The impact of enhanced, demand-side sanitation and hygiene promotion on sustained behaviour change and mental well-being in Ethiopia

Publication Details

3ie Funded Evaluation, TW11.1016. A link to the completed study will appear here when available.

Matthew Freeman, Kebede Faris, Zerihun Tadesse, Craig Hadley, Bethany Caruso, Tom Clasen
Institutional affiliations
None specified
Grant-holding institution
None specified
Middle East and North Africa
Water and Sanitation
Rural Water and Sanitation
Gender analysis
Rural Water and Sanitation
Gender analysis
Equity Focus
Evaluation design
Randomised Control Trials (RCT)
Ongoing 3ie Funded Studies
3ie Funding Window
Sanitation and Hygiene Thematic Window


This evaluation assesses the impact of community-led total sanitation and hygiene (CLTSH) on behaviour change, sanitation security and mental well-being.


A multisectoral approach is needed to meet the World Health Organisation’s (WHO) target to eliminate morbidity due to soil-transmitted helminthiases (STH) in children by 2020. In addition to deworming, WHO recommends improving hygiene education and sanitation to reduce soil transmitted helminthiases transmission. CLTSH, a modified form of CLTS, focusses additionally on hygiene, specifically handwashing with soap or a soap substitute and hygienic handling of drinking water. With CLTSH, there is considerable focus on ‘triggering’ collective awareness of the problem of open defecation and behaviour change. CLTSH in Ethiopia is a government-backed, low-cost, and locally acceptable approach to improving sanitation and hygiene. It is being scaled up throughout Amhara in Ethiopia.

There are few studies that assess the impact of CLTSH. The study is therefore policy-relevant as it will generate evidence on the effectiveness of this programme design as well as its cost effectiveness. 

Research questions

Evaluation questions of interest

Primary research question: What is the effectiveness of an enhanced CLTSH model on equitable improvements in WASH-related outcomes and health impacts compared to the usual standard of care?

These are the specific research questions that are part of the overarching research question:

  • Does enhanced CLTSH lead to a change in social norms; an increase in the uptake, maintenance, exclusive use of sanitation facilities for defecation; and hygiene behaviours?
  • Does CLTSH affect sanitation security, and does water security modify the effectiveness of the intervention to change hygiene behaviours?
  • What is the impact of enhanced CLTSH on mental well-being?


Theory of change

CLTSH will be integrated with the Health Extension Programme in the four target districts of Amhara, Ethiopia. This will presumably facilitate household progression along the sanitation ladder. The sustained adoption of improved sanitation and hygiene behaviours is expected to result in improvement in equitable WASH-related health outcomes and well-being in the region. 

Evaluation design

The study uses a mixed-method approach to obtain data to test the hypotheses and make attributional claims along the causal chain. It includes a cluster-randomised controlled trial, where the primary sampling unit is sub-districts within the four districts in Amhara identified as having high trachoma prevalence and low sanitation coverage.

Qualitative methods include focus group discussions, in-depth interviews and free listing; quantitative methods include structured surveys and observations of facilities.

Data will be collected on measures of mental well-being and sanitation and hygiene behaviour change from 25 randomly selected households within 50 clusters, for a total sample of 1,250 households.

Scroll to Top