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.

Improving water, sanitation, and hygiene in schools in Indonesia: A cross-sectional assessment on sustaining infrastructural and behavioral interventions.

Water, sanitation, and hygiene (WASH) in schools are important for child health, development, and educational performance; yet coverage in Indonesian schools remains low. To address this deficiency, UNICEF and partners conducted a WASH intervention in 450 schools across three provinces in Indonesia. A survey evaluating the sustainability of infrastructure and behavioral interventions in comparison to control districts was conducted one year after completion of the intervention. The survey data were also compared with national government data to assess the suitability of government data to report progress on the Sustainable Development Goals (SDGs). Logistic regression was used to explore associations between WASH conditions and behaviors. Intervention schools were more likely to have handwashing stations with soap and water. In multivariable analyses, schools with a toilet operation and maintenance fund were more likely to have functional toilets. Students who learn hygiene skills from their teachers were less likely to defecate openly, more likely to share hygiene knowledge with their parents, and more likely to wash their hands. Survey data were comparable with government data, suggesting that Indonesian government monitoring may be a reliable source of data to measure progress on the SDGs. This research generates important policy and practice findings for scaling up and sustaining WASH in schools and may help improve WASH in schools programs in other low-resource contexts.