PWAT-D-24-00167

Understanding end-user preferences for hand hygiene enabling technologies: a mixed-methods study in peri-urban Lusaka.

PLOS Water

Dear Dr. Dreibelbis,

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PLOS Water

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Additional Editor Comments (if provided):

Thank you for submitting this article to PLOS Water. We apologise for the delay in reverting with a decision on the manuscript due to difficulties in securing enough appropriate reviewers at the end of the year.

Overall, this is an important contribution on addressing user preferences for different handwashing facilities - a clear gap in the literature. The reviewers raise several good points below which should be easily addressed in a revised version of the manuscript, most notably one of the reviewers is asking for further discussion on the role played by pricing (often underappreciated by device designers). The other reviewer has asked whether it would be possible to also make available aspects of the qualitative data in a repository - for example here: The Qualitative Data Repository | Qualitative Data Repository .

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Water’s publication criteria ? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: This study provides valuable insights into user preferences for handwashing facilities in peri-urban Lusaka with potential for broader geographical impacts. The mixed-methods approach is appropriate, and the findings have practical implications for WASH interventions. Below are suggestions to further strengthen your manuscript.

• There are some inconsistencies in the use of handwashing facilities vs HWFs – it’s unclear why sometimes ‘handwashing facilities’ is used after HWFs is defined and why the acronym is defined again on line 121.

• There are some minor spelling errors (e.g., “comparision” in the abstract).

• One of the participant groups for phase 1 was ‘people living with disabilities’ but I didn’t read mention of this group beyond the methods. Could you add findings linked with this participant group?

• Additional discussion based on the qualitative data collected during ranking (phase 2) could strengthen findings. For example, could you expand on why different demographic groups may have prioritized different attributes? This additional insight could help tailor future interventions to specific user groups and could support broader geographical implications.

• The quantitative dataset is deposited in a repository, which meets journal requirements. Would you consider making qualitative data (e.g., thematic coding framework or anonymized quotes) available as supplementary material? This would enhance transparency and reproducibility.

Reviewer #2: I found this work to be sensible, responsibly conducted, clearly communicated, and with presentation of the results that is appropriately circumspect. Understanding consumer preferences is imperative for achieving widespread uptake of health innovations, and achieving widespread handwashing behavior change has proven extremely difficult. This is welcome and important work.

I suggest accepting this manuscript with minor revision.

My sole critique of the paper is its under-emphasis on the role of price. By far the most important results in this manuscript are presented Figure 2, which shows how consumer preferences change when they are made aware of product price. The results are dramatic, even as they are unsurprising. The Kalingalinga Bucket becomes the overwhelmingly preferred product under conditions of price awareness. The result is striking (in terms of degree of preference change) and important in its own right but is also relevant to the discussion of attribute rankings. I am aware that the authors do mention the pattern in the Discussion, but it is largely to ponder why it is that price figures more prominently among Matero participants (which the authors posit as seeming counterintuitive). They do also state that "it is crucial manufacturers consider the costs of HWFs in the design process." I'll submit that this is a vast understatement.

Indeed, despite the fact that only caregivers and Matero residents report price as a key product attribute, Figure 2 makes clear that all subgroups consider price to be very important, with the Kalingalinga Bucket becoming the overwhelmingly preferred product among all of them under conditions of price awareness.

The implication here is that the stated importance of price as an attribute in Table 4 among subgroups other than Caregivers and Matero residents does not comport with “revealed” preference (as captured by the price-aware product rankings). My own interpretation is that only Caregivers and Matero residents felt comfortable enough in the FGDs to be forthright about the role of price relative to other attributes.

This shift in interpretation is crucial, in my view, because of the widespread failure of many product suppliers and program implementers to understand and take seriously consumer valuation (specifically, how their valuation changes as a function of price – the demand function). The result is that sanitation and hygiene product marketing seeks to sell products at vastly higher prices than the target markets are willing to pay. I am not suggesting that the researchers go back to the field to do revealed willingness-to-pay experiments; but the manuscript discussion should elevate more forcefully the need to understand price considerations more directly in future research and practice.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: PWAT-D-24-00167_review_JA.docx

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

PWAT-D-24-00167R1

Dear Dr. Dreibelbis,

We are pleased to inform you that your manuscript 'Understanding end-user preferences for hand hygiene enabling technologies: a mixed-methods study in peri-urban Lusaka, Zambia.' has been provisionally accepted for publication in PLOS Water.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow-up email from a member of our team. 

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

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Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Water.

Best regards,

Robert Bain

Academic Editor

PLOS Water

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Additional Editor Comments (if provided):

Reviewer Comments (if any, and for reference):