Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial.

BACKGROUND: Community-led total sanitation (CLTS) uses participatory approaches to mobilise communities to build their own toilets and stop open defecation. Our aim was to undertake the first randomised trial of CLTS to assess its effect on child health in Koulikoro, Mali. METHODS: We did a cluster-randomised trial to assess a CLTS programme implemented by the Government of Mali. The study population included households in rural villages (clusters) from the Koulikoro district of Mali; every household had to have at least one child aged younger than 10 years. Villages were randomly assigned (1:1) with a computer-generated sequence by a study investigator to receive CLTS or no programme. Health outcomes included diarrhoea (primary outcome), height for age, weight for age, stunting, and underweight. Outcomes were measured 1·5 years after intervention delivery (2 years after enrolment) among children younger than 5 years. Participants were not masked to intervention assignment. The trial is registered with ClinicalTrials.gov, number NCT01900912. FINDINGS: We recruited participants between April 12, and June 23, 2011. We assigned 60 villages (2365 households) to receive the CLTS intervention and 61 villages (2167 households) to the control group. No differences were observed in terms of diarrhoeal prevalence among children in CLTS and control villages (706 [22%] of 3140 CLTS children vs 693 [24%] of 2872 control children; prevalence ratio [PR] 0·93, 95% CI 0·76-1·14). Access to private latrines was almost twice as high in intervention villages (1373 [65%] of 2120 vs 661 [35%] of 1911 households) and reported open defecation was reduced in female (198 [9%] of 2086 vs 608 [33%] of 1869 households) and in male (195 [10%] of 2004 vs 602 [33%] of 1813 households) adults. Children in CLTS villages were taller (0·18 increase in height-for-age Z score, 95% CI 0·03-0·32; 2415 children) and less likely to be stunted (35% vs 41%, PR 0·86, 95% CI 0·74-1·0) than children in control villages. 22% of children were underweight in CLTS compared with 26% in control villages (PR 0·88, 95% CI 0·71-1·08), and the difference in mean weight-for-age Z score was 0·09 (95% CI -0·04 to 0·22) between groups. In CLTS villages, younger children at enrolment (<2 years) showed greater improvements in height and weight than older children. INTERPRETATION: In villages that received a behavioural sanitation intervention with no monetary subsidies, diarrhoeal prevalence remained similar to control villages. However, access to toilets substantially increased and child growth improved, particularly in children <2 years. CLTS might have prevented growth faltering through pathways other than reducing diarrhoea. FUNDING: Bill & Melinda Gates Foundation.

Final report: impact evaluation of community-led total sanitation (CLTS) in rural Mali

Globally 2.5 billion people lack access to an improved sanitation facility; in Mali, only 15% of rural households use improved sanitation (JMP 2014). Community-led total sanitation (CLTS) uses participatory approaches to facilitate sustained behavior change to eliminate open defecation by mobilizing communities in order to achieve that goal. Although CLTS has been implemented in over 50 countries, there is a lack of rigorous and objective data on its outcomes in terms of sanitation and hygiene behavior, and on health impact such as diarrhea and child growth. This report covers the main findings of the impact evaluation of a community-led total sanitation (CLTS) campaign implemented by the government of Mali (Direction Nationale de l'Assainissement) with the technical and financial support of UNICEF. We conducted a cluster-randomized controlled trial among 121 villages randomly selected in the region of Koulikoro in order to evaluate health and non-health program impacts. Baseline data was collected during April-June 2011, the CLTS intervention program was implemented in 60 villages between September 2011 and June 2012, and follow-up data was collected in April-June 2013. A total of 4,532 households were enrolled at baseline and 5,206 were visited at follow up; 89% of baseline households (N=4,031) were successfully matched to a household at follow up. The primary outcomes and impacts presented in this report are reported for those households present at both baseline and follow up. The CLTS campaign was highly successful in increasing access to private latrines, improving the quality of latrines, and reducing self-reported open defecation. Access to a private latrine almost doubled among households in CLTS villages (coverage increased to 65% in CLTS villages compared to 35% in control villages). Self-reported open defecation rates fell by 70% among adult women and men, by 46% among older children (age 5-10), and by 50% among children under five. Children too young to use latrines were also more likely to use a child potty in CLTS villages. The program also increased perceived privacy and safety during defecation among women. These results were sustained over time. Observations by field staff support respondent-reported reductions in open defecation, use of cleaner latrines, and improved hygiene in CLTS villages. Latrines in the CLTS households were 3 times more likely to have soap present (PR: 3.17, 95% CI: 2.18-4.61) and 5 times more likely to have water present (PR: 5.3, 95% CI: 3.49-8.05). Latrines at CLTS households were more than twice as likely to have a cover over the hole of the pit (PR: 2.78, 95% CI: 2.24-3.44), and 31% less likely to have flies observed inside the latrine (PR: 0.79, 95% CI: 0.68-0.93). CLTS households were also half as likely to have piles of human feces observed in the courtyard (PR: 0.54, 95% CI: 0.37-0.79). Statistically significant impacts on child diarrheal or respiratory illness were not observed among children under five years of age when analyzing follow-up data only. It should be noted that even though randomization occurred after baseline data collection was complete and socio-economic characteristics were balanced across groups, most symptoms of diarrheal and respiratory illness were more prevalent in CLTS villages at baseline.