The effect of two community-based interventions on sanitation and hygiene outcomes in rural Malawi: a controlled before-and-after (CBA) trial

IntroductionCommunity Led Total Sanitation (CLTS) has been used to increase sanitation coverage and use. However, robust evaluations of CLTS with and without other community-based interventions remain limited. We evaluated the effectiveness of standard CLTS and CLTS combined with a community-based "Care Group" model on sanitation and hygiene outcome compared to a non-intervention control in Chiradzulu District, rural Malawi. MethodsWe conducted a three-arm controlled before-and-after trial. One arm received standard CLTS, one received CLTS plus Care Group (CLTS+CG), and one served as control. Baseline and endline surveys were administered to 1,400 randomly sampled households. Difference-in-difference analysis assessed changes in sanitation and handwashing outcomes between May-June 2023 (baseline) and April-May 2024 (endline). ResultsAccess and use of sanitation facilities were generally high at baseline in all study arms. The primary outcome of the trial was access to a private sanitation facility of any quality. Both intervention arms were associated with improved odds of household having access to a private sanitation facility at endline compared to the control (CLTS: adjusted odds ratio [aOR] 3.11 (95% confidence interval [CI] 2.06-4.70); CLTS+CG: aOR 2.16 (CI 1.34-3.48)). However, there was no evidence that either intervention increased the odds of having a sanitation facility meeting quality standards for Sustainable Development Goals (SDG) 6. There was no observable difference between the two treatment arms on reported sanitation use. The odds of having a basic handwashing facility were higher in the CLTS+CG group versus control (aOR 2.62, CI 1.19-5.75) and CLTS+CG group versus standard CLTS group (aOR 2.89, CI 1.14-7.34); however, absolute increases in handwashing station coverage were limited. ConclusionThis study suggests that CLTS is unlikely to result in improvements in sanitation of quality required to meet SDG targets and has minimal impact on household level investment in hygiene facilities. Standard CLTS should no longer be the de facto rural sanitation policy.