(Patil et al. 2014; Dickinson et al. 2015; Pickering et al. 2015). Studies that do find any significant relationship either focus on CLTS programs accompanied by water-supply interventions (Godfrey et al. 2014) or find the reduction in only a specific subgroup of project beneficiaries (Borja-Vega 2014).

The empirical literature, however, indicates that CLTS interventions have a positive impact on nutritional outcomes in children under five. In their study of rural Orissa, India, Dickinson et al. (2015) find that mid-upper-arm circumference increased by two standard deviations in treatment villages relative to control villages. In Mali, children under five in treatment villages were taller and less likely to be severely underweight than their counterparts from control villages. The effect was more pronounced among children under two years (Pickering et al. 2015). A similar result is reported for Mali by Gertler et al. (2015), where CLTS interventions led to a 0.17 standard deviation increase in height-for-age Z scores (HAZ). The authors, however, find no significant effect on HAZ in India and Indonesia. Using pooled village-level data from India, Indonesia, and Mali, the study estimates that in a village where everyone practices open defecation, the complete eradication of open defecation would lead to a 0.44 standard deviation increase in HAZ. However, a modest reduction in open defecation or any further reduction where the rates of open defecation are already low, is unlikely to have any detectable impact on HAZ (Gertler et al. 2015).

The project interventions in Punjab have adopted a CLTS approach, with the BCC campaign as a central pillar. The BCC campaign was geared toward both changing personal behavior and creating demand for toilets. It intended to make open defecation repulsive by making people understand that by defecating in the open they end up eating each other’s feces and risking their lives as well as the lives of their children and neighbors. The campaign took a multipronged approach. Daily morning vigils were meant to prevent people from defecating in the open by creating a sense of shame. Toilets were also being presented as a status symbol. A hygiene and cleanliness program first put forward by the Education Department was revived to promote good hygiene practices among school students. Students were informed about the ill effects of open defecation, and the importance of hygiene. To the extent a child can influence the behavior of other household members, awareness programs in schools also sought to promote household decisions to construct and use toilets. The morning vigils also sought to help form beneficial habits. Importantly, the BCC campaign has been spearheaded by motivators and master motivators who are members of the local community, specially trained in BCC by experts hired by DWSS. As suggested by the literature (Crocker et al. 2016), the continuous involvement of local motivators and champions throughout project implementation is likely to have a positive impact on turning public opinion against open defecation and promoting collective action to achieve ODF status. Moreover, the project in Punjab involves a holistic look at hygiene and sanitation, and is not focused on toilets alone. It promotes handwashing with soap and educates community members on how to safely dispose of child feces. The incentive money offered to eligible households for the construction of new 11