Open defecation, which is still practiced by about a billion people worldwide, is one of the most compelling examples of how place influences health in developing countries. Efforts by governments and development organizations to address the world’s remaining open defecation would be greatly supported by a better understanding of why some people adopt latrines and others do not. We analyze the 2005 and 2012 rounds of the India Human Development Survey (IHDS), a nationally representative panel of households in India, the country which is home to 60% of the people worldwide who defecate in the open. Among rural households that defecated in the open in 2005, we investigate what baseline properties and what changes over time are associated with switching to latrine use between 2005 and 2012. We find that households that are richer or better educated, that have certain demographic properties, or that improved their homes over this period were more likely to switch to using a latrine or toilet. However, each of these effect sizes is small; overall switching to latrine use from open defecation is low; and no ready household-level mechanisms are available for sanitation programs to widely influence these factors. Our research adds to a growing consensus in the literature that the social context should not be overlooked when trying to understand and bring about change in sanitation behavior.

Exposure to open defecation has serious consequences for child mortality, health, and human capital development. South Asia has the highest rates of open defecation worldwide, and although the incidence declines as household income rises, differences across South Asian countries are not explained by differences in per capita income. The rate of open defecation in sub-national regions of Bangladesh, India and Nepal is highly correlated with the fraction of the population that identifies as Hindu, in part because certain rituals of purity and pollution discourage having latrines in close proximity to one’s home. Almost all open defecation occurs in rural areas, and this paper estimates how much the rate could be reduced if rural households in regions that have a higher fraction of Hindus, where open defecation is still common, altered their behaviour to reflect that of non-Hindu households in regions that are predominantly non-Hindu, where the rate of open defecation is much lower. Using nonparametric reweighting methods, this paper projects that rural open defecation in Bangladesh, India, and Nepal could be reduced to rates of between 6 and 8 per cent, compared to the prevailing level of 65 per cent.

Background Children in India are exposed to high levels of ambient fine particulate matter (PM 2.5 ). However, population-level evidence of associations with adverse health outcomes from within the country is limited. The aim of our study is to estimate the association of early-life exposure to ambient PM 2.5 with child health outcomes (height-for-age) in India. Methods We linked nationally-representative anthropometric data from India’s 2015–2016 Demographic and Health Survey ( n = 218,152 children under five across 640 districts of India) with satellite-based PM 2.5 exposure (concentration) data. We then applied fixed effects regression to assess the association between early-life ambient PM 2.5 and subsequent height-for-age, analyzing whether deviations in air pollution from the seasonal average for a particular place are associated with deviations in child height from the average for that season in that place, controlling for trends over time, temperature, and birth, mother, and household characteristics. We also explored the timing of exposure and potential non-linearities in the concentration-response relationship. Results Children in the sample were exposed to an average of 55 μ g/m 3 of PM 2.5 in their birth month. After controlling for potential confounders, a 100 μg/m 3 increase in PM 2.5 in the month of birth was associated with a 0.05 [0.01–0.09] standard deviation reduction in child height. For an average 5 year old girl, this represents a height deficit of 0.24 [0.05–0.43] cm. We also found that exposure to PM 2.5 in the last trimester in utero and in the first few months of life are significantly ( p < 0.05) associated with child height deficits. We did not observe a decreasing marginal risk at high levels of exposure. Conclusions India experiences some of the worst air pollution in the world. To our knowledge, this is the first study to estimate the association of early-life exposure to ambient PM 2.5 on child height-for-age at the range of ambient pollution exposures observed in India. Because average exposure to ambient PM 2.5 is high in India, where child height-for-age is a critical challenge in human development, our results highlight ambient air pollution as a public health policy priority. Electronic supplementary material The online version of this article (10.1186/s12940-019-0501-7) contains supplementary material, which is available to authorized users.

HighlightsBetter sanitation accounts for Cambodia’s increase in child height from 2005 to 2010.Sanitation improvements in regions over time are associated with height improvements.Community open defecation matters more for child height than household open defecation.

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