title: Beliefs, Behaviors, and Perceptions of Community-Led Total Sanitation and Their Relation to Improved Sanitation in Rural Zambia.
abstract: Inadequate hygiene and sanitation remain leading global contributors to morbidity and mortality in children and adults. One strategy for improving sanitation access is community-led total sanitation (CLTS), in which participants are guided into self-realization of the importance of sanitation through activities called "triggering." This qualitative study explored community members' and stakeholders' sanitation, knowledge, perceptions, and behaviors during early CLTS implementation in Zambia. We conducted 67 in-depth interviews and 24 focus group discussions in six districts in Zambia 12-18 months after CLTS implementation. Triggering activities elicited strong emotions, including shame, disgust, and peer pressure, which persuaded individuals and families to build and use latrines and handwashing stations. New sanitation behaviors were also encouraged by the hierarchical influences of traditional leaders and sanitation action groups and by children's opinions. Poor soil conditions were identified as barriers to latrine construction. Taboos, including prohibition of different generations of family members, in-laws, and opposite genders from using the same toilet, were barriers for using sanitation facilities. CLTS, through community empowerment and ownership, produced powerful responses that encouraged construction and use of latrines and handwashing practices. These qualitative data suggest that CLTS is effective for improving sanitation beliefs and behaviors in Zambia.
authors.affiliation: Zambia Center for Applied Health Research and Development, Lusaka, Zambia; Center for Global Health and Development, Boston University, Boston, Massachusetts; Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts; Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Water, Sanitation, and Hygiene (WASH) Section, United Nations Children's Fund (UNICEF) Zambia, Lusaka, Zambia; Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts ymq1@cdc.gov.
authors.forename: J Joseph
authors.initials: JJ
authors.lastname: Lawrence
authors.affiliation: Zambia Center for Applied Health Research and Development, Lusaka, Zambia; Center for Global Health and Development, Boston University, Boston, Massachusetts; Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts; Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Water, Sanitation, and Hygiene (WASH) Section, United Nations Children's Fund (UNICEF) Zambia, Lusaka, Zambia; Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts.
authors.forename: Kojo
authors.initials: K
authors.lastname: Yeboah-Antwi
authors.affiliation: Zambia Center for Applied Health Research and Development, Lusaka, Zambia; Center for Global Health and Development, Boston University, Boston, Massachusetts; Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts; Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Water, Sanitation, and Hygiene (WASH) Section, United Nations Children's Fund (UNICEF) Zambia, Lusaka, Zambia; Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts.
authors.forename: Godfrey
authors.initials: G
authors.lastname: Biemba
authors.affiliation: Zambia Center for Applied Health Research and Development, Lusaka, Zambia; Center for Global Health and Development, Boston University, Boston, Massachusetts; Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts; Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Water, Sanitation, and Hygiene (WASH) Section, United Nations Children's Fund (UNICEF) Zambia, Lusaka, Zambia; Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts.
authors.forename: Pavani K
authors.initials: PK
authors.lastname: Ram
authors.affiliation: Zambia Center for Applied Health Research and Development, Lusaka, Zambia; Center for Global Health and Development, Boston University, Boston, Massachusetts; Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts; Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Water, Sanitation, and Hygiene (WASH) Section, United Nations Children's Fund (UNICEF) Zambia, Lusaka, Zambia; Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Osbert
authors.affiliation: Zambia Center for Applied Health Research and Development, Lusaka, Zambia; Center for Global Health and Development, Boston University, Boston, Massachusetts; Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts; Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Water, Sanitation, and Hygiene (WASH) Section, United Nations Children's Fund (UNICEF) Zambia, Lusaka, Zambia; Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts.
authors.forename: Lora L
authors.initials: LL
authors.lastname: Sabin
authors.affiliation: Zambia Center for Applied Health Research and Development, Lusaka, Zambia; Center for Global Health and Development, Boston University, Boston, Massachusetts; Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts; Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York; Water, Sanitation, and Hygiene (WASH) Section, United Nations Children's Fund (UNICEF) Zambia, Lusaka, Zambia; Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts.
authors.forename: Davidson H
authors.initials: DH
authors.lastname: Hamer
mesh_terms: D003256:Community Participation; D006235:Hand Disinfection / Q000592:standards*; D006801:Humans; D012424:Rural Population; D013609:Taboo; D014038:Toilet Facilities / Q000592:standards*; D015024:Zambia