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      Could the Supertowel be used as an alternative hand cleaning product for emergencies? An acceptability and feasibility study in a refugee camp in Ethiopia

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          Abstract

          Background

          Diarrhoeal diseases are a major contributor to morbidity and mortality in humanitarian crises. Handwashing with soap may reduce diarrhoea by up to 47%, however, the circumstances associated with displacement make it challenging for crisis-affected populations to be able to wash their hands with soap. The Supertowel is an alternative hand-cleaning product, proven to be as efficacious as handwashing with soap. The Supertowel is a micro-fibre towel with an anti-microbial treatment. When dipped in water it is capable of removing and killing pathogens from hands. This study aims to assess whether the Supertowel could be an acceptable and feasible product for crisis-affected populations.

          Methods

          The study took place in an Eritrean refugee camp located in Tigray state in Ethiopia. We used a mix of qualitative methods to understand use and acceptability, including baseline observations (n = 13), behaviour trials involving interviews at three time points (n = 19) and focus group discussions (n = 3). We thematically analysed data from interviews and discussions.

          Results

          Participants indicated that the Supertowel was convenient, easy to use and saved them water and money. All households participating in the behaviour trials had at least one Supertowel in use at the end of the trials (follow-up visit two). In discussions participants reported that the Supertowel was more desirable than comparable hand cleaning products. In interviews, trial participants explained that the product enabled them to clean their hands at times when they might not normally bother. The research also identified some issues with the smell of the Supertowel and its intuitive use.

          Conclusions

          The Supertowel was found to be an acceptable and useful hand-cleaning product that could complement soap use in crisis contexts. This pilot study also identified areas of future research including the need to compare different distribution models for the Supertowel (distribution in hygiene kits compared to distribution with an accompanying communication package) and to evaluate its use at scale over a longer time period.

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          Most cited references17

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          Effect of washing hands with soap on diarrhoea risk in the community: a systematic review

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            Over-Reporting in Handwashing Self-Reports: Potential Explanatory Factors and Alternative Measurements

            Handwashing interventions are a priority in development and emergency aid programs. Evaluation of these interventions is essential to assess the effectiveness of programs; however, measuring handwashing is quite difficult. Although observations are considered valid, they are time-consuming and cost-ineffective; self-reports are highly efficient but considered invalid because desirable behaviour tends to be over-reported. Socially desirable responding has been claimed to be the main cause of inflated self-reports, but its underlying factors and mechanisms are understudied. The present study investigated socially desirable responding and additional potential explanatory factors for over-reported handwashing to identify indications for measures which mitigate over-reporting. Additionally, a script-based covert recall, an alternative interview question intended to mitigate recall errors and socially desirable responding, was developed and tested. Cross-sectional data collection was conducted in the Borena Zone, Ethiopia, through 2.5-hour observations and 1-hour interviews with the primary caregivers in households. A total sample of N = 554 was surveyed. Data were analysed with correlation and multiple regression analyses and dependent t-tests. Over-reporting of handwashing was associated with factors assumed to be involved in (1) socially desirable responding, (2) encoding and recall of information, and (3) dissonance processes. The latter two factor groups explained over-reported handwashing beyond socially desirable responding. The alternative interview question—script-based covert recall—reduced over-reporting compared to conventional self-reports. Although the difficulties involved in measuring handwashing by self-reports and observations are widely known, the present study is the first to investigate the factors which explain over-reporting of handwashing. This research contributes to the limited evidence base on a highly important subject: how to evaluate handwashing interventions efficiently and accurately.
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              Designing a handwashing station for infrastructure-restricted communities in Bangladesh using the integrated behavioural model for water, sanitation and hygiene interventions (IBM-WASH)

              Background In Bangladesh diarrhoeal disease and respiratory infections contribute significantly to morbidity and mortality. Handwashing with soap reduces the risk of infection; however, handwashing rates in infrastructure-restricted settings remain low. Handwashing stations – a dedicated, convenient location where both soap and water are available for handwashing – are associated with improved handwashing practices. Our aim was to identify a locally feasible and acceptable handwashing station that enabled frequent handwashing for two subsequent randomized trials testing the health effects of this behaviour. Methods We conducted formative research in the form of household trials of improved practices in urban and rural Bangladesh. Seven candidate handwashing technologies were tested by nine to ten households each during two iterative phases. We conducted interviews with participants during an introductory visit and two to five follow up visits over two to six weeks, depending on the phase. We used the Integrated Behavioural Model for Water, Sanitation and Hygiene (IBM-WASH) to guide selection of candidate handwashing stations and data analysis. Factors presented in the IBM-WASH informed thematic coding of interview transcripts and contextualized feasibility and acceptability of specific handwashing station designs. Results Factors that influenced selection of candidate designs were market availability of low cost, durable materials that were easy to replace or replenish in an infrastructure-restricted and shared environment. Water storage capacity, ease of use and maintenance, and quality of materials determined the acceptability and feasibility of specific handwashing station designs. After examining technology, psychosocial and contextual factors, we selected a handwashing system with two different water storage capacities, each with a tap, stand, basin, soapy water bottle and detergent powder for pilot testing in preparation for the subsequent randomized trials. Conclusions A number of contextual, psychosocial and technological factors influence use of handwashing stations at five aggregate levels, from habitual to societal. In interventions that require a handwashing station to facilitate frequent handwashing with soap, elements of the technology, such as capacity, durability and location(s) within the household are key to high feasibility and acceptability. More than one handwashing station per household may be required. IBM-WASH helped guide the research and research in-turn helped validate the framework.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: ValidationRole: Writing – review & editing
                Role: Formal analysisRole: VisualizationRole: Writing – original draft
                Role: Data curationRole: InvestigationRole: Project administration
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: ResourcesRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                6 May 2019
                2019
                : 14
                : 5
                : e0216237
                Affiliations
                [1 ] Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
                [2 ] Independent Consultant, Tigray, Ethiopia
                [3 ] Real Relief ApS, Kolding, Denmark
                University of South Florida, UNITED STATES
                Author notes

                Competing Interests: We have read the journal's policy and the authors of this manuscript have the following competing interests: Sian White, Jessica F Petz and Kifle Desta declare no conflicts of interest. Torben Holm Larsen has a patent pending for the SuperTowel. He is also a full time employee of Real Relief, the private company which developed the SuperTowel and which holds the IPR of the product. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0003-2402-6080
                Article
                PONE-D-18-36595
                10.1371/journal.pone.0216237
                6502319
                31059540
                fa74ac52-0b6a-4b95-b1ce-2c8a5a459994
                © 2019 White et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 21 December 2018
                : 16 April 2019
                Page count
                Figures: 2, Tables: 5, Pages: 18
                Funding
                Funded by: Humanitarian Innovation Fund
                Award ID: 27626
                Award Recipient :
                This research was supported by Elrha’s Humanitarian Innovation Fund (HIF), a grant making facility supporting organizations and individuals to identify, nurture and share innovative and scalable solutions to the most pressing challenges facing effective humanitarian assistance. The HIF is funded by aid from the UK government and the Swedish International Development Agency (SIDA). The grant was awarded to THL. The grant number is 27626. The funder website is: http://www.elrha.org/hif/home/. Real Relief provided support for this study in the form of salary for THL. The specific roles of these authors are articulated in the ‘author contributions’ section. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Biology and Life Sciences
                Neuroscience
                Sensory Perception
                Smell
                Biology and Life Sciences
                Psychology
                Sensory Perception
                Smell
                Social Sciences
                Psychology
                Sensory Perception
                Smell
                Physical Sciences
                Chemistry
                Chemical Compounds
                Salts
                Soaps
                Biology and Life Sciences
                Psychology
                Behavior
                Social Sciences
                Psychology
                Behavior
                Ecology and Environmental Sciences
                Natural Resources
                Water Resources
                Medicine and Health Sciences
                Public and Occupational Health
                Hygiene
                Social Sciences
                Sociology
                Human Families
                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Bacterial Pathogens
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Pathogens
                Microbial Pathogens
                Bacterial Pathogens
                Biology and Life Sciences
                Anatomy
                Musculoskeletal System
                Body Limbs
                Arms
                Hands
                Medicine and Health Sciences
                Anatomy
                Musculoskeletal System
                Body Limbs
                Arms
                Hands
                Custom metadata
                The data underlying the results presented in the study are available from Figshare at this address: https://doi.org/10.6084/m9.figshare.7448231.v1.

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