A Social Norm Based Analysis of Community Led Total Sanitation
Final Project - Advances in Social Norms and Social Change Course
Chris Cormency
Introduction
Over the last few years, the UNICEF WASH programming strategy has shifted from hardware
focused to software focused. That is, UNICEF has shifted from the drilling wells to promoting
household level water treatment and safe storage. There has been a directed movement away
from constructing latrines at the household level to promoting community based sanitation.
Additionally, UNICEF has focused increased efforts on the promotion of handwashing with
soap. This shift has effectively moved WASH from engineering based programming to
communication based programming with an emphasis on social and behavior change, both at the
community and family level.
In the West and Central Africa region we’ve had the most success with the strategic shift in
regards to sanitation promotion programming using an approach called community led total
sanitation (CLTS). CLTS is a non-subsidized approach to sanitation that aims to eliminate open
defecation through social and behavior change. The “total sanitation” part of CLTS is defined as
the complete absence of open defecation. That is, everyone in the community uses latrines and
100% of the excreta is hygienically disposed.
UNICEF focuses on sanitation improvements because they have been shown to significantly
reduce the spread of fecal-oral diseases and specifically impacts diarrheal morbidity, reducing it
by up to 36%. As diarrhea is one of the top 3 killers of children less than 5 years old, sanitation
improvements can significantly reduce child mortality. Improved sanitation also increases
nutritional status, increases school attendance, and improves overall quality of life.
Previous UNICEF sanitation strategies targeted the individual, offering a subsidy for latrine
construction. The strategy succeeded sometimes, improving latrine coverage in some villages
significantly but rarely above 50% coverage. The approach focused on increasing access to
latrines, not necessarily on increasing the use of latrines. In some cases, there were even
examples of latrines being built, thanks to subsidies, which were subsequently used for offices,
chicken coops or storage. The new CLTS approach diverges significantly from the old
approach. There are no longer latrine subsidies given at the family level, the program targets the
community as a whole and not the individual, and program starts not with a technical latrine
design but rather with a communication strategy that aims to create a new social norm.
The CLTS strategy began in South East Asia nearly a decade ago and has since spread through
the world. In late 2008 and early 2009, the WCA region of UNICEF introduced CLTS to
governments in the region through a series of regional workshops. The majority of these
governments have since adopted the strategy in their national planning and are currently
expanding from pilot projects to national programs. Figure 1 shows results from the initial pilot
of CLTS in Mali. Sanitation coverage in the 15 villages targeted went from an initial coverage
of approximately 30% to 100% coverage in less than 3 months.
Figure 1: Mali CLTS results
The results from Mali and similar results from other countries, both in the region and globally,
have inspired WASH professionals to scale up CLTS programming. This paper analyzes CLTS
using social norm theoretical tools to understand better why the strategy works so well and to
subsequently investigate the potential of applying key concepts to other WASH behavioral
change interventions such as handwashing with soap.
CLTS Strategy
The CLTS strategy works through the use of a series of participatory tools that help facilitate a
self-realization that by practicing open defecation the community themselves are essentially
eating fecal matter. The strategy uses specific tools that invoke a sense of shame and disgust that
inspire community members to improve their sanitation situation. The tools require the explicit
use of the word shit and actual shit is used in some of the demonstrations. The key tools in the
strategy include:
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Village transect walk to determine the open defecation sites
Village mapping that includes homes, schools, health centers, and defecations sites
Calculation of volume of feces spread around the village
Demonstration of contaminated water with feces (hair/shit)
Demonstration of contaminated food with feces (bread/flies/shit)
Calculation of the annual expenses for treatment of diarrhea (medicines, treatment)
Through the use of the tools, the community members arrive at a moment of “triggering” where
they declare, as a community, to stop open defecation. Based on this agreement, a plan is
outlined by community members themselves on how they will build their latrines. The plan
details how they will monitor their progress and includes a target date for when they will become
open defecation free (ODF).
After the triggering, regular follow-up visits are necessary to support the community in achieving
their goal and to assist with any technical challenges in the latrine building. This usually is done
through weekly or biweekly support missions to the communities. Once a community has
become fully ODF, the community is inspected and certified by the government and the event is
publicly celebrated through music, dance, and speeches. The celebrations often become large
events with participation from both traditional and elected leaders.
CLTS Social Norm Theoretical Analysis
In the West and Central Africa (WCA) region, open defecation can normally be classified as a
descriptive norm, but in some cases it can also be considered a social norm. A descriptive norm
is one that is based on empirical expectations, that is, on how one expects others to act. In these
cases, open defecation is the norm for the community; it is a habit that everyone practices.
There are no inherent cultural pressures to practice open defecation, rather there has just been a
historical lack of latrines in the community so latrine use has never been adopted. Through years
of this behavior, the descriptive norm has become a convention for the community and there is
no perceived need to change the behavior.
On the other hand, in some communities, open defecation can also be classified as a social norm.
A social norm is a norm that includes the empirical expectations of a descriptive norm but also
includes normative expectations. Normative expectations are those that are linked to what
someone think that others think they should do. Normative expectations are often linked to
informal or formal social sanctions. In these cases, there is a perception from the individual that
others in the community expect them to practice open defecation for social-cultural reasons. If
someone doesn’t act this way, there are resulting sanctions, such as being made fun of or
ostracized. In these communities, open defecation is the preferred behavior and the adoption of
latrines is resisted.
Examples of reasons that open defecation becomes a social norm vary across the region and
include such beliefs as: gasses from latrine holes cause abortion (Ivory Coast), two holes should
never face each other (Guinea), one person’s feces cannot contact another person’s feces (Togo),
fathers and daughter’s-in-law should never share latrines (Mali), and that the use of latrines
shortens lifespan (Burkina Faso). In these cases, open defecation is expected to be practiced by
individual community members and there are pressures from the greater community that keep
this practice going. In some cases where this social norm exists, it survives due to pluralistic
ignorance - the majority of the community would, in fact, prefer to have latrines but they don’t
realize that others also would prefer to have latrines. Thus the behavior remains the norm for the
community in spite of the majority of the community opposing it.
Regardless of whether open defecation is classified as a social norm or a descriptive norm, using
game theory analysis, open defecation remains because of a conflict between the good of the
individual and the community. This is called a social dilemma; the behavior of the individual is
not what is best for the community. In this case, it will always be beneficial for some individuals
to practice open defecation, whether for cultural reasons, financial reasons (cost of latrine), or
simply ease of access. Thus, in spite of the obvious benefits of increased access to sanitation, the
stable norm of the community becomes open defecation as there are no drivers to make a
behavior change at the collective level.
As such, to address open defecation, it is necessary to create a new social norm, one that limits
the practice by creating both empirical and normative expectations that generate a new
defecation script that requires latrine use. The CLTS technique, through the use of extremely
powerful tools based on universal emotions of disgust and shame, has been able to create this
norm in a sustainable fashion.
As described in the first section, the CLTS strategy is a community based intervention that
empowers the community to make changes to improve their sanitation situation. The tools listed
in the first section are the driving force behind CLTS. The tools are based around the strong and
universal emotions of shame and disgust. These emotions are strong and quickly generate a
momentum to change that is based on pride and respect. Aside from the tools themselves, from a
social norm theory perspective, the strategy has several additional key elements that allow it to
succeed:
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Community Engagement: CLTS works directly with community members. A CLTS
facilitator is taught to go into a community with the idea of “being there to learn”. It is
not a prescriptive strategy; there are no latrine plans given or directive health statements
made.
Triggering: The CLTS tools facilitate a dialogue around sanitation that ultimately
arrives at a situation where the community members themselves decide to change their
situation. The tools are designed to arrive at this moment and a good facilitator does not
push the triggering too fast, rather allows the community themselves to arrive at the
triggering moment.
Public Declaration: Once the triggering has occurred and the community has decided to
change their sanitation situation, a public declaration is made by all community members
to their fellow community members. This is the moment when the new social norm is
created and it is no longer accepted to defecate in the open.
Community Action Plan and Monitoring: Following the public declaration, the
community develops their own plan on how to improve their sanitation situation and sets
itself time limits to complete. A simple map is often drawn that shows families with and
without latrines. This map then serves as the monitoring tool, with community members
able to quickly see who has complied with the new social norm and who hasn’t. This
creates a community “by-law” that is self-enforced by the community.
Incentives: The strategy creates both internal and external incentives to achieving ODF
status. Positive internal incentives include showing pride in their community and
negative internal incentives include shame and disgust in the act of open defecation.
External incentives include the ODF certification process which is normally run by the
government and includes a celebration for achieving the ODF status.
Diffusion: Through the celebration process, traditional and political leaders are engaged
from neighboring communities and districts. This supports the scaling up of CLTS as
neighboring communities engage in the process. There have even been cases of “self-
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triggering” in neighboring villages. As CLTS is scaled up, there is also national diffusion
as national level celebrations also are organized, with district political and traditional
leaders being invited to the national stage to celebrate district ODF status.
Network Theory: During the triggering, “natural leaders” are identified through their
participation in the process. These leaders are then implicated closely in the process to
ensure community compliance and offer support as needed. These natural leaders are
also then implicated in triggering in nearby villages, often alongside traditional leaders
and local political leaders. The identification of these individuals to serve as key
“bridges and nodes” for the acceleration the strategy has been critical.
Rural targeting: CLTS typically concentrates on the rural sector where there is a strong
sense of community. When CLTS has been applied to peri-urban areas, there have not
been the same impressive results as seen in the rural sector. There are several reasons for
this, including a weakened sense of community due to the more transient population,
issues surrounding land rights, and the increased material costs of building latrines.
The CLTS strategy has proven successful in improving sanitation coverage due to the underlying
integration of many social change elements. The CLTS strategy is essentially creating a new
social norm to use latrines where there have previously been no norms associated with the latrine
use. In fact, CLTS has even been able to successfully break the social norm of open defecation
while creating the new norm. The tools are the critical component of the strategy, but the
integration of many other behavior change components as detailed above are the main reasons
that the approach has been successful.
Extension of CLTS concepts
The successes being seen in sanitation using the CLTS strategy are unfortunately not being seen
in other key health behavioral change initiatives. These include exclusive breast feeding, use of
mosquito nets, handwashing with soap, condom use, safe water storage, etc. For WASH
programming, handwashing promotion is a key activity that is being implemented in most
countries in the region. The results of the current activities though are not convincing and could
possibly benefit from some of the CLTS lessons learned.
The most basic use of CLTS would be to include target other interventions to villages and
districts that have been declared ODF. These communities have proven that they are organized
and have already achieved success in achieving their sanitation goals. As such they may be more
open, willing, and motivated to accept other “new” ideas from the outside. UNICEF has recently
started doing this with breast feeding promoting in Sierra Leone but the results are not yet
available.
Another approach is to integrate other interventions directly into the CLTS strategy. Mali and
Mauritania have had good success in merging handwashing with CLTS. In both countries,
communities cannot achieve ODF status unless their latrines have integrated a handwashing
station. This requirement was agreed upon by the government line ministries for their specific
countries. Though this type of integration might potentially weaken the triggering process, for
handwashing promotion the link seems similar enough that it has not interfered with the
community commitment achieved through the CLTS triggering.
Beyond integration of other approaches into existing CLTS interventions, is there room for some
of the underlying behavior change elements to be used to improve other social and behavior
change approaches? For the specific case of handwashing promotion, there are similarities to
sanitation promotion but there are also significant differences. Like sanitation, there is no social
norm surrounding the practice of handwashing in most communities in the WCA region. Also,
like with sanitation, in some communities there is resistance to handwashing due to local beliefs
such as handwashing reducing the possibility to make money and handwashing removing natural
“powers”. These are not as common though as the beliefs associated with sanitation so should
pose and lower hindrance to norm creation. Another key difference is that soap is a consumable
as opposed to latrines that are one-off constructions and then minor maintenance. The fact that
family members must allocate a percentage of their monthly income to handwashing can be a
major obstacle, especially considering the poverty levels in the region.
Ultimately the goal of a handwashing promotion program is the same as in CLTS, to create a
new social norm surrounding the practice. Thus, based on the above social norm analysis of
CLTS, the greatest potential adaption could be from the following:
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Community Engagement: Handwashing promotion is already often community based
though it frequently focuses on regional and national promotion using social marketing
techniques (its “cool” to wash with soap, washing makes you smell good, etc). The
community based focus could be strengthened, though this increases costs.
Triggering: There are certainly less “triggering” tools for handwashing than those found
in CLTS. Powerful tools such as the transect walk, mapping, and shit/bread/flies
demonstration are impossible to translate to handwashing promotion. However, a tool
based on the disgust emotion could be developed that is based on rinsing hands in water
and subsequently asking a community member to drink the rinsed water. This could
demonstrate that even if hands appear clean, they are not. There are also products on the
market like Glo-germ that could be used as a powerful tool. This product is applied to
the hands after washing them with soap to show areas where germs could still remain.
The product however is external to the community and requires a UV light source which
could complicate the implementation at scale. With some inventive programming, 0a
weakened triggering moment could occur, but it is unlikely to result in a strong
community commitment and thus less likely to result in a public declaration for
handwashing.
Diffusion: Systematic diffusion techniques could be integrated both at intra- and intercommunity levels through group “dinners”, either simulated or actual. Eating from a
common plate is already common in most cultures in the region. Adding a step for
handwashing to the process could be demonstrated easily and quickly replicated through
ceremonial dinners throughout the community and district.
Network Theory: Through accurate knowledge of which community members are
respected and listen to, focused efforts could be made to change the behavior of these
individuals and families to serve as catalysts for the rest of the community. Additionally,
schools and health centers serve as an important “node” for behavior change and
promotion work could be systematically increased in these areas, perhaps designing
specific new tools that are tailored to the different audiences. In Muslim countries, the
Imam can also play a key role as there is a strong link in Islam between prayers and
cleanliness.
Unfortunately, some of the other elements of CLTS are not so easily integrated, such as the
public declaration, community level monitoring, and incentives/rewards. However, this analysis
of how CLTS strategies can be adopted of its underlying elements can be integrated into
handwashing promotion and offer some new opportunities for improving UNICEF’s current
programming strategies.
Conclusion
Community Led Total Sanitation has proved to be a successful strategy for sanitation promotion
in the West and Central Africa region. The strategy uses powerful tools, based on shame and
disgust to create a new social norm around latrine use. Through an analysis of CLTS based on
social norm theory, the underlying reasons why the strategy succeeds have been identified.
These elements have the potential to then be applied to other health based behavioral change
initiatives. An initial attempt has been applied to the promotion of handwashing with soap.
Though this does not give the solutions to the challenges of handwashing promotion, the social
norm based analysis does give insights and ideas on ways to improve programming.