How Does Health Promotion Work? Evidence from the Dirty Business of Eliminating Open Defecation

46 Pages Posted: 9 Mar 2015 Last revised: 16 May 2022

See all articles by Paul J. Gertler

Paul J. Gertler

University of California, Berkeley - Haas School of Business; National Bureau of Economic Research (NBER)

Manisha Shah

UCLA; NBER

Maria Laura Alzua

Universidad Nacional de La Plata

Lisa A. Cameron

University of Melbourne - Melbourne Institute: Applied Economic & Social Research; IZA Institute of Labor Economics; J-PAL

Sebastian Martinez

Inter-American Development Bank (IDB) - Office of Strategic Planning and Development Effectiveness

Sumeet Patil

University of California, Berkeley

Date Written: March 2015

Abstract

We investigate the mechanisms underlying health promotion campaigns designed to eliminate open defecation in at-scale randomized field experiments in four countries: India, Indonesia, Mali, and Tanzania. Health promotion works through a number of mechanisms, including: providing information on the return to better behavior, nudging better behavior that one already knows is in her self-interest, and encouraging households to invest in health products that lower the marginal cost of good behavior. We find that health promotion generally worked through both convincing households to invest in in-home sanitation facilities and nudging increased use of those facilities. We also estimate the causal relationship between village open defecation rates and child height using experimentally induced variation in open defecation for identification. Surprisingly we find a fairly linear relationship between village open defecation rates and the height of children less than 5 years old. Fully eliminating open defecation from a village where everyone defecates in the open would increase child height by 0.44 standard deviations. Hence modest to small reductions in open defecation are unlikely to have a detectable effect on child height and explain why many health promotion interventions designed to reduce open defecation fail to improve child height. Our results suggest that stronger interventions that combine intensive health promotional nudges with subsidies for sanitation construction may be needed to reduce open defecation enough to generate meaningful improvements in child health.

Suggested Citation

Gertler, Paul J. and Shah, Manisha and Alzua, Maria Laura and Cameron, Lisa A. and Martinez, Sebastian and Patil, Sumeet, How Does Health Promotion Work? Evidence from the Dirty Business of Eliminating Open Defecation (March 2015). NBER Working Paper No. w20997, Available at SSRN: https://ssrn.com/abstract=2575483

Paul J. Gertler (Contact Author)

University of California, Berkeley - Haas School of Business ( email )

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National Bureau of Economic Research (NBER)

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Manisha Shah

UCLA ( email )

Department of Public Policy
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United States

HOME PAGE: http://luskin.ucla.edu/person/manisha-shah

NBER ( email )

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Maria Laura Alzua

Universidad Nacional de La Plata

Lisa A. Cameron

University of Melbourne - Melbourne Institute: Applied Economic & Social Research ( email )

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Parkville, Victoria 3010
Australia

IZA Institute of Labor Economics ( email )

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J-PAL ( email )

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France

HOME PAGE: http://www.povertyactionlab.org/cameron

Sebastian Martinez

Inter-American Development Bank (IDB) - Office of Strategic Planning and Development Effectiveness ( email )

Washington, DC
United States

Sumeet Patil

University of California, Berkeley ( email )

310 Barrows Hall
Berkeley, CA 94720
United States

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