Community-Led Total Sanitation: A Mixed-Methods Systematic Review of Evidence and Its Quality

Abstract

Background:Community-led total sanitation (CLTS) is a widely applied rural behavior change approach for ending open defecation. However, evidence of its impact is unclear.Objectives:We conducted a systematic review of journal-published and gray literature to a) assess evidence quality, b) summarize CLTS impacts, and c) identify factors affecting implementation and effectiveness.Methods:Eligible studies were systematically screened and selected for analysis from searches of seven databases and 16 websites. We developed a framework to appraise literature quality. We qualitatively analyzed factors enabling or constraining CLTS, and summarized results from quantitative evaluations.Discussion:We included 200 studies (14 quantitative evaluations, 29 qualitative studies, and 157 case studies). Journal-published literature was generally of higher quality than gray literature. Fourteen quantitative evaluations reported decreases in open defecation, but did not corroborate the widespread claims of open defecation–free (ODF) villages found in case studies. Over one-fourth of the literature overstated conclusions, attributing outcomes and impacts to interventions without an appropriate study design. We identified 43 implementation- and community-related factors reportedly affecting CLTS. This analysis revealed the importance of adaptability, structured posttriggering activities, appropriate community selection, and further research on combining and sequencing CLTS with other interventions.Conclusions:The evidence base on CLTS effectiveness available to practitioners, policy makers, and program managers to inform their actions is weak. Our results highlight the need for more rigorous research on CLTS impacts as well as applied research initiatives that bring researchers and practitioners together to address implementation challenges to improve rural sanitation efforts. https://doi.org/10.1289/EHP1965

Assessing the Impact and Equity of an Integrated Rural Sanitation Approach: A Longitudinal Evaluation in 11 Sub-Saharan Africa and Asian Countries

“…Prior to the intervention, many of the program countries had existing government-supported CLTS activities taking place, and in many cases SNV was involved in those pilots. Countries also had, to some extent, efforts to improve supply-chain [17,18]. However, at the time, CLTS was implemented at the village level and while successful in a number of villages, there was no clear road to scale or sustainability.…”

“…Stalled progress and slippage were important problems that SSH4A hoped to address. Stalled progress occurred in many of these countries for various reasons, including remaining villages are often more rural and difficult to reach with CLTS campaigns, late adopters are often less interested in the interventions, quality of triggering, supply chain limitations, and scaling strategies and both human and monetary resources are sometimes inadequate [18]. Slippage has also been a considerable problem as CLTS interventions often result in unimproved or low durability latrines [19].…”

PROTOCOL: Community‐led total sanitation in rural areas of low‐ and middle‐income countries: a systematic review of evidence on effects and influencing factors

“…• Unlike Venkataramanan et al (2018) we will focus only on studies that analysed CLTS in rural or semi-rural settings. We believe that sanitation poses quite different challenges in urban settings and that it is not appropriate to synthesise evidence from urban and rural settings together.…”

“…However, it also means that they extracted factors influencing CLTS from all of the 200 studies of which a large part was assessed as of low quality. We consider their finding about generally poor quality of evidence as a starting point and, unlike Venkataramanan et al (2018), we will use a quality and information content appraisal to select and consider only studies of acceptable quality for the extraction of data on the second review question. Venkataramanan et al (2018) descriptively characterised outcomes and influencing factors identified from the considered primary studies but did not report on links between particular factors and specific outcomes. The latter is one of the main goals of our review with respect to the second review question.…”

A study on open air defecation practices among the population above 6 years in rural field practice area of Santhiram Medical College, Nandyal, Kurnool dist, Andhra Pradesh

“…Even if the goal is met by 2015, 5.4 million children will still die. 4 Human faeces left in the open fields, bushes or drains generate millions of viruses, bacteria and parasites. House flies usually fly between these faeces and the food we eat including fruits.…”