Table 8b shows similar comparisons for a range of other symptoms of child illness. Changes in health symptoms that are unlikely to be affected by the treatment can be used to confirm that the observed differences between the treatment and control communities are not attributable to systematic reporting bias. Bruising/abrasions and itchy skin/scalp are two symptoms that are unlikely to be affected by the intervention. Table 8b shows that the differences in these symptoms between control and treatment communities are small and statistically insignificant.

Indeed, most of the reported symptoms show no difference between the control and treatment groups in the endline. However, the prevalence of mucus or blood in the stool is significantly lower for children in the treatment group (0.8 percent _cf._ 2.0 percent). Refusal to eat is also lower in the treatment group. Apart from these symptoms, only the prevalence of nasal congestion differs between the control and treatment communities. It is higher in the treatment communities.

# _8.8 Anemia, Anthropometric, and Developmental Measures_

Poor sanitation leads to diarrhea and diarrhea can increase the prevalence of anemia because it reduces the absorption of nutritional intake, including the absorption of iron, which is used in the production of hemoglobin. Any child with hemoglobin levels below 110 g/L is considered anemic as per WHO guidelines for children under five years of age (UNICEF, WHO, and United Nations University, 2001; WHO, 2011). Hemoglobin levels rose during the study period, consistent with the children having aged between baseline and endline. This translates into a much lower proportion of children with anemia at the end of the study period than at the beginning (44.2 versus 71.2 percent). However, there is no evidence of great declines in treatment communities vis-à-vis control communities. There is no significant difference in hemoglobin levels and anemia between the control and treatment groups.

Anthropometric measurements (weight, height, arm and head circumference, body mass index) were taken for all children under five years old at the time of the baseline in the surveyed households. Child anthropometric measurements provide useful information about nutritional intake and so are adversely affected by illnesses such as diarrhea. Weight (conditional on height and gender) typically varies in the short-term so is used as a measure of current health status whereas height, given age and gender, is an indicator of longer-term health and welfare (Thomas, et al., 1991).

To assess the child’s growth and general nutritional status, we used a standardized age- and gender-specific growth reference based on the WHO (2006, 2007) standard to calculate _z_ -scores for a) weight-for-height, b) height-for-age, c) weight-for-age, d) body-mass-index, e) head circumference-for-age, and f) arm circumference-for-age.<sup>18</sup> All of the child growth measures

> 18 For example, a _z_ -score for height subtracts from the child’s height, the median height in the reference population, for a child of the same gender and age in months, and divides by the standard deviation of height in the reference population, also for a child of the same gender and age in months. A weight-for-height _z_ -score is defined in an analogous manner, except that the standardization is done using the reference population median and standard

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