Treatment impacts on hygiene behavior.

BackgroundOpen defecation (OD) remains a significant public health challenge in India, contributing to adverse child health outcomes. Eliminating OD and improving child health necessitates both universal access and adoption of toilets. Despite the success of removing credit constraints and enhancing access to subsidized toilets through national sanitation campaigns, the adoption of these toilets is still lagging in India. This is because households might also be lacking information about the benefits of using toilets (information constraint).MethodsIn this paper, we test for the joint efficacy of the removal of information and credit constraints versus solely addressing the credit constraint at eliminating OD, based on a cluster randomized control trial in rural India. We implemented two interventions: a universal community-led behavior change campaign along with subsidized construction of individual household toilets for every household that opted for subsidy (cluster A) and only subsidized construction of individual household toilet construction for every household that opted for the subsidy (cluster B). No behavior change was provided in cluster B. The control group did not receive any intervention.ResultsWe find that the removal of information and credit constraints at a near-universal level in cluster A resulted in improved toilet access and adoption, eliminating OD at the community level, with a significant gain in child weight-for-age z-scores (WAZ scores). There was an increase in the percentage of households that owned individual household toilets from 2% to 98% and a decline in female respondents practicing OD from 98% to 4% in cluster A. In cluster B, ownership of individual household toilets improved by 78 percentage points (from 6% to 84%), but OD decreased by only 45 percentage points (from 95% to 50%) for the respondents. The control group saw no significant changes. For children under five, there was a statistically significant increase in WAZ scores by 0.68-0.69 standard deviations in cluster A, while cluster B showed insignificant changes when compared to the control group.ConclusionsThe study implies that supplementing universal financial support with community-level information intervention enhances sustainable adoption of improved sanitation facilities, aiding India’s progress towards an open defecation-free nation and improving child health outcomes.背景 露天排便（Open Defecation, OD）仍是印度面临的重大公共卫生挑战，会对儿童健康产生不利影响。要消除露天排便、改善儿童健康，需要实现厕所的全面普及与使用推广。尽管印度通过全国性卫生运动消除了信贷约束、提升了补贴式厕所的可及性，但厕所的使用普及率仍处于较低水平。究其原因，家庭可能缺乏对使用厕所益处的了解，即存在信息约束。 方法 本研究基于印度农村地区的整群随机对照试验，对比验证了同时消除信息约束与信贷约束，与仅消除信贷约束这两种方案在消除露天排便方面的联合效果。我们设置了两组干预措施：A组为全域社区主导的行为改变宣传活动，结合为所有申请补贴的家庭提供户用单体厕所的补贴建设服务；B组仅为申请补贴的家庭提供户用单体厕所的补贴建设服务，未开展任何行为改变宣传。对照组不接受任何干预措施。 结果 研究发现，A组在近乎全域范围内同时消除信息与信贷约束后，厕所的可及性与使用率均得到提升，实现了社区层面的露天排便消除，且儿童年龄别体重Z评分（Weight-for-Age Z-score, WAZ评分）得到显著改善。A组中拥有户用单体厕所的家庭占比从2%提升至98%，报告露天排便的女性受访者占比从98%下降至4%。B组中户用单体厕所的家庭占比提升了78个百分点（从6%升至84%），但受访者中露天排便的比例仅下降了45个百分点（从95%降至50%）。对照组未出现显著变化。对于5岁以下儿童，A组的WAZ评分较对照组提升了0.68至0.69个标准差，差异具有统计学意义；而B组的变化与对照组相比无统计学显著性。 结论 本研究表明，在全域财政支持的基础上补充社区层面的信息干预措施，能够提升改良卫生设施的可持续使用普及率，助力印度实现无露天排便国家的目标，并改善儿童健康结局。