This study was conducted to evaluate the effectiveness of the implementation of Community-Led Total Sanitation and Hygiene (CLTSH) approach on the prevention of diarrheal disease in children less than five years of age. Statistical analyses done on the differences of diarrheal disease prevalence and factors associated with diarrhea between intervention and comparison districts were found to be significant.
This study showed that there was 8.2 percentage point greater reduction in the prevalence of diarrhea after the implementation of the intervention in intervention district. This is supported by a study conducted in Hadaleala district, Ethiopia, which showed that human excreta management was associated with childhood diarrheal disease (7).
In our study, in the intervention district, implementation of CLTSH resulted in a 5.6 percentage point increase in household private latrine ownership than in comparison district. This is supported by a cluster-randomized controlled trial conducted on the effect of a community-led sanitation intervention on child diarrhea and child growth in rural Mali, which showed latrine ownership rose more steeply as a result of CLTS; latrine ownership increased by 39 percentage points (22). Another study conducted on the effect of CLTS on latrine ownership in Mozambique showed that the proportion of people owning latrine is increasing with increasing extend of CLTS-related information and highest in the group of CLTS participation (79%) (23).
The coverage of private latrine ownership is also greater than the finding of a study conducted rural settings of Dangla District, Northwest Ethiopia, which showed that majority of households in both ODF (89.7%) and OD (92.8%) kebeles had a private latrine (24). The possible explanation for this variation might be due to the difference in the extent of the implementation of WASH intervention or due to differences in the study design employed.
In addition to increased possession of latrine, participants in the intervention district were more likely to report latrine utilization at posttest assessment compared to baseline. This is supported by a study conducted on the effect of community led total sanitation and hygiene approach on improvement of latrine utilization in Laelay Maichew District, North Ethiopia, which showed that implementation of CLTS improves the utilization of latrine by 16.2 percentage points (16).
This study revealed that the availability of hand washing facility near latrine was reduced in both intervention and comparison districts from baseline to posttest survey. It was reduced from 70.3–62.7% (-7.6 pp) and from 74–54.8% (-19.2 pp) in intervention and comparison districts respectively. The finding is higher than the study from Yaya Gulele district, which showed that more than half of the participants, (54%) in CLTSH implemented and (63%) unimplemented kebeles had no hand-washing facility in or close to the latrine (25). The possible explanation for this variation might be due to the difference in the extent of the implementation of the intervention or due to differences in the study period.
Our study showed that, from baseline to posttest, the availability of soap at hand washing facility was more increased in intervention district than in comparison district as compared to the baseline, which is greater than the study conducted on Community-Level Sanitation Coverage in rural Mali (22). This variation might be due to the difference in the level of the sanitation coverage and geographical variation between the study populations.
The practice of open defecation was more decreased by 3.5 percentage points in intervention district, at posttest assessment compared to baseline. This is almost similar with a study conducted to evaluate the sustainability of community-led total sanitation outcomes in Ethiopia and Ghana, which shows that open defecation practice was decreased by 12 and 17 percentage points respectively, in villages receiving CLTS interventions (26).
CLTS processes can precede and lead on to, or occur simultaneously with, improvement of latrine design; the adoption and improvement of hygienic practices; solid waste management; waste water disposal; care; protection and maintenance of drinking water sources; and other environmental measures (27). Our finding also showed that there was 20.2 percentage point increase in safe management of solid waste in intervention district. This is greater than the finding of Dabat Health and Demographic Surveillance System conducted on Sanitation predictors of childhood morbidities (28). This variation might be due to the difference in the level of implementation of WASH intervention.
As with open defecation, unsafe disposal of child excreta poses a health risk to anyone living or playing nearby. When left in the open in the yard or direct vicinity of the household, child feces, which may carry a higher pathogen load than adult feces (child feces can be 20 times more dangerous than adult feces (29,30)), pose a particular risk for young children, whose play areas frequently overlap with disposal areas. Safe disposal of children’s feces is therefore at least as important as stopping open defecation (31). Our findings also showed that 96.2% of households in intervention district practice safe disposal of child feces, and there is a 16.5 percentage point greater increase in safe disposal of child feces from baseline to posttest survey, as compared to comparison district. This is greater than the evidence from Ethiopia using EDHS data, which showed that 4.72% children used latrine for defecation, 27.84% of children’s stools were put/rinsed into latrine, (42.01%) of children’s stools were left in the open/not disposed of, 14.08% of the children’s stools thrown into garbage, and (1.11%) of children’s stools was buried (32). It is also greater than the finding from Benishangul Gumuz Regional State, North West Ethiopia, which showed 55% of the households disposed children’s’ stool in an improper manner (33). This variation might be due to the difference in the study period and level of implementation of WASH intervention.
Participants in both intervention and comparison districts reported a significant increase on hand washing practice at critical times. But there is a 0.5 percentage points greater increase in intervention district from baseline to posttest survey, as compared to comparison district. This is greater than the finding of a study in Sheko district, Southwest Ethiopia and Jabithennan district, Northwest Ethiopia, which shows that 61.5% and 72.6% of households practiced hand washing at critical times respectively (34,35). The possible explanations for these variations might be due to the difference in the extent of the implementation of the intervention on the study populations and the study period in which the data collection period for our study is recent than that of these studies.
In our study, the availability of cover for water container during storage was 97.9% and 98.6% in intervention and comparison districts, respectively, but declined as compared to the base line. In intervention district, it was decreased by 1.1 percentage points, which is the reverse of the intended effect of the intervention. This is higher than the finding of a study from Mali, which shows that 96% of households had stored water covered at the time of sample collection (12). Another similar study with our finding from rural Ethiopia, shows that drinking water was stored in the household primarily in a container with a lid (98%) (36).
In our study, the practice of safe drawing of water from the storage was 60.1% and 72% in intervention and comparison districts, respectively, and declined in both intervention and comparison districts as compared to the base line. In intervention district, it was decreased by 16.4 percentage points, which is the reverse of the intended effect of the intervention. This is lower than the finding of a study conducted on Diarrheal status and associated factors in under five years old children in relation to implemented and unimplemented community-led total sanitation and hygiene in Yaya Gulele district, which shows that the practice of safe drawing of water from the storage was 99% and 84% for CLTS implemented and non-implemented districts respectively (25). This might be happened due to the difference on the awareness level of the study populations.
This study also revealed that, the practice of water treatment at home level was 15.9% and 20.7% in intervention and comparison districts, respectively, and declined as compared to the base line. In intervention district, it was more decreased by 4.6 percentage points than in comparison district, which is the reverse of the intended effect of the intervention. This is higher than the finding of a study conducted on appropriate household water treatment methods in Ethiopia, which shows that the number of households treating their water prior to drinking with any treatment options was 8.0% in 2005, 10.2% in 2011, and 9.4% in 2016 (37). The difference might be happened due to the difference on the water sources used by the study populations, and difference on the time of data collection. The possible explanation of the reduction of this practice between the baseline and posttest survey in our study might be due to the expansion of safe water supply between the baseline and posttest survey.
There were some limitations such as lack of random assignment which is the major limitation of quasi-experimental study. Besides, since the baseline data was not collected prior to the implementation of the intervention for comparison district, there are threats to the internal validity.