Volume 97, Issue 5
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Open defecation is practiced by more than one billion people throughout the world and leads to significant public health issues including infectious disease transmission and stunted growth in children. Zambia implemented community-led total sanitation (CLTS) as an intervention to eliminate open defecation in rural areas. To support CLTS and the attainment of open defecation free communities, chiefs were considered key agents of change and were empowered to drive CLTS and improve sanitation for their chiefdom. Chiefs were provided with data on access to sanitation in the chiefdom during chiefdom orientations prior to the initiation of CLTS within each community and encouraged to make goals of universal sanitation access within the community. Using a survival regression, we found that where chiefs were orientated and mobilized in CLTS, the probability that a village would achieve 100% coverage of adequate sanitation increased by 23% (hazard ratio = 1.263, 95% confidence interval = 1.080–1.478, = 0.003). Using an interrupted time series, we found a 30% increase in the number of individuals with access to adequate sanitation following chiefdom orientations (95% confidence interval = 28.8–32.0%). The mobilization and support of chiefs greatly improved the uptake of CLTS, and empowering them with increased CLTS knowledge and authority of the program in their chiefdom allowed chiefs to closely monitor village sanitation progress and follow-up with their headmen/headwomen. These key agents of change are important facilitators of public health goals such as the elimination of open defecation in Zambia by 2020.


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  1. Fuller JA, Goldstick J, Bartram J, Eisenberg JNS, , 2016. Tracking progress towards global drinking water and sanitation targets: a within and among country analysis. Sci Total Environ 541: 857864.[Crossref]
  2. Mara D, Lane J, Scott B, Trouba D, , 2010. Sanitation and health. PLoS Med 7: e1000363.[Crossref]
  3. Bartram J, Lewis K, Lenton R, Wright A, , 2005. Focusing on improved water and sanitation for health. Lancet (London, England) 365: 810812.[Crossref]
  4. Black RE, of WHO and UNICEF Child Health Epidemiology Reference Group , 2010 . Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet 375: 19691987.[Crossref]
  5. Keino S, Plasqui G, Ettyang G, van den Borne B, , 2014. Determinants of stunting and overweight among young children and adolescents in sub-Saharan Africa. Food Nutr Bull 35: 167178.[Crossref]
  6. Guerrant RL, DeBoer MD, Moore SR, Scharf RJ, Lima AAM, , 2013. The impoverished gut: a triple burden of diarrhoea, stunting and chronic disease. Nat Rev Gastroenterol Hepatol 10: 220229.[Crossref]
  7. Central Statistic Office [Zambia], Ministry of Health [Zambia], ICF International, 2014. Zambia Demographic and Health Survey 2013–14. Rockville, MD: ICF International.
  8. Kar K, Chambers R, , Plan UK, 2008. Handbook on Community-Led Total Sanitation. Brighton, United Kingdom: Plank UK.
  9. Baldwin K, , 2013. Why vote with the chief? Political connections and public goods provision in Zambia. Am J Pol Sci 57: 794809.
  10. Markle L, Maganani A, Katooka O, Tiwari A, Osbert N, Larsen DA, Winters B, ,2017. A mobile platform enables unprecedented sanitation uptake in Zambia. 11: e0005131.
  11. Lawrence JJ, Yeboah-Antwi K, Biemba G, Ram PK, Osbert N, Sabin LL, Hamer DH, , 2016. Beliefs, behaviors, and perceptions of community-led total sanitation and their relation to improved sanitation in rural Zambia. Am J Trop Med Hyg 94: 553562.[Crossref]
  12. Ziegelbauer K, Speich B, Mäusezahl D, Bos R, Keiser J, Utzinger J, , 2012. Effect of sanitation on soil-transmitted helminth infection: systematic review and meta-analysis. PLoS Med 9: e1001162.[Crossref]
  13. Strunz EC, Addiss DG, Stocks ME, Ogden S, Utzinger J, Freeman MC, ,2014. Water, sanitation, hygiene, and soil-transmitted helminth infection: a systematic review and meta-analysis. PLoS Med 11: e1001620.
  14. Okun DA, , 1988. The value of water supply and sanitation in development: an assessment. Am J Public Health 78: 14631467.[Crossref]
  15. Asaolu S, Ofoezie I, , 2003. The role of health education and sanitation in the control of helminth infections. Acta Trop 86: 283294.[Crossref]
  16. Clasen TF, Bostoen K, Schmidt W-P, Boisson S, Fung IC-H, Jenkins MW, Scott B, Sugden S, Cairncross S, , 2010. Interventions to improve disposal of human excreta for preventing diarrhoea. Cochrane Database Syst Rev 6: CD007180.
  17. Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA, , 2008. Hand washing for preventing diarrhoea. Cochrane Database Syst Rev 1: CD004265.
  18. Pickering AJ, Djebbari H, Lopez C, Coulibaly M, Alzua ML, , 2015. Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial. Lancet Glob Health 3: e701e711.[Crossref]
  19. Airhihenbuwa CO, Ford CL, Iwelunmor JI, , 2014. Why culture matters in health interventions: lessons from HIV/AIDS stigma and NCDs. Health Educ Behav 41: 7884.[Crossref]
  20. Zimba R, 2016. Chiengi District, Zambia open defecation free after 1 year of community-led total sanitation. Am J Trop Med Hyg 95: 925927.[Crossref]
  21. Toulmin C, , 2009. Securing land and property rights in sub-Saharan Africa: the role of local institutions. Land Use Policy 26: 1019.[Crossref]
  22. De Soto H, ,2000 The Mystery of Capital: Why Capitalism Triumphs in the West and Fails Everywhere Else. New York, NY: Basic Books.
  23. Cotula L, Chauveau J, ,2007. Changes in “Customary” Land Tenure Systems in Africa.
  24. Ayittey G, , 2006. Indigenous African Institutions, 2nd edition. Leiden, The Netherlands: BRILL.
  25. Keulder C, , 1998. Traditional Leaders and Local Government in Africa: Lessons for South Africa. Pretoria, South Africa: HSRC Printers.
  26. Oomen B, , 2000. Tradition on the Move: Chiefs, Democracy and Change in Rural South Africa. Amsterdam, The Netherlands: Netherlands Institute for Southern Africa.
  27. Logan C, , 2009. Selected chiefs, elected councillors and hybrid democrats: popular perspectives on the co-existence of democracy and traditional authority. J Mod Afr Stud 47: 101128.
  28. Hamer DH, Herlihy JM, Musokotwane K, Banda B, Mpamba C, Mwangelwa B, Pilingana P, Thea DM, Simon JL, Yeboah-Antwi K, Grogan C, Semrau KEA, , 2015. Engagement of the community, traditional leaders, and public health system in the design and implementation of a large community-based, cluster-randomized trial of umbilical cord care in Zambia. Am J Trop Med Hyg 92: 666672.[Crossref]
  29. Green EC, Dlamini C, D’Errico NC, Ruark A, Duby Z, , 2009. Mobilising indigenous resources for anthropologically designed HIV-prevention and behaviour-change interventions in southern Africa. Afr J AIDS Res 8: 389400.[Crossref]
  30. Campbell C, , 2010. Political will, traditional leaders and the fight against HIV/AIDS: a South African case study. AIDS Care 22 (Suppl 2): 16371643.[Crossref]
  31. Odoch WD, Kabali K, Ankunda R, Zulu JM, Tetui M, , 2015. Introduction of male circumcision for HIV prevention in Uganda: analysis of the policy process. Health Res Policy Syst 13: 31.[Crossref]
  32. Rowe AK, Kachur SP, Yoon SS, Lynch M, Slutsker L, Steketee RW, , 2009. Caution is required when using health facility-based data to evaluate the health impact of malaria control efforts in Africa. Malar J 8: 209.[Crossref]
  33. Barnard S, Routray P, Majorin F, Peletz R, Boisson S, Sinha A, Clasen T, , 2013. Impact of Indian total sanitation campaign on latrine coverage and use: a cross-sectional study in Orissa three years following programme implementation. PLoS One 8: e71438.
  34. Patil SR, Arnold BF, Salvatore AL, Briceno B, Ganguly S, Colford JM, Gertler PJ, , 2015. The effect of India’s total sanitation campaign on defecation behaviors and child health in rural Madhya Pradesh: a cluster randomized controlled trial. PLoS Med 11: e1001709.[Crossref]
  35. Clasen T, 2014. Effectiveness of a rural sanitation programme on diarrhoea, soil-transmitted helminth infection, and child malnutrition in Odisha, India: a cluster-randomised trial. Lancet Glob Health 2: e645e653.[Crossref]
  36. Garn JV, Sclar GD, Freeman MC, Penakalapati G, Alexander KT, Brooks P, Rehfuess EA, Boisson S, Medlicott KO, Clasen TF, , 2016. The impact of sanitation interventions on latrine coverage and latrine use: a systematic review and meta-analysis. Int J Hyg Environ Health 220: 329340.[Crossref]

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  • Received : 27 Jul 2016
  • Accepted : 03 Apr 2017

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