where ma-jority of the people can be reached. In addition, use of massmedia such as radio and television could also be used toeducate people about the importance of tippy-taps. Train-ings for community volunteers are also needed to empowerthem with information on how they can support communi-ties to build their own tippy-taps. Another important issueto consider is that we only identified one study that evalu-ated the effectiveness of the tippy-taps. Moreover, the studyhad some methodological problems that impacted on thevalidity and reliability of the findings. Thus, evidence on theeffectiveness of tippy-taps in preventing infectious disease isstill limited. Rigorous interventional studies with fidelitymeasures are needed to evaluate the effectiveness of tippy-taps in reducing waterborne and other infectious diseases.Furthermore, although schools are places where childrenspend much of their time, interact with others and easilyget or transmit infections, only five studies [18, 24, 28, 34]included in this review had schools as a study setting. Fu-ture studies conducted in school settings are therefore ne-cessary. Government policies that can promote the use oftippy-taps by providing subsidies or empowering communi-ties and households through trainings to build and usetippy-taps are also needed (Hayes et al. 2019).

ConclusionTippy-taps have great potential to improve health out-comes of people living in resource-limited settings where

waterborne diseases are common. However, with limiteddata, it is difficult to ascertain how common tippy-tapsare within the community or how effective they are inreducing infections associated with poor hand hygiene.More prevalence and experimental studies are warrantedto provide a good understanding of the use, adoption,and effectiveness of tippy-taps. To the best of the au-thors’ knowledge, this is the first systematic review to as-sess the use, adoption, and effectiveness of tippy-taphandwashing station in promoting hand hygiene prac-tices in a resource-limited setting.

Supplementary informationSupplementary information accompanies this paper at https://doi.org/10.1186/s12889-020-09101-w.

Additional file 1: Supplementary material A. Standardised dataextraction form

AbbreviationsAMED: AMED Allied and Complementary Medicine; CINAHL: CumulativeIndex of Nursing and Allied Health Literature; COCHRANE: Cochranedatabase of systematic reviews; COVID-19: Coronavirus disease 19; DOAJ: TheDirectory of Open Access Journals; EMBASE: Excerpta Medica dataBASE;MMAT: The Mixed Methods Appraisal Tool; PRISMA: Preferred ReportingItems for Systematic Reviews and Meta-Analyses; PROSPERO: TheInternational Prospective Register of Systematic Reviews;PsycINFO: Psychological Information Database; UNICEF: The United NationsInternational Children’s Emergency Fund; UNC: University of North Caroline;WHO: World Health Organisation

AcknowledgementsNot applicable

Authors’ contributionsBMC, FWK & MZ designed the literature review, wrote the protocol that ispublished in the PROSPERO and searched the literature. Data analysis wasdone by all authors who also wrote the manuscrips and contributed to theintellectual revisions and content All authors have read and approved themanuscript.

FundingThere was no funding for this systematic review.

Availability of data and materialsThe data and materials used in this systematic review are available from thecorresponding author on request.

Ethics approval and consent to participateNot applicable.

Consent for publicationNot applicable.

Competing interestsThe authors declare no competing interests.

Author details1St John’s Institute for Health, P.O. Box 18, Mzuzu, Malawi. 2Mzuzu University,Private Bag 201, Luwinga, Mzuzu 2, Malawi.


https://doi.org/10.1186/s12889-020-09101-w

https://doi.org/10.1186/s12889-020-09101-w

Received: 4 October 2019 Accepted: 12 June 2020

References1. UNICEF. The Human Right to Water and Sanitation. Geneva: United Nations;

2015.2. WHO & UNICEF. Water, sanitation and hygiene in health care facilities: status

in low and middle income countries and way forward. Geneva: WHO; 2015.3. Center for Disease Control and Prevention: Hand Hygiene in Healthcare

Settings. In. USA: Center for Disease Control and Prevention; ND.4. Hutton G, Haller L, WHO Evaluation of the costs and benefits of water and

sanitation improvements at the global level. Geneva: WHO; 2004.5. UNICEF. Fact sheet: child survival fact sheet: water and sanitation, vol. 2020.

USA: UNICEF; 2004.6. Eshuchi R. Promoting handwashing with soap behaviour in Kenyan schools:

learning from puppetry trials among primary school children in Kenya.Doctoral Thesis. Australia: Queensland University of Technology; 2013.

7. Adam B. Enabling technologies for handwashing with soap : a case studyon the tippy-tap in Uganda. Uganda: Water and Sanitation Program; 2011.

8. UNICEF Zambia. The programme. Zambia: UNICEF; 2012.9. How to build a tippy tap for hand washing. Available from http://hip.fhi360.

org/file/19778/CC%20How%20to%20Build%20Tippy%20Tap%20FINAL.pdf.[cited 2020 June 16].

10. Pickering AJ, Davis J, Blum AG, Scalmanini J, Oyier B, Okoth G, Breiman RF,Ram PK. Access to waterless hand sanitizer improves student hand hygienebehavior in primary schools in Nairobi, Kenya. Am J Trop Med Hyg. 2013;89(3):411–8.

11. Morgan P. The Mukombe - Zimbabwe’s first “tippy tap” : A description of itsvalue and use [https://www.aquamor.info/uploads/3/4/2/5/34257237/the_mukombe.pdf].

12. UNICEF. Water, Sanitation and Hygiene for School children in Emergencies:A Guidebook for Teachers, vol. 75. USA: UNICEF; 2011.

13. WaterAid. Hygiene framework. London: WaterAid; 2012.14. Mbakaya BC, Zgambo M, Kalembo FW: Use, adoption and effectiveness of

tippy-tap handwashing station in promoting hand hygiene practices inresource limited setting. PROSPERO database. 2017;CRD42017074331.

15. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items forsystematic reviews and meta-analyses: the PRISMA statement. Int J Surg.2010;8(5):336–41.

16. Abass K, Achegbulu A. Financial inclusion and safe sanitation in slumcommunities of Abuja, Nigeria. In: 41st WEDC International Conference.Nakuru: Kenya Loughborough University; 2018.

17. Aiemjoy K, Gebresillasie S, Stoller NE, Shiferaw A, Tadesse Z, Chanyalew M,Aragie S, Callahan K, Keenan JD. Epidemiology of soil-transmitted helminthand intestinal protozoan infections in preschool-aged children in theAmhara region of Ethiopia. Am J Trop Med Hyg. 2017;96(4):866–72.

18. Bresee S, Caruso B, Sales J, Lupele J, Freeman M. A child is also a teacher’:exploring the potential for children as change agents in the context of aschool-based WASH intervention in rural eastern Zambia. Health Educ Res.2016;31(4):521–34.

19. Cantrell BL. An evaluation of a water, sanitation, and hygiene program inrural communities outside of Port-Au-Prince, Haiti. Thesis. USA: GeorgiaState University; 2013.

20. Chisanga HJ. Process evaluation on the implementation of Mwanzo boranutrition program on the reduction of childhood stunting: a case of KiloloDistrict in Tanzania. Doctoral Thesis. Tanzania: Mzumbe University; 2018.

21. Chidziwisano K, Tilley E, Malolo R, Kumwenda S, Musaya J, Morse T. Riskfactors associated with feeding children under 2 years in rural Malawi—aformative study. Int J Environ Res Public Health. 2019;16(12):2146.

22. Christensen G, Dentz HN, Pickering AJ, Bourdier T, Arnold BF, Colford JM Jr,Null C. Pilot cluster randomized controlled trials to evaluate adoption ofwater, sanitation, and hygiene interventions and their combination in ruralwestern Kenya. Am J Trop Med Hyg. 2015;92(2):437–47.

23. Contzen N, Meili IH, Mosler H-J. Changing handwashing behaviour insouthern Ethiopia: a longitudinal study on infrastructural and commitmentinterventions. Soc Sci Med. 2015;124:103–14.

24. Dajaan DS, Addo HO, Ojo L, Amegah KE, Loveland F, Bechala BD, BenjaminBB. Hand washing knowledge and practices among public primary schoolsin the Kintampo municipality of Ghana. Int J Community Med Public Health.2018;5(6):2205–16.

25. Hurtado E. Rapid assessment procedures in formative research for acommunication intervention on water-related hygiene behaviours. FoodNutr Bull. 1994;15(1):1–6.

26. Kamuteera E, Trimmer J. Finding sustainable funding for WASH facilitymonitoring through nutrient recovery in southwest Uganda. In: 41st WEDCInternational Conference. Nakuru: Kenya Loughborough University; 2018.

27. Mbuya MN, Tavengwa NV, Stoltzfus RJ, Curtis V, Pelto GH, Ntozini R,Kambarami RA, Fundira D, Malaba TR, Maunze D. Design of an interventionto minimize ingestion of fecal microbes by young children in ruralZimbabwe. Clin Infect Dis. 2015;61(suppl_7):S703–9.

28. Musoke D, Ndejjo R, Halage AA, Kasasa S, Ssempebwa JC, Carpenter DO.Drinking water supply, sanitation, and hygiene promotion interventions intwo slum communities in Central Uganda. J Environ Public Health. 2018;2018.

29. Mwakitalima A, Massa K, Seleman A, Kassile T. Scaling up rural sanitation inTanzania: evidence from the National Sanitation Campaign. J Water SanitHyg Dev. 2018;8(2):290–306.

30. Pietropaoli J, Moses P, Forrester H. Using trials of improved practices to shiftnutrition and hygiene behaviours in Sierra Leone. Field Exchange 54, vol. 33;2017.

31. Shukla M. Implementing innovative and sustainable methods to tacklegrassroot level problems at anganwadi centers in Virpapura Village,Karnataka (India). J Dental Res Rev. 2018;5(4):139.

32. Singh D, Cumming R, Mohajer N, Negin J. Motivation of community healthvolunteers in rural Uganda: the interconnectedness of knowledge,relationship and action. Public Health. 2016;136:166–71.

33. Singh D, Negin J, Orach CG, Cumming R. Supportive supervision forvolunteers to deliver reproductive health education: a cluster randomizedtrial. Reprod Health. 2016;13(1):126.

34. Zhang C, Mosa A, Hayward A, Matthews SA. Promoting clean hands amongchildren in Uganda: a school-based intervention using ‘tippy-taps’. PublicHealth. 2013;127(6):586.

35. Pluye P, Robert E, Cargo M, Bartlett G, O’cathain A, Griffiths F, Boardman F,Gagnon M-P, Rousseau M. Proposal: a mixed methods appraisal tool forsystematic mixed studies reviews. Montréal: McGill University; 2011. p. 1–8.

36. Boerleider AW, Wiegers TA, Manniën J, Francke AL, Devillé WL. Factorsaffecting the use of prenatal care by non-western women in industrializedwestern countries: a systematic review. BMC Pregnancy Childbirth. 2013;13(1):81.

37. Peek ST, Wouters EJ, van Hoof J, Luijkx KG, Boeije HR, Vrijhoef HJ. Factorsinfluencing acceptance of technology for aging in place: a systematicreview. Int J Med Inform. 2014;83(4):235–48.

38. Pieper MJ, van Dalen-Kok AH, Francke AL, van der Steen JT, ScherderEJ, Husebø BS, Achterberg WP. Interventions targeting pain orbehaviour in dementia: a systematic review. Ageing Res Rev. 2013;12(4):1042–55.

39. Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, Britten N,Roen K, Duffy S: Guidance on the conduct of narrative synthesis insystematic reviews: A product from the ESRC methods programme Version.Lancaster: Lancaster University 2006, 1(2.1):1018.4643.

40. Noyes J, Booth A, Moore G, Flemming K, Tunçalp Ö, Shakibazadeh E.Synthesising quantitative and qualitative evidence to inform guidelines oncomplex interventions: clarifying the purposes, designs and outlining somemethods. BMJ Glob Health. 2019;4(Suppl 1):e000893.

41. Brewster L, Mountain G, Wessels B, Kelly C, Hawley M. Factors affecting frontline staff acceptance of telehealth technologies: a mixed-method systematicreview. J Adv Nurs. 2014;70(1):21–33.

42. Dai Y, Livesley J. A mixed-method systematic review of the effectiveness andacceptability of preoperative psychological preparation programmes to reducepaediatric preoperative anxiety in elective surgery. J Adv Nurs. 2018;74(9):2022–37.

43. Mbakaya BC, Lee PH, Lee RL. Hand hygiene intervention strategies toreduce diarrhoea and respiratory infections among schoolchildren indeveloping countries: a systematic review. Int J Environ Res Public Health.2017;14(4):371.

44. Stephenson R, Simon C, Finneran C. Community factors shaping early ageat first sex among adolescents in Burkina Faso, Ghana, Malawi, and Uganda.J Health Popul Nutr. 2014;32(2):161.

45. WHO. Guidelines on Hand Hygiene in Health Care: First Global PatientSafety Challenge. In: Clean Care is Safer Care. Geneva: WHO; 2019.

46. UNICEF. Soap, toilets and taps: A foundation for healthy children. NewYork: UNICEF; 2009, 3(4).


http://hip.fhi360.org/file/19778/CC%20How%20to%20Build%20Tippy%20Tap%20FINAL.pdf

http://hip.fhi360.org/file/19778/CC%20How%20to%20Build%20Tippy%20Tap%20FINAL.pdf

https://www.aquamor.info/uploads/3/4/2/5/34257237/the_mukombe.pdf

https://www.aquamor.info/uploads/3/4/2/5/34257237/the_mukombe.pdf

47. Jeffries M, Phipps D, Howard RL, Avery A, Rodgers S, Ashcroft D.Understanding the implementation and adoption of an informationtechnology intervention to support medicine optimisation in primary care:qualitative study using strong structuration theory. BMJ Open. 2017;7(5):e014810.

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