FIGURE 1 Evaluating WASH interventions
1
Did randomized intervention importantly change WASH behavior?
Source: Authors’ schematic.
research. Similarly, much more research is needed on exactly how fecal germs contaminate children’s environments. Which are the most important path- ways, and how can they be interrupted? If open defecation in rural India is indeed embed-
ded in longstanding social forces, it may prove diffi- cult to change. But this would be all the more reason to strive to beter understand how to do so. Studies from a diversity of methodological approaches— from quantitative intervention experiments to qual- itative fieldwork—are urgently needed to improve policy tools to eliminate open defecation. Although clear evidence now links sanitation to
child nutrition, another important open question asks about the effects of WASH on maternal nutri- tion. Maternal nutrition is a critical determinant of a child’s birth weight, of neonatal mortality, and of subsequent nutritional and developmental outcomes. How much less do pregnant mothers weigh when they live in an environment of fecal germs, and what are the consequences for children?
POLICY IMPLICATIONS
A growing base of evidence supports the inclusion of improving sanitation—and particularly reducing open defecation—among nutrition-supporting policy priorities. Tis is especially true in places, such as rural India, where open defecation remains common amid high population density, leading growing children
to be especially likely to be exposed to fecal germs. Reducing open defecation requires urgent invest- ments in learning how to reduce this practice. We must beter understand how to change behavior and promote latrine use, especially in societies where open defecation is widespread and latrine use is resisted. Te importance of WASH for nutritional out-
comes may or may not imply that WASH and nutritional programs should directly work together. Whether this is the case depends on two types of interactions: biological and pragmatic. Biologically, ongoing field experiments will provide evidence on whether certain ideally implemented nutritional and WASH interventions work best when implemented together. However, even if such a biological syn- ergy exists, governance arrangements may be either improved or worsened by an atempt to converge WASH and nutrition programs. Tis uncertainty illustrates the broader impor-
tance of governance constraints and limited state capacity. In some contexts where demand for latrine use is high, such as Bangladesh and Cambodia, san- itation has improved as households have purchased latrines from private suppliers. However, house- holds are unlikely to purchase latrines from markets where demand for latrine use is low. In places such as rural India, building demand for latrine use is likely to require public action. Although the challenge is great, the benefits for improved child nutrition could be just as substantial. ■
THE POWER OF WASH 23
2
Did nutritional outcome change?
Knowledge gained about effect of WASH on nutrition
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