How Has Urban Community Led Total Sanitation (U-CLTS) Affected Open Defecation in Urban Communities in the Tamale Metropolis

doi:10.21203/rs.3.rs-1567032/v1

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Research Article

How Has Urban Community Led Total Sanitation (U-CLTS) Affected Open Defecation in Urban Communities in the Tamale Metropolis

https://doi.org/10.21203/rs.3.rs-1567032/v1

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The study assessed the impact of Urban Community-Led Total Sanitation (U-CLTS) on open defecation in Tamale Metropolis. The objectives of the study were to assess frequency and reasons for open defecation and to assess the factors that influence the implementation of community-led total sanitation in the Tamale Metropolis. The study obtained data from 398 landlords and interviewed some officers of Civil Society Organisations (CSOs) and United Nations International Children Education Fund (UNICEF), some Opinion Leaders and Landlords. The study used structural equation model to determine the factors that influence implementation of U-CLTS at each stage. T-test was also used to determine the effect of U-CLTS programme on open defecation. Interview responses were also transcribed to complement the inferential analysis. The findings indicated that reasons for frequent open defecation before CLTS include poor maintenance of public and private latrines, financial hardship and social norms problems. The study also found that CLTS has significantly reduced open defecation in the Tamale Metropolis. Policy environment, community participation and implementation quality significantly affected effective implementation of U-CLTS. The study recommends that CLTS should be scaled-up in other communities where open defection is rampant.

City Management and Urban Policy

Community-Led Total Sanitation

Open Defecation

urban Communities

The world’s cities continue to experience rapid population growth. However, governmental agencies are not able to provide adequate infrastructure to meet to the waste generation of the growing population (Tukahirwa et al, 2010). This phenomenon has resulted in sanitation problem in many urban communities in particular. The provision of facilities and services for the safe disposal of human urine and faeces is referred to as sanitation in general. According to WaterAid (2011), Sanitation denotes the proper management of human excreta from the point of discharge to its disposal, treatment or reuse. Sanitation in the urban environment is broader than just human excreta; it involves the management of waste (solid), grey water and surface drainage. In broader sense, sanitation is more than just physical infrastructure; it includes policies, management and legal frameworks and investments which serve as catalyst to achieving sanitation for all.

Sanitation in Ghana in general has deteriorated leading to Ghana being ranked as the 7th worst performing country in the world with regards to poor sanitation WHO/UNICEF (2015). According to the Ghana Statistical Service Multiple Indicator Cluster Survey 2017/18 report, 11.4% and 30.6% of Ghanaian population practice open defecation in bushes, gutters and other unapproved places in urban and rural areas respectively (Multiple Indicator Cluster Survey, 2018). Governments over the years have attempted to address sanitation problems in Ghana. Most initiatives aimed at reducing this canker, on the other hand, are frequently executed without input or engagement from stakeholders and recipients. (Rosemarin et al, 2008). In the recent times, new strategy to dealing with the sanitation problem has been propounded. This new approach is termed as Community Led Total Sanitation ((Ekong, 2015).

Community-Led Total Sanitation (CLTS) concentrates on eliminating open defecation in rural, and now urban areas of low- and middle-income countries. CLTS basically is a behaviour change approach that focuses on community action instead of individual households. CLTS works best when there is the involvement of the entire community to achieve a common goal of open defecation free status. It employs series of participatory activities which are led by local facilitators in triggering processes, community members are enrolled in the process and natural leaders would emerge as role models for the community. CLTS employs tools that evoke strong feelings of shame and disgust to trigger people to start latrine construction processes and originally does not offer hardware subsidies (Kar & Chambers, 2018).

UNICEF is assisting Ghana's government in implementing and refining a national approach to rural sanitation; however, there is no clear national response to urban issues. As a result, UNICEF is assisting the Ghanaian government in developing a model for expanding urban poor access to improved sanitation and hygiene practices. This entails increasing access to improved household sanitation in urban communities through an appropriate demand creation/behaviour change approach, sanitation marketing (which addresses the supply side to meet the demand) and the development of social norms. The approach used by UNICEF is consistent with CLTS.

Tamale Metropolis is among the few CLTS beneficiaries which have been implemented since 2016. Similarly, Ghana adopted the Community Led Total Sanitation (CLTS) approach, developed by Kamal Kar to address the issue of sanitation and hygiene across the country in 2010. This was due to the pressing need not to miss the MDG sanitation demand in the country (Stephen, 2012). With majority of Ghanaians exposed to defecating in the open in both urban and rural areas, the CLTS approach appears fit for the task given that it tackles open defecation in community-wide manner. CLTS is gaining acceptance in Ghana because of its contributions to eradication of open defecation in other countries (Venkataramanan et al., 2018).

For example, Alzua et al (2015) did an assessment of the impact of Community Led Total Sanitation in non-urban communities in Mali which revealed a very significant expansion in access to household latrines (nearly a double in CLTS communities), quality of latrines improved, and significant reduction in open defecation practices. Also, Crocker et al (2016) conducted an assessment of Community-Led Total Sanitation in Ethiopia and found that overall, open defecation fell by 15.3 percentage points, but did not alter in areas where open defecation was less than 30%. Overall, the percentage of people who own a latrine with a stable floor climbed by 8.7%. Yeboah-Antwi et al (2019) evaluated the impact of Zambia Sanitation and Hygiene Program (ZSHP) in randomly selected households and found that in Zambia, the introduction of Community Led Total Sanitation enhanced access to improved sanitation facilities, reduced open defecation, and improved hand washing behaviours.

Even though, remarkable achievements have been made in other countries where the approach was adopted to address their sanitation challenges, same cannot be said about Ghana; thus, the need to assess the effects of CLTS on basic sanitation in the urban communities. The study was therefore carried out to assess frequency and reasons for open defecation and to determine the factors that influence effective implementation of Community Led Total Sanitation in the Tamale Metropolis.

2.1. Theory of Social Learning

Social learning theory is concerned with learning that occurs in a social setting. Albert Bandura is the most well-known proponent of this hypothesis. According to Kearsley (1994), Bandura's social learning theory "emphasizes the importance of seeing and modelling the behaviours, attitudes, and emotional reactions of others." Kearsley goes on to say that moral judgments about right and wrong can be developed in part through modelling. According to Bandura's (1977) theory, learning would be extremely difficult, if not impossible, if people had to rely entirely on the consequences of their own actions to instruct them what to do. Fortunately, the majority of human behaviour is learned by observation and modelling: by observing others, one can learn how new behaviours are performed, and this coded information can then be used as a guide for action.

According to the social learning hypothesis, behavioural processes are directly learnt through the constantly dynamic interplay between the individual and their social environment (Mc Connell, 2008). By studying a role model, a person can learn new reactions, how to carry out or avoid previously taught responses and how to learn a general rule that can be applied to a number of scenarios (Rosenthals & Zimmerman, 2009). Modelling can be used to learn a variety of actions, at least in part. Children, for example, learn what to do at home by witnessing their siblings fight with their parents or throw rubbish around the house.

Reinforcement and punishment are used to aid in the learning process. Any occurrence that improves the likelihood of a reaction occurring again is referred to as reinforcement (Coon, 2011). When a child is rewarded with a sweet for doing something positive, such as appropriately utilizing the toilet seat, the child is more likely to repeat the behaviour. The candy serves as a form of reinforcement. The observer is also automatically reinforced by the candy. For example, in order to be accepted by a group of colleagues, a youngster can modify his or her way of dressing or begin to exercise simple personal cleanliness such as cutting finger nails and brushing teeth without any external reinforcement. Intrinsic reinforcement, as defined by Bandura (1977), is a type of internal reward that includes feelings of pride, contentment, and accomplishment. Punishment is any occurrence that occurs as a result of a reaction and reduces the likelihood of it happening again (Bandura et al, 1980). If a child gets caned for not washing his hands before eating, he is less likely to repeat the behaviour, and caning becomes a penalty. Health habits are picked up in one's most influential learning environment, the home, and from one's most powerful role models, the parents. As a result, the manner in which the parents behave in the home has a substantial impact on the sanitation conditions that prevail. For the household to acquire the skills essential to maintain health-promoting behaviour, social learning is required. The majority of our daily activities are picked up in the home. Individuals develop behaviour patterns as early as childhood by studying their parents and then their siblings. Therefore, based on this theory, individuals learn new attitudes and behaviour towards sanitation from other individuals within the society or outside the society (Agbola, 2012), thereby helping to reduce sanitation problem

2.1.1 Conceptual Framework

The researchers developed a conceptual framework to guide the study. The conceptual framework was developed from the Theory of Social Learning.

From the Theory of Social Learning, individuals learn from each other in other to change their lives for a better. Community Led Total Sanitation is meant to change the negative behaviour of individuals toward sanitation. However, the effectiveness of community led total sanitation in a community such as Tamale Metropolis is influenced by many factors policy environment, implementation quality, administrative context, community environment, community capacity, community participation and community behaviour. Effective implementation of community led total sanitation programme would be able to inculcate into individuals’ positive attitudes towards sanitation, thereby eliminating the occurrence of open defecation and indiscriminate disposal of refuse.

2.2 Literature Review

2.2.1 The Problem of Open Defecation

Open defecation can be explained as the practice of defecating in the open spaces, waterways without any proper disposal of human excreta (Boschi-Pinto et al., 2009; Jones et al., 2012). Open defecation can also be seen as human practice of defecating in the open rather than into the toilet. This is where human faeces are disposed off in the fields, forests, bushes, and open bodies of water, beaches, and other open spaces (WHO/UNICEF, 2013). Defecating in the open is an old practice. In ancient times, there were availability of spaces and limited population pressure on the use of land. It was perceived that defecating in the open spaces causes little harm on people. But, with development and urbanization, open defecating started becoming an issue of public health and human dignity (Reilly and Kathleen, 2016).

Many Ghanaian communities lack access to appropriate sanitation. According to a 2005 report by the Ghana Water Sector Restructuring Secretariat (WSRS), around 40% of the population in urban areas and 35% in rural areas have access to improved toilet facilities. The country has also been performing poorly, with only 15% of the population having access to sanitation, making open defecation a major sanitation issue because people lack access to basic facilities (Coffey and Spears, 2014). Ghana's open defecation problem is worrying, and the country was ranked second in Africa for open defecation behind Sudan, with five million Ghanaians lacking access to a toilet facility. Compound houses, rather than self-contained residences, are preferred by 60.6 percent of Ghanaians.

Open defecation creates many problems such as diarrhoea which is the third most common disease in the communities due to the continuous practice of open defecation; Cholera, diarrhoea, typhoid, and dysentery are among the diseases troubling people in the communities which affect the health and wellbeing of the people (Ghana Statistical Service, 2013). WHO reports that 1.8 million people in low and middle-income countries suffer from severe trachoma (WHO/UNICEF, 2017); a root cause of visual impairment which is transmitted via flies that breed on human excreta with a tendency to spread through eye discharge of infected persons. Likewise, more than 200 million people are infected with schistosomiasis (snail fever) worldwide (WHO/UNICEF, 2017); a chronic parasitic disease transmitted through human faeces to freshwater snails and the infection spread in humans when the skin comes in contact with infection carrying snails or consumption of contaminated water and modulate their immune systems (Colley et al., 2014). Improved sanitation interventions can play a constructive role in disease prevention, including diarrhea and soil-transmitted infections (Ziegelbauer et al., 2012).

2.2.2 Empirical Review

2.2.2.1 Community-Led Total Sanitation and Open Defecation

Venkataramanan et al. (2018) in their study “Community-Led Total Sanitation: A Mixed-Methods Systematic Review of Evidence and Its Quality” sought to summarise CLTS impacts and also identify factors affecting implementation and effectiveness. The study found that 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. Adaptability, planned post-triggering activities, proper community selection, and more research on combining and sequencing CLTS with other interventions were all found to be important in the study.

Crocker and Bartram (2017) conducted a study in Ethiopia and Ghana to assess the long-term viability of community-led total sanitation (CLTS) outcomes. The study surveyed 3831 homes one year after the implementation ended and examined latrine use and quality to measure post-intervention changes in sanitation outcomes. One of the four interventions assessed (health extension worker-facilitated CLTS in Ethiopia) resulted in an 8 percentage point rise in open defecation a year after implementation ceased, casting doubt on our previous conclusions. The early reductions in open defecation of 8–24 percentage points were sustained in the other three interventions, with no significant changes happening a year following introduction. Ethiopian latrines were, on average, of lesser quality than those in Ghana.

Lawrence et al. (2016) adopted a qualitative study explored community members' and stakeholders' sanitation, knowledge, perceptions, and behaviours during early CLTS implementation in Zambia. The study conducted 67 in-depth interviews and 24 focus group discussions in six districts in Zambia 12–18 months after CLTS implementation. Triggering activities elicited strong emotions, including shame, disgust, and peer pressure, which persuaded individuals and families to build and use latrines and handwashing stations. New sanitation behaviours were also encouraged by the hierarchical influences of traditional leaders and sanitation action groups and by children's opinions. Poor soil conditions were identified as barriers to latrine construction. Taboos, including prohibition of different generations of family members, in-laws, and opposite genders from using the same toilet, were barriers for using sanitation facilities. CLTS, through community empowerment and ownership, produced powerful responses that encouraged construction and use of latrines and hand washing practices

In "Teachers and Sanitation Promotion: An Assessment of Community-Led Total Sanitation in Ethiopia," Crocker et al. (2016) used a quasi-experimental study design to compare two interventions in Ethiopia: traditional CLTS in which health workers and local leaders provided facilitation and an alternative approach in which teachers provided facilitation. Surveys and interviews were used to look at the differences between the interventions. The reduction in open defecation associated with teacher-facilitated CLTS was 8.2 percentage points lower (p = 0.048) than that associated with traditional CLTS. Teachers had multiple responsibilities and lacked assistance from local officials at first, which may have hampered their success. Teachers may be better suited to a supporting rather than a leading position in sanitation promotion because they have demonstrated their ability and commitment.

Brian et al (2018) conducted a study titled “A Cluster-Randomized Trial to Evaluate the Impact of an Inclusive, Community-Led Total Sanitation Intervention on Sanitation Access for People with Disabilities in Malawi”. The study evaluated an intervention to improve inclusion of people with disability in CLTS through training facilitators. The trial included 171 people with disabilities (78 control and 93 intervention) living in 15 intervention and 15 control communities. The study found that Inclusive CLTS could improve sanitation access for people with disability but requires support to households beyond that provided in this trial.

A study by Radin et al (2020) titled “Benefit–Cost Analysis of Community-Led Total Sanitation: Incorporating Results from Recent Evaluations” found that CLTS interventions would pass a benefit–cost test in many situations, but that outcomes are not as favourable as some previous studies suggest. The model results are sensitive to baseline conditions, including the value of time, income level used to calculate the value of a statistical life, discount rate, case fatality rate, diarrhoea incidence, and time spent traveling to defecation sites. We conclude that many communities likely have economic investment opportunities that are more attractive than CLTS.

Crocker et al (2016) also in “Building capacity for water, sanitation, and hygiene programming: Training evaluation theory applied to CLTS management training in Kenya” developed a conceptual framework for evaluating training in WaSH by reviewing and adapting concepts from literature. The study found that 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.

Another study by Basiru et al (2018) titled “Barriers to Accessing Sanitation Facilities in Aboabo, Ghana” sought to identify and discuss the specific factors that impede access to sanitation facilities in Aboabo urban slum in the Asokore-Mampong Municipal Area of Ghana. A qualitative approach was employed for the study. Findings from the study suggested that, inadequate income to acquire private household toilet facilities, inadequate space in the homes for toilets, high user fees to use public toilets, low level of education and unhygienic toilet facilities were identified as obstacles preventing access to sanitation facilities in the urban slum.

3.1 Research Approach and Design

The mixed method approach was used for this study. Creswell (2009) argued that mixed method approach is not committed to any one system of worldview or paradigm. Therefore, based on the approach, the researcher could use different forms of data collection and analysis to address the impact of the Urban Community Led Total Sanitation (U-CLTS) on eradicating open defecation in urban communities in the tamale metropolis. This study also adopted both descriptive and case study research design based on the research approach. According to Nancy and Grove (2001), descriptive research design is done to present the true picture of a phenomenon as it occurs. For Kothari (2014), descriptive research design helps to accurately portray the characteristics of persons, situations or groups. Thus, this type of survey is concerned with investigating existing phenomena and answering research questions on the subject matter. With this research design, the behaviour of the study’s participants are described, their behaviour towards open defecation before and after Urban Community Led Total Sanitation (U-CLTS) are described. The descriptive research design seeks in-depth knowledge of existing phenomenon and permit generalizations based on exact description of activities and conditions or relationship such as prevailing conditions, practices and attitudes (Best & Khan, 2015).

3.2 Target Population

The population consists of all constituents that meet a certain criterion to be included in a study (Burns & Grove 2003). The study targeted four groups as the population of the study. They were landlords, opinion leaders (Assembly member and Chief (s) in the project community), Civil Society Organizations in the area and officials of UNCEF. The metropolis has about 56 electoral areas, comprising of 31 urban electoral areas and 25 rural electoral areas (Electoral Commission of Ghana, 2020). However, the programme is being implemented in the 31 urban electoral areas. The landlords in the 31 urban electoral areas, according to the Ghana Statistical Service (2010) is about 79,600.

A sample size is defined as an identified group selected from a population with the purpose of obtaining information from the group to make generalization (Fraenkel et al., 2012). In simple language, it is a sub-set of a population. Even though the researcher would have wished to cover all the units in the population to make the study more representatives, it was not possible to do so considering logistical and time constraints. This study therefore adopted a formula by Saunders et al. (2007) in Eq. 1, to determine the sample size of the landlords in the 31 urban electoral areas as follows;

n = N/1 + N (a)² ………………………………………………………………equation 1

Where n = Sample size; N = Population; and α = margin of error (0.05).

Based on the formula, the sample size of the landlords in the 31 urban electoral areas is calculated as follows;

n = 79,600/1 + 79600*0.05² = 398 landlords

Aside, the landlords who formed the main respondents of the study, the researchers also sampled opinion leaders, officers of CSOs and UNICEF for interview.

3.2.1 Sampling Procedure

The study employed two main sampling techniques and these were purposive and convenience sampling techniques. Purposive sampling helps to sample informants with a specific type of knowledge or skill regarding the issue under investigation (Bah et al 2016). The Tamale Metropolis was purposively selected for the study. As indicated already, Tamale Metropolis is an urban community and “Urban Community Led Total Sanitation (U-CLTS) is being implemented in the metropolis. The metropolis was also noted for open defecation by some community members. Thus, Tamale Metropolis, is a good representation of metropolis and districts that have benefited from U-CLTS programme. Within the Metropolis, the study purposively selected individuals who have in-depth knowledge about U-CLTS and sanitation. The individuals were landlords. The study further sampled opinion leaders (Assembly member and Chief (s)), Civil Society Organizations (CSOs) and officials of UNICEF in the Tamale Metropolis since these groups of people are directly involved sanitation management in the study area.

After identifying the target groups, the study used convenience sampling technique to select respondents from each group. Convenience sampling is where a researcher has a study population in mind (Henn et al., 2015). Convenience sampling uses criteria such as willingness to participate in a study, proximity and availability of data or individuals as respondents (Babbie, 2010). This study used proximity and willingness to participate in a study as a criterion to sample the landlords from the 31 urban electoral areas in the Tamale Metropolis. The study conveniently sampled between 12 and 13 landlords from each of the 31 urban electoral areas. This was done to minimize the possibility of sampling far higher number of landlords from one or few electoral areas at the expense of others. The study further conveniently sampled 2 opinion leaders, 2 officers of Civil Society Organization and 2 officers of UNICEF in the Tamale Metropolis.

3.3 Data Collection Instruments

The study used two data collection instruments and these were questionnaire and interview guide. Questionnaire is mostly used in research due to its advantages over other instruments. Questionnaire helps to gather data quickly at a cheaper administration cost (Bryman, 2014). This is because the researcher does not necessarily need to be present for respondents to provide their responses or the questions have predetermined responses from which respondents choose responses. This study employed questionnaire also because it helps to gather standardized information for the same variable(s) from every respondent (Kothari, 204). In view of the advantages of questionnaire administration, it was used to gather data from landlords who were the main respondents in this study since the study was about them for which reason they had a large sample size.

The questionnaire was divided into four parts: A, B and C. Part A was about the personal information and covered sex, age, marital status, educational level and household size. Part B focused on factors that influence the implementation of U-CLTS programme and this part has seven sub-headings, namely policy environment, implementation quality, administrative context, community environment, community capacity, community participation and community behaviour. Part C focused on reasons for open defecation.

Two Field Assistants were employed to help in the questionnaire administration. The Field Assistants were trained to understand the purpose of the study, actual meaning of the questions and how to handle the questionnaires. To avoid waste of time and energy, the respondents were encouraged to fill in the questionnaires in the presence of Field Assistants. The purpose of this was to ensure high response rate and to assist respondents who could not read or write to fill in their questionnaires. In most cases when questionnaires are left with respondents, the response rate is low since some do not return them. More so, not all respondents could read or write and even some had never been to school, hence there was the need for Field Assistants to guide them to fill in their questionnaires. In a situation where a respondent could not speak English, discussion was held in their local language with the assistance of an interpreter of their choice. The questionnaire administration was done in the homes of the respondents. Though the questionnaire administration was time consuming, at the end of the questionnaire administration, 398 landlords had clearly and completely filled in their questionnaires.

Interviewing is a method of data collection in research where an interviewer asks questions while an interviewee responds directly. This instrument allows respondents to express their views, beliefs, practices and concerns (Freebody, 2015). Interviewing has a number of advantages. Interviewing offers the opportunity for both interviewee and interviewer to seek for clarification. Interview makes it possible to check on the reliability of responses by asking the same question differently and at different stages of the interview (Freebody, 2015).

This study used interview to collect data from a number of stakeholders in U-CLTS in the Tamale Metropolis. The groups considered for interviews were UNICEF, Opinion Leaders (Chiefs and Assembly Members) and Civil Society Organizations. The study was guided by Bryman’s (2014, pg. 38) advice on the use of interviewing in data collection. The advice included developing interview guides, avoiding double barrelled questions, identification of possible interview themes, identification of respondents, selecting mode of recording interview, seeking permission for interview and selecting interview time. The study officially sought permission from the key stakeholders to inform them of the study and to request interview with them. The date of interview for each institution was scheduled and a day before each interview, the researcher made a call to remind each institution of their meetings and to confirm if they would be able to grant him the interview. All confirmed their preparedness for the meeting. The interview with each participant lasted for not more than one hour. The participants were informed the purpose of the interview and the extent of their engagement. The researchers explained to the participants that the interview was for the purpose of academic research only and they were assured of strict confidentiality. Upon the consent of interviewees, the researchers recorded the interviews with their mobile phone. This was to facilitate the free flow of interview and to avoid time wasting by writing the responses manually during the interview. The interviews were conducted by the researchers and they thanked the interviewees and their respective institutions for their cooperation.

3.4 Reliability and Validity of Instruments

The researchers ensured that the questionnaire and interview guides were reliable and valid. Seidu (2011) defined reliability as the consistency of instruments providing results. However, validity is when research instrument measures what it is intended to measure (Cohen, Manin & Morrison, 2003). Seidu (2011) indicated that reliability and validity are inevitable in scientific research such as this current thesis. To ensure reliability of the questionnaire and interview, the study pre-tested the questionnaire on the 20 landlords and interview guide on 2 opinion leaders. The pre-test was done on 10th July, 2021. After the pre-test test, the study performed reliability test for responses obtained from the questionnaire, using Cronbach’s Alpha (α). According to Cronbach (1959, Cronbach's Alpha of at least 0.7 (ie α = 0.7), gives an indication that the instrument is reliable. The overall Cronbach’s Alpha scored obtained for the pre-test data from questionnaire was 0.891, indicating the questionnaire as a wholes was reliable.

Furtherance, this study used content validity to ensure that the questionnaire and the interview guide were valid. Content validity shows that the questionnaire and interview adequately covered the scope of the study as per its specific objectives. To ensure content validity of the instruments, the researchers sought expert opinions from Civil Society Organizations into sanitation, Environmental health and Sanitation Directorate in Tamale. They all offered opinions on the structure of questioning and content of the questionnaire and interview guide and these helped to know the right questions to ask as per each research objective.

3.5 Data Analysis

The data from the questionnaire were examined, cleansed, organised and coded and entered into statistical package for social sciences (SPSS), version 21.0. Questionnaire data was analysed using inferential statistics. The analysis were done based on data from structured questionnaire and interview guides. The analysis of the data from questionnaire were done both descriptively and econometrically. This study employed mean and standard deviations to analyze the factors that influence U-CLTS success, and participants engagement in open defecation and the reasons behind such a practice in the Tamale Metropolis. The mean scores were interpreted as shown in Table 1.

Table 1

Decision Rule for Likert Scale Responses
WA range	Likert Scale	Decision rule
1.00-1.49	Strongly disagree	disagreement
1.50–2.49	Disagree	Disagreement
2.50–3.49	Neutral	Disagreement
3.50–4.49	Agree	Agreement
4.50-5.00	Strongly agree	Agreement
Source: Authors’ Construct (2021)

3.5.1 Econometric Analysis

This study employed structure equation model (SEM) to estimate the effect of selected factors of U-CLTS on the successes of U-CLTS at each stage of U-CLTS implementation. SEM involves the construction of a model, an informative representation of some observable or theoretical phenomenon. In this model, different factors are theorized to be related to successes of U-CLTS with a structure. The structure implies statistical and often causal relationships between variables, error terms and can include multiple equations. This study further used t-test to estimate the effect of U-CLTS on open defecation. The study had two period. Period before and after the U-CLTS programmes in the Tamale Metropolis.

3.5.2 Interview Data

The researchers transcribed the interview in English Language and used the relevant information as a supplement to data from questionnaire that is using direct quotes from respondents.

3.6 Ethical Considerations

As part of the researchers’ responsibility, they ensured that the rights and general well-being of the participants were highly protected, regardless of their sex, class etc. The researchers duly followed the codes of practice in research which provide guidelines that reinforce the basic principles of both human rights and ethics; with the aspects being legally enforceable, this has been confirmed by the work of (Torabinejad et al., 1985). Ethical issues were addressed when we sought consent and made sure participants understood the instruments before responding to them. Truthfulness is also central to obtaining informed consent since, without this, participants cannot exert their right to informed consent, justice or fairness, Adequate measures were also taken, privacy and confidentiality were highly upheld in order not to bridge the Data Protection Act 1998.

4.1 Engagement in Open Defecation

The study sought to find out from the study participants the extent to which people engage in open defecation in their communities. The study employed five-point likert scale responses, ranging from rarely (1) to most frequently (5). The responses given were summarized and presented in Table 2

Table 2

Extent of Engagement in Open Defecation
Period	N	Min.	Max.	Mean	Std. Dev
Before U-CLTS	398	1	5	4.3342	0.47229
After U-CLTS	398	1	5	1.6834	0.66224
Source: Field Data (2021)

Some of the respondents indicated as captured in Table 2 that people always defecated openly and some of the respondents also indicated that people never defecated openly. This does show that each of the respondents had his or her own perception about frequency of open defecation in the communities. Moreover, it was indicated in Table 2 that majority (Mean = 4.3342: Std. dev. =0.47229) of the respondents perceived open defecation to be very frequent before the implementation of the community-led total sanitation in Tamale Metropolis. However, after the implementation of community-led total sanitation in Tamale Metropolis, most (Mean = 1.6834: Std. dev = 0.66224) of the respondents indicate that open defecation was not frequent.

4.2 Reasons for Open Defecation

This section focused on the reasons why people engage in open defecation. The study listed several factors or reasons based on literature as asked the respondents to indicate their extent of agreement or disagreement for each. The responses were summarized and presented in Table 3.

Table 3

Reasons for Open Defecation
Reasons	Mean	Std. dev.	Ranking	Implications /Decision
Financial challenge	3.9214	1.6292	2nd	Very important reason
Lack of proper maintenance of toilet facilities	4.1384	0.32631	1st	Very important reason
Social norms	3.5793	1.4728	3rd	Very important reason
Religion (dominance of Islamic region)	1.2375	1.8593	4th	Not a reason
Source: Field Data (2021)

The results in Table 3 shows that the important reasons cited for open defecation in the study area include (in order of importance) lack of proper maintenance of toilet facility (both private and public toilet facilities), financial challenges and social norms where open defecation has been a common practice or behaviour among majority of people. During the interview of the interview participants who were Landlords indicated as stated below;

“The construction toilet facility requires huge sums of money and this is high for many people in the is community. People often say they cannot conceive sleeping in thatched-roof huts and on the other hand build latrines with cement and reinforcing steel just to defecate. Thus, they give less importance to the latrines than to other facilities and do not want to invest in latrine” (Key Informant, Male, Landlord, 46 years of age)

Another participant attributed open defecation to superstition:

“During the night, many spirit come out to harm many people. It is even possible for a witch to disguise as a maggot. As a result, anybody who attends communal toilets can contract spiritual marriages as one exposes his/her private organs and may never be able to marry again” (Key Informant, Female, Caretaker, 31 years of age).

The findings are consistent with reasons for open defecation cited by Boschi-Pinto et al., (2009) and Jones et al., (2012). For example, Connell (2014) noted that open defecation is described as traditional, habitual, and part of one’s daily routine, and these social norms are also held more strongly by open defecators. For example, In Tanzania, 40 percent of all respondents agree or strongly agree that “it is normal for people to defecate in the open in their community.” In one area surveyed, as many as 80 percent of respondents agreed or strongly agreed with social norm as a reason for open defecation (Connell, 2014). The results agrees with (Reilly and Kathleen, 2016) that open defecation causes little harm to people with the rise in urbanisation

4.3 Estimating the Factors Influencing Success of U-CLTS Implementation

The study employed Structural Equation Model (SEM) to estimate the factors that influence the success of the U-CLTS programme in the Tamale Metropolis. The SEM results are shown in Fig. 2 and Table 4.

Table 4

**Factors Influencing the Successes of U-CLTS at Each Stage** able 16:
Factors	Model 1 (Pre-triggering Success	Model 2 (Triggering Success)	Model 3 (Post-Triggering Success)
Policy environment	0.7342 (0.1245)***	0.4351 (0.1213)***	0.3878 (0.0759)***
Implementation quality	1.3390 (0.1534)***	1.3411 (0.1494)***	1.6289 (0.0935)***
Administrative capacity	-0.2279 (0.15517)	0.4108 (0.1477)**	-0.0183 (0.0924)
Community governance	-0.2157 (0.6067)***	-0.2000 (0.0591)**	-0.0074 (0.0369)
Community capacity	-0.04126 (0.1294)	-0.3248 (0.1261)**	-0.9384 (0.7887)***
Community participation	0.5005 (0.1035)**	0.5593 (0.1008)***	0.02950 (0.0631)***
Community behaviour	-0.04459 (0.0892)	-0.1087 (0.086)	0.4236 (0.0544)***
Constant	-0.0724 (0.0885)	0.0301 (0.8626)	-0.0207 (0.0540)***
Source: Field Data (2021) Significant at 5%; *Significant at 1%;

From Fig. 2 and Table 4, policy environment, implementation quality and community participation significantly improved the pre-triggering, triggering and post-triggering successes. However, administrative capacity significantly improved the triggering success but did not significantly affect the pre-triggering and post-triggering successes. Community governance significantly undermined the pre-triggering and triggering successes but did not significantly affect the post-triggering success. Community capacity significantly undermined the triggering and post-triggering successes but did not significantly affect pre-triggering success. Community behaviour significantly improved the post-triggering success but did not significantly affect pre-triggering and triggering successes.

4.4 Conclusion and Recommendation

This study investigated the effect of U-CLTS on open defecation in the Tamale Metropolis. Through rigorous analysis, this study concludes that U-CLTS has been successful in the Tamale Metropolis. However, not all the recommended factors for implementation U-CLTS in literature helped to improve the success of U-CLTS. Those factors that have helped to improve U-CLTS in all the stages are policy environment, implementation quality and community participation. Though open defecation was frequent, U-CLTS has helped to significantly reduce open defecation in the Tamale Metropolis. This was possible through construction of latrine in homes by landlords who did not have one and instilling positive attitude into people by change changing the social norms of the people.

The study based on the research findings recommends that the facilitators must focus on changing the negative social norms of people in the Tamale Metropolis. The stakeholder of U-CLTS must pay much attention to policy environment, implementation quality and community participation even at the post-triggering stage since these factors can help sustain the success of the programme with regard to ending open defecation. The implementers of U-CLTS should consider providing funding on credit to landlords who are in financial need to help achieve one latrine for every house. The funding should have lowest interest rate as compared to prevailing interest rate on loan in Ghana. Community education and engagement should be on-going even during the post-triggering stage. This will help to sustain the successes of the U-CLTS in the communities of Tamale Metropolis. U-CLTS should be scaled-up in other urban communities where open defecation is a common phenomenon. This will help achieve clean environment and improved health in the Tamale Metropolis and in Ghana as a whole.

Acknowledgement

Authors recognise the contribution of all participants in the Tamale Metropolis who provided responses to all the questions during the data collection process. The authors also acknowledged all scholars who research works provided the basis for literature review for this study.

Funding

Authors did not receive any funding to undertake this study.

Competing interest

Authors declare no competing interest

Ethical approval

The ethical issues were seriously taken into consideration in the course of conducting this research. Participants were provided with consent form to fill voluntarily and anybody who decided not to be part of the study was not coerced to do so. Anonymity and confidentiality of information given by participants was also duly ensured.

Conflict of Interest

Authors declare no conflict of interest

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How Has Urban Community Led Total Sanitation (U-CLTS) Affected Open Defecation in Urban Communities in the Tamale Metropolis

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Abstract

Figures

1.0 Introduction

2.0. Theoretical Framework

2.1. Theory of Social Learning

2.1.1 Conceptual Framework

2.2 Literature Review

2.2.1 The Problem of Open Defecation

2.2.2 Empirical Review

2.2.2.1 Community-Led Total Sanitation and Open Defecation

3.0 Materials And Methods

3.1 Research Approach and Design

3.2 Target Population

3.2.1 Sampling Procedure

3.3 Data Collection Instruments

3.4 Reliability and Validity of Instruments

3.5 Data Analysis

3.5.1 Econometric Analysis

3.5.2 Interview Data

3.6 Ethical Considerations

4.0 Results And Discussions

4.1 Engagement in Open Defecation

4.2 Reasons for Open Defecation

4.3 Estimating the Factors Influencing Success of U-CLTS Implementation

4.4 Conclusion and Recommendation

Declarations

References

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