Role of Implementation Factors for the Success of Community-Led

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Ecotoxicology and Human Environmental Health

THE ROLE OF IMPLEMENTATION FACTORS FOR THE SUCCESS OF CLTS ON LATRINE COVERAGE. A CASE STUDY FROM RURAL GHANA Miriam Harter, Jonathan Lilje, and Hans-Joachim Mosler Environ. Sci. Technol., Just Accepted Manuscript • DOI: 10.1021/acs.est.9b01055 • Publication Date (Web): 04 Apr 2019 Downloaded from http://pubs.acs.org on April 13, 2019

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Environmental Science & Technology

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TITLE. THE ROLE OF IMPLEMENTATION FACTORS FOR THE SUCCESS

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OF CLTS ON LATRINE COVERAGE. A CASE STUDY FROM RURAL

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GHANA.

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Authors.

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Miriam Harter a, b, Jonathan Lilje a, Hans-Joachim Mosler a

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a Affiliation: Eawag,

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8600 Duebendorf, Switzerland

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b

Swiss Federal Institute of Aquatic Science and Technology, Ueberlandstrasse 133,

Corresponding author: [email protected], +41 +41 58 765 5798

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ACS Paragon Plus Environment


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ABSTRACT

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Community-Led Total Sanitation (CLTS) is an approach to improving sanitation to combat

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open defecation (OD). OD is a health threat to children under five. CLTS promotes the

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construction of latrines with the goal of declaring communities open defecation free. However,

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which factors of the implementation process are most important for the success has yet to be

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ascertained. We implemented a cluster-randomized controlled trial in rural Ghana. The sample

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comprised 134 communities with an average of 25 households each (n=3216). Communities

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were randomly assigned to either the CLTS intervention or the control arm. Outcome measures

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were assessed at baseline and 4-6 months later and included process information on intervention

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implementation and acceptance. The influence of implementation factors on the latrine

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coverage of communities was assessed using multiple regression analysis. Latrine coverage was

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significantly related to attendance at the CLTS meeting, the number of supportive community

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leaders, the expectation of participants of receiving an incentive, and the number of follow-up

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visits. Implementers of CLTS should direct their attention to the processes following the

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community meeting. The success of CLTS can be improved by investing in follow-up visits,

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the support of local leaders, and the careful application of incentives.

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Keywords: CLTS, Community-Led Total Sanitation, Latrine coverage, follow-up visits, natural

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leaders

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INTRODUCTION

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In 2015, 2.3 billion people did not have access to safe sanitation facilities and were forced

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to defecate in the environment surrounding their communities [1]. The unsafe disposal of

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human faeces is one major reason for diarrheal diseases [2, 3], which lead to 1.6-2.5 million

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deaths per year and account for 19% of all deaths of children under five years in developing

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countries [3]. Children exposed to open defecation tend to be smaller [4] and have lower

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cognitive skills [5].

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Community-Led Total Sanitation (CLTS) focuses on latrine construction and usage to eliminate

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open defecation. This set of community-based and participatory activities has been

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implemented in communities worldwide by local governmental and nongovernmental

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institutions [6]. The goal of CLTS is to trigger a movement of change towards an improved

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sanitation situation [7]. This change is achieved by the commitment of all community members.

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Only if every single person has access to and uses a household latrine does the community

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become open defecation free (ODF) and can be judged a hygienically safe environment. CLTS

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is implemented in three stages: a pre-triggering phase in which information is gathered, the

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triggering event that uses participatory activities to foster latrine construction, and a post-

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triggering phase that provides support in a series of follow-up visits.

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Overall, CLTS’s effectiveness in changing people’s behaviour is scientifically and practically

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proven [6, 8, 9] and broadly discussed. But its success rates vary widely across projects and

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countries. The success of CLTS is typically measured by latrine coverage, the percentage of

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households within a community that have access to their own latrines. A literature review of

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sanitation campaigns has reported an average increase in latrine coverage following CLTS of

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12% [10], and Robinson (11) presents results of up to 96% latrine coverage in a single case in

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Malawi. In Ghana, where the majority of the regions have adapted CLTS as their sanitation

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strategy [6], the effects are surprisingly low, with a national increase in sanitation access in ACS Paragon Plus Environment


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recent years of only 4% [1, 12], although some specific projects in Ghana have achieved a

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reduction of open defecation by 19.9% [13]. The wide range in CLTS success rates raises the

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question how these differences can be explained.

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FACTORS ENHANCING THE EFFECTIVENESS OF CLTS

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A review of CLTS published by USAID in 2018 comments that the “success of CLTS programs

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is likely to be a function of the implementation modality, as well as both physical environmental

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and contextual factors. While such factors are cited frequently as crucial, they are not usually

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well defined.” ([6], page 35). The review’s authors then divide the characteristics of CLTS

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implementation processes into two groups: programmatic conditions and community

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conditions. Programmatic conditions include the implementation, its quality, and its political

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environment. Community conditions include the physical and social structure of the community

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and the preconditions for CLTS, such as baseline latrine coverage and social norms. Further

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indicators for successful implementation can be derived from the Handbook on CLTS [7], such

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as inviting as many community members as possible to the triggering event.

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P ROGRAMMATIC CONDITIONS

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The first aspect of programmatic conditions that the review considers is the quality and

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responsibility of implementation. The authors state that “implementation quality encompasses

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a number of elements, including the persuasiveness of facilitators of triggering events” and

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“‘intensity’—as defined by frequency of facilitator visits, which can vary greatly from program

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to program.” (Page 27). Another literature review of CLTS research by Venkataramanan and

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colleagues showed that 23% of the articles reviewed focused on the skills of the facilitators and

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another 40% included information on the quality of the triggering event itself [8]. One case

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study in India goes so far as to say that the quality of the CLTS outcome depends on the

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facilitator alone [14]. Kamal Kar, the inventor of CLTS, states that while “not everyone can be

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a good facilitator, the behaviour and attitude of the facilitator is one of the most crucial factors


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for the success of CLTS [7]”. That would mean that the more a facilitator convinces and is

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liked, the more the community is motivated to construct household latrines. The second aspect

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included in the USAID review is the frequency of follow-up visits by facilitators. Several

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projects that implemented CLTS stress the need for follow-up visits to sustain the changes

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achieved by CLTS [8, 11]. The Handbook on CLTS unambiguously states that triggering

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without follow-up visits is “bad practice” (page 43, [7]). Most of the literature collected by

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Venkataramanan et al. refers to follow-up visits as one of the main measures to ensure the

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quality of CLTS [8]. Cameron and Shah found a positive influence on CLTS outcomes with

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both higher charisma of facilitators and higher frequency of follow-up visits [15]. Another

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aspect mentioned is the presence of so-called natural leaders. CLTS focuses strongly on the

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involvement of such committed community members: they “are activists and enthusiasts who

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emerge and take the lead during CLTS processes ([7], page 5). The Handbook recommends

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selecting 2-4 natural leaders per community [7]. Crocker, Abodoo (13)], studying in rural

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communities in Ghana, found the success of CLTS being significantly higher when such

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motivated community members were selected and trained than following the usual CLTS

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implementation without such specific training.

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C OMMUNITY CONDITIONS

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Besides the initial latrine coverage and the social context in the community, the community

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conditions described in the USAID review also include subsidies. The review shows that the

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discussion on subsidies is broad and diverse. The pure CLTS approach works strictly without

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subsidies, but attempts at combinations have been implemented worldwide with varying effects.

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The review by Garn and colleagues reports better effects in latrine coverage using subsidy

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interventions than using CLTS alone [10]. Pattanayak et al. compared the combination of CLTS

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and subsidies with CLTS alone and found 2-10% higher increases in latrine coverage in the



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communities that received CLTS and subsidies [16]. Venkataramanan et al. report that opinions

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range from supporting only strict nonsubsidized approaches to the use of targeted subsidies [8].

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THE

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Some aspects are not included in either of the groups outlined in the USAID review but are

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stressed by the Handbook on CLTS. These include the use of activities to evoke feelings of

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shame and disgust. The activities implemented in the community should provide an emotional

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spur to behaviour change: “Triggering is based on stimulating a collective sense of disgust and

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shame among community members as they confront the crude facts about mass open defecation

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and its negative impacts on the entire community” ([7], page 21). Pattanayak et al. showed that

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campaigns that included shaming activities explained two thirds of their intervention effects

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[16]. Nevertheless, critics of CLTS observe that evoking such feelings is not in accordance with

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the protection of human rights and query whether it is even necessary to evoke negative feelings

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for CLTS to succeed [17, 18]. Whether such feelings as shame and disgust are necessary to

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driving latrine construction is not yet understood. Another aspect that is strongly stressed by

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the Handbook is participation in CLTS. It seems obvious that without participation nothing will

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change. But research on CLTS has not yet provided any scientific results on the relationship

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between participation rate and latrine coverage. Of the articles included in the literature review

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by Venkataramanan et al., 82% reported the participation rate being one of the success factors

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of CLTS [8]. The Handbook tells its readers: “remember the more people from the community

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participate the better are the chances of successful triggering” (page 62). The Handbook also

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refers to the time aspect of latrine construction. The process of becoming open defecation free

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(ODF) takes a community three weeks to three months from the triggering event. However, to

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our best knowledge the relationship between time since triggering and latrine coverage in the

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community has not yet been analysed.

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RESEARCH QUESTIONS

H ANDBOOK ON CLTS


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This study investigates the contributions of the implementation factors described above on

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latrine coverage in communities. We hypothesize that higher participation in the triggering

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event, better liking of facilitators, higher conviction and motivation after the triggering event,

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stronger feelings of shame and disgust, higher number of natural leaders selected, higher

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number of follow-up visits, greater perception of receiving incentives for latrine construction

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and longer time since the triggering event are positively related to latrine coverage on

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community level. The goal of this article is to quantify the individual contributions of these

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factors towards the success of CLTS as measured by latrine coverage at community level.

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MATERIALS AND METHODS

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This study was implemented in rural Ghana jointly by the Swiss Federal Research Institute for

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Aquatic Science and Technology (Eawag), USAID, and Global Communities Ghana. The

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project was funded by the Bill and Melinda Gates Foundation. A cluster-randomized controlled

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trial was implemented with a broad baseline survey in March to April 2016. Community

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clusters were randomly assigned to four different intervention arms and one control arm.

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Interventions were developed by Eawag and Global Communities; these were then piloted and

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implemented in the target area between August and November 2016 by Global Communities.

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A follow-up survey was conducted four to six months after implementation, in March to April

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2017. The research trial was approved by the Ethics Board of the University Zurich and the

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Ghana National Health Service.

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PROCEDURES

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Two districts in Northern Ghana were selected for this cluster-randomized controlled trial,

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where no CLTS intervention had been realized before: Sawla-Tuna-Kalba district and Bole

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district. Within these two districts, the local government representatives selected 134

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communities according to two selection criteria: accessibility by road and minimum number of

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25 households (minimum cluster size). A team of 33 local data collectors was trained in a sixACS Paragon Plus Environment


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day workshop for both surveys. The main part of the training involved discussion of the

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structured questionnaire, which included questions on demographics, the sanitation practices of

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different household members, latrine construction, psycho-social determinants, and the social

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context of the community. The survey included short observations of the hygienic situation of

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the household and the latrine, if applicable. The questionnaire for the follow-up survey also

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included questions on respondents’ perceptions of the interventions. All questions were

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discussed in English and translated into seven local languages: Brefo, Dagaare, Gonja, Waale,

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Safalba, Twi, and Mo. Data collectors agreed on keywords in their language for every question.

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The second part of the training included roleplays, discussions on ethics, and close feedback on

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interview techniques. The questionnaire was pretested in 66 interviews in two days and adapted

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to local conditions where appropriate.

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In each community, 25 households were selected randomly by the data collectors following the

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random route method described by Hoffmeyer-Zlotnik [19]. Data collectors were advised to

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interview every third household in the section of the community they were assigned to.

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Respondents had to be at least 18 years old and inhabitants of the community for at least 3

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months prior to the survey. Adult men and women were considered equally, because the

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decision for latrine construction was considered to be influenced by both. If no one was at home

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or the household refused to participate, the data collector tried the next household. Every

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participant was informed about the purpose of the survey provided written consent for his or

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her voluntary participation. The face-to-face interview was conducted using electronic devices

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and lasted 60 minutes on average. Every interview was supervised, and data quality was

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checked every evening. The same respondents were interviewed again for the follow-up survey.

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SAMPLE

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The sample size of 3125 households was calculated a priori for a longitudinal cluster-

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randomized trial with an expected power of 80%, an α-level (two-tailed) of 5%, and an expected


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medium effect size of 20% between control group and intervention groups on the dichotomous

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primary outcome variable, latrine ownership. Final sample size exceeds the calculated sample

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by 91 cases. During the baseline survey, we realized that not all communities contained 25

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households, so more communities were included, and again 25 households interviewed

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wherever possible, resulting in a total sample size of 3216 households (baseline survey). For

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the follow-up survey, 2704 respondents were interviewed again. The main reasons for drop-out

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were that the respondents had travelled (n=243) or moved out of the community (n=137), and

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66 individuals had died. The sample consisted of 42.7% female respondents, participants were

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on average 44.7 years old (SD=16.32), and 21% were able to read and write. Some 49.2%

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reported Christianity to be their religion, 26.1% Islam, and 19.2% traditional religions. Most of

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the households were farmers (80.4%); they had an average monthly income of 202.30 New

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Ghanaian Cedi (equivalent of 43 USD, SD=380.39 GHS) and an average household size of 8.7

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individuals (SD=4.9). The sample used for the study was restricted to 94 communities (1877

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households), for which complete data in all hypothesized variables was available at time of data

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analysis.

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INTERVENTIONS

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The protocols for CLTS implementation in the research area were developed following the

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official Handbook on CLTS. Global Communities selected and trained staff for the realization

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of CLTS, which was implemented in three phases:

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Pre-triggering. The community was assessed for its social structure and size, and a date for the

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triggering event was agreed with community leaders. They were asked to invite female and

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male community members from all ethnic groups to the triggering event.

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Triggering. Facilitators started the session by presenting each other, an opening prayer, and

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welcoming community members. They facilitated the drawing of a community map on the

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ground with community institutions such as mosques and water sources. Then, they invited ACS Paragon Plus Environment


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participants to locate both their houses and the spots they used for open defecation. By asking

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questions about possible paths of the faecal-oral transmission route, the facilitators helped

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participants recognize the sanitation threat that they faced in their surroundings. If participants

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seemed hesitant about the sanitation improvement of their community, facilitators were

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instructed to introduce more activities. These included the presentation of a sealed bottle of

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water. This was offered to participants to open and taste. A facilitator then took a stick, touched

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the soil with it, and then dipped it in the water. The water was then presented to participants

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again. This was to illustrate the contamination of water by small particles, such as those

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transferred by flies. Facilitators asked participants to agree a date for the community to become

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open defecation free and set a community action plan in place. The community was exhorted

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to start digging pits for latrines immediately, and facilitators promised to return the following

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week. People that emerged as local leaders were identified during the triggering event, their

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names were noted, and they were later invited to a central training event for natural leaders. At

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least two natural leaders were identified for every triggered community and trained in the

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importance of latrine usage and the faecal-oral transmission route. The role of natural leaders

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in the communities included supporting other community members during latrine construction,

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spreading knowledge of health hazards, and being role models in the latrine construction

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process. The triggering event was documented by using the Intervention Monitoring Form

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(Supporting Information Figure S1).

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Post-triggering. Facilitators visited the community every week for 4 weeks, then reduced the

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frequency of visits to 2 times per month, and later to monthly visits until the community reached

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the open-defecation-free state. These follow-up visits were used to discuss problems and

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supervise latrine construction. Global Communities (the local implementing NGO) did not

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provide any latrines for free but provided construction materials such as cement and vent pipes

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at wholesale price instead of retail prices. The NGO also encouraged the construction of latrines


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with locally available materials. Follow-up visits were documented using the Follow-Up

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Monitoring Form (see Supporting Information Figure S2).

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MEASURES

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While some of the variables considered for this analysis come from the two monitoring forms

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used by the implementing NGO, most data come from information gathered during interviews

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with respondents in the individual households. This data was first aggregated at community

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level to match the variables from the monitoring of the triggering sessions. This means that this

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data represents the average response from all participants within one community as an

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aggregated measure.

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To measure latrine coverage, which is the outcome measure in this analysis, information from

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individual households within each community was combined using two of the original

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questionnaire items. Respondents were asked during the interviews whether their household

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owns a latrine. This information was verified by the data collector. Households without a latrine

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were scored with “0”, and households that had a latrine at the time of the interview were scored

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with “1” even if the latrine was still under construction. The final measure thus represents the

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proportion of households within the community sample having a latrine; this ranges from 0%

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to 100% coverage (aggregated mean (Magg) = 68.0%; standard deviation (SD) = 31.3). This

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value is considered an approximate measure of latrine coverage across the whole community,

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because the households interviewed were chosen at random.

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Attendance at the triggering event was captured in the interviews when respondents were asked

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whether they participated in the activity (“1” = yes; “0” = No; Magg = 83.4%; SD = 14.3).

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Facilitators from Global Communities rated the quality of each meeting on the Intervention

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Monitoring Form. This uses a four-point scale to represent the level of enthusiasm sensed within

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the target community in accordance with the terms specified in the Handbook on CLTS.



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However, this item only provides minimal variance with a very high ceiling effect, so we did

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not consider this measure.

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To measure the quality of the meeting, we used data from the individual interviews conducted

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with the community members of the communities enrolled in the CLTS program. Several

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questions captured the participant’s perception of the meeting and the facilitators. Only

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respondents who confirmed their presence during the meeting gave answers to these items.

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Participants were asked to rate the quality and their perceptions of the meeting and its activities

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using several items. Participants were asked to rate how much the meeting both convinced and

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motivated them to build a latrine on a five-point Likert-scale. As the inter-item correlation

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between these two items was high (α = .74; Magg = 4.64; SD = .28), they were combined into a

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single variable for analysis. To capture the level of shame and disgust evoked by activities

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during the CLTS meeting, participants were again asked to rate their perception, and items were

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combined (α = .61; Magg = 2.08; SD = .46). Lastly, participants were asked how much they liked

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the meeting and the facilitators using the same kind of scale. The two items correlated closely

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and so were combined for analysis (α = .91; Magg = 4.71; SD = .31).

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Further, the number of follow-up visits of the facilitators to the community was captured during

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the interviews by asking respondents whether facilitators had come back to their community

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and how often (M = 2.09; SD = 0.99). This means that this variable does not necessarily capture

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how many follow-up visits were actually made, but rather how many visits were recalled on

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average by the respondents within a community.

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In addition, participants were asked whether they were promised anything in return for latrine

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construction by the facilitators or had understood that there would be incentives (“1” = Yes,

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“0” = No; Magg = 56.5%; SD = 25.5). If participants understood that they would receive

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something in return for constructing a latrine, they were asked what they had been promised.


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In 65% (n=373) of the cases, they expected a borehole and in 24% (n=139), construction

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materials at reduced prices.

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Data that was derived directly from the monitoring forms at community level provided the

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following information. Time since triggering event was measured using the difference between

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the recorded date of the meeting and the follow-up survey in March 2017. Time since triggering

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was measured in months (Magg = 6.16; SD = 2.29). The monitoring forms also provided the

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number of natural leaders (female and male combined) during the triggering session (Magg =

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5.5; SD = 2.6). Data was analysed using IBM SPSS Version 22 (Armonk, NY, USA).

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RESULTS

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All factors hypothesized as relevant were entered simultaneously into a linear regression model

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as predictors of the dependent variable, latrine coverage. Full information was available and

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entered into analysis from 1877 households across 94 communities (Magg = 19.97 households

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per community; SD = 3.06; range 6 - 25). Descriptive statistics, size, and significance of the

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correlations between all variables with the outcome are displayed in Table 1.

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Table 1: Descriptive statistics, correlations with outcome Std.

Correlation

Mean

Deviation

N

with outcome

Sign.

67.99

31.30

94

time since triggering

6.16

2.29

94

.054

.303

attendance at meeting

83.36

14.34

94

.47

.000

5.46

2.59

94

.13

.106

56.51

25.51

94

.56

.000

convinced and motivated

4.64

.278

94

.39

.000

ashamed and disgusted

2.08

.46

94

.13

.112

latrine coverage

number of natural leaders incentive promised



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liking facilitators

4.71

.31

94

.17

.056

number of follow-up visits

2.09

1.00

94

.60

.000

292

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The model containing all variables was able to explain 51.2% of the variance in the outcome

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(adjusted R2) with significant change from the zero model. Standardized coefficients and level

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of significance of the individuals’ predictors are displayed in Table 2. The average Variance

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Inflation Factor (VIF) was 1.51, with all individual VIFs below 2.1. Four variables yielded

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significant explanatory power. The largest contribution to the power of the regression model

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came from the incentive promised (β= .38), followed by the number of follow-up visits to the

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community (β= .37), then the number of natural leaders (β= .21), and attendance at the meeting

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(β = .20).

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Table 2: Linear regression model of predictors of community latrine coverage Unstandardized Standardized Coefficients Variables in the model

95% Confidence

Coefficients

Interval for B Lower

Upper

Sig.

Bound

Bound

.694

-126.44

84.58

Std. B

Error

-20.93

53.07

time since triggering

-1.96

1.13

-0.14

.086

-4.21

0.29

attendance at meeting

0.43

0.20

0.20

.035

0.03

0.83

number of natural

2.50

0.90

0.21

.007

0.71

4.28

incentive promised

0.47

0.12

0.38

.000

0.24

0.70

convinced and

5.55

10.80

0.05

.609

-15.93

27.02

(Constant)

Beta

leaders

motivated


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ashamed and

-1.99

5.38

-0.03

.712

-12.70

8.71

liking facilitators

-4.44

8.65

-0.04

.609

-21.63

12.75

number of follow-up

11.74

3.27

0.37

.001

5.24

18.25

disgusted

visits 302 303

Note: R2 = .512; (ps < .000). Confidence intervals are 95% bias corrected and accelerated. Confidence intervals and standard errors based on 1000 bootstrap samples.

304 305

According to these results, an increase in latrine coverage can be expected if any of these four

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parameters increases. In other words, while all other predictors remain stable, an increase in

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coverage of around 0.5% can be expected from every person more out of 100 who attends the

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meeting or to whom an incentive is promised during the meeting. Further, every single follow-

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up visit to the community should increase latrine coverage by about 11.5%; every additional

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natural leader identified should increase latrine coverage by about 2.5%.

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DISCUSSION

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To our knowledge, this is the first time that several implementation factors describing the CLTS

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process have been tested simultaneously for their influence on latrine coverage in communities.

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This was possible because of the large sample size of communities in this project and because

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information was collected at both individual and community levels. This allows firm

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suggestions to be made about improving the CLTS implementation process.

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Discussion of factors influencing the success of CLTS

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Our results suggest that for CLTS to be maximally successful it is important that as many

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community members as possible participate at the triggering meeting. Therefore, good

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preparation of the meeting is important to ensure that all people in the community are aware of

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the meeting and that it is also attractive or even a social norm to attend the meeting. However,

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the effect of the number of people who attend the triggering event is not that large, and it might ACS Paragon Plus Environment


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be that the social influence of these attendees on those that did not participate is more important

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than participation rate alone, as Harter et al. [20] have shown. Consequently, the effect of the

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triggering event may be enhanced by prompting attendees to influence community members

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who did not attend, for example by facilitating further exchange between community members.

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According to our results, promoters of CLTS should also try to identify as many natural leaders

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from a community as possible. Of course, there is a limit to the possible number of natural

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leaders in each community. However, facilitators could also be trained in motivating natural

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leaders. One might consider persuasion training with the aim of eliciting the undeclared

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aspirations and skills of community members. In this project, the implementing NGO, Global

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Communities, invited natural leaders to attend training together with leaders from other

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communities. They were trained in the goals of CLTS, the necessity of latrine construction, and

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the threats of fecal-oral transmission of bacteria. Our study findings indicate that this procedure

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seems to be promising. The importance of training natural leaders has been shown in a

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randomized-controlled trial in Ghana [13], and another study showed that the success of CLTS

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is mediated by changes in norms, such as the approval of latrine construction by leaders of the

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community, as natural leaders might be [20]. The training of natural leaders should be

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considered more thoroughly. A recent study revealed that the success of CLTS is enabled by

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focusing on social norms and the belief of participants in their ability to construct and maintain

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a latrine, fostering the development of detailed action plans towards latrine construction, and

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leaders publicly showing their approval of latrines [21]. This could be done by natural leaders.

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The number of follow-up visits emerged as a very influential factor. Our results imply that every

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follow-up visit increases latrine coverage by 11.5%. However, this data was self-reported by

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respondents in the communities, and perhaps they could not recall or did not witness some

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follow-up visits. The number might be much higher than reported. The strong influence of

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follow-up visits on latrine coverage is in line with previous research [15] and was also one of


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the main factors mentioned as influential by 27% of the literature reviewed by Venkataramanan,

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Crocker (8)]. Further implementation protocols for CLTS should definitely plan consistent

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follow-up visits. Facilitators should therefore attend to problems faced in the process of latrine

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construction and serve as consultants for the natural leaders.

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Interestingly, we did not find an effect of performance or the acceptance of the facilitator on

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latrine coverage. In contrast to other factors that were considered in the analysis, the influence

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of these factors were not significant. Facilitators were trained thoroughly in this project by the

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implementing organization and supervised closely during the CLTS process. This might also

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be a reason why there were no great differences in the perception and performance of

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facilitators, as their values on the rating scales were uniformly high. Cameron and Shah [15]

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described the positive influence of implementation intensity on CLTS outcome. This intensity

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was described as the number of facilitators present during the triggering event, the number of

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follow-up visits, and the charisma of the facilitators. Our data suggests that the latter does not

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necessarily provide incremental gain to the CLTS outcome.

362

We also found that the perception of a promise was an important success factor for CLTS in

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this project. Global Communities drilled boreholes in parallel with the CLTS process, but only

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for communities that were assessed as especially in need of these. Nonetheless, the condition

365

for the community to receive a borehole was that it was open defecation free. People seem to

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have understood that an open-defecation-free community receives a new water source in any

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case. An example statement from one of the respondents illustrates this perception: “They

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promised if the entire community constructed their own latrines, they would provide the

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community with water”. Whether this was the case for this specific community was the decision

370

of the implementing NGO. And boreholes were drilled where needed and possible. Problems

371

might arise where the community has misunderstood that it will receive a borehole when it will

372

not. It might result in rejection of the importance of latrines and the opposition to the CLTS



373

process [22]. On the other hand, a problem may arise if people construct latrines for another

374

reason than because they think they need them. As long as no false promises are given and the

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latrines are used, this appears to be a viable strategy. The expectation of incentives for ODF

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status, their actual provision, and the provision of subsidies in triggered communities were

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factors reported elsewhere as enhancing CLTS outcomes in the post-triggering phase [8].

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We did not find an effect of the emotions elicited through CLTS, and our results indicate that

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the intensity of shame and disgust was not very high. One explanation could be that facilitators

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prefer to avoid strong reactions due to taboos and cultural impropriety. Some very frequent

381

activities of the CLTS canon were not used in this project, such as a transect walk or the rice-

382

and-shit activity. This was due to cultural impropriety. Another explanation is that emotions are

383

ephemeral: they arise intensely in a moment but disappear in a few minutes or hours and are

384

therefore not remembered in a follow-up after some months, as previous reports on CLTS have

385

also described [23].

386

We expected that the time since triggering was relevant for latrine coverage, as some

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communities might need more time than others. And indeed, we found that the variance

388

between communities is high. Some are strongly motivated and complete their latrines rapidly,

389

while others need weeks and months. This might be the reason why time overall is not a relevant

390

factor. On average, the communities in this project needed more time than anticipated by the

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Handbook on CLTS [7]; this states that communities should only take 3 months after the

392

triggering event to become open defecation free. Venkataramanan et al. [8] show that 6% of the

393

studies they reviewed report lack of time for latrine construction as an important individual

394

constraint, but no study has yet discussed the time needed to become open defecation free at

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community level. Future research might consider the preconditions of communities for the

396

success of CLTS and the interaction effects of time and follow-up visits. As the number of


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follow-up visits is clearly a relevant predictor, frequent follow-up visits might not only increase

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the probability of constructing latrines, but also accelerate the building process.

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STRENGTHS AND LIMITATIONS

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This study has several key strengths. One is the size of the sample, with 3216 households and

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134 communities, out of which 94 communities were considered for this analysis. Data was

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aggregated at community level with an average of 25 households per community, and

403

households were selected randomly in each community. Implementation of CLTS was realized

404

across a broad range of contextual settings (e.g., community size, community composition,

405

location), so the results hold strong external validity. CLTS as implemented in this study might

406

be considered scalable both for other regions of Ghana and for other countries in West Africa.

407

However, our study also has some limitations that need to be considered. Our data is nested, as

408

individuals are clustered in communities, and statistical analysis should control for the variance

409

within and between communities. This was not considered in this analysis. A further limitation

410

is that we did not consider initial community conditions that may influence CLTS success, such

411

as the social context of communities, which has been shown to be relevant to success [24]. We

412

also included influencing factors based on practical considerations rather than on theoretical

413

background. Of course, it might be the case that other influencing factors, such as the

414

implementation of by-laws and sanctions [8], influenced the success of CLTS in our study

415

significantly but that these were not considered in this analysis.

416

Overall, our findings suggest that the triggering event of CLTS is only the starting point. But

417

whether people experience any strong feelings, whether they are convinced by the event, and

418

whether they like the facilitator and the meeting is not relevant for the long-term latrine

419

coverage of the community. CLTS unfolds its power in the weeks after the triggering event.

420

However the time elapsed since the triggering event is not an explanation for success. The more

421

community members participate in CLTS, the more the movement spreads. Trained natural ACS Paragon Plus Environment


422

leaders have to supervise the process kicked off by the triggering event, and facilitators need to

423

return and provide support. The belief or hope of receiving an incentive such as a borehole

424

seems to be an important driving factor that accelerates the construction process.

425

ACKNOWLEDGEMENTS

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This research project was funded by the Bill and Melinda Gates Foundation and formed part of

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the USAID funded Wash for Health project in Ghana. We are grateful to Global Communities

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Ghana for the coordination and implementation of CLTS in the research communities; to the

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District Authorities in Bole and Sawla-Tuna-Kalba districts for logistic support, to Eawag,

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especially Dr. Jennifer Inauen, for the scientific advice throughout the project. We thank all out

431

colleagues of Global Communities, our field supervisors, masters students and interns for their

432

valuable contributions. We are further grateful to our data collectors for their effort and our

433

respondents in Bole and Sawla-Tuna-Kalba districts for their participation.

434

435

SUPPORTING INFORMATION.

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Figure S1: Intervention Monitoring Form of Global Communities used for CLTS

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implementation monitoring

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Figure S2: Follow-Up Monitoring Form of Global Communities used for the monitoring of the

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follow-up visits after CLTS implementation


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REFERENCES

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22. Rains SA, Turner MM. Psychological reactance and persuasive health communication: A test and extension of the intertwined model. Human Communication Research. 2007;33(2):241-69. 23. Tyndale-Biscoe P, Bond M, Kidd R. ODF Sustainability Study. FH Designs Australia: PLAN International. 2013:1-181. 24. Cameron L, Olivia S, Shah M. Initial Conditions Matter: Social Capital and Participatory Development. Available at SSRN: https://ssrncom/abstract=2704614 or http://dxdoiorg/102139/ssrn2704614. 2015.

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Role of Implementation Factors for the Success of Community-Led

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