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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
* 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
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 Page 2 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.
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 3 of 25
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
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
8
Google Scholar Title & abstract Tippy-taps and handwashing 4040
EMBASE 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
12
Reference search fromother sources
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
Total recordssearched
4091
Total articlesincluded
20
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 4 of 25
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]
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 5 of 25
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
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 6 of 25
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
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 7 of 25
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
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 8 of 25
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
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 9 of 25
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.
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 10 of 25
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
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 11 of 25
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.
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 12 of 25
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%
).
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 13 of 25
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
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 14 of 25
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).
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 15 of 25
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
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 16 of 25
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
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?
Y
Cantrell,(2013) [19]
Quantitativedescriptive Survey
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)?applicable, an acceptable response rate (60% or above), or anacceptable
Y
Chisanga et al.2018 [20]
Quantitative crosssectional
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
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%
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 17 of 25
Table 3 MMAT (Continued)
Name of studyauthor
Type of study Methodological quality criteria Yes Comments Score
the qualitative and quantitative aspects of the mixed methodsquestion (or objective)?
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?
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%
2.2. Is there a clear description of the allocation concealment (orblinding when applicable)?
N
2.3. Are there complete outcome data (80% or above)? Y
2.4. Is there low withdrawal/drop-out (below 20%)? Y
Dajaan et al.(2018) [24]
Quantitative
cross 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)?applicable, an acceptable response rate (60% or above), or anacceptable
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%
1.2. Is the process for analysing qualitative data relevant to addressthe research question (objective)?
Y
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
Kamuteera et al.2018 [26]
Quantitative crosssectional survey
4.1. Is the sampling strategy relevant to address the quantitativeresearch question (quantitative aspect of the mixed methodsquestion)?
Y not clear 75%
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)?applicable, an acceptable response rate (60% or above), or anacceptable
N
Mbuya et al.,(2015) [27]
Qualitative 1.1. Are the sources of qualitative data (archives, documents,informants, observations) relevant to address the research question(objective)?
Y 75%
1.2. Is the process for analyzing qualitative data relevant to addressthe research question (objective)?
Y
1.3. Is appropriate consideration given to how findings relate to Y
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 18 of 25
Table 3 MMAT (Continued)
Name of studyauthor
Type of study Methodological quality criteria Yes Comments Score
the context, e.g., the setting, in which the data were collected?
1.4. Is appropriate consideration given to how findings relate toresearchers’ influence, e.g., through their interactions withparticipants?
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%
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
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]
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 analyzing 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
Shukla (2018)[31]
Quantitativedescriptive
4.1. Is the sampling strategy relevant to address the quantitativeresearch question (quantitative aspect of the mixed methodsquestion)?
Y Info not given 75%
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)? N
Singh et al.(2016) [32]
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 analysing qualitative data relevant to addressthe research question (objective)?
Y
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?
Y
Singh et al.(2016b) [33]
Randomisedcontrolled trial
2.1. Is there a clear description of the randomization (or anappropriate sequence generation)?
Y 75%
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 19 of 25
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
Table 3 MMAT (Continued)
Name of studyauthor
Type of study Methodological quality criteria Yes Comments Score
2.2. Is there a clear description of the allocation concealment (orblinding when applicable)?
N
2.3. Are there complete outcome data (80% or above)? Y
2.4. Is there low withdrawal/drop-out (below 20%)? Y
Zhang et al.(2013) [34]
Randomizedcontrolled trial
2.1. Is there a clear description of the randomization (or anappropriate sequence generation)?
Y 75%
2.2. Is there a clear description of the allocation concealment (orblinding when applicable)?
N
2.3. Are there complete outcome data (80% or above)? Y
2.4. Is there low withdrawal/drop-out (below 20%)? Y
*Both qualitative and quantitative results
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 20 of 25
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
Mbakaya et al. BMC Public Health (2020) 20:1005 Page 21 of 25
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
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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.
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