How does Community-Led Total Sanitation (CLTS) promote latrine construction, and can it be improved? A cluster-randomized controlled trial in Ghana

Miriam Harter,Jennifer Inauen,Hans-Joachim Mosler

doi:10.1016/j.socscimed.2019.112705

Abstract

RationaleOpen defecation is connected to poor health and child mortality, but billions of people still do not have access to safe sanitation facilities. Community-Led Total Sanitation (CLTS) promotes latrine construction to eradicate open defecation. However, the mechanisms by which CLTS works and how they can be improved remain unknown. The present study is the first to investigate the psychosocial determinants of CLTS in a longitudinal design. Furthermore, we tested whether CLTS can be made more effective by theory- and evidence-based interventions using the risks, attitudes, norms, abilities, and selfregulation (RANAS) model. MethodsA cluster-randomized controlled trial of 3216 households was implemented in rural Ghana. Communities were randomly assigned to classic CLTS, one of three RANAS-based interventions, or to the control arm. Prepost surveys at 6-month follow-up included standardized interviews assessing psychosocial determinants from the RANAS model. Regression analyses and multilevel mediation models were computed to test intervention effects and mechanisms of CLTS. ResultsLatrine coverage increased pre-post by 67.6% in all intervention arms and by 7.9% in the control arm (p < .001). The combination with RANAS-based interventions showed non-significantly greater effects than CLTS alone. The effects of CLTS on latrine construction were significantly mediated by changes in four determinants: others' behaviour and approval, self-efficacy, action planning and commitment. Changes in vulnerability, severity, and barrier planning were positively connected to latrine construction but not affected by CLTS. ConclusionThis study corroborates the effectiveness of CLTS in increasing latrine coverage, and additional activities can be improved further. Behaviour change techniques within CLTS that strengthened the relevant factors should be maintained. The study also recommends interventions based on the RANAS approach to improve CLTS. Further research is needed to understand the effects of RANAS-based interventions combined with CLTS at longer follow-up

Highlights

The global community has set itself the goal of providing access to safe sanitation facilities for all by 2030 (Goal number 6, Sustainable Development Goals)
The trial comprised four intervention arms and one control arm: (1) classic Community-Led Total Sanitation (CLTS), (2) CLTS combined with an extended public commitment, (3) CLTS combined with a household action planning, (4) CLTS combined with public commitment and household action planning, and (5) a control arm with no intervention
This study investigated the intervention effect of a classic CLTS intervention on latrine construction

Summary

Introduction

The global community has set itself the goal of providing access to safe sanitation facilities for all by 2030 (Goal number 6, Sustainable Development Goals). As a result of open defecation, 1.8 billion people worldwide use drinking water that is contaminated with faecal bacteria (WHO & UNICEF, 2017). Wolf et al (2018) show that among adults, sanitation interventions reach up to 25% reduction in diarrheal diseases, and evidence is presented that the effect is higher in communities with higher latrine coverages. This fact shows that open defecation is an individual health hazard. Collective behaviour change is required to achieve an environment free of open defecation

Methods

Results

Conclusion