Cost and effectiveness of water, sanitation and hygiene promotion intervention in Ghana: the case of four communities in the Brong Ahafo region

Abstract

Knowledge of cost and effectiveness of Ghana's main hygiene promotion intervention (HPI), Community-Led Total Sanitation (CLTS), is critical for policy direction. Cost and resultant effect of HPI is examined using a case study of four communities. Surveys were conducted with 300 households, CLTS implementers and relevant agencies during the study period (May 2012 to February 2014). The HPI produced marginal but statistically significant effect (8%, p < 0.001). Improvement in hygiene behaviour was statistically associated with both government investments (p < 0.001) and household investments (p < 0.001). Actual HPI cost is US$ 90 per household: US$ 51 and 39 from government and households respectively. Cost-effectiveness of the HPI is US$ 106.42 per capita of improved hygiene behaviour.

How community engagement in water and sanitation interventions impacts human health, infrastructure and service longevity in low- and middle-income countries: a realist review

“…Without external support, shame can promote access to and individual/household ownership of latrines (22,31,38,55,57,62,65,77) and handwashing facilities (30,33,62). These outcomes are limited in communities and households with financial and technical challenges (24,35,61,65). Enablers include initiating shame by leaders and people known within the community, which helps the acceptance, monitoring and enforcement of new norms (22,31,55,57,62,77).…”

“…Social cohesion and connectedness also enable 'shame' to be transmitted throughout a community. However, when communities lack technical or financial capabilities (24,65), access may be compromised by construction of low standard latrines, although when the new social norm is sufficiently established, communities may seek to repair or rebuild such latrines (55,65). The shame of losing in a competition can have a negative effect on the non-winners who may be demotivated as a result (62).…”

“…Efforts to avoid shame can result in change in sanitation behaviour (i.e. reduction in open defecation and increase latrine use (10,11,24,30,31,34,35,40,65,68,77)) and an increase in levels of overall hygiene behaviour, including hand washing (24,25) and safe drinking water and storage (24). These changes impact health outcomes such as reduction childhood in diarrheal disease, roundworm infestation and stunting (31,35,61,65,77).…”

“…Shame is more effective for behaviour change in small, cohesive, and isolated total communities with similar views, as people want to fit in and conform to social norms (68), where effective leadership and community involvement help reinforce change in social norms (10,30,65), and where high social cohesion and connectedness makes people more likely to conform for the benefit of the community (8,61), especially as social pressure mounts and community tolerance for the undesirable behaviour decreases (11,22,61). (10,24,55,65). Without ongoing support and acknowledgement of change, behaviour change is unlikely to be sustained as there is a tendency for fatigue or loss of motivation within communities (22)(23)(24).…”

“…Failure of interventions can occur for several reasons, such as lack of community involvement in design (15,16), lack of ownership (17,18), abuse of funds or poor financial management, lack of willingness of community members to contribute (18)(19)(20), lack of communication and connectedness (21) and no ongoing support and acknowledgement of change (22)(23)(24). In addition to an increased understanding of success and failures in WASH interventions, there is a growing trend to use community participation to drive health programmes, based on the expectation working with communities can help ensure interventions are more relevant to local priorities (25).…”