Skip Navigation
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.


The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

National Institute of Environmental Health Sciences

to Top

Improving Community-Led Total Sanitation Outcomes through Training

By Ty Lawson

Nearly one in three people worldwide lack proper sanitation and nearly one in eight practice open defecation, according to the World Health Organization (WHO). These practices contribute to the global burden of disease due to contaminated drinking water. To help address these problems, the United Nation’s Sustainable Development Goals have set a target to end open defecation by 2030.

Two research studies, conducted by Jonny Crocker, Ph.D., an NIEHS training grantee, in partnership with Plan International and researchers at the University of North Carolina at Chapel Hill, highlight how training community members can assist in decreasing open defecation. Thus, Crocker is evaluating the effectiveness of community-based training as an NIEHS research trainee, focusing on implementation science. The research studies contrasted four different approaches to intervention in rural Ethiopia and Ghana.

One method to reduce open defecation is through a program called community-led total sanitation (CLTS). CLTS compels community members to action through a triggering moment when they collectively realize that open defecation leads to consuming fecal matter. CLTS relies on the diffusion of innovation theory, looking to spark behavior change through the triggering moment, or social pressures.

A project village in the Oromia region, Ethiopia.
A project village in the Oromia region, Ethiopia.
(Photo courtesy of Jonny Crocker)

In Ethiopia, the study compared training local health extension workers (HEW) to teachers facilitating CLTS. Following training, each facilitator implemented CLTS in Ethiopia’s kebeles, for a year. A kebele is the smallest administrative unit in Ethiopia, consisting of a cluster of villages in a rural area.

In the teacher-facilitated CLTS, the kebele leadership was trained, but fewer leaders from each kebele were involved. The conventional CLTS intervention using HEW decreased the open defecation by 22%, while the teacher-led intervention decreased it by 14%. The authors found that teacher-led interventions were less effective than the HEW-led interventions. To explain this difference, the authors reason that HEWS had prior relationships with kebele leaders, while teachers did not engage with the kebele leaders as quickly.

In Ghana the study looked to evaluate the effectiveness of training "natural leaders" to help encourage better sanitation practices. Natural leaders were identified during the initial triggering of the CLTS intervention as the most motivated community members, often early adopters of pit latrines. To help identify the effectiveness of the natural leaders in decreasing open defecation rates, the study looked at conventional NGO-facilitated CLTS and compared that with NGO-facilitated CLTS with the addition of natural leaders.

The addition of natural leader training to a the CLTS interventions in Ghana resulted in a 20% decrease of open defecation. Training as few as two natural leaders per 100 community members resulted in improved sanitation behavior of communities. The study shows that training natural leaders can have a significant impact on intervention outcomes.

A trained natural leader in the Volta region, Ghana.

A trained natural leader in the Volta region, Ghana.
(Photo courtesy of Jonny Crocker)

Crocker, the lead author of both studies, attested to the value of the NIEHS training grants, saying: "the fellowship funding allowed me to pursue my career goals, and covered my time for three years during these projects. The funding let me explore the social aspects of sanitation behaviors, in addition to the cost effectiveness of CLTS implementation."

"The fellowship also allowed me to study how implementation research has been applied in other fields. A lot of studies give you a thumbs-up or thumbs-down on whether an intervention is effective. But when you work with implementers, there is a lot more interest in how to make an intervention more efficient and effective given the challenges they are facing. These are the kinds of questions that implementation research can help answer. I have enjoyed this type of research and I am looking now to build my career around it."

Recently, Crocker finished his postdoctoral position with the Water Institute at UNC, and will begin a new position with the University of Washington. He plans to expand his skills in implementation research and apply them to water and sanitation problems in the future.