{"paper_id":"137b37dc-28fc-4a9b-bec0-28ad722263f5","body_text":"1 \n \nSanitation-Hygiene Practices and Social Norms in Community-led Total Sanitation for 1 \nSustainability of Open Defecation Free Status: A Survey of Suna West Sub-County, 2 \nMigori County, Kenya. 3 \nNaomi R. Aluoch1, Collins O. Asweto2, Patrick O. Onyango3 4 \n1. School of Public Health and Community Development, Maseno University 5 \n2. School of Nursing, University of Embu 6 \n3. School of Physical and Biological Sciences, Maseno University  7 \nCorresponding author: 8 \nNaomi R. Aluoch; roosenash@gmail.com 9 \n 10 \nABSTRACT 11 \nBackground: Community-led total sanitation (CLTS) has been used to stir sanitation -related 12 \nbehaviour change and attain open defecation free (ODF) status. CLTS interventions suffer high 13 \nrates of reversion such that their gains are unsustainable in most contexts. 14 \nObjective: This study aimed to determine the role of sanitation hygiene practices and social 15 \nnorms on open defecation free status in Suna West Sub County. 16 \nMethodology: A cross -section study design was employed using question naire and 17 \nobservation checklist to collect data from 384 households.  18 \nResults: Results revealed that 66.1% households had partially reverted to non-ODF status. The 19 \nsanitation-hygiene practices associated with being ODF includes: use of elevated racks 20 \n(AOR=0.81; CI= 0.34-1.90; p=0.625), use of treating water (AOR=2.81; CI= (0.97-8.06); 21 \np=0.055), regularly clean latrines (AOR=2.96; CI= 0.63-13.89; p=0.17), pouring of ash over 22 \nthe pit of the latrine (AOR=4.08; CI= 1.73-9.62; p<0.001) and use of dug out pits for waste 23 \ndisposal (AOR=2.41; CI= 1.02-5.68; p<0.045). On social norms, the study found that 24 \nlaws/penalties (AOR=4.15; CI= 2.20-7.80; p<0.001) and rewards/incentives (AOR=0.17; 25 \nCI=0.096-0.306; p<0.001) had less odds of being ODF. Moreover, odds of being ODF was low 26 \nfor households who reported that construction/maintenance materials were expensive 27 \n(AOR=0.17; CI=0.84-2.79; p=0.169), that it was embarrassing to people defecate in the open 28 \n(AOR=0.060; CI0.19-1.23=; p<0.129) and that it is okay to defecate in bushes/r ivers/dams 29 \n(AOR=0.623; CI=;0.329-1.179 p<0.146).  30 \nConclusion: The results of this study show partial reversion to non -ODF status in previously 31 \ncertified villages. However, households that sustained ODF status had several sanitation 32 \nhygiene practices. Interestingly, households that displayed social norms were less likely to be 33 \nODF. Overall, the findings of the present study demonstrate  that the CLTS process failed to 34 \ninstil social norms around proper sanitation to inspire community collective action thus little 35 \ninfluence on sustainable behaviour change. The findings of this study therefore highlight the 36 \nneed to enhance good hygiene sani tation practices, while instilling social norms to inspire 37 \ncommunity collective action. 38 \nKEY WORDS : Community -led total sanitation (CLTS) ; Open defecation free (ODF) ; 39 \nsanitation hygiene practices; social norms. 40 \n 41 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n2 \n \nINTRODUCTION 42 \nAccording to the World Health Organisation (WHO), roughly 842,000 lives are lost in low - 43 \nand middle -income countries annually as a consequence of inadequate water, hygiene and 44 \nsanitation (1). Indeed, poor sanitation has been connected to infections such as  (2) diarrhoeal 45 \ndiseases, nematode infections and environmental enteropathy (EE). In Kenya, for instance, 46 \ndiarrhoea claims the lives of roughly 3,100 children annually and trachoma, schistosomiasis 47 \nare health problems linked to poor sanitation. In part, the burden of these diseases is attributed 48 \nto open defecation that exposes a large part of the population to sanitation-related diseases (3).  49 \nIt is in light of such negative impacts of poor sanitation that the Government of Kenya adopted 50 \nCommunity-led Total Sanitation (CLTS) as a strategy to improve sanitation. Community -led 51 \nTotal Sanitation was introduced by Plan International Kenya in 2007 and was approved by the 52 \nthen Ministry of Public Health and Sanitation (MOPHS) as a key framework for promoting 53 \nhygiene and sanitation at the household level. In 2011, MOPHS established CLTS as the 54 \nnational strategy for ensuring rural sanitation and set a national target to reduce open defecation 55 \n(4).  56 \nCommunity led total sanitation involves three main steps: pre -triggering, triggering and post-57 \ntriggering(5). At the pre-triggering stage the community members are mobilised for triggering 58 \nprocess in which community members are able to see the reality of mass defecation and how it 59 \naffects the community negatively (6). Finally, the post -triggering phase involves follow -up 60 \naimed at verification and certification of the villages as open defecation free(7).  61 \nThere has been a lot of research on why people do what they do, what influences their actions. 62 \nIn the recent sanitation interventions and community -led total sanitation, key emphasis has 63 \nbeen on establishing social norm around unacceptability of open defecation (6). The process of 64 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n3 \n \nCLTS has been known to cause peer pressure by invoking emotions such as shame and disgust 65 \nand change perceived social norms to establish open defecation as being socially 66 \nunacceptable(8). Social norms and how strong they are, has been found to greatly influence 67 \nsustainable behaviour change in relation to sanitation practices. Where positive social norms 68 \nwere well rooted, the chances of achieving sustainable behaviour change were higher(9). 69 \nIt is important to understand why people engage in open defecation for failure to do so has led 70 \nto failed interventions(10). Open defecation has been known to be an independent action, that 71 \nis, people engage in open defecation because they believe it meets their needs and that it is not 72 \nharmful to them and others, it is a custom rather than a social norm (11). However, to eliminate 73 \nopen defecation in a particular group, there is need to create a social norm promoting latrine 74 \nuse and maintenance. People will need to think that their reference network think they should 75 \nuse and maintain latrines and them believing in that will motivate them to engage in open 76 \ndefecation-free behaviour(10). 77 \nThe results of a study on the sustainability of ODF status in Kenya conducted by (12) revealed 78 \nthat the sustainability of ODF achievements remained a major concern with over 70% of 79 \nvillages that had received partial or full OD F status reverting to non -ODF status. Among the 80 \nfactors that demotivate community members from using a latrine after becoming ODF relates 81 \nto physical aspects of the latrine (such as lack of privacy and fear of the latrine collapsing) and 82 \nsharing a latrine with other people (14). In addition, slippage from ODF status has also been 83 \nlinked to collapse or poor structural integrity of latrines as well as unsustainable behaviour 84 \nchange following sanitation -related interventions (14). The objective of this study was to 85 \ninvestigate the ODF status of households in ODF certified villages of Suna West Sub County 86 \nand to determine association between ODF status with sanitation-hygiene practices and social 87 \nnorms in households of Suna West Sub-County, western Kenya. 88 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n4 \n \nMATERIALS AND METHODS 89 \nStudy Area 90 \nThe study was done in Suna West Sub -County in Migori County which has a population of 91 \n117,539 with a density of 406 persons per km 2 and 29,251 households. The sub -county, one 92 \namong eight others, has four wards; Ragana-Oruba, Wasweta II, Wiga and Wasimbete wards. 93 \nIt is bordered by Kuria West sub-county to the south-east, Nyatike sub-county to the west, Suna 94 \nEast Sub-County to the north-eastern side and Tanzania to the south -west. Migori county has 95 \npoverty level measured at 32.0 (2016) and is listed among the counties with the most income 96 \ninequality as measured by the gini coefficient. Migori county’s a gini index is 0.464(15).  97 \nStudy Design 98 \nA cross-sectional study design was used across two wards, Ragana-Oruba and Wasweta II, that 99 \nwere purposively chosen for having attained ODF status at least one year to the study which 100 \nwas carried out from 17th to 21st July, 2020.  101 \nTarget population 102 \nThe unit of analysis was the household with the targeted participants being the household 103 \nheads. The sample size for households featured in the study was determined using the statistical 104 \nformula as used by Fisher .(16). The households that had participated in the initial verification 105 \nwere included and any child -headed household was ex cluded. The data collection was done 106 \nacross 384 households identified through simple random sampling of the households as found 107 \nin MOH 513 which is the household register maintained by the Community Health Volunteers 108 \n(CHVs). 109 \n 110 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n5 \n \nSampling Design 111 \nThe sample size for households in the village featured in the study was determined using 112 \nFisher’s formula; the standard deviation set at 1.96, which corresponds to 95% CI. The 113 \nproportion of desired population was assumed at 0.50, the margin of error 0.05. We u sed the 114 \ninitial sample size of 384 to capture the true variability of the population. 115 \nData Collection Tools and Procedure 116 \nThe survey tools were developed in line with the constructs of the key questions that we sought 117 \nto answer with reference to previously  validated instruments that were reviewed by my 118 \nsupervisors and peers. Once that was done, we pre -tested the tool and adjusted any questions 119 \nthat we sought to answer. Cronbach’s alpha was computed to test for reliability of data 120 \ncollection instrument and output yielded result of an internal consistency 0.7. 121 \nValidated structured questionnaire and observation checklist were used in this study. 122 \nObservation checklist was used to collect information to corporate or refute claims made by 123 \nrespondents in the questionnaires. 124 \nThe researcher provided scientific oversight of this study including training and technical 125 \nsupport for the research team and oversaw the development of coding frame and data analysis. 126 \nUnder supervision, the research assistants (RAs) helped  in the recruitment and obtaining 127 \ninformed consent from the participants to take in the part in the study.  128 \nThe tools were provided in English. 129 \nStudy Variables 130 \nDependent Variables    131 \nDependent variables were measured as follows: a) access to a latrine - availability of Individual 132 \nlatrine, shared latrine/neighbours; b) privacy - availability of door or some form of barricade 133 \nprovided for each superstructure; c) Squat hole cover – a barrier to prevent movement of flies 134 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n6 \n \nin and out of the latrine hole d) hand washing facility - availability of tap/leaky tin near latrine 135 \nwith water inside, soap/ash available; e) no exposed faeces – via simple transect walk, no 136 \nvisible faeces should be found within the surrounding of the home. For a household to be ODF, 137 \nall the 5 parameters must be met and the absence of any one would be an indication of partial 138 \nreversion to non-ODF status while absence of all the five indicators would reflect full reversion 139 \nto non-ODF status of the household. 140 \nIndependent Variables   141 \nFor independent variables, the frequency of variables such as treating water (boiling or use of 142 \nchemicals), covering food using lid over cooking pots when cooking and during storage, using 143 \nelevated racks to hold utensils off the ground while drying, regular cleaning of latrine, 144 \napplication of ash around & the squat hole of latrine, and using dugout pit for waste disposal 145 \nwere measured using Likert scale: always, most of the time, sometimes, rarely, not at all. Scores 146 \nwere aggregated into two - Yes (always, most of the time, sometimes) and no (rarely, not at 147 \nall).  148 \nWhile variables such as Care of the family - Empirical & normative expectation regarding 149 \nhealth of the family, Shame/disgust/fear/pride Regrettable occurrence/ unpleasant emotion that 150 \ncause a feeling of resolution, Cultural/social/religious beliefs - Person’s belief alignment as 151 \npertaining culture, society and religion, Laws/penalties - Rules within a given set up and 152 \npunishment imposed for breaking the set rules, Need to improve things in the family -  153 \nEmpirical & normative expression of obligation to make things better, Follow ups and support 154 \n-  The subsequent actions following CLTS and material assistance for the same, 155 \nRewards/incentives - Some form of payment given in recognition of work done or to stimulate 156 \ngreater output, and Peer pressure - The empirical &normative expectation regarding consistent 157 \nlatrine use were measured using Likert scale: strongly disagree, disagree, neutral, agree and 158 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n7 \n \nstrongly agree. The scores were aggregated into two; Yes (agree and strongly agree), No 159 \n(strongly disagree, disagree, neutral). 160 \nStatistical Analysis 161 \nSummation for the observed non-negotiable indicators was done to determine the ODF status.  162 \nWilcoxon signed-rank test was used to determine if there was a significant difference in ODF 163 \nstatus as at the time of the study and verification. Chi -square test of independent was used to 164 \ndetermine association between sanitation and hygiene practices, social norms a nd ODF status 165 \nand binary logistic regression was done to determine the relationship between sanitation 166 \nhygiene practices, social norms and ODF status.  167 \nWhile the outcome variable was highly prevalent, raising concerns about the potential for odds 168 \nratios to over-estimate the true association compared to risk ratios, we chose to use logistic 169 \nregression as it offers a robust framework for adjusting for multiple confounders and provides 170 \na straightforward method for hypothesis testing. Nevertheless, we interpret ed the results with 171 \ncaution, to effectively utilize established statistical methodologies and maintain consistency 172 \nwith previous research in similar contexts. 173 \nEthical considerations 174 \nEthical approval for the study was granted by the Maseno University Ethics Review 175 \nCommittee; Ref: MSU/DRPI/MUERC/00821/99 and National Commission for Science 176 \nTechnology and innovation, Kenya. To protect the privacy and anonymity of participants, their 177 \npersonal identifying information was not recorded in the questionnaires or checklists and 178 \nhouseholds were reported as numbers. The data was coded to secure the privacy and anonymity 179 \nof participants. Further, there was disclosure regarding the nature of the stu dy, its purpose, 180 \nwhat it involves, the procedures to be done, risks -if any by taking part in the study and since 181 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n8 \n \nthe study did not involve experimental drugs or procedures used in the study, the study posed 182 \nno significant risk to participants. 183 \nInformed consent. 184 \nWritten informed consent was gotten from the participants. They were also informed that 185 \ntaking part in the study was out of free will and that they were free to withdraw from the study 186 \nat any time. 187 \nRESULTS  188 \nSocio-demographic characteristics of study participants  189 \nOf the 384 participants, 62.8% were females, 73.4% were aged 25 -59 years, while 58.6% and 190 \n31.8% had primary education and secondary education respectively. On socio-economic status, 191 \nthree-quarter (75.3%) of households had $0 -38.9 monthly income. A half (53.1%) of the 192 \nhouseholds had 0 -5 years old child and 27.1% had at least one member with a disability or 193 \nchronic illness. Socio-demographic characteristics of the study participants are summarized in 194 \nTable 1. 195 \nTable 1: Socio-demographic characteristics of study participants from Suna West Sub-196 \nCounty, Kenya 197 \n Variable Frequency \n(n) \nPercentage \n(%) \nGender Male 143 37.2 \n Female  241 62.8 \nRespondents’ Age 18-24 years 58 15.1 \n 25-59 years 282 73.4 \n 60 and above 44 11.5 \nLevel of Education No education 26 6.8 \n Primary education 225 58.6 \n Secondary education 122 31.8 \n Tertiary education 11 2.9 \nLevel of Income 0-38.9 289 75.3 \n 39-77.9 72 18.8 \n 78-155.8 6 1.6 \n 155.9-233.7 3 0.8 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n9 \n \n 233.8-311.6 6 1.6 \n 311.7 and over 8 2.1 \nHousehold \ncomposition \nWith persons 0-5 years. 204 53.1 \n With persons 6-12 years. 278 72.4 \n With persons 13-24 years. 299 77.9 \n With persons 25-59 years. 354 92.2 \n With persons above 60 years. 72 18.8 \n Persons with disability or \nchronic illness \n104 27.1 \nTable legend 1: The average exchange rate as at the time of the study was KES 128.37 for \na dollar \nOpen Defecation Free Status 198 \nOn ODF status, only 33.9 % (n=130) were found to be ODF one year after certification.  When 199 \nthe indicators were analysed singly, it was observed that access to latrine and no exposed faeces 200 \nwere at 100%; with 95.3% (n=366) owning individual latrines while the remaining 4.7% 201 \n(n=18) reporting to use shared latrines, Table 2.  202 \nTable 2: Results on ODF indicators 203 \nIndicator  Median percentage \n(%) \nP value No. of villages \nreporting 100%  \nAccess to latrine 100 1.0 13 (100%) \nSquat hole cover present 63 0.002 0 (0%) \nPrivacy 82.4 0.002 0 (0%) \nHand washing facility 82.4 0.004 2 (15%) \nNo exposed faeces 100 0.056 8 (61.5%) \n 204 \nAssociation between sanitation and hygiene practices and open defecation free status  205 \nThis analysis determined the association between various household sanitation practices and 206 \nthe likelihood of being Open Defecation Free (ODF). The results show that household that pour 207 \nash into latrines had higher odds of ODF status compared to households that do not 208 \n(AOR=4.082; 95% CI:1.730 – 9.615; p value = 0.001), while households that dug out pits for 209 \nwaste disposal had higher odds of ODF status compared to household s that do not 210 \n(AOR=2.410; 95% CI:1.018 – 5.682; p value = 0.045). Other practices such as treating water, 211 \nusing elevated racks, and regularly cleaning of latrines were not significantly associated with 212 \nODF as shown in Table 3.  213 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n10 \n \nTable 3: Association between sanitation and hygiene practices and open defecation free status 214 \nin Suna West Sub-County, Kenya 215 \nCharacteristic ODF \nn (%) \nOR (95%CI) P value AOR (95%CI) P Value \nTreating water      \nYes 123 (35.3) 3.226(0.912–8.547) 0.019 2.809 (0.978-8.065) 0.055 \nNo 5 (14.7) Ref  Ref  \nUsing elevated racks  \nYes 117 (35.7) 2.203 (1.106-4.444) 0.027 0.808 (0.343-1.901) 0.625 \nNo 11 (20.4) Ref  Ref  \nRegular cleaning of the latrine \nYes 128 (35.2) 4.878 (1.122-13.513) 0.035 2.959 (0.629-13.889) 0.170 \nNo 2 (10.0) Ref  Ref  \nPouring of ash  \nYes 121 (38.5) 4.348 (2.083-9.091) <0.001 4.082 (1.730-9.615) 0.001 \nNo 9 (12.9) Ref  Ref  \nDug out pit for waste disposal \nYes 122 (38.4) 4.504 (2.083-9.804) <0.001 2.410 (1.018-5.682) 0.045 \nNo 8 (12.1) Ref  Ref  \n 216 \nAssociation between social norms and open defecation free status  217 \nThis study found association in a number of the social norms and ODF status.  For instance, 218 \nindividuals who were not subjected to laws and penalties were considerably more inclined to 219 \nbe ODF compared to those who were (AOR = 4.145; 95% CI: 2.203 –7.802; p < 0.001), 220 \nindicating that the implementation and enforcement of legal frameworks are not essential for 221 \nencouraging ODF behaviours. Furthermore, the lack of follow-ups and support was correlated 222 \nwith increased odds of open defecation (OR = 1.985; p = 0.025), although the adjusted effect 223 \nwas not statistically significant (AOR = 2.111; p = 0.118). While follow-up support appears to 224 \nhave some effect, its impact weakens when accounting for other variables. Interestingly, those 225 \nwho did not anticipate receiving incentives were notably more likely to retain ODF status 226 \n(AOR = 0.172; 95% CI: 0.096 –0.306; p < 0.001). The reliance on intrinsic motivation and 227 \ncommunal norms could prove to be more sustainable  than dependence on external incentives 228 \nfor fostering sanitation practices. Additionally, it is important to highlight that individuals who 229 \ndid not consider the construction or maintenance of latrines to be costly were more likely to be 230 \nODF (OR = 1.934; p = 0.003), albeit this was not significant after adjustment (AOR = 1.526; 231 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n11 \n \np = 0.169). Perceived costs may initially influence the uptake of latrines, but other factors like 232 \nnorms and enforcement may take precedence in determining long -term behaviour. Finall y, 233 \nrespondents from communities where the majority felt embarrassed about not having a latrine 234 \nwere more likely to be ODF (AOR = 1.412; p = 0.046), suggesting that collective social 235 \npressure and shared values regarding sanitation can serve as a significant  motivator in 236 \nachieving and maintaining ODF status, as illustrated in Table 4. 237 \nTable 4: Association between social norms and open defecation free status Suna West 238 \nSub-County, Kenya 239 \nSocial Norms  ODF \nn (%) \nOR (95% CI) p value  AOR (95% CI) p value \nSubjection to laws and penalties  \nYes 60 (24.3) Ref  Ref  \nNo 70 (51.1) 3.256 (2.090-5.074) <0.001 4.145 (2.203-7.802) <0.001 \nFollow-ups and support \nYes 115 (33.3) Ref  Ref  \nNo 15 (50.0) 1.985 (1.089-3.620) 0.025 2.111 (0.827-5.387) 0.118 \nExpectation of rewards/Incentives \nYes 60 (22.6) Ref  Ref  \nNo 70 (58.8) 0.239 (0.150-0.380) <0.001 0.172 (0.096-0.306) <0.001 \nConstruction/maintenance expensive \nYes 70 (28.5) Ref  Ref  \nNo 50 (49.5) 1.934 (1.251-2.991) 0.003 1.526 (0.835-2.788) 0.169 \nEmbarrassing to see people defecate in open \nYes 91 (32.0) Ref  Ref  \nNo 39 (41.9) 1.587 (0.982-2.567) 0.06 0.489 (0.194-1.232) 0.129 \nMajority ashamed for not having latrine \nYes 86 (29.8) Ref  Ref  \nNo 41 (45.6) 1.927 (1.188-3.126) 0.008 1.412 (1.014-5.739) 0.046 \nOkay to defecate in rivers/bushes/dams \nYes 84 (28.2) Ref  Ref  \nNo  46 (56.1) 0.254 (0.151-0.427) <0.001 0.623 (0.329-1.179 0.146 \n 240 \n 241 \n 242 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n12 \n \nDISCUSSION 243 \nOpen defecation status 244 \nThis study found 66.1% reversion one -year post -ODF in previously certified households. 245 \nSimilarly, an earlier study had shown that 70% of villages reverted back to open defecation, 246 \nthree years after certification among seven sub -counties featured in the stu dy (12). However, 247 \nlow reversion rates have been observed (8%) in Ethiopia and Ghana after one year of CLTS 248 \nimplementation and (14.5%) in Indonesia after two years of ODF certification (4; 10). In these 249 \nstudies, latrine presence - latrine presence and usage – was used as the measure for 250 \nsustainability, the possible reasons for recording lower reversion rate. Nevertheless, reversion 251 \nhas been found to be common in villages within sub -Saharan Africa where it  has been 252 \nassociated with several factors (17 ,9 ) Moreover, sustainability of ODF achievements has been 253 \npreviously found to be a major challenge in Kenyan communities.  254 \nIn a study by Tyndale-Boscoe et al. (2013) in Uganda, Kenya, Ethiopia and Sierra Leone two 255 \nyears after CLTS, a 13% reversion was reported when latrine presence was used to measure 256 \nsustainability. However, the reversion rate would have drastically increased to 92% had the 257 \nstudy used the 5 indicators used during the initial verification process which included 258 \nfunctional latrine, means of keeping flies away (water seal or squat hole cover), absence of 259 \nfaecal matter, presence of hand washing facility with soap/ash and evidence of  latrine use in 260 \nthe re-verification (18). This, is a much higher reversion rate like the 66.1% observed in this 261 \nparticular study when all the indicators are used to measure sustainability.  262 \nWhile governments and most organisations have been very successful in getting households to 263 \nbuild and retain latrines, less success has been achieved in improving sanitation behaviour 264 \nchange which is the major aim of CLTS  (18). Overall, the findings of this study suggest that 265 \nthere is need to harmonise or standardize indicators of ODF status. Furthermore, although the 266 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n13 \n \ncurrent protocol is very clear on the non-negotiable indicators, there is need to re-look at their 267 \nrole in defining ODF status. Doing so will help in defining concepts upfront, in developing any 268 \nkind of monitoring tool of post-ODF status.  269 \nAssociation between sanitation hygiene practices and open defecation status 270 \nWe found significant association between sanitation hygiene practices and ODF status. Further, 271 \ndemonstrated that households that complied with the sanitation hygiene practices were more 272 \nlikely to be ODF. This resonates with studies done in Indonesia in which participant s from 273 \nbetter performing villages on ODF outcomes reported that messages around sanitation 274 \npromotion and good hygiene had been constantly promoted through mosques and churches. 275 \nFurther, local groups carried out monitoring after CLTS implementation in an effort to promote 276 \nhand washing with soap, treating of drinking water, proper food handling, solid and liquid 277 \nwaste management by households(10).  278 \nThat households that poured ash in the pit latrines were found to be ODF is not surprising 279 \nbecause pouring of ash in the pit latrines manages smell from latrines and therefore encourages 280 \nconsistent latrine use by all members of the household. This finding supports findings of 281 \nprevious study in which it was reported that smelly and unimproved latrines turned people back 282 \nto open defecation in Ethiopia (19). Further, latrine usage by women was tampered with 283 \nnegatively as a result of perceptions around latrine cleanliness and smell inside (10). While this 284 \nparticular study found that 21% of households presented no evidence of the use of a hand -285 \nwashing facility and 46% households did not wash their hands with soap and water always 286 \nafter using a latrine, in a study done in four African countries, there was an overall reversal rate 287 \nof 17% for signs of use of a handwashing facility and 75% for consistent handwashing with 288 \nsoap and water. Reversion for consistent hand washing with soap and water in Homa Bay and 289 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n14 \n \nKilifi stood at 83% and 67% (18).  Thus, this study recorded much lower reversal rate on 290 \nconsistent hand washing with soap as compared to previous studies. 291 \nTraining on hand washing with soap, water treatment, preparing food in a hygienic way and 292 \nproper storage and solid wastes disposal are standard parts of sanitation program  (20). 293 \nAccording to Lilje, in a study done in Chad, the  individual perception to treating water was 294 \nrated high. Respondents thought positively about the issues of water treatment and did not 295 \nperceive it to be taking much effort, time or cost (21). This mirrors the findings of this present 296 \nstudy, households that treated water were high. Water treatment commodities were available 297 \nin public health offices and distributed by CHVs at household level during dry seasons, other 298 \ncommodities were offered at health facilities to mothers attend ing clinics and further, there 299 \nwere chlorine dispensers strategically situated in communal water points.  300 \nAssociation between social norms and open defecation status 301 \nThe study found association between a given number of normative and empirical expectations 302 \nand ODF status a reflection of the existence of social norms within Suna West Sub County. 303 \nIndeed, the existence of social norms is predicated on their functions, which in turn are driven 304 \nby ecological expectation  (11). This notion is supported by the results of this study. However, 305 \na potential limitation of the current study is whether such norms have broader functions needed 306 \nto support programmes such as CLTS beyond their active phase. 307 \nResults of this study found that household that responded that the health of the family motivates 308 \nthem to be ODF were less likely to be ODF. This is in spite of previous  studies like that done 309 \nby UNICEF that reported that the most prominent motivator towards ODF status was concern 310 \nfor the health of the family(17). Households believed that stopping open defecation resulted in 311 \nreduction in diar rheal diseases thus motivating them to stop open defecation (14). In another 312 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n15 \n \nstudy, Moran, (2017) reports that health, even though may not have been a driver for the initial 313 \ndefecation behaviour change, people do continue to make effort to maintain and use latrine 314 \nbecause of their health and that of the family(22). 315 \nFurther, the study found no association between care for the family, latrine accessibility and 316 \nODF status a reflection of no prudential personal normative belief and no association was found 317 \nin privacy/security offered by latrine and even peer pressure and ODF status. In a previous 318 \nstudy, provision for privacy for superstructure, pride and the convenience of using of latrines 319 \nwere found to be important drivers for women in respect to building latrines in Indonesia (10). 320 \nThis particular study found an correlation between those that were embarrassed about not 321 \nhaving a latrine and ODF status. This is  in tandem with previous studies that reported that 322 \nshame/ disgust motivated households into behaviour change(14).  323 \nThis study found that individuals who did not consider the construction or maintenance of 324 \nlatrines to be costly were more likely to be ODF, however, this was not significant after 325 \nadjustment to indicate that perceived costs may initially influence the upta ke of latrines, but 326 \nother factors may take precedence in determining long -term behaviour change. This is 327 \nconsistent with previously studies that reported high cost of building, maintenance and repair 328 \nof latrines were among the reasons for reversion to non -ODF status (19). In their study, 329 \nBongartz et al. (2016) suggested that though CLTS was a zero-subsidy strategy, there was need 330 \nfor incorporation of sanitation marketing to CLTS to help those who can afford make informed 331 \nchoice even though this could pose challenge of interfering with behaviour change process  332 \n(23). 333 \nThose that said rewards and incentives motivate them to be ODF were found to be less likely 334 \nto be ODF. This resonates with the findings of a study done in East Java in which households 335 \nthat received some form of subsidy did not become ODF, it was discovered that subsidy was 336 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n16 \n \ndivisive since it was never enough for all households and thus hampered collective action, also, 337 \nincentives has been found to have the capacity to corrupt intrinsic motivation ( 19; 11). In the 338 \nstudy done on sustainability by UNICEF (2014), some of the enablers of sustainability were 339 \nnatural leaders working together and post-ODF follow up by CHVs (14) 340 \nNovotný et al. (2017), in their study, concluded that so cial norms were important 341 \ninstrumentally as sanitation outcomes depended on the level to which social influences were 342 \nable to shape the perceptions of benefits or risks on sanitation -related awareness in positive 343 \nways(8). Similarly, Odagiri et al. (2017) found that in addition to economic levels and lack of 344 \nreliable access to water, weaker social norms were significantly associated with the reversion 345 \nto open defecation practices (10). When looked at singly, latrine usage and open defecation 346 \nwere sustained meaning the social sanctions played out well. However, in the other areas of 347 \nhand washing with soap, provision of privacy and use of squat hole cover, there was significant 348 \nreversion registered meaning the social sanctions weren’t applied across all the non-negotiable 349 \nindicators. Suna West sub county had no deep -rooted social norms neither did the CLTS 350 \nprocess inculcate new norms to bring about the overall change in sanitation hygiene practices 351 \ndesired and to sustain it after the pressure of certification was off. 352 \nCONCLUSION 353 \nThere was partial reversion to non-ODF status in households one year after certification. This 354 \nwas mainly attributed to 3 major indicators: provision of hand washing facility, squat hole 355 \ncover and privacy. Moreover, there was sustained ODF status in househ olds with good 356 \nsanitation hygiene practices. It was, however, evident that social norms were not embedded on 357 \nthe CLTS process, thus failing to create social norms around sanitation and hygiene practices 358 \nto enhance community collective action towards ODF st atus sustainability. Therefore, it is 359 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 5, 2025. ; https://doi.org/10.1101/2025.08.01.25332764doi: medRxiv preprint \n\n17 \n \nimportant to enhance good hygiene sanitation practices, while instilling social norms to inspire 360 \ncollective and sustainable action needed in programmes such as CLTS. 361 \nACKNOWLEDGEMENT 362 \nWe acknowledge the people of Suna West Sub-County without whom this research would not 363 \nhave been done.  364 \nAUTHORS CONTRIBUTION 365 \nN.R.A. conceived the presented idea. N.R.A. developed and performed the study under the 366 \nsupervision of C.O.A. and P.O.O. 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