the role of implementation factors for the success of ... - ACS Publications

Subscriber access provided by UNIV OF LOUISIANA

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

Just Accepted “Just Accepted” manuscripts have been peer-reviewed and accepted for publication. They are posted online prior to technical editing, formatting for publication and author proofing. The American Chemical Society provides “Just Accepted” as a service to the research community to expedite the dissemination of scientific material as soon as possible after acceptance. “Just Accepted” manuscripts appear in full in PDF format accompanied by an HTML abstract. “Just Accepted” manuscripts have been fully peer reviewed, but should not be considered the official version of record. They are citable by the Digital Object Identifier (DOI®). “Just Accepted” is an optional service offered to authors. Therefore, the “Just Accepted” Web site may not include all articles that will be published in the journal. After a manuscript is technically edited and formatted, it will be removed from the “Just Accepted” Web site and published as an ASAP article. Note that technical editing may introduce minor changes to the manuscript text and/or graphics which could affect content, and all legal disclaimers and ethical guidelines that apply to the journal pertain. ACS cannot be held responsible for errors or consequences arising from the use of information contained in these “Just Accepted” manuscripts.

is published by the American Chemical Society. 1155 Sixteenth Street N.W., Washington, DC 20036 Published by American Chemical Society. Copyright © American Chemical Society. However, no copyright claim is made to original U.S. Government works, or works produced by employees of any Commonwealth realm Crown government in the course of their duties.

Page 1 of 23

Environmental Science & Technology

1

TITLE. THE ROLE OF IMPLEMENTATION FACTORS FOR THE SUCCESS

2

OF CLTS ON LATRINE COVERAGE. A CASE STUDY FROM RURAL

3

GHANA.

4 5

Authors.

6

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

7

a Affiliation: Eawag,

8

8600 Duebendorf, Switzerland

9

b

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

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

10

ACS Paragon Plus Environment


11

ABSTRACT

12

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

13

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

14

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

15

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

16

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

17

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

18

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

19

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

20

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

21

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

22

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

23

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

24

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

25

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

26

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

27

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

28

leaders

29


Page 2 of 23

Page 3 of 23

30


INTRODUCTION

31

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

32

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

33

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

34

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

35

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

36

cognitive skills [5].

37

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

38

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

39

implemented in communities worldwide by local governmental and nongovernmental

40

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

41

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

42

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

43

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

44

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

45

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

46

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

47

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

48

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

49

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

50

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

51

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

52

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

53

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

54

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


55

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

56

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

57

question how these differences can be explained.

58

FACTORS ENHANCING THE EFFECTIVENESS OF CLTS

59

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

60

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

61

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

62

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

63

implementation processes into two groups: programmatic conditions and community

64

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

65

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

66

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

67

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

68

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

69

P ROGRAMMATIC CONDITIONS

70

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

71

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

72

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

73

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

74

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

75

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

76

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

77

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

78

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

79

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


Page 4 of 23

Page 5 of 23


80

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

81

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

82

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

83

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

84

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

85

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

86

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

87

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

88

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

89

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

90

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

91

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

92

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

93

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

94

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

95

implementation without such specific training.

96

C OMMUNITY CONDITIONS

97

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

98

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

99

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

100

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

101

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

102

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

103

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



104

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

105

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

106

THE

107

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

108

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

109

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

110

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

111

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

112

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

113

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

114

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

115

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

116

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

117

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

118

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

119

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

120

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

121

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

122

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

123

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

124

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

125

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

126

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

127

community has not yet been analysed.

128

RESEARCH QUESTIONS

H ANDBOOK ON CLTS


Page 6 of 23

Page 7 of 23


129

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

130

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

131

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

132

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

133

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

134

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

135

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

136

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

137

MATERIALS AND METHODS

138

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

139

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

140

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

141

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

142

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

143

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

144

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

145

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

146

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

147

Ghana National Health Service.

148

PROCEDURES

149

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

150

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

151

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

152

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

153

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


154

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

155

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

156

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

157

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

158

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

159

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

160

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

161

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

162

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

163

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

164

to local conditions where appropriate.

165

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

166

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

167

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

168

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

169

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

170

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

171

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

172

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

173

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

174

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

175

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

176

SAMPLE

177

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

178

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


Page 8 of 23

Page 9 of 23


179

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

180

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

181

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

182

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

183

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

184

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

185

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

186

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

187

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

188

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

189

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

190

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

191

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

192

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

193

analysis.

194

INTERVENTIONS

195

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

196

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

197

of CLTS, which was implemented in three phases:

198

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

199

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

200

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

201

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

202

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

203

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


204

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

205

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

206

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

207

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

208

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

209

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

210

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

211

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

212

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

213

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

214

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

215

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

216

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

217

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

218

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

219

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

220

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

221

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

222

(Supporting Information Figure S1).

223

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

224

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

225

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

226

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

227

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

228

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


Page 10 of 23

Page 11 of 23


229

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

230

Monitoring Form (see Supporting Information Figure S2).

231

MEASURES

232

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

233

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

234

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

235

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

236

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

237

aggregated measure.

238

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

239

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

240

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

241

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

242

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

243

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

244

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

245

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

246

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

247

because the households interviewed were chosen at random.

248

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

249

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

250

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

251

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

252

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



253

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

254

not consider this measure.

255

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

256

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

257

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

258

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

259

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

260

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

261

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

262

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

263

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

264

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

265

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

266

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

267

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

268

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

269

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

270

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

271

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

272

average by the respondents within a community.

273

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

274

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

275

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

276

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


Page 12 of 23

Page 13 of 23


277

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

278

materials at reduced prices.

279

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

280

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

281

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

282

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

283

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

284

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

285

RESULTS

286

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

287

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

288

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

289

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

290

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

291

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



Page 14 of 23

liking facilitators

4.71

.31

94

.17

.056

number of follow-up visits

2.09

1.00

94

.60

.000

292

293

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

294

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

295

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

296

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

297

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

298

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

299

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

300

(β = .20).

301

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


Page 15 of 23


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

306

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

307

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

308

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

309

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

310

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

311

DISCUSSION

312

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

313

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

314

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

315

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

316

suggestions to be made about improving the CLTS implementation process.

317

Discussion of factors influencing the success of CLTS

318

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

319

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

320

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

321

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

322

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


323

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

324

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

325

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

326

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

327

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

328

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

329

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

330

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

331

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

332

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

333

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

334

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

335

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

336

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

337

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

338

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

339

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

340

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

341

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

342

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

343

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

344

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

345

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

346

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

347

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


Page 16 of 23

Page 17 of 23


348

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

349

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

350

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

351

construction and serve as consultants for the natural leaders.

352

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

353

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

354

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

355

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

356

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

357

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

358

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

359

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

360

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

361

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

363

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

364

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

366

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

367

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

368

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

369

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

375

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

376

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

377

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

378

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

379

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

380

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

387

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

391

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

395

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


Page 18 of 23

Page 19 of 23


397

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

398

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

399

STRENGTHS AND LIMITATIONS

400

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

401

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

402

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

426

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

427

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

428

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

429

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

430

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.

436

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

437

implementation monitoring

438

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

439

follow-up visits after CLTS implementation


Page 20 of 23

Page 21 of 23


440

REFERENCES

441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490

1. WHO, UNICEF. Progress on drinking water, sanitation and hygiene: 2017 update and SDG baselines; World Health Organization; 2017. 2. Prüss‐Ustün A, Bartram J, Clasen T, Colford JM, Cumming O, Curtis V, et al. Burden of disease from inadequate water, sanitation and hygiene in low‐and middle‐income settings: a retrospective analysis of data from 145 countries. Tropical Medicine & International Health. 2014;19(8):894-905. 3. Mara D, Lane J, Scott B, Trouba D. Sanitation and health. PLoS medicine. 2010;7(11):e1000363. 4. Spears D. How much international variation in child height can sanitation explain?; Sustainable Development Network; The World Bank; 2013. 5. Spears D, Lamba S. Effects of early-life exposure to sanitation on childhood cognitive skills: Evidence from India’s Total Sanitation Campaign. Journal of Human Resources. 2015. 6. USAID. An Examination of CLTS’s Contributions toward Universal Sanitation. Washington, DC.: 2018. 7. Kar K, Chambers R. Handbook on community-led total sanitation. 2008. 8. Venkataramanan V, Crocker J, Karon A, Bartram J. Community-led total sanitation: a mixedmethods systematic review of evidence and its quality. Environmental health perspectives. 2018;26001:1. 9. Pickering AJ, Djebbari H, Lopez C, Coulibaly M, Alzua ML. Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial. The Lancet Global Health. 2015;3(11):e701-e11. doi: 10.1016/S2214-109X(15)00144-8. 10. Garn JV, Sclar GD, Freeman MC, Penakalapati G, Alexander KT, Brooks P, et al. The impact of sanitation interventions on latrine coverage and latrine use: A systematic review and meta-analysis. International Journal of Hygiene and Environmental Health. 2016. 11. Robinson A. Final Evaluation: Pan African CLTS program 2010-2015. Plan Netherlands; 2016. 12. Monney I, Baffoe-Kyeremeh A, Amissah-Reynolds PK. Accelerating rural sanitation coverage in Ghana: what are the speed bumps impeding progress? Journal of Water Sanitation and Hygiene for Development. 2015;5(4):531-43. doi: 10.2166/washdev.2015.005. 13. Crocker J, Abodoo E, Asamani D, Domapielle W, Gyapong B, Bartram J. Impact Evaluation of Training Natural Leaders during a Community-Led Total Sanitation Intervention: A ClusterRandomized Field Trial in Ghana. Environmental Science & Technology. 2016;50(16):8867-75. 14. Kumar N, Shukla J. Doing CLTS in a Countrywide Programme Context in India: Public Good, Private Good? L Mehta and S Movik: Shit Matters: The Potential of Community-Led Total Sanitation London; Practical Action. 2008. 15. Cameron L, Shah M. Scaling up sanitation: Evidence from an rct in indonesia. IZA Discussion Paper No 10619 Available at SSRN: https://ssrncom/abstract=2940609. 2017. 16. Pattanayak SK, Yang J-C, Dickinson KL, Poulos C, Patil SR, Mallick RK, et al. Shame or subsidy revisited: social mobilization for sanitation in Orissa, India. Bulletin of the World Health Organization. 2009;87:580-7. 17. Engel S, Susilo A. Shaming and Sanitation in Indonesia: A Return to Colonial Public Health Practices? Development and Change. 2014;45(1):157-78. doi: 10.1111/dech.12075. 18. Bartram J, Charles K, Evans B, O'Hanlon L, Pedley S. Commentary on community-led total sanitation and human rights: should the right to community-wide health be won at the cost of individual rights? Journal of water and health. 2012;10(4):499-503. doi: 10.2166/wh.2012.205. 19. Hoffmeyer-Zlotnik JH. New sampling designs and the quality of data. Developments in applied statistics Ljubljana: FDV Methodoloski zvezki. 2003:205-17. 20. Harter M, Mosch S, Mosler H-J. How does Community-Led Total Sanitation (CLTS) affect latrine ownership? A quantitative case study from Mozambique. BMC Public Health. 2018;18(1):387. doi: 10.1186/s12889-018-5287-y. 21. Mosler H-J, Mosch S, Harter M. Is Community-Led Total Sanitation connected to the rebuilding of latrines? Quantitative evidence from Mozambique. PloS one. 2018;13(5):e0197483. ACS Paragon Plus Environment


491 492 493 494 495 496 497

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.

498


Page 22 of 23

Page 23 of 23


For TOC art only


the role of implementation factors for the success of ... - ACS Publications

Recommend Documents