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Improving Sanitation and Hygiene through Community-Led Total Sanitation: The Zambian Experience

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  • 1 Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts;
  • | 2 National Health Research Authority, Lusaka, Zambia;
  • | 3 Water, Sanitation and Hygiene Section, United Nations International Children’s Emergency Fund (UNICEF) Zambia, Lusaka, Zambia;
  • | 4 Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts
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In 2012, approximately 5.6 million Zambians did not have access to improved sanitation and around 2.1 million practiced open defecation. The Zambia Sanitation and Hygiene Program (ZSHP), featuring community-led total sanitation, began in November 2011 to increase the use of improved sanitation facilities and adopt positive hygiene practices. Using a pre- and post-design approach with a population-level survey, after 3 years of implementation, we evaluated the impact of ZSHP in randomly selected households in 50 standard enumeration areas (representing 26 of 65 program districts). We interviewed caregivers of children younger than 5 years old (1,204 and 1,170 female caregivers at baseline and end line, respectively) and inspected household toilet facilities and sites for washing hands. At end line, 80% of households had access to improved sanitation facilities versus 64.1% at baseline (prevalence ratio [PR] = 1.25; 95% CI: 1.18–1.31) and 14.1% did not have a toilet facility compared with 19.4% at baseline. At end line, 10.6% of households reported living in an open defecation-free certified village compared with 0.3% at baseline (PR = 32.0; 95% CI: 11.9–86.4). In addition, at end line, 33.4% of households had a specific place for washing hands and 61.4% of caregivers reported handwashing with a washing agent after defecation or before preparing food compared with 21.1% (PR = 1.59; 95% CI: 1.39–1.82) and 55.2% (PR = 1.11; 95% CI: 1.04–1.19) at baseline, respectively. Community-led total sanitation implementation in Zambia led to improvements in access to improved sanitation facilities, reduced open defecation, and better handwashing practices. There is however a need for enhanced investment in sanitation and hygiene promotion.

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Author Notes

Address correspondence to Davidson H. Hamer, Department of Global Health, Boston University School of Public Health, 801 Massachusetts Ave., Crosstown, 3rd Floor, Boston, MA 02118. E-mail: dhamer@bu.edu

Financial support: The Department for International Development (DFID), through UNICEF, provided funding for the impact evaluation. The views expressed in this manuscript do not necessarily represent those of UNICEF, DFID, or the Government of the Republic of Zambia.

Authors’ addresses: Kojo Yeboah-Antwi, William B. MacLeod, and Caitryn M. McCallum, Department of Global Health, School of Public Health, Boston University, Boston, MA, E-mails: kyantwi@bu.edu, wmacleod@bu.edu, and caitryn@bu.edu. Godfrey Biemba, National Health Research Authority, Lusaka, Zambia, E-mail: gbiemba@gmail.com. Patrick Sijenyi, Alexandra Höhne, and Lavuun Verstraete, Water, Sanitation and Hygiene Section, UNICEF Zambia, Lusaka, Zambia, E-mails: psijenyi@unicef.org, alexandra.hoehne@gmail.com, and lverstraete@unicef.org. Davidson H. Hamer, Department of Global Health, School of Public Health, Boston University, Boston, MA, and Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, E-mail: dhamer@bu.edu.

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