Community-Led Total Sanitation implementation in Malawi: process evaluation of a sanitation and hygiene intervention

Community-Led Total Sanitation (CLTS) seeks to eliminate open defecation by empowering households to adopt improved sanitation and hygiene behaviours. While widely integrated into national sanitation strategies of low- and middle-income countries, limited evidence exists on how implementation processes drive behaviour change. This study aimed to evaluate the implementation fidelity, reach, dose, adaptation, and mechanisms of impact of a CLTS intervention in Chiradzulu District, Malawi. We conducted a retrospective mixed methods process evaluation between January 2022 and February 2023, using 1,151 household surveys, 36 in-depth interviews, and 28 focus group discussions with community members and implementers. Outcomes assessed were latrine and handwashing facility (HWF) availability, with logistic regression used to explore associations with intervention exposure. All planned activities were delivered, but fidelity was variable ranging from low fidelity for training delivery to high fidelity for household engagement. Intervention reach was suboptimal, with limited household contact and low recall of hygiene campaigns. Combined exposure to both community and household-based activities significantly increased odds of latrine ownership (OR = 1.63, CI = 1.55-1.72) and HWF presence (OR = 1.39, CI = 1.03-1.86). CLTS programmes should strengthen intervention fidelity, integrate affordable climate resilient facilities, and strengthen household-based engagement to enhance sustainability and impact.