An estimated 946 million people in the world practiced open defecation in 2015, 90% of whom lived in rural areas Poor sanitation poses a substantive environmental health and development challenge. Community-led total sanitation (CLTS) has become the predominant behavior change approach to improve sanitation in rural communities in lower income countries. It is acknowledged as flexible and context-specific, but a systematic analysis of its implementation was lacking. The purpose of this dissertation was to study the context and process of CLTS implementation in various settings to identify factors that influence implementation and thereby, outcomes of the intervention. I conducted a systematic literature review of the available evidence on CLTS to document adaptations, effectiveness on sanitation and health outcomes, and quality of evidence. I found that the diffusion of CLTS worldwide was backed by minimal rigorous evidence of its effectiveness. I also found that, although CLTS adaptations had been widely documented by practitioners, no study had characterized adaptations to understand how best to structure programs to improve their effectiveness in various settings. Therefore, I analyzed adaptations through qualitative case studies of CLTS implementation in seven countries. Data collection included interviews with 293 respondents, and 34 community visits. Rather than being a “community-led” approach, I found that CLTS can be categorized into three broad implementation modalities: NGO-led CLTS, government-led CLTS, and mixed leadership of CLTS. I applied an implementation research framework to these case studies to systematically analyze context and process factors that influence CLTS implementation. This framework serves as both a hypothesis generating tool for researchers and a diagnostic tool for practitioners. My work suggests that an honest exploration and understanding of CLTS implementation is vital to identify improvements, to understand the potential of the approach to achieve desired outcomes, and to recognize ways in which it can be implemented to improve rural sanitation in different contexts and settings. By building a stronger evidence base of mixed methods, and offering concrete tools and recommendations for practitioners and policymakers, the aim is to bridge the gaps between academic implementation theory, ambitious policymaking, and dynamic CLTS practice to improve sanitation programs.Doctor of Philosoph
