Sustainability of Open-Defecation Free Status Achieved through Community-Led Total Sanitation and Hygiene in Arsi Zone, Ethiopia Público

Abstract

Ethiopia has a nationally mandated sanitation plan aimed at reducing the prevalence of open defecation behavior through the use of Community-Led Total Sanitation and Hygiene (CLTSH). It is important to understand in what ways and to what extent, CLTSH as an intervention is effective in improving sanitation long term in the communities where it has been implemented. Purpose: The objectives of this thesis are to: 1) Determine the current status of open-defecation behavior, latrine ownership, and latrine usage behavior in Dodota and Sire woredas in rural Ethiopia. 2) Identify factors for further study that may explain the differences (if any) in open-defecation behavior, latrine ownership, and latrine usage behavior in different communities in Dodota and Sire woredas. 3) Complete spatial analysis to determine patterns of the indicators of latrine ownership, open-defecation behavior, and latrine usage behavior; as well as the corresponding factors thought to be related to those behaviors. Results: The proportion of households displaying evidence of open defecation ranged from 0 to 31% in woredas surveyed. Additionally, spatial analysis shows a sharp divide between Dodota and Sire in OD behavior and the amount of follow-up received from Health Extension Workers. Recommendations: CLTSH implementing organizations should conduct process evaluations and post-implementation follow-ups to assess fidelity to CLTSH and understand its impact in the short and long term. Organizations should also consider moving from unimproved sanitation facilities towards safely managed sanitation. Policy makers should include supplemental interventions to CLTSH in WASH policy to achieve national sanitation goals.    

Table of Contents

Table of Contents             

Distribution Agreement................................................................................................ i

Acknowledgements....................................................................................................... vi

Table of Contents......................................................................................................... vii

Table of Figures............................................................................................................... xi

Definition of Terms..................................................................................................... xiii

Chapter 1: Introduction............................................................................................... 1

Statement of Purpose / Objectives.............................................................................................. 2

Justification / Significance......................................................................................................... 4

Chapter 2: Literature Review................................................................................... 6

Sanitation Globally................................................................................................................... 7

State of Sanitation.................................................................................................................... 7

Sanitation Goals Past and Present............................................................................................ 8

Levels of Sanitation –MDGs and SDGs..................................................................................... 9

Open Defecation..................................................................................................................... 11

Open Defecation and Diseases......................................................................................................................................................... 12

Open Defecation when latrines are present................................................................................................................................... 13

Past and Current Sanitation Interventions............................................................................. 13

Community-Led Total Sanitation and Hygiene......................................................................... 14

CLTSH Process....................................................................................................................... 16

Criticism of CLTSH................................................................................................................... 21

Dearth of Evidence on CLTSH................................................................................................ 21

Theoretical Concerns.............................................................................................................. 22

Ethical Concerns..................................................................................................................... 23

Sanitation in Ethiopia................................................................................................................ 25

Current Status of Sanitation in Ethiopia.................................................................................. 26

Ethiopia’s CLTSH policy........................................................................................................... 27

Verification procedure............................................................................................................ 29

Government levels of certification............................................................................................ 30

Ethiopia’s NGO sector.............................................................................................................. 30

History of Proclamation No. 621............................................................................................. 31

Summary of Current Literature.............................................................................................. 33

Chapter 3: Methodology............................................................................................. 35

Introduction............................................................................................................................. 35

Study Setting............................................................................................................................. 35

Previous Intervention Follow-Up............................................................................................ 36

2015 Follow-up Variables...................................................................................................... 36

Population and Sample.............................................................................................................. 37

Population Estimates.............................................................................................................. 37

Sample Size Calculations........................................................................................................ 39

Sampling Process.................................................................................................................... 39

Instrument Design..................................................................................................................... 40

Survey Design......................................................................................................................... 40

Survey Informatics.................................................................................................................. 41

Key Informant Interview Design.............................................................................................. 41

Enumerator Training and Piloting.......................................................................................... 42

Data Collection........................................................................................................................ 43

Qualitative Data Collection – Subject Recruitment.................................................................. 43

Qualitative Data Collection – Tool Design.............................................................................. 43

Qualitative Data Collection – Interview Process and Language.............................................. 44

Quantitative Data Collection................................................................................................... 44

Planned Analysis Methods....................................................................................................... 46

Map Building and Spatial Analysis........................................................................................... 47

Ethical Considerations............................................................................................................. 48

Chapter 4: Results........................................................................................................... 50

Introduction............................................................................................................................. 50

Use of Qualitative Data............................................................................................................ 50

Population Characteristics...................................................................................................... 50

Spatial Components of Latrine Coverage and Open Defecation.............................................. 52

Latrine Coverage by Cluster.................................................................................................... 52

Observed Evidence of Open Defecation by Cluster.................................................................. 53

Latrine Coverage and Open Defecation Behavior.................................................................... 55

Self-Reported Open Defecation Status..................................................................................... 56

Open Defecation Status Self-Report vs. Observation................................................................ 57

Factors Related to Open Defecation Behavior........................................................................ 59

Types of Issues experienced by Latrine Owners........................................................................ 59

Time since last HEW follow-up................................................................................................ 60

Household Factors and Open Defecation Free Status............................................................. 61

Spatial Characteristics of Factors Related to Open Defecation............................................ 62

Health Extension Worker Household Visits.............................................................................. 62

Physical Difficulties with Latrine Structures............................................................................. 66

Chapter 5: Discussion..................................................................................................... 68

Introduction............................................................................................................................. 68

Results in Context..................................................................................................................... 69

Overall Findings..................................................................................................................... 69

Superstructure / Structural results............................................................................................ 69

Factors associated with open defecation................................................................................. 70

Woreda-Level Differences........................................................................................................ 72

Limitations and delimitations................................................................................................... 73

Chapter 6: Areas of Further Study / Recommendations........................ 76

For Funders and Implementers................................................................................................. 76

For Governments and Policy Makers....................................................................................... 77

References............................................................................................................................ 79

Appendices............................................................................................................................. 93

Appendix A Survey Instrument................................................................................................. 93

Appendix B Key Informant Interview Guide............................................................................ 112

Appendix C Structure of Ethiopian National Health System ⁹⁴............................................. 118

Appendix D Social Ecological Model Between Proclamation No. 621 and OD..................... 120

Appendix E Post-Study Presentation to CRS Stakeholders.................................................... 121

Appendix F Additional Maps.................................................................................................... 124

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Palavra-chave	CLTSH Water, Sanitation and Hygiene Ethiopia Public Health WASH
Committee Chair / Thesis Advisor	McGriff, Joanne, Emory University
Partnering Agencies	International Non-governmental organization (e.g., CARE, Inc.)

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