community-led total sanitation community-led total sanitation community-led total sanitation (clts) is an approach used mainly in developing countries to improve sanitation and hygiene practices in a community. the approach tries to achieve behavior change in mainly rural people by a process of "triggering", leading to spontaneous and long-term abandonment of open defecation practices. it focuses on spontaneous and long-lasting behavior change of an entire community. the term "triggering" is central to the clts process: it refers to ways of igniting community interest in ending open defecation, usually by building simple toilets, such as pit latrines. clts involves actions leading to increased self-respect and pride in one's community. it also involves shame and disgust about one's own open defecation behaviors. clts takes an approach to rural sanitation that works without hardware subsidies and that facilitates communities to recognize the problem of open defecation and take collective action to clean up and become "open defecation free". clts triggering process: community members in ghana are drawing a map of open defecation for their community. the concept was developed around the year 2000 by kamal kar for rural areas in bangladesh. clts became an established approach around 2011. non-governmental organizations were often in the lead when clts was first introduced in a country. local governments may reward communities by certifying them with "open defecation free" (odf) status. the original concept of clts purposefully did not include subsidies for toilets as they might hinder the process. clts is practiced in at least 53 countries. clts has been adapted to the urban context. it has also been applied to post-emergency and fragile states settings. challenges associated with clts include the risk of human rights infringements within communities, low standards for toilets, and concerns about usage rates in the long-term. clts is in principle compatible with a human rights based approach to sanitation but there are bad practice examples in the name of clts. more rigorous coaching of clts practitioners, government public health staff and local leaders on issues such as stigma, awareness of social norms and pre-existing inequalities are important. people who are disadvantaged should benefit from clts programmes as effectively as those who are not disadvantaged. definitions open defecation is the practice of defecating out in the open, rather than using a toilet. "open defecation free" (odf) is a central term for community-led total sanitation (clts) programs. it primarily means the eradication of open defecation in the entire community. however, odf can also include the additional criteria, such as: household latrines or toilets are hygienic, provide the safe containment of feces, offer privacy and a roof to protect the user, have a lid to cover the hole, or a water seal for toilets. all household members and all members of the community use these latrines or toilets. a handwashing facility with water, soap or ash is nearby and used regularly. even more stringent criteria which may be required before a community is awarded "odf status" might include: safe drinking water and storage. food hygiene. greywater disposal. solid waste management. provision of toilets for schools, markets, clinic or visitors to the community. overview a facilitator and the community during a triggering in malda district, west bengal, india school-led total sanitation "triggering" event: these school children in west bengal, india are looking at a glass of water and fresh feces. flies will pass from the water to the feces and back, which demonstrates how water can get polluted with pathogens. this is what clts tries to stop: open defecation in rural bihar, india clts focuses on community-wide behavioural change, rather than merely toilet construction. the process raises the awareness that as long as even a minority continues to defecate in the open, everyone is at risk of disease. clts uses community-led methods, such as participatory mapping and analyzing pathways between feces and the mouth (fecal-oral transmission of disease), as a means of teaching the risks associated with od. a tool called "triggering" is used to propel people into taking action. this takes place over a day with a team of facilitators. the team visits a community which is identified as practicing open defecation and encourages villagers to become aware of their own sanitation situation. this aims to cause disgust in participants, and the facilitators help participants to plan appropriate sanitation facilities. using the term "shit" (or other locally used crude words) during triggering events or presentations – rather than feces or excreta – is a deliberate aspect of the clts approach, as it is meant to be a practical, straight forward approach rather than a theoretical, academic conversation. clts is practiced in at least 53 countries. to be successful in the longer term, clts should be treated as part of a larger wash (water, sanitation and hygiene) strategy rather than as a singular solution to changing behavior. pre-triggering pre-triggering is the process by which communities are assessed to be suitable for clts intervention. this involves visits and a number of different criteria, which are used to identify communities likely to respond well to triggering. during pre-triggering, facilitators introduce themselves to community members and begin to build a relationship. triggering the "clts handbook" from 2008 states that there is no "one way" of doing triggering in clts. a rough sequence of steps is given in this handbook which could be followed. facilitators are encouraged to modify and change activities depending on the local situation. the unicef manual approved for use of clts in sierra leone suggests the following steps for the triggering process: visit the community, emphasising the purpose of learning about their sanitation situation facilitate "kaka mapping" – drawing a map of important locations in the village, then adding common sites for defecation pretend to leave facilitate a "walk of shame" to sites with frequent open defecation collect a piece of feces in a bag put feces on the ground where all present can see it, and discuss how flies move between food and feces wait for the shocked realization that the community is indirectly eating each other's feces put some feces into a water bottle and ask if anyone would drink it calculate how much feces is produced each day and ask where it goes ignition (see below) wait for the emergence of "natural leaders" to work with in order to develop a plan of action. the "ignition" phase occurs when the community becomes convinced that there is a real sanitation problem, and motivated to do something about it. natural leaders are members of the community who are engaged by the process, and able to drive change. the goal of the triggering process is to let people see the problem first-hand, thereby evoking disgust. however, it has been reported that communities which respond favorably tend to be motivated more by improved health, dignity, and pride than by shame or disgust. post-triggering after a positive response to the ignition phase, ngo facilitators work with communities to deliver sanitation services by providing information and guidance relevant to the local situation. there are many challenges that occur in the post-triggering phase. these are mainly related to the supply of durable and affordable latrine hardware and technical support on latrine construction. toilet owners may need advice how to upgrade and improve sanitation and handwashing facilities using local materials. subsidies the original concept of clts did not include subsidies for toilets. clts proponents at that time believed that provoking behavior change in the people alone would be sufficient to lead them to take ownership of their own sanitation situation, including paying for and constructing their own toilets. this was not always the case. applications to urban situations, schools and other settings since about 2016, clts has been adapted to the urban context. for example, in kenya the ngos plan and practical action have implemented a form of urban clts. clts has also been used in schools and the surrounding communities, which is referred to as "school-led total sanitation". the school children act as messengers of change to households. clts has also been applied to post-emergency and fragile states settings. there has been some experience with this in haiti, afghanistan, pakistan, philippines and indonesia. in 2014, unicef reported positive outcomes with clts in fragile and insecure contexts, namely in somalia and south sudan. people who are disadvantaged should benefit from clts programmes as effectively as those who are not disadvantaged. this is referred to as equality and nondiscrimination (eqnd). outcomes and health aspects millions of people worldwide have benefitted from clts which has resulted reductions in open defecation and increases in latrine coverage in many rural communities. practitioners have declared many villages as "odf villages", where odf stands for "open defecation free". reviews of effectiveness a systematic review of 200 studies concluded in 2018 that the evidence base on clts effectiveness is still weak. this means that practitioners, policy makers, and program managers have little available evidence to inform their actions. there is currently a lack of scientific review about the effectiveness of clts, although this has been changing since 2015. a study in 2012 reviewed reports by ngos and practitioners and found that there was little review of the impact of local natural leaders, that anecdotes were used without assessing impacts, and that claims were made without supporting evidence. it concluded that these kinds of reports focus on the 'triggering' stage of ctls instead of the measurable outcomes. a peer-reviewed article considered the sustainability of clts in the longer term: it found that there was little monitoring or evaluation of the impacts of clts, even though large international organizations were involved in funding the process. reviews about the effectiveness of clts to eliminate open defecation, reduce diarrhea and other gastrointestinal diseases, and decrease stunting in children are currently underway. in some cases, clts has been compared with india's total sanitation campaign (tsc) when assessing the effectiveness of the approach. however, this comparison may be invalid, as the presence of subsidies in the tsc process may fundamentally change the effectiveness of the clts process. comparison of different clts programmes one small study compared different clts programmes. participants from ngos involved in delivering clts reported that although they included some of the activities described in the guidance materials, they often omitted some and included others depending on the local situation. some reported that subsidies were included, and some offered specific design and construction options. health outcomes a cluster-randomized controlled trial in rural mali conducted during 2011 to 2013 found that clts with no monetary subsidies did not affect diarrhea incidences, but substantially increased child growth (thereby reducing stunting), particularly in children under two years of age. challenges and difficulties a health worker (centre) gets villagers to draw a map of the area, showing the main features like the road and the river (a village near lake malawi, malawi). villagers go to the place where meals are prepared to observe how flies are attracted to human feces and carry diseases by landing on the food (village near lake malawi, malawi). villagers making a transect walk or 'walk of shame' to the open defecation places, singing 'let us end open defecation' (village near lake malawi, malawi) human rights the clts behavioral change process is based on the use of shame. this is meant to promote collective consciousness-raising of the severe impacts of open defecation and trigger shock and self-awareness when participants realize the implications of their actions. the triggering process can however infringe the human rights of recipients, even if this was not intended by those promoting clts. there have been cases of fines (monetary and non-monetary), withholding of entitlements, public taunting, posting of humiliating pictures and even violence. in some cases clts successes might be based on coercion only. on the other hand, clts is in principle compatible with a human rights based approach to sanitation but there are bad practice examples in the name of clts. more rigorous coaching of clts practitioners, government public health officials and local leaders on issues such as stigma, awareness of social norms and pre-existing inequalities are important. catarina de alburquerque, the former united nations special rapporteur on the right to water and sanitation, is quoted as saying that "observers have also recognized that incentives for encouraging behavior change and the construction of latrines are sometimes unacceptable, and include public shaming, including photographing, of those who