Family and social effects on adoption of preventative health measures

环境卫生-广义地说，是通过防止人类接触危险废物，特别是人类废物，促进健康的卫生手段-长期以来一直被认为是疾病预防和初级保健方案的一个不可或缺的要素（《阿拉木图宣言》，1978年）。估计有23亿人无法获得基本卫生服务，45亿人无法获得安全管理的卫生设施。因此，这一问题的规模是紧迫的，改善环境卫生被纳入千年发展目标和可持续发展目标。据估计，改善卫生设施可以防止每年361 000名5岁以下儿童中的大多数与疟疾有关的死亡。改善卫生条件也将对发展中国家的经济增长产生重大影响：世界银行的水和卫生项目估计，印度，拟议研究的背景下，由于卫生条件不足，每年损失超过6%的GDP。在发展中世界，提高卫生设施覆盖率的战略主要侧重于提供信息和信贷或补贴，以鼓励建造私人家庭厕所。然而，最近对低收入国家卫生干预措施进行的大量影响评价研究发现，卫生干预措施对厕所的使用和使用影响不大。对于旨在改善环境卫生、进而改善健康和生产力的政策的设计和针对性而言，至关重要的是要更深入地了解是什么缺陷和制约因素导致环境卫生干预措施未能充分发挥其潜力。拟议的研究旨在通过确定社会因素在解释卫生设施采用决定中的重要性，为有效的卫生设施干预措施和政策的设计提供信息。特别是，我们的研究将侧重于了解家庭内部动态的作用，例如可能对卫生设施有不同价值的丈夫和妻子之间的动态，以及同龄群体内部的动态，这对于通过社区内的群体提供的小额信贷等干预措施特别重要。我们重点关注印度的情况，全球近10亿露天排便人口中有近60%来自印度（世卫组织/联合国儿童基金会JMP，2017年）。印度政府致力于到2030年实现可持续发展目标6，即人人享有清洁水和卫生设施，包括通过其雄心勃勃的清洁印度运动，该运动旨在到2019年使印度无露天排便。与此同时，印度仍然是一个父权制社会，妇女往往被视为从属于男子，社会上对社区内的社会交往有着非常严格的规范。因此，社会因素，特别是与性别和社区有关的因素，可能对印度的卫生投资构成特别强烈的限制。首先，我们要问的是，妇女是否确实承担了露天排便的更高成本，并相对于男子对厕所给予了更高的评价。第二，由于妇女在印度贫困家庭中的议价能力往往较低，我们将调查家庭内部就预算和流动性进行的讨价还价在多大程度上限制了她们通过建造私人厕所或使用社区厕所来投资卫生设施的能力。第三，鼓励个人通过小额信贷投资于私人厕所的有效性也可能取决于共同责任小额信贷团体中关键个人的偏好和行为。我们将探讨这种群体内的动态以及领导者如何影响卫生投资决策。最后，我们将模拟和测试投资厕所是否会让婚姻市场上的新郎更有机会吸引更高质量的新娘（或任何新娘）。

Sanitation - broadly defined as hygienic means of promoting health through prevention of human contact with the hazards of waste and in particular human waste - has long been acknowledged as an indispensable element of disease prevention and primary health care programmes (Declaration of Alma-Ata, 1978). An estimated 2.3 billion people do not have access to basic sanitation services, and 4.5 billion people do not have access to safely managed sanitation. Hence the scale of the problem is urgent, and improving sanitation is included in both the Millennium and Sustainable Development Goals (MDGs and SDGs). It is estimated that better sanitation could prevent the majority of diarrheal-related deaths of 361,000 children aged less than 5 years each year. Improved sanitation would also have substantial impacts on developing countries' economic growth: the Water and Sanitation Program of the World Bank estimates that India, the context of the proposed research, loses more than 6% of its annual GDP due to inadequate sanitation. Strategies to improve sanitation coverage across the developing world have focused predominantly on providing information and credit or subsidies to encourage the construction of private household toilets. However, a large number of recent impact evaluation studies on sanitation interventions in low-income countries find only modest impacts on toilet uptake and usage. It is crucial for the design and targeting of policies aimed at improving sanitation, and consequently health and productivity, to gain a deeper understanding of what imperfections and constraints are driving this observed failure of sanitation interventions to achieve their full potential. The proposed research aims to inform the design of effective sanitation interventions and policies by identifying the importance of social factors in explaining sanitation adoption decisions. In particular, our research will focus on understanding the role of dynamics within the household, such as between husband and wife who may value sanitation differently, and within peer groups, which are particularly important in interventions such as micro-credit which are delivered through groups within the community. We focus on the context of India, which contributes almost 60% of the close to one billion people who defecate in the open globally (WHO/UNICEF JMP, 2017). The Government of India is committed to achieving SDG 6 of clean water and sanitation for all by 2030, including via its ambitious Clean India Movement which aims to make India open-defecation-free by 2019. At the same time, India remains a patriarchal society, where women are often seen as subordinate to men, and a society with very strict norms governing social interactions within the community. Social factors, and in particular those related to gender and community, are therefore likely to pose particularly strong constraints on sanitation investments in India.We will seek to answer a number of important and related questions. First, we will ask whether women indeed bear higher costs of open defecation and place a higher valuation of toilets relative to men. Yet second, since women often have lower bargaining power within poor Indian households, we will investigate to what extent bargaining within the household over budget and mobility constrains their ability to invest in sanitation via building private latrines or using community toilets. Third, the effectiveness of encouraging individuals to invest in private latrines via microfinance lending is also likely to depend on the preferences and behaviour of key individuals within joint-liability microfinance groups. We will explore such intra-group dynamics and how leaders influence sanitation investment decisions. Finally, we will model and test whether investing in toilets allows grooms on the marriage market a better chance of attracting higher-quality brides (or any bride at all).