The state of reporting context and implementation in peer-reviewed evaluations of water, sanitation, and hygiene interventions: A scoping review.

INTRODUCTION: To accurately assess evidence from environmental and public health field trials, context and implementation details of the intervention must be weighed with trial results; yet these details are under and inconsistently reported for water, sanitation, and hygiene (WASH), limiting the external validity of the evidence. METHODS: To quantify the level of reporting of context and implementation in WASH evaluations, we conducted a scoping review of the 40 most cited evaluations of WASH interventions published in the last 10 years (2012-2022). We applied criteria derived from a review of existing reporting guidance from other sectors including healthcare and implementation science. We subsequently reviewed main articles, supplements, protocols, and other associated resources to assess thoroughness of context and implementation reporting. RESULTS: Of the final 25 reporting items we searched for, four-intervention name, approach, location, and temporality-were reported by all studies. Five items-theory, implementer qualifications, dose intensity, targeting, and measured fidelity-were not reported in over a third of reviewed articles. Only two studies (5%) reported all items in our checklist. Only 74% of items were found in the main article, while the rest were found in separate papers (7%) or not at all (19%). DISCUSSION: Inconsistent reporting of WASH implementation illustrates a major challenge in the sector. It is difficult to know what interventions are actually being evaluated and how to compare evaluation results. This inconsistent and incomplete implementation reporting limits the ability of programmers and policy makers to apply the available evidence to their contexts. Standardized reporting guidelines would improve the application of the evidence for WASH field evaluations.

Assessing drivers of implementing "Scaling-up the Systems Analysis and Improvement Approach" for Prevention of Mother-to-Child HIV Transmission in Mozambique (SAIA-SCALE) over implementation waves.

BACKGROUND: The Systems Analysis and Improvement Approach (SAIA) is an evidence-based package of systems engineering tools originally designed to improve patient flow through the prevention of Mother-to-Child transmission of HIV (PMTCT) cascade. SAIA is a potentially scalable model for maximizing the benefits of universal antiretroviral therapy (ART) for mothers and their babies. SAIA-SCALE was a stepped wedge trial implemented in Manica Province, Mozambique, to evaluate SAIA's effectiveness when led by district health managers, rather than by study nurses. We present the results of a qualitative assessment of implementation determinants of the SAIA-SCALE strategy during two intensive and one maintenance phases. METHODS: We used an extended case study design that embedded the Consolidated Framework for Implementation Research (CFIR) to guide data collection, analysis, and interpretation. From March 2019 to April 2020, we conducted in-depth individual interviews (IDIs) and focus group discussions (FGDs) with district managers, health facility maternal and child health (MCH) managers, and frontline nurses at 21 health facilities and seven districts of Manica Province (Chimoio, Báruè, Gondola, Macate, Manica, Sussundenga, and Vanduzi). RESULTS: We included 85 participants: 50 through IDIs and 35 from three FGDs. Most study participants were women (98%), frontline nurses (49.4%), and MCH health facility managers (32.5%). An identified facilitator of successful intervention implementation (regardless of intervention phase) was related to SAIA's compatibility with organizational structures, processes, and priorities of Mozambique's health system at the district and health facility levels. Identified barriers to successful implementation included (a) inadequate health facility and road infrastructure preventing mothers from accessing MCH/PMTCT services at study health facilities and preventing nurses from dedicating time to improving service provision, and (b) challenges in managing intervention funds. CONCLUSIONS: The SAIA-SCALE qualitative evaluation suggests that the scalability of SAIA for PMTCT is enhanced by its fit within organizational structures, processes, and priorities at the primary level of healthcare delivery and health system management in Mozambique. Barriers to implementation that impact the scalability of SAIA include district-level financial management capabilities and lack of infrastructure at the health facility level. SAIA cannot be successfully scaled up to adequately address PMTCT needs without leveraging central-level resources and priorities. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03425136 . Registered on 02/06/2018.

The Systems Analysis and Improvement Approach: specifying core components of an implementation strategy to optimize care cascades in public health.

BACKGROUND: Healthcare systems in low-resource settings need simple, low-cost interventions to improve services and address gaps in care. Though routine data provide opportunities to guide these efforts, frontline providers are rarely engaged in analyzing them for facility-level decision making. The Systems Analysis and Improvement Approach (SAIA) is an evidence-based, multi-component implementation strategy that engages providers in use of facility-level data to promote systems-level thinking and quality improvement (QI) efforts within multi-step care cascades. SAIA was originally developed to address HIV care in resource-limited settings but has since been adapted to a variety of clinical care systems including cervical cancer screening, mental health treatment, and hypertension management, among others; and across a variety of settings in sub-Saharan Africa and the USA. We aimed to extend the growing body of SAIA research by defining the core elements of SAIA using established specification approaches and thus improve reproducibility, guide future adaptations, and lay the groundwork to define its mechanisms of action. METHODS: Specification of the SAIA strategy was undertaken over 12 months by an expert panel of SAIA-researchers, implementing agents and stakeholders using a three-round, modified nominal group technique approach to match core SAIA components to the Expert Recommendations for Implementing Change (ERIC) list of distinct implementation strategies. Core implementation strategies were then specified according to Proctor's recommendations for specifying and reporting, followed by synthesis of data on related implementation outcomes linked to the SAIA strategy across projects. RESULTS: Based on this review and clarification of the operational definitions of the components of the SAIA, the four components of SAIA were mapped to 13 ERIC strategies. SAIA strategy meetings encompassed external facilitation, organization of provider implementation meetings, and provision of ongoing consultation. Cascade analysis mapped to three ERIC strategies: facilitating relay of clinical data to providers, use of audit and feedback of routine data with healthcare teams, and modeling and simulation of change. Process mapping matched to local needs assessment, local consensus discussions and assessment of readiness and identification of barriers and facilitators. Finally, continuous quality improvement encompassed tailoring strategies, developing a formal implementation blueprint, cyclical tests of change, and purposefully re-examining the implementation process. CONCLUSIONS: Specifying the components of SAIA provides improved conceptual clarity to enhance reproducibility for other researchers and practitioners interested in applying the SAIA across novel settings.

Association between service readiness and PMTCT cascade effectiveness: a 2018 cross-sectional analysis from Manica province, Mozambique.

BACKGROUND: Despite high coverage of maternal and child  health services in Mozambique, prevention of mother-to-child transmission of HIV (PMTCT) cascade outcomes remain sub-optimal. Delivery effectiveness is modified by health system preparedness. Identifying modifiable factors that impact quality of care and service uptake can inform strategies to improve the effectiveness of PMTCT programs. We estimated associations between facility-level modifiable health system readiness measures and three PMTCT outcomes: Early infant diagnosis (polymerase chain reaction (PCR) before 8 weeks of life), PCR ever (before or after 8 weeks), and positive PCR test result. METHODS: A 2018 cross-sectional, facility-level survey was conducted in a sample of 36 health facilities covering all 12 districts in Manica province, central Mozambique, as part of a baseline assessment for the SAIA-SCALE trial (NCT03425136). Data on HIV testing outcomes among 3,427 exposed infants were abstracted from at-risk child service registries. Nine health system readiness measures were included in the analysis. Logistic regressions were used to estimate associations between readiness measures and pediatric HIV testing outcomes. Odds ratios (OR) and 95% confidence intervals (95%CI) are reported. RESULTS: Forty-eight percent of HIV-exposed infants had a PCR test within 8 weeks of life, 69% had a PCR test ever, and 6% tested positive. Staffing levels, glove stockouts, and distance to the reference laboratory were positively associated with early PCR (OR = 1.02 [95%CI: 1.01-1.02], OR = 1.73 [95%CI: 1.24-2.40] and OR = 1.01 [95%CI: 1.00-1.01], respectively) and ever PCR (OR = 1.02 [95%CI: 1.01-1.02], OR = 1.80 [95%CI: 1.26-2.58] and OR = 1.01 [95%CI: 1.00-1.01], respectively). Catchment area size and multiple NGOs supporting PMTCT services were associated with early PCR testing OR = 1.02 [95%CI: 1.01-1.03] and OR = 0.54 [95%CI: 0.30-0.97], respectively). Facility type, stockout of prophylactic antiretrovirals, the presence of quality improvement programs and mothers' support groups in the health facility were not associated with PCR testing. No significant associations with positive HIV diagnosis were found. CONCLUSION: Salient modifiable factors associated with HIV testing for exposed infants include staffing levels, NGO support, stockout of essential commodities and accessibility of reference laboratories. Our study provides insights into modifiable factors that could be targeted to improve PMTCT performance, particularly at small and rural facilities.

Maternal and Child Health Care Service Disruptions and Recovery in Mozambique After Cyclone Idai: An Uncontrolled Interrupted Time Series Analysis.

INTRODUCTION: Climate change-related extreme weather events have increased in frequency and intensity, threatening people's health, particularly in places with weak health systems. In March 2019, Cyclone Idai devastated Mozambique's central region, causing infrastructure destruction, population displacement, and death. We assessed the impact of Idai on maternal and child health services and recovery in the Sofala and Manica provinces. METHODS: Using monthly district-level routine data from November 2016 to March 2020, we performed an uncontrolled interrupted time series analysis to assess changes in 10 maternal and child health indicators in all 25 districts before and after Idai. We applied a Bayesian hierarchical negative binomial model with district-level random intercepts and slopes to estimate Idai-related service disruptions and recovery. RESULTS: Of the 4.44 million people in Sofala and Manica, 1.83 (41.2%) million were affected. Buzi, Nhamatanda, and Dondo (all in Sofala province) had the highest proportion of people affected. After Idai, all 10 indicators showed an abrupt substantial decrease. First antenatal care visits per 100,000 women of reproductive age decreased by 23% (95% confidence interval [CI]=0.62, 0.96) in March and 11% (95% CI=0.75, 1.07) in April. BCG vaccinations per 1,000 children under age 5 years declined by 21% (95% CI=0.69, 0.90) and measles vaccinations decreased by 25% (95% CI=0.64, 0.87) in March and remained similar in April. Within 3 months post-cyclone, almost all districts recovered to pre-Idai levels, including Buzi, which showed a 22% and 13% relative increase in the number of first antenatal care visits and BCG, respectively. CONCLUSION: We found substantial health service disruptions immediately after Idai, with greater impact in the most affected districts. The findings suggest impressive recovery post-Idai, emphasizing the need to build resilient health systems to ensure quality health care during and after natural disasters.

Measurement of benefits in economic evaluations of nutrition interventions in low- and middle-income countries: A systematic review.

Economic evaluation of nutrition interventions that compares the costs to benefits is essential to priority-setting. However, there are unique challenges to synthesizing the findings of multi-sectoral nutrition interventions due to the diversity of potential benefits and the methodological differences among sectors in measuring them. This systematic review summarises literature on the interventions, sectors, benefit terminology and benefit types included in cost-effectiveness, cost-utility and benefit-cost analyses (CEA, CUA and BCA, respectively) of nutrition interventions in low- and middle-income countries. A systematic search of five databases published from January 2010 to September 2019 with expert consultation yielded 2794 studies, of which 93 met all inclusion criteria. Eighty-seven per cent of the included studies included interventions delivered from only one sector, with almost half from the health sector (43%), followed by food/agriculture (27%), water, sanitation and hygiene (WASH) (10%), and social protection (8%). Only 9% of studies assessed programmes involving more than one sector (health, food/agriculture, social protection and/or WASH). Eighty-one per cent of studies used more than one term to refer to intervention benefits. The included studies calculated 128 economic evaluation ratios (57 CEAs, 39 CUAs and 32 BCAs), and the benefits they included varied by sector. Nearly 60% measured a single benefit category, most frequently nutritional status improvements; other health benefits, cognitive/education gains, dietary diversity, food security, knowledge/attitudes/practices and income were included in less than 10% of all ratios. Additional economic evaluation of non-health and multi-sector interventions, and incorporation of benefits beyond nutritional improvements (including cost savings) in future economic evaluations is recommended.

Cost effectiveness of community led total sanitation in Ethiopia and Ghana.

We conducted cost effectiveness analyses of four different CLTS interventions implemented in Ethiopia and Ghana. In each country, a pilot approach in which additional local actors were trained in CLTS facilitation was compared to the conventional approach. Data were collected using bottom-up costing, household surveys, and observations. We assessed variability of cost effectiveness from a societal perspective for latrine ownership and latrine use outcomes in different contexts. Cost effectiveness ranged from $34-$1897 per household ($5.85-$563 per person) gaining access to a private latrine or stopping open defecation, depending on the intervention, context, and outcome considered. For three out of four interventions, CLTS appeared more cost effective at reducing open defecation than at increasing latrine ownership, although sensitivity analysis revealed considerable variation. The pilot approaches were more cost effective at reducing open defecation than conventional approaches in Ethiopia, but not in Ghana. CLTS has been promoted as a low-cost means of improving the ownership and use of sanitation facilities. In our study, the cost of CLTS per household gaining latrine access was slightly higher than in other studies, and the cost of CLTS per household stopping OD was slightly lower than in other studies. Our results show that aggregate measures mask considerable variability in costs and outcomes, and thus the importance of considering and reporting context and uncertainty in economic analysis of sanitation interventions.

Correction to: Systems analysis and improvement approach to optimize the hypertension diagnosis and care cascade for PLHIV individuals (SAIA-HTN): a hybrid type III cluster randomized trial.

Following publication of the original article [1], the authors reported a typo in the title of the article.

Systems analysis and improvement approach to optimize the hypertension diagnosis and care cascade for PLHIV individuals (SAIA-HTN): a hybrid type III cluster randomized trial.

BACKGROUND: Across sub-Saharan Africa, evidence-based clinical guidelines to screen and manage hypertension exist; however, country level application is low due to lack of service readiness, uneven health worker motivation, weak accountability of health worker performance, and poor integration of hypertension screening and management with chronic care services. The systems analysis and improvement approach (SAIA) is an evidence-based implementation strategy that combines systems engineering tools into a five-step, facility-level package to improve understanding of gaps (cascade analysis), guide identification and prioritization of low-cost workflow modifications (process mapping), and iteratively test and redesign these modifications (continuous quality improvement). As hypertension screening and management are integrated into chronic care services in sub-Saharan Africa, an opportunity exists to test whether SAIA interventions shown to be effective in improving efficiency and coverage of HIV services can be effective when applied to the non-communicable disease services that leverage the same platform. We hypothesize that SAIA-hypertension (SAIA-HTN) will be effective as an adaptable, scalable model for broad implementation. METHODS: We will deploy a hybrid type III cluster randomized trial to evaluate the impact of SAIA-HTN on hypertension management in eight intervention and eight control facilities in central Mozambique. Effectiveness outcomes include hypertension cascade flow measures (screening, diagnosis, management, control), as well as hypertension and HIV clinical outcomes among people living with HIV. Cost-effectiveness will be estimated as the incremental costs per additional patient passing through the hypertension cascade steps and the cost per additional disability-adjusted life year averted, from the payer perspective (Ministry of Health). SAIA-HTN implementation fidelity will be measured, and the Consolidated Framework for Implementation Research will guide qualitative evaluation of the implementation process in high- and low-performing facilities to identify determinants of intervention success and failure, and define core and adaptable components of the SAIA-HTN intervention. The Organizational Readiness for Implementing Change scale will measure facility-level readiness for adopting SAIA-HTN. DISCUSSION: SAIA packages user-friendly systems engineering tools to guide decision-making by front-line health workers to identify low-cost, contextually appropriate chronic care improvement strategies. By integrating SAIA into routine hypertension screening and management structures, this pragmatic trial is designed to test a model for national scale-up. TRIAL REGISTRATION: ClinicalTrials.gov NCT04088656 (registered 09/13/2019; https://clinicaltrials.gov/ct2/show/NCT04088656).

Cascade Analysis: An Adaptable Implementation Strategy Across HIV and Non-HIV Delivery Platforms.

BACKGROUND: Cascades have been used to characterize sequential steps within a complex health system and are used in diverse disease areas and across prevention, testing, and treatment. Routine data have great potential to inform prioritization within a system, but are often inaccessible to frontline health care workers (HCWs) who may have the greatest opportunity to innovate health system improvement. METHODS: The cascade analysis tool (CAT) is an Excel-based, simple simulation model with an optimization function. It identifies the step within a cascade that could most improve the system. The original CAT was developed for HIV treatment and the prevention of mother-to-child transmission of HIV. RESULTS: CAT has been adapted 7 times: to a mobile application for prevention of mother-to-child transmission; for hypertension screening and management and for mental health outpatient services in Mozambique; for pediatric and adolescent HIV testing and treatment, HIV testing in family planning, and cervical cancer screening and treatment in Kenya; and for naloxone distribution and opioid overdose reversal in the United States. The main domains of adaptation have been technical-estimating denominators and structuring steps to be binary sequential steps-as well as logistical-identifying acceptable approaches for data abstraction and aggregation, and not overburdening HCW. DISCUSSION: CAT allows for prompt feedback to HCWs, increases HCW autonomy, and allows managers to allocate resources and time in an equitable manner. CAT is an effective, feasible, and acceptable implementation strategy to prioritize areas most requiring improvement within complex health systems, although adaptations are being currently evaluated.

Making Smarter Decisions Faster: Systems Engineering to Improve the Global Public Health Response to HIV.

PURPOSE OF REVIEW: This review offers an operational definition of systems engineering (SE) as applied to public health, reviews applications of SE in the field of HIV, and identifies opportunities and challenges of broader application of SE in global health. RECENT FINDINGS: SE involves the deliberate sequencing of three steps: diagnosing a problem, evaluating options using modeling or optimization, and providing actionable recommendations. SE includes diverse tools (from process improvement to mathematical modeling) applied to decisions at various levels (from local staffing decisions to planning national-level roll-out of new interventions). Contextual factors are crucial to effective decision-making, but there are gaps in understanding global decision-making processes. Integrating SE into pre-service training and translating SE tools to be more accessible could increase utilization of SE approaches in global health. SE is a promising, but under-recognized approach to improve public health response to HIV globally.

Scaling-up the Systems Analysis and Improvement Approach for prevention of mother-to-child HIV transmission in Mozambique (SAIA-SCALE): a stepped-wedge cluster randomized trial.

BACKGROUND: The introduction of option B+-rapid initiation of lifelong antiretroviral therapy regardless of disease status for HIV-infected pregnant and breastfeeding women-can dramatically reduce HIV transmission during pregnancy, birth, and breastfeeding. Despite significant investments to scale-up Option B+, results have been mixed, with high rates of loss to follow-up, sub-optimal viral suppression, continued pediatric HIV transmission, and HIV-associated maternal morbidity. The Systems Analysis and Improvement Approach (SAIA) cluster randomized trial demonstrated that a package of systems engineering tools improved flow through the prevention of mother-to-child HIV transmission (PMTCT) cascade. This five-step, facility-level intervention is designed to improve understanding of gaps (cascade analysis), guide identification and prioritization of low-cost workflow modifications (process mapping), and iteratively test and redesign these modifications (continuous quality improvement). This protocol describes a novel model for SAIA delivery (SAIA-SCALE) led by district nurse supervisors (rather than research nurses), and evaluation procedures, to serve as a foundation for national scale-up. METHODS: The SAIA-SCALE stepped wedge trial includes three implementation waves, each 12 months in duration. Districts are the unit of assignment, with four districts randomly assigned per wave, covering all 12 districts in Manica province, Mozambique. In each district, the three highest volume health facilities will receive the SAIA-SCALE intervention (totaling 36 intervention facilities). The RE-AIM framework will guide SAIA-SCALE's evaluation. Reach describes the proportion of clinics and population in Manica province reached, and sub-groups not reached. Effectiveness assesses impact on PMTCT process measures and patient-level outcomes. Adoption describes the proportion of districts/clinics adopting SAIA-SCALE, and determinants of adoption using the Organizational Readiness for Implementing Change (ORIC) tool. Implementation will identify SAIA-SCALE core elements and determinants of successful implementation using the Consolidated Framework for Implementation Research (CFIR). Maintenance describes the proportion of districts sustaining the intervention. We will also estimate the budget and program impact from the payer perspective for national scale-up. DISCUSSION: SAIA packages user-friendly systems engineering tools to guide decision-making by frontline health workers, and to identify low-cost, contextually appropriate PMTCT improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial is designed to test a model for national intervention scale-up. TRIAL REGISTRATION: ClinicalTrials.gov NCT03425136 (registered 02/06/2018).

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

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.

The true costs of participatory sanitation: Evidence from community-led total sanitation studies in Ghana and Ethiopia.

Evidence on sanitation and hygiene program costs is used for many purposes. The few studies that report costs use top-down costing methods that are inaccurate and inappropriate. Community-led total sanitation (CLTS) is a participatory behavior-change approach that presents difficulties for cost analysis. We used implementation tracking and bottom-up, activity-based costing to assess the process, program costs, and local investments for four CLTS interventions in Ghana and Ethiopia. Data collection included implementation checklists, surveys, and financial records review. Financial costs and value-of-time spent on CLTS by different actors were assessed. Results are disaggregated by intervention, cost category, actor, geographic area, and project month. The average household size was 4.0 people in Ghana, and 5.8 people in Ethiopia. The program cost of CLTS was $30.34-$81.56 per household targeted in Ghana, and $14.15-$19.21 in Ethiopia. Most program costs were from training for three of four interventions. Local investments ranged from $7.93-$22.36 per household targeted in Ghana, and $2.35-$3.41 in Ethiopia. This is the first study to present comprehensive, disaggregated costs of a sanitation and hygiene behavior-change intervention. The findings can be used to inform policy and finance decisions, plan program scale-up, perform cost-effectiveness and benefit studies, and compare different interventions. The costing method is applicable to other public health behavior-change programs.

Sustainability of community-led total sanitation outcomes: Evidence from Ethiopia and Ghana.

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.

Sustainability of community-led total sanitation outcomes: evidence from Ethiopia and Ghana

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 8­24 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.

Building capacity for water, sanitation, and hygiene programming: Training evaluation theory applied to CLTS management training in Kenya.

Training and capacity building are long established critical components of global water, sanitation, and hygiene (WaSH) policies, strategies, and programs. Expanding capacity building support for WaSH in developing countries is one of the targets of the Sustainable Development Goals. There are many training evaluation methods and tools available. However, training evaluations in WaSH have been infrequent, have often not utilized these methods and tools, and have lacked rigor. We developed a conceptual framework for evaluating training in WaSH by reviewing and adapting concepts from literature. Our framework includes three target outcomes: learning, individual performance, and improved programming; and two sets of influences: trainee and context factors. We applied the framework to evaluate a seven-month community-led total sanitation (CLTS) management training program delivered to 42 government officials in Kenya from September 2013 to May 2014. Trainees were given a pre-training questionnaire and were interviewed at two weeks and seven months after initial training. We qualitatively analyzed the data using our conceptual framework. The training program resulted in trainees learning the CLTS process and new skills, and improving their individual performance through application of advocacy, partnership, and supervision soft skills. The link from trainees' performance to improved programming was constrained by resource limitations and pre-existing rigidity of trainees' organizations. Training-over-time enhanced outcomes and enabled trainees to overcome constraints in their work. Training in soft skills is relevant to managing public health programs beyond WaSH. We make recommendations on how training programs can be targeted and adapted to improve outcomes. Our conceptual framework can be used as a tool both for planning and evaluating training programs in WaSH.

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

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.

Interpreting the Global Enteric Multicenter Study (GEMS) Findings on Sanitation, Hygiene, and Diarrhea.

In this Perspective on the GEMS study by Kelly Baker and colleagues, Jonny Crocker and Jamie Bartram consider the implications of associations found and not found between diarrheal disease and sanitation and hygiene.