The Effect of Community Led Sanitation Programs in Ghana.

[NNadir]

The paper I'll discuss in this brief post is this one: Environ. Sci. Technol.2019, 53, 9, 5466-5472 (Harter, Miriam Harter, *Jonathan Lilje, and Hans-Joachim Mosler, Environ. Sci. Technol.2019, 53, 9, 5466-5472]

I come from another time which has clearly passed, when I was born, the woman pictured in my posts was still alive, and to her, if not to us, as more "modern" liberals, those who were without mattered.

The introduction paper, especially (at least to me) what I have put in bold says something we forget as we prattle on about our consumer fantasies about our "green" cars, our LEDs showing our commitment to "efficiency" the people who mine the stuff so we can be "green" notwith standing. As the risk of being accused of paternalism by a moral superior, I reproduce it here, again, with my own bold.

In 2015, 2.3 billion people did not have access to safe sanitation facilities and were forced to defecate in the environment surrounding their communities.(1) The unsafe disposal of human faeces is one major reason for diarrheal diseases,(2,3) which lead to 1.6–2.5 million deaths per year and account for 19% of all deaths of children under five years in developing countries.(3) Children exposed to open defecation tend to be smaller(4) and have lower cognitive skills.(5) Open defecation further does not only pose an individual health risk: an individual not defecating in the open but living in the proximity of others doing so, remains at risk.(6−8)

Community-Led Total Sanitation (CLTS) aims at stopping open defecation by motivating participants to construct household latrines and reach high latrine coverages in target communities. This set of community-based and participatory activities has been implemented in communities worldwide by local governmental and nongovernmental institutions.(9) The goal of CLTS is to trigger a movement of change towards an improved sanitation situation.(10) This change is achieved by the commitment of all community members. In the case of Ghana, where this study is located, a community is declared open defecation free, if every single person has access to a latrine and at least 80% of the community owns a household latrine.(11) CLTS is implemented in three stages: a pre-triggering phase in which information is gathered, the triggering event that uses participatory activities to foster latrine construction, and a post-triggering phase that provides support in a series of follow-up visits.

The current literature points to the ability of CLTS to generate significant short-term reductions in open defecation as well as increases in latrine coverage and use, as well as suggestive evidence of child growth benefits in high-performing programs.(9,12−14) But its success rates vary widely across projects and countries and slippage rates as well as long-term effects have received too little scientific attention so far.(15) The success of CLTS can be measured by latrine coverage, the percentage of households within a community that have access to their own latrines. A literature review of sanitation campaigns has reported an average increase in latrine coverage following CLTS of 12%, though not statistically significant,(16) and Robinson(17) presents results of up to 96% latrine coverage in a single case in Malawi. In Ghana, where the majority of the regions have adapted CLTS as their sanitation strategy,(9) the effects are surprisingly low, with a national increase in sanitation access in recent years of only 4%,(1,18) although some specific projects in Ghana have achieved a reduction of open defecation by 19.9%.(19) The wide range in CLTS success rates raises the question how these differences can be explained.

This disturbs me all the time, that we have trillions of dollars to spend on things that don't work and won't work, and nothing to spend on the billions of people lacking basic sanitation.

In Ghana, apparently the success rates of the programs have been marginal, and so the authors explored a program where the initiation involved the community, rather than programs offered from above.

We hypothesize that higher participation in the triggering event, better liking of facilitators, higher conviction and motivation after the triggering event, stronger feelings of shame and disgust, higher number of natural leaders selected, higher number of follow-up visits, greater perception of receiving incentives for latrine construction, and longer time since the triggering event are positively related to latrine coverage in communities. The goal of this article is to quantify the individual contributions of these factors toward the success of CLTS as measured by latrine coverage in communities.

I'm not sure though, how "community oriented" it is to have Swiss visit you in Ghana:

This study was implemented in rural Ghana jointly by the Swiss Federal Research Institute for Aquatic Science and Technology (Eawag), USAID, and Global Communities Ghana. The project was funded by the Bill and Melinda Gates Foundation. Global Communities implemented CLTS according to the Handbook on CLTS and National Guidelines for CLTS, which also included guidance on the verification of ODF communities, such as 80% of the community’s inhabitants have to own a ventilated improved pit latrine and 100% need to have access to such sanitation services.(11) Baseline data was assessed in March to April 2016. After the implementation of CLTS in July to December 2016, a first follow-up survey was conducted in March to April 2017.

Here's how they involved the community in any case:

Pretriggering

The community was assessed for its social structure and size, and a date for the triggering event was agreed with community leaders. They were asked to invite female and male community members from all ethnic groups to the triggering event.



Triggering

Facilitators started the session by presenting each other, an opening prayer, and welcoming community members. They facilitated the drawing of a community map on the ground with community institutions such as mosques and water sources. Then, they invited participants to locate both their houses and the spots they used for open defecation. By asking questions about possible paths of the fecal–oral transmission route, the facilitators helped participants recognize the sanitation threat that they faced in their surroundings. If participants seemed hesitant about the sanitation improvement of their community, facilitators were instructed to introduce more activities. These included the presentation of a sealed bottle of water. This was offered to participants to open and taste. A facilitator then took a stick, touched the soil with it, and then dipped it in the water. The water was then presented to participants again. This was to illustrate the contamination of water by small particles, such as those transferred by flies. Facilitators asked participants to agree on a date for the community to become open defecation free and set a community action plan in place.

Happily their did seem to be an improvement, meaning that maybe have Swiss visit you is good for you:

Overall, community latrine coverage increased pre-post by 67.6%. The selected communities had a mean community size of 466 households (SD = 337). Within communities, some 49.2% reported Christianity to be their religion, 26.1% Islam, and 19.2% traditional religions. Most were farming communities (80.4%); with a mean monthly income of 202.30 New Ghanaian Cedi (equivalent of 43 USD, SD = 380.39 GHS) and an average household size of 8.7 individuals (SD = 4.9). The sample used for the study was comprised of 94 communities (1877 households in total), for which complete data in all hypothesized variables was available at time of data analysis. For this analysis, 8 communities were excluded because of missing information either on the total population size, the attendance rates or the number of selected natural leaders

The authors conclude:

Our results suggest that for CLTS to be maximally successful it is important that as many community members as possible participate at the triggering meeting. Therefore, good preparation of the meeting is important to ensure that all people in the community are aware of the meeting and that it is also attractive. The more people participate in the meeting the more are also communicating within a community about this event and the messages are transmitted to non-participants more likely. The diffusion of CLTS information to non-participants was already shown in previous research Harter et al.(23) Consequently, the effect of the triggering event may be enhanced by prompting attendees to influence community members who did not attend, for example by facilitating further exchange between community members.

Apparently though, the Swiss feel that they need to keep coming back:

Overall, our findings suggest that the triggering event of CLTS is only the starting point. But whether people experience any strong feelings, whether they are convinced by the event, and whether they like the facilitator and the meeting are not relevant for the long-term latrine coverage of the community. CLTS unfolds its power in the weeks after the triggering event. However, the time elapsed since the triggering event is not an explanation for success. The more community members participate in CLTS, the more the movement spreads. Trained natural leaders have to supervise the process kicked off by the triggering event, and facilitators need to return and provide support. The belief or hope of receiving an incentive such as a borehole seems to be an important driving factor that accelerates the construction process.

This is not physical science but social science, but I actually believe that irrespective of issues of paternalism or whatever, we should care about all human beings. I may be a dinosaur, but that's what I think.

Have a nice evening.