Evaluation of a district-wide sanitation programme in rural Malawi: does it include people living with disabilities?

Community-led total sanitation (CLTS) is embraced as a key strategy to achieve universal sanitation coverage (Sustainable Development Goal 6.2). Although inclusion is identified as a predictor of CLTS success, people living with disabilities are often excluded from community sanitation programmes and there is limited research exploring CLTS participation amongst people living with disabilities. This study aims to explore the extent to which people living with disabilities participated in a CLTS intervention delivered in rural Malawi. This cross-sectional study was conducted in the Chiradzulu district of Malawi. A household questionnaire was administered to collect information about CLTS participation. Multivariable logistic regression was performed to compare participation in different CLTS activities between households with (n=80) and without a member with a disability (n=167), and between household members with (n=55) and without a disability (n=226). No difference in CLTS participation was observed at the household-level, but there were marked differences in CLTS participation between household members with and without a disability. Household members without a disability reported higher attendance at the triggering session (OR=2.09, 95%CI 1.00–4.37), gave more input in triggering activities (OR=3.72, 95%CI 1.46-9.51), and reported higher participation in the transect walk (OR=4.03, 95%CI 1.52-10.68), community action planning (OR=2.89, 95%CI 1.23-6.79), and follow-up visits (OR=3.37, 95%CI 1.67-6.82) compared to household members with disabilities. There was no difference in the likelihood of being invited to triggering (OR=0.98, 95%CI 0.43–2.22) or participating in community mapping (OR=2.38, 95%CI 0.63-8.99) between household members with and without a disability. This study revealed intra-household inequalities in CLTS participation. To improve participation in CLTS interventions, facilitators should be trained on action steps to make CLTS more inclusive. Further research could include an in-depth analysis of predictors of CLTS participation amongst people living with disabilities, including disability types, severity and age. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Funding was awarded to RD by World Vision USA (grant number: 102239IC). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Travel for KD was supported by LSHTM MSc Project Funding. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval was gained from LSHTM’s MSc Research Ethics Committee (Ref 28569) and Malawi’s National Committee on Research in the Social Sciences and Humanities (NCST/RTT/2/6, P.09/22/673). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data has been deposited within a data repository (LSHTM Data Compass) and is under review. DOI pending.