WASH for Everyone Trial: Testing alternative approaches to CLTS implementation in rural Malawi

Introduction
The United Nations Sustainable Development Goals aim to achieve universal sanitation coverage and end open defecation by 2030. However, this ambitious target is unlikely to be achieved due to slow progress on expanding access to basic sanitation in many low- and middle-income countries (LMICs). Community Led Total Sanitation (CLTS) has been used widely to promote sanitation interventions at household level. However, integration of CLTS with other community-based approaches for the delivery of health interventions has not been fully assessed. We conducted a study to assess the effectiveness of traditional CLTS interventions compared to those combined with a Care Group model on sanitation and hygiene outcomes in Chiradzulu District, rural Malawi.

Methods
From May 2023 to April 2024, we conducted a controlled before-and-after trial with two treatment arms and a control group. One arm received a combined CLTS and the Care Group intervention, one arm received CLTS only, and one arm served as the control group. Direct observations and household surveys during baseline and endline evaluation were applied to the randomly sampled 1,400 households; i.e. 400 in each treatment arm and 600 in the control arm. Difference in Difference analysis will be used to compare changes in sanitation coverage and use, hygiene behaviours and access to handwashing facilities, and Sanitation-related Quality of life (SanQoL-5) in the two intervention arms compared to changes in the control arm as well as between the two intervention models. The trial was part of the wider Water, Sanitation, and Hygiene (WASH) for Everyone (W4E) project, led by World Vision Malawi and Water for People, which aims to expand access to drinking water, sanitation, and hygiene services across the entire district of Chiradzulu.

Results
At baseline, household characteristics were similar across arms with most survey respondents being female (83%) with at least some primary education (67%). Approximately half (49%) of households had a child under the age of five years and lived below World Bank’s poverty line. Most households (79%) had unimproved latrines and 38% had verified handwashing facilities in the home; most of which were mobile objects (e.g., bucket, jug, kettle). Endline data, collected in April and May 2024, is currently being analyzed. The analysis will compare changes in sanitation and handwashing facility coverage and observed handwashing with soap in each intervention group against the control as well as compare the two intervention groups directly. Analysis will be completed by July 2024 and results shared during the verbal presentation.