Community-Led Total Sanitation (CLTS) Workshop

Last week I attended most of a 5-day UNICEF-funded workshop on a new technique for mobilizing communities to improve their sanitation practices (which is a nice way of saying “convincing people to stop open defecation”). The technique, which is called Community-Led Total Sanitation (CLTS), was developed a few years ago in Asia and has successfully been implemented in two other regions of The Gambia, but never in our region (LRR).

CLTS is different from traditional sanitation development projects in the country (which largely have failed) because it is focused on changing people's understanding of sanitation, and thus motivating a change in their behavior, rather than building latrines or providing building materials for latrines. The concept of using behavior change communication to empower communities to create local solutions to their problems is very much in line with Peace Corps' (and also CARE's) approach to development, so I went into the workshop very interested to learn more about it.

The part I was skeptical about, however, is that way that CLTS motivates people to change their attitudes and thus their behavior is by using different tools and demonstrations, as well as using crude local words (equivalent of the word “shit” in English) to trigger a shame or disgust reaction. It is important to note that public health facilitators DO NOT tell the village what to think or do – they just present the community with information and let them draw their own conclusions. So the idea is to call a community meeting, then employ the following tools, proceeding through them until reaching a “trigger” point, where the village (ON THEIR OWN) comes to the conclusion that they cannot continue open defecation and decide they want to find a solution to the problem (ON THEIR OWN):

1) Defecation area mapping – Create a map of the village on the ground. In addition to key landmarks, identify the locations of compounds, latrines, and ask the people without latrines to show where they go to defecate (see pictures below).

2) Defecation area transit walk – Ask community members to take you to visit a commonly used open defecation site (people will be embarrassed and not really want to do this).

3) Fecal-oral contamination – Collect a sample of fresh feces while on the transit walk, return to the meeting site, and place the feces in the center of the circle. Take a piece of fresh bread, eat a bite, offer it to community members, then place the bread next to the feces in the center of the circle (flies will quickly start to gather on the feces and move back and forth between the bread and the feces). Take a cup of fresh water, take a sip, offer it to community members, then take a thread, drag it through the feces, dip it in the water, then offer the water to community members (they will refuse it). Offer the bread to community members (they will refuse it). Ask the community why they no longer want the bread and water when their food and water is contaminated by feces all the time because of their open defecation near their village.

4) Shit calculation – Calculate the amount of faeces a single compound produces in a week, a month, and a year.

5) Medical expense calculation – Calculate the cost of a single visit to the hospital for diarrheal disease (including cost of travel, the hospital visit, buying medicine at the pharmacy, the value of a day of work lost, etc).

I observed two triggering activities, both in small villages off the road in our area. The first village had 20 compounds and I think 4 or 5 latrines. Our team went through Tools 1, 2, and 3 before deciding the village was sufficiently “triggered.” The second village had 23 compounds and 8 latrines. That village “triggered” after only Tool 1. I expected the communities to be angry or offended when we used the crude language and brought them to realize that they are quite literally “eating their own shit.” In reality, they were engaged and appreciative and motivated to change.

The next step is the communities are having follow-up meetings to create a plan for construction of latrines (using locally available materials like wood from the bush and local cement made from cow dung and termite mounds). Each community will send two representatives (one man and one woman) to a day-long workshop in a nearby town to flesh out their plans with deadlines and responsibilities. Local health staff will be responsible for following up and monitoring progress. When the local health staff deem the village “open defecation-free,” the village will throw a party to celebrate their accomplishment.

Originally I was concerned about encouraging people to make local latrines rather than strong cement ones that will last longer. However, after discussion with local health staff, I realized that latrine-building and -subsidizing programs generally only can afford a few latrines per village, far fewer than are needed (and they generally end up in the village elders compounds), and when attitude and behavior change strategies are not used, there is no guarantee that people will actually use them. Individual compounds or the village as a whole can always save up for improved latrines later, but the attitude and behavior change elements have to come first. Additionally, building local latrines is free, so it allows even the poorest compounds to contribute fully to the village's achievement of “open defecation-free” status without financial strain.

I mentioned earlier that at first I was uncomfortable with the idea of disgusting and shaming people into doing what we think they should (regardless of whether it would be beneficial to their health). However, when I thought about it, I learned in my biological anthropology courses that human disgust reactions evolved as a powerful and innate defense mechanism. It makes sense to tap into that biological mechanism. Also, remembered that I read somewhere that Americans are significantly more likely to wash their hands after going to the bathroom if they are in a public restroom with other people around. Same idea. No matter what the situation, peer pressure and shame are always powerful motivators for behavior change. Very interesting stuff.

Below are some pictures from the two triggering activities:

Village 1, shot of the village. This is what a typical small Fula community off the main road looks like. Notice all the green that has replaced the red-brown dust everywhere. Woo rain!


Village 1, making the community map


Village 1, completed map. Sorry for the weird angle - I was trying to fit as much of the map in the picture as possible. The branch is the tree under which we were holding our meeting, the upside-down bowl is the mosque, the bidong is the seed store, the circles with white cards in the middle are wells, the blue cards are compounds, the green cards are latrines, and the sawdust represents the routes people without latrines take when they go to their preferred open defecation spots.


Village 2, Musa facilitating the triggering activity


Village 2, village elder and "natural leader" driving home a point to his community


Village 2, attentive community. We had an excellent turnout in this village.


Village 2, completed map. Slightly less creative than the previous day, but the idea is the same.