Family and social effects on adoption of preventative health measures

卫生设施--广义上定义为通过防止人类接触废物、特别是人类排泄物的危害来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不可或缺的要素(1978年《阿拉木图宣言》)。据估计，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，这一问题的规模十分紧迫，改善卫生设施已列入千年发展目标和可持续发展目标(千年目标和可持续发展目标)。据估计，更好的卫生条件每年可防止361,000名5岁以下儿童因腹泻而死亡。卫生条件的改善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，由于卫生设施不足，拟议中的研究背景下的印度每年损失超过6%的GDP。提高发展中世界卫生复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，最近关于低收入国家卫生干预措施的大量影响评估研究发现，对厕所的吸收和使用只有轻微的影响。对于制定和确定旨在改善卫生设施、进而改善健康和生产力的政策至关重要，要更深入地了解是什么不完善和制约因素在推动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方面的重要性，为有效卫生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，例如可能以不同方式重视卫生设施的夫妻之间以及同龄人群体之间的动态，这在通过社区内的群体提供的小额信贷等干预措施中尤其重要。我们重点关注印度的情况，在全球近10亿露天排便的人中，印度贡献了近60%(世卫组织/儿童基金会联合计划，2017年)。印度政府致力于到2030年实现人人享有清洁水和卫生设施的可持续发展目标6，包括通过其雄心勃勃的清洁印度运动，目标是到2019年使印度实现无人排便。与此同时，印度仍然是一个父权社会，女性往往被视为从属于男性，而且这个社会对社区内的社会互动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，可能会对印度的卫生投资造成特别大的制约。我们将设法回答一些重要的和相关的问题。首先，我们会问，女性是否真的承担了更高的露天排便成本，并比男性更看重厕所的价值。其次，由于女性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关于预算和流动性的讨价还价在多大程度上限制了她们通过修建私人厕所或使用社区厕所来投资卫生设施的能力。第三，通过小额信贷鼓励个人投资私人厕所的有效性也可能取决于共同责任小额信贷集团内关键个人的偏好和行为。我们将探讨这种集团内部的动态，以及领导人如何影响卫生投资决策。最后，我们将建模并测试投资厕所是否会让婚姻市场上的新郎有更好的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).