Multi-Level Assessment of Community-Led Total Sanitation Performance across Local Government Areas in Nigeria

Open defecation remains a significant environmental and public health challenge in low- and middle-income countries, contributing to diarrheal diseases, cholera, typhoid fever, and other sanitation-related infections. Community-Led Total Sanitation (CLTS) is a community-based behavioral change approach that promotes the elimination of open defecation through collective action and community mobilization. This study evaluated the effectiveness of CLTS in improving sanitation coverage and reducing open defecation in selected communities of Benue and Cross River States, Nigeria. A multilevel observational study was conducted using complete household enumeration data from 79,095 households across five Local Government Areas. Data was obtained from household sanitation records, structured monitoring tools, observational checklists, and programme reports. Descriptive statistics, Wilcoxon signed-rank tests, two-proportion z-tests, and Difference-in-Differences logistic regression with cluster-robust standard errors were applied to assess programme effectiveness. Improved sanitation coverage increased significantly from 9.60% before implementation to 22.55% after implementation, representing a 12.95 percentage-point improvement (p < 0.001), while open defecation declined from 56.99% to 7.24%, a 49.75 percentage-point reduction. Cross River State achieved greater improvements than Benue State, with a significantly stronger intervention effect (OR = 4.41; p < 0.001). The findings demonstrate that CLTS is an effective strategy for improving sanitation coverage and reducing open defecation, highlighting the importance of sustained community participation, effective local leadership, and continuous programme monitoring to achieve Sustainable Development Goal 6.