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Impact Evaluation of Training Natural Leaders during a Community-Led Total Sanitation Intervention: A Cluster-Randomized Field Trial in Ghana.

ABSTRACT: We used a cluster-randomized field trial to evaluate training natural leaders (NLs) as an addition to a community-led total sanitation (CLTS) intervention in Ghana. NLs are motivated community members who influence their peers' behaviors during CLTS. The outcomes were latrine use and quality, which were assessed from surveys and direct observation. From October 2012, Plan International Ghana (Plan) implemented CLTS in 60 villages in three regions in Ghana. After 5 months, Plan trained eight NLs from a randomly selected half of the villages, then continued implementing CLTS in all villages for 12 more months. The NL training led to increased time spent on CLTS by community members, increased latrine construction, and a 19.9 percentage point reduction in open defecation (p < 0.001). The training had the largest impact in small, remote villages with low exposure to prior water and sanitation projects, and may be most effective in socially cohesive villages. For both interventions, latrines built during CLTS were less likely to be constructed of durable materials than pre-existing latrines, but were equally clean, and more often had handwashing materials. CLTS with NL training contributes to three parts of Goal 6 of the Sustainable Development Goals: eliminating open defecation, expanding capacity-building, and strengthening community participation.

SUBMITTER: Crocker J

PROVIDER: S-EPMC4989246 | biostudies-literature | 2016 Aug

REPOSITORIES: biostudies-literature

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Impact Evaluation of Training Natural Leaders during a Community-Led Total Sanitation Intervention: A Cluster-Randomized Field Trial in Ghana.

Crocker Jonny J Abodoo Elvis E Asamani Daniel D Domapielle William W Gyapong Benedict B Bartram Jamie J

Environmental science & technology 20160729 16

We used a cluster-randomized field trial to evaluate training natural leaders (NLs) as an addition to a community-led total sanitation (CLTS) intervention in Ghana. NLs are motivated community members who influence their peers' behaviors during CLTS. The outcomes were latrine use and quality, which were assessed from surveys and direct observation. From October 2012, Plan International Ghana (Plan) implemented CLTS in 60 villages in three regions in Ghana. After 5 months, Plan trained eight NLs ...[more]

PMID: 27428399

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Project description:We conducted a study to evaluate the sustainability of community-led total sanitation (CLTS) outcomes in Ethiopia and Ghana. Plan International, with local actors, implemented four CLTS interventions from 2012 to 2014: health extension worker-facilitated CLTS and teacher-facilitated CLTS in Ethiopia, and NGO-facilitated CLTS with and without training for natural leaders in Ghana. We previously evaluated these interventions using survey data collected immediately after implementation ended, and concluded that in Ethiopia health extension workers were more effective facilitators than teachers, and that in Ghana training natural leaders improved CLTS outcomes. For this study, we resurveyed 3831 households one year after implementation ended, and analyzed latrine use and quality to assess post-intervention changes in sanitation outcomes, to determine if our original conclusions were robust. In one of four interventions evaluated (health extension worker-facilitated CLTS in Ethiopia), there was an 8 percentage point increase in open defecation in the year after implementation ended, challenging our prior conclusion on their effectiveness. For the other three interventions, the initial decreases in open defecation of 8-24 percentage points were sustained, with no significant changes occurring in the year after implementation. On average, latrines in Ethiopia were lower quality than those in Ghana. In the year following implementation, forty-five percent of households in Ethiopia repaired or rebuilt latrines that had become unusable, while only 6% did in Ghana possibly due to higher latrine quality. Across all four interventions and three survey rounds, most latrines remained unimproved. Regardless of the intervention, households in villages higher latrine use were more likely to have sustained latrine use, which together with the high latrine repair rates indicates a potential social norm. There are few studies that revisit villages after an initial evaluation to assess sustainability of sanitation outcomes. This study provides new evidence that CLTS outcomes can be sustained in the presence of training provided to local actors, and strengthens previous recommendations that CLTS is not appropriate in all settings and should be combined with efforts to address barriers households face to building higher quality latrines.

Project description: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.

Dataset Information

Impact Evaluation of Training Natural Leaders during a Community-Led Total Sanitation Intervention: A Cluster-Randomized Field Trial in Ghana.

Publications

Impact Evaluation of Training Natural Leaders during a Community-Led Total Sanitation Intervention: A Cluster-Randomized Field Trial in Ghana.

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