status is associated with access to an improved toilet (World Bank provincial nutrition status notes, based on either a bivariate or a multivariate test depending on the province); access to piped water (Headey, Hoddinott, and Park 2016; Mahmood 2001; World Bank provincial nutrition status notes, based on either a bivariate or a multivariate test depending on the province); or treatment of water for drinking or handwashing with soap or ash (Fazal et al. 2013).

The lack of effect documented in some studies suggests that access to, and use of, piped water and toilet facilities may not guarantee clean water for drinking and hygiene, or safe sanitation. The 2012–13 DHS finds that 10% of households shared toilet facilities with other households. In villages outside of Karachi, Sindh, Baker et al. (2016) find that shared access to facilities is positively associated with the likelihood of child diarrhea. Assessments at water samples at diverse sites across Pakistan find bacterial contamination above WHO guidelines. Memon et al. (2011) find that 85% of samples from water bodies (dug wells, shallow pumps canal water, and water supply schemes) in three districts of Sindh were contaminated. Examining water quality in southern Lahore, Punjab, Haydar, Arshad, and Aziz (2009) detect no bacterial contamination at source, but contamination in 63% of household connections, rising to 75% after the monsoon rains.<sup>42</sup> Cheema (2013) finds 47% of household samples are contaminated in Punjab, and that household access to piped water is positively associated with the likelihood of child diarrhea in urban areas, presumably because of cross contamination between water and sanitation pipelines. Examining villages in southern Punjab, Jensen et al. (2004) find high levels _of Escherichia coli_ contamination in household water containers. As noted earlier, the 2012–13 DHS finds that only 8% of households appropriately treat water before drinking.

_Community-level factors_ : Two studies examine the effects of community indicators related to reproductive, maternal, and child healthcare service and sanitation. Headey, Hoddinott, and Park (2016) find that the open defecation rate at the survey cluster level is negatively associated with HAZ. Along the same lines, Arif et al. (2014) find that the percentage of dwellings with flush toilets at the village level is positively associated with WHZ and WAZ, but not HAZ. The study also finds that the percentage of households visited by LHWs at the village level is positively associated with WHZ, WAZ, and HAZ.

_Findings from qualitative studies_ : Available qualitative research suggests other potentially important determinants of child nutrition status. For example, based on interviews of households that had used severe acute malnutrition (SAM) treatment services at health facilities in Sindh, Puett and Guerrero (2014) identify several factors that may have discouraged the full use of such services. These include: seasonal migration; extreme weather (high temperatures, flooding); long travel times; poor road conditions and limited, affordable transport options; foregone earnings and other opportunity costs; cultural restrictions on women’s mobility; and limited knowledge of nutrition services and of the benefits of nutrition and health.<sup>43</sup> Based on interviews with health workers in communities around a hospital in KPK, Dykes et al. (2012) suggest that maternal and child nutrition status is undermined by poor awareness among women and men of what constitutes

> 42 For the same sample, 50% of the house connections were contaminated with fecal coliform, rising to 75% after the monsoon rains.

> 43 A child is considered to suffer from severe acute malnutrition if his or her <mark>WHZ is three standard deviations</mark> below the international reference population median, or he or <mark>she is observed to be severely wasted or have signs of nutritional oedema (WHO 2009).</mark>

22