CLTS implementation in Malawi : lessons from process evaluation of a sanitation and hygiene intervention

Panulo, Mindy Francis and Chidziwisano, Kondwani and Kapazga, Timeyo and Dreibelbis, Robert and Beattie, Tara K. and Morse, Tracy (2024) CLTS implementation in Malawi : lessons from process evaluation of a sanitation and hygiene intervention. In: 2024 UNC Water & Health Conference, 2024-10-14 - 2024-10-18, Friday Center, Chapel Hill.

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Abstract

Background: To promote sanitation and hygiene at household level, many low- and middle-income countries have adopted Community Led Total Sanitation (CLTS) as an approach to reducing open defecation. Despite its widespread implementation, evaluations of the effectiveness and sustainability of CLTS outcomes show considerable variability. Little research has been conducted to determine if the impact and sustainability of CLTS is affected by the way in which implementation is undertaken and managed. We conducted a process evaluation of a district-level CLTS programme to understand the challenges of implementation in Malawi and track how implementation could impact short- and long-term sanitation and hygiene outcomes. Methods: From January 2022 to March 2023, we conducted a retrospective process evaluation of a CLTS-based intervention implemented by World Vision and Water for People in four Traditional Authorities in Chiradzulu district, rural Malawi. A mixed methods approach was used, including: Key Informant Interviews (n=27), Focus Group Discussions (n=14), and household surveys (n=1151). Additionally, secondary data from project implementers were examined to enhance the evaluation. Specifically, the study assessed the context, implementation fidelity, reach and dose and whether sanitation and hygiene related benefits were achieved through the intervention. Results: Despite a delay in implementation, all planned activities were completed, delivering the anticipated dosage. CLTS pre-triggering activities, including meeting with chiefs and scheduling of a triggering day were implemented with high fidelity. However, fidelity of subsequent phases (i.e. training of facilitators, triggering sessions and post-triggering phases) was variable across the programme areas. For example, training of CLTS facilitators was shortened, resulting in little to no training on important CLTS activities e.g. food and faeces demonstrations. Some triggering activities, such as selecting natural leaders, were completed outside of the planned triggering sessions. To support efforts to end ODF status, more household visits were undertaken than planned, affecting the fidelity. None of the CLTS stages achieved 100% reach; 57% of study participants received information on upcoming triggering sessions in their community and 46% attended triggering sessions. Post triggering follow up visits were reported in 66% of the households. Low rates of participation were recorded among children and elderly populations. Community leaders played a role in supporting household follow ups, however, there is need for continuous engagement so that their action should not be detrimental to the uptake of sanitation behaviours. In the quantitative analysis, age and gender were not associated with reported participation in triggering events but there was a small increase in the odds of participation based on prior school attendance (OR: 1.09, p < 0.01). At follow-up, household presence of latrine was associated with reported attendance at a local triggering session (OR: 1.6, p< 0.01) and reporting that the household received post-triggering household follow-up visits (OR: 1.6, p < 0.01). Discussion: Our process evaluation indicates that achievement of ODF status is associated with attending triggering sessions and receiving household visits. Thus, to achieve successful implementation and fast uptake of latrine building, triggering sessions and household follow-up must target a diverse variety of people and follow guidelines.

ORCID iDs

Panulo, Mindy Francis ORCID logoORCID: https://orcid.org/0000-0002-0241-0180, Chidziwisano, Kondwani, Kapazga, Timeyo, Dreibelbis, Robert, Beattie, Tara K. ORCID logoORCID: https://orcid.org/0000-0002-5593-8368 and Morse, Tracy ORCID logoORCID: https://orcid.org/0000-0003-4185-9471;
CORE (COnnecting REpositories)