Understanding end-user preferences for hand hygiene enabling technologies: A mixed-methods study in peri-urban Lusaka, Zambia

Handwashing facilities (HWFs) are associated with higher rates of handwashing with soap, and the presence of a HWF is the global proxy indicator of household handwashing behaviour. There is limited information on HWF attributes important to end-users with few comparative assessments of HWFs from a user-perspective. We aimed to identify HWF attributes important to end-users and determine how pre-manufactured HWFs ranked by these attributes. This two-phased study was conducted with a diverse group of targeted end-users in two peri-urban communities in Lusaka, Zambia. We identified eight pre-existing HWFs: two manufactured locally (Kalingalinga bucket and Tippy tap) and six industrially produced, imported designs (Jengu, SatoTap, SaniTap, HappyTap, SpaTap, and Kohler Cleanse). In the first phase, focus group discussions explored what participants liked and disliked about each HWF, and thematic analysis defined nine attributes for comparison. In the second phase, participants individually ranked each HWF by these attributes, their overall preference, and their preference once estimated retail prices were revealed. Participants also ranked attributes by importance. Ranking data were modelled using rank-ordered logistic regression. Discussions revealed nine attributes important to end-users: appearance, water management, hygienic use, convenience, water disposal, vulnerability to theft or breakage, ease of use, price and maintenance. Hygienic use and water management were considered most important attributes. Excluding price, facilities resembling a sink, such as the Happy Tap (34%) and Jengu (28%), had the highest probability of being ranked first. With consideration for price, participants preferred lower-cost HWFs such as the Kalingalinga bucket (44%), Tippy Tap (13%) and SATO Tap (10%). This study identified nine attributes important to end-users that can inform future design efforts. Future work will explore user preferences in situ by rotating households through specific HWFs for an extended period. Potential manufacturers should continue to iterate on HWF designs emphasizing reducing costs.