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2 coffey hemoglobin-presentation_short_version

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2 coffey hemoglobin-presentation_short_version

  1. 1. open defecation and hemoglobin deficiency in young children Diane Coffey rice, a research institute for compassionate economics Office of Population Research, Princeton University Centre for Development Economics, Delhi School of Economics prepared for Child Height & Disease Conference, Aug. 2 & 3, 2013
  2. 2. what is hemoglobin deficiency?  hemoglobin is a protein in red blood cells that carries oxygen  hemoglobin deficiency is a marker of anemia  anemia is defined having hemoglobin concentration below a threshold ◦ 11 gm/dL blood for kids (WHO, 2005)
  3. 3. why does it matter?  consequences in adults ◦ reduced work capacity (Basta et al., 1979; Thomas et al., 2004) ◦ maternal survival (Rush, 2000)  consequences in children ◦ increased susceptibility to infection (Scrimshaw, 2000) ◦ impaired cognitive ability (Grantham McGregor & Ani, 2001) ◦ impaired physical development (Walter et al., 1989)
  4. 4. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 WHO (2005) estimated anemia prevalence among children under five
  5. 5. hypothesis:
  6. 6. outline  background  3 analyses ◦ 1. cross country results ◦ 2. cross sectional results from India & Nepal ◦ 3. fixed effects results from Nepal  summary, implications for policy & next steps
  7. 7. background
  8. 8. causes of hemoglobin deficiency in young children • malaria • intestinal parasites • environmental enteropathy • dietary deficiencies on diet and disease, see Friis et al., 2003 background
  9. 9. links between OD & hemoglobin • open defecation spreads intestinal parasites – worms live in feces – feces on the ground get onto feet and into mouths – this has been known since at least the 1930s (Cairncross, 2003) • open defecation exposes kids to fecal pathogens that could lead to enteropathy background
  10. 10. links between height & hemoglobin • this study is consistent with other research on open defecation and height – open defecation thought to cause stunting through enteropathy and diarrhea • research indicates that hemoglobin deficiency causes children to be shorter and thinner – larger bodies need more red blood cells to transport oxygen (see Owen, 1989) background
  11. 11. 3 analyses
  12. 12. 1. cross country analysis
  13. 13. data • hemoglobin: Demographic & Health Surveys from 45 countries – 81 surveys have kids 6-35 months – surveys date from 1995 – 2012 – almost 60% of surveys are from SSA • GDP/capita: Penn World Tables • malaria: WHO incidence estimates (Korenromp, 2005) cross country analysis
  14. 14. identification how are open defecation levels across countries and years associated with hemoglobin levels across countries and years? cross sectional analysis
  15. 15. open defecation predicts average hemoglobin across countries
  16. 16. specification • hcry is the average gm/dL of hemoglobin of children 6-35 months in country c, in region r, in year y • odcry is the fraction of households openly defecating in country c, in region r, in year y • mcr2004: the country’s estimated incidence of malaria (new cases per year/number of people at risk) • GDPcry: country and year specific per capita GDP • y : year fixed effects cross country analysis
  17. 17. open defecation predicts average hemoglobin across countries
  18. 18. additional specifications (not shown) • use log of open defecators per square kilometer as an independent variable • use the 77 country years with hemoglobin measures for kids aged 6 to 59 months cross country analysis
  19. 19. 2. cross sectional analysis from India & Nepal
  20. 20. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 1990 2010 fractionofthepopulationwithnoaccesstosanitation open defecation is worst in South Asia from: WHO & Unicef Joint Monitoring Report, 2012
  21. 21. data • India’s National Family Health Survey 3 (2005) – 36,000 kids 6-59 months with hemoglobin data – 26,000 kids with hemoglobin & food intake data • Nepal’s Demographic & Health Survey (2011) – 2,100 kids with hemoglobin data – 1,000 kids with hemoglobin & food intake data cross sectional analysis: India & Nepal
  22. 22. identification how is open defecation across places within South Asian countries associated with hemoglobin levels of children in those places? cross sectional analysis: India & Nepal
  23. 23. summary statistics
  24. 24. specification • hip is the hemoglobin (gm/dL) of child i in primary sampling unit (PSU) p • odp is the fraction of households openly defecating in the child’s PSU • Mip (medicine): does the child take iron supplements?; did she take de-worming medicine in last 6 months? • Fip (food): breast feeding; number of time fed solid/semi-solid food in last 24 hours; ate meat in last 24 hours; ate dark green leafy vegetables in last 24 hours cross sectional analysis: India & Nepal
  25. 25. • elecp is the fraction of households in the child’s PSU with electricity • urbanp is whether or not the child’s PSU is urban • Eip (mother’s education): linear or dummy variable controls for mother’s education • SESip (socioeconomic status): child’s household wealth percentile, or asset ownership dummies • (AipXsexip): 120 sex-specific age-in-month indicators cross sectional analysis: India & Nepal
  26. 26. open defecation predicts hemoglobin in India
  27. 27. open defecation predicts hemoglobin in Nepal
  28. 28. additional specifications (not shown) • interaction of open defecation & parasite medicine in India • parasite medicine has less of an effect on hemoglobin where open defecation is more widespread! cross sectional analysis
  29. 29. 3. fixed effects analysis from Nepal
  30. 30. data • Nepal’s Demographic & Health Surveys from 2006 and 2011 – 4,680 kids 6-59 months in 2006 – 2,100 kids 6-59 months in 2011 • 15 percentage point drop in open defecation from 2006-2011 – about 50% of households (2006) to about 35% of households (2011) fixed effects analysis: Nepal
  31. 31. identification how is change over time in open defecation within 25 urban and rural parts of each DHS region (subsequently referred to as regions) associated with change in hemoglobin levels in those regions? fixed effects analysis: Nepal
  32. 32. specification • hiyr: hemoglobin measure of child i, in year y, in region r • odyr: fraction of HH openly defecating in the child’s region • elecyr: fraction of HH with electricity in the child’s region • y: year of survey fixed effect (indicator for 2011) • δr: region fixed effect • Eiyr: indicators for mother’s years of education • SESiyr: economic status dummies • (Aiyr X sexiyr): 120 sex-specific age-in-month indicators fixed effects analysis: Nepal
  33. 33. change in open defecation predicts change in hemoglobin in Nepal
  34. 34. summary, implicati ons for policy & next steps
  35. 35. summary  discussed two mechanisms through with open defecation could impact hemoglobin ◦ parasites ◦ environmental enteropathy  presented results of 3 analyses which support an effect of open defecation on hemoglobin ◦ cross country results from 81 surveys ◦ cross sectional results from India & Nepal ◦ fixed effects results from Nepal
  36. 36. implications for policy (1 of 3) This study provides econometric evidence that open defecation may be an important cause of hemoglobin deficiency.
  37. 37. implications for policy (2 of 3) It suggests that current efforts to improve hemoglobin by supplementing diets and fortifying foods could be importantly complemented by sanitation provision.
  38. 38. implications for policy (3 of 3) This study adds to a growing body of research that shows the importance of sanitation for nutrition, particularly in South Asia.
  39. 39. next steps for this project  understand why/how OD in Nepal decreased  compare effect sizes with those associated with other causes of hemoglobin deficiency  control for variation in malaria exposure within South Asia  explore the effect of open defecation on hemoglobin among women  your ideas…?
  40. 40. questions? comments?
  41. 41. hemoglobin level by age in India & Nepal
  42. 42. summary statistics

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