Mobility up the sanitation ladder following community-led total sanitation in rural Zambia

Abstract

Scaling the sanitation ladder decreases exposure to various illnesses including diarrheal disease, soil-transmitted helminths and trachoma. In rural Zambia, community-led total sanitation (CLTS) has been deployed to help Zambians scale the sanitation ladder. Analysis of monthly routine surveillance data of village-level sanitation coverage of 13,688 villages shows that villages moved up the sanitation ladder following CLTS intervention with more than one third of villages achieving 100% coverage of adequate sanitation. Villages also moved down the sanitation ladder – approximately half of those achieving 100% coverage of adequate sanitation also dropped from that coverage at some point during monitoring. Larger villages were less likely to achieve 100% coverage, and more likely to drop if they did achieve 100% coverage. Drops were more likely to occur during the wet season. Of those villages dropping from 100% coverage, more than half rebounded to 100% coverage. The adequate latrine components most likely to drop off from 100% coverage were handwashing stations and lids to cover holes, both key components in preventing disease transmission. These results have implications for water, sanitation and hygiene (WASH) programming – sustained support may be required to ensure villages move up the sanitation ladder and stay there.

How community engagement in water and sanitation interventions impacts human health, infrastructure and service longevity in low- and middle-income countries: a realist review

“…The focus of such monitoring may be progress towards achieving a goal. The goal may be about access to a service -e.g., to ensure that sanitation facilities are in place (10,22,31,33), that facilities meet the needs of people with disabilities (38), or that water is accessible (39,40). The goal may also be resource preservation (safety and/or accessibility) so that water is available to be accessed as desired -e.g., to check water samples for faecal or arsenic contamination (15,41), or to assess the level of groundwater available for agriculture throughout the year (32).…”

“…Internal monitoring can be conducted by a chief or village headman (10,22,31), locally trained volunteers (41), community members (32) or by the community's health or water committee (39)(40)(41).…”

“…transparent and has open channels for communicating with community members (10,22,31,40) and the use of technology allows up to date monitoring (31). Accountability is also strengthened where there is a functional, long-standing water or health committee whose members are active, motivated and committed, and have clear roles and responsibilities (39,40).…”

“…They spread innovations by using their shared knowledge of the language, social, cultural and religious beliefs and their existing relationships with and within communities (30,31). Innovators and early adopters in a community include teachers (30,55), leaders (10,22,30,31,34,55,56), healthcare workers (30,42,55,57,58), and community committees (21,46,59,60). Diffusion can contribute to the three outcomes -access, change and sustainability.…”

“…Failure of interventions can occur for several reasons, such as lack of community involvement in design (15,16), lack of ownership (17,18), abuse of funds or poor financial management, lack of willingness of community members to contribute (18)(19)(20), lack of communication and connectedness (21) and no ongoing support and acknowledgement of change (22)(23)(24). In addition to an increased understanding of success and failures in WASH interventions, there is a growing trend to use community participation to drive health programmes, based on the expectation working with communities can help ensure interventions are more relevant to local priorities (25).…”