# **_6.5._ Health Outcomes**

The TSSM and HWWS interventions are aimed at provoking handwashing and sanitation related behavior change with the ultimate goal of improving the population’s health, particularly health outcomes amongst children under 5. These results are presented in Table 13. We analyze the program’s impact on the probability of diarrhea in the past 7 and 14 days as a short term measure of health from exposure to pathogens; hemoglobin levels/anemia and weight as medium term measures of health; and height and head circumference as longer term indicators of the cumulative effects of improved health.

For the analysis of diarrhea we use the large-scale household listing survey measuring the existence of one or more diarrheal episodes amongst children under 5 in the past 14 days (n= 34,045), as well as the caregiver report during the in-depth household survey on symptoms of diarrhea amongst children under 5 (n=5,768). The diarrhea incidence from the listing data includes a much larger sample size and a longer time horizon when compared to the in-depth household survey data, thereby providing more power for the measure of impacts on this variable. Using the listing data, we estimate a decline in diarrhea of 2.1 percentage points (significant at the 10% level) in the combined treatment group, which constitutes a relative reduction of 12.5% compared to the control group where 16.8% of children are reported as having had diarrhea in the past 14 days. The estimated coefficients in the TSSM and HWWS only groups are negative but insignificant. However, when we analyze the household selfreported outcomes on diarrhea symptoms in the past 7 days we observe no significant differences between treatment and control groups. Diarrhea symptoms are reported for 8.6% of children in the control group, and while the coefficients on the three treatment groups are negative, they are small and statistically insignificant.

Hemoglobin (Hb) levels test for the presence of iron-deficiency anemia, which proxies for the child’s nutrient intake and absorption. Nutrient absorption can be affected by intestinal pathogens that reduce the absorptive capacity of the child’s intestinal tract. We observe no differences in either the level of measured Hb or the probability of anemia for children in the TSSM and HWWS only groups. However, in the combined treatment group, children show a small but significant decline of 1.65 g/L in hemoglobin (a 1.5% relative decline compared to the average of 111.4 g/L in the control group) and a significant increase in the probability of being anemic (defined as Hb<110 g/L), 6 percentage points higher than the 41.4% incidence observed in the control group. A second indicator that does not change in the singular treatment arms is weight-for-age (z-score), an indicator of children’s short term health. The average weight-for-age z-score in the combined intervention group declines by 0.075 standard deviations off of an average weight-for-age z-score of -1.03. Although biologically insignificant, the unexpected direction of the effects of the program on children’s health, as measured through anemia and weight, particularly in light of reduced presence of diarrhea in the same population, is a puzzle that we explore further in the next section.

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