Higher local Ebola incidence causes lower child vaccination rates.

Ebola is a highly infectious and often fatal zoonotic disease endemic to West and Central Africa. Local outbreaks of the disease are common, but the largest recorded Ebola epidemic originated in Guinea in December 2013, spreading to Liberia, and Sierra Leone in the following year and lasting until April 2016. The epidemic presented a serious challenge to local healthcare systems and foreign aid agencies: it degraded services, caused the loss of healthcare professionals, disrupted the economy, and reduced trust in modern healthcare. This study aims to estimate the extent to which variation in one long-term measure of the quality of local healthcare (the child vaccination rate) is a consequence of local variation in the intensity of the epidemic. Applying a "difference-in-differences" model to household survey data from before and after the epidemic, we show that in 2018-2019, overall rates of vaccination for BCG, DPT, measles, and polio are lower in Guinean and Sierra Leonean districts that had a relatively high incidence of Ebola; statistical analysis indicates that this is a causal effect. The effects of the epidemic on access to healthcare have been local effects, at least in part.

Unlocking the Role of Social Norms: How They Shape Women's Public Toilet Usage in India.

Poor access to toilets has significant impacts on hygiene, health, safety, and well-being. Women in resource-poor areas may not use public toilets because of concerns about personal safety and the disapproval of others. This study examines social beliefs about women's use of public toilets in India, using data from 5,052 households in rural, semi-urban, and urban slum areas of Bihar and Tamil Nadu in 2018. We asked respondents about their beliefs regarding the prevalence of young women aged 16 to 30 years using public toilets alone and whether this behavior was approved of in their community. We also asked about their personal beliefs on this issue. We used hypothetical vignettes to assess perceptions of a young woman's behavior in different settings regarding public toilet usage by women. Our results show that people who believe many women in their community use public toilets alone and approve of it are more likely to have positive beliefs about this behavior. The experimental vignettes suggest a potential causal link between the prevalence and approval of public toilet usage among young women and their likelihood of using it. These findings are consistent across Bihar and Tamil Nadu and the three administrative regions, indicating that interventions aimed at changing social expectations about women's use of public toilets should focus on highlighting community members' usage and approval. Efforts to encourage woman's access to public toilets and services should target shifting beliefs about public toilet usage among women without disapproval from others.

Are High-Altitude Residents More Susceptible to Covid-19 in India? Findings and Potential Implications for Research and Policy.

In this paper, we study the incidence of COVID-19 and the associated fatality with altitude using high frequency, district level data from India. To understand the implications of the nationwide lockdown after the outbreak, we use data for about four months- two from the lockdown period starting from March 25 till May 31, 2020 and about two months after unlocking was initiated (June 1-July 26, 2020). The multivariate regression result indicates slower growth in average rate of infection during the lockdown period in hilly regions, the gains of which attenuated after the unlocking was initiated. Despite these early gains, the rate of fatalities is significantly higher during the lockdown period in comparison to the plains. The findings remain robust to multiple alternative specifications and methods including one that accounts for confounding possibilities via unobservable and provides consistent estimates of bias adjusted treatment effects. The evidence supports the need for provisioning of public health services and infrastructure upgradation, especially maintenance of adequate stock of life support devices, in high altitude regions. It also underscores the necessity for strengthening and revising the existing Hill Areas Development Programme and integrating important aspects of public health as part of this policy.

Social beliefs and women's role in sanitation decision making in Bihar, India: An exploratory mixed method study.

In low- and middle-income countries, poor autonomy prevents women from making financial decisions, which may impact their access to improved sanitation facilities. Inadequate access to improved sanitation disproportionately affects women's and children's health and wellbeing. Although socio-cultural factors are known contributors to gender inequity, social beliefs that potentially motivate or dissuade women from making sanitation-related household decisions are not well understood. These beliefs may vary across settlement types. To empower more women to make sanitation-related decisions, the relevant socio-cultural norms and underlying social beliefs need to be addressed. In this mixed methods study, we explored women's role in sanitation-related decision making in three settlement types, urban slums, peri-urban, and rural communities in Bihar. Trained qualitative researchers conducted six focus group discussions with women of two age groups: 18-30 years old, and 45-65 years old to understand the norm-focused factors around women's role in getting a toilet for their household. Using insights generated from these group discussions, we developed and conducted a theory-driven survey in 2528 randomly selected participants, to assess the social beliefs regarding women making toilet construction decisions in these communities. Overall, 45% of the respondents reported making joint decisions to build toilets that involved both men and women household members. More women exclusively led this decision-making process in peri-urban (26%) and rural areas (35%) compared to urban slums (12%). Social beliefs that men commonly led household decisions to build toilets were negatively associated with women's participation in decision making in urban slums (adjusted prevalence ratio, aPR: 0.53, 95% CI: 0.42, 0.68). Qualitative insights highlighted normative expectations to take joint decisions with elders, especially in joint family settings. Surrounding norms that limited women's physical mobility and access to peers undermined their confidence in making large financial decisions involved in toilet construction. Women were more likely to be involved in sanitation decisions in peri-urban and rural contexts. Women's involvement in such decisions was perceived as widely acceptable. This highlights the opportunity to increase women's participation in sanitation decision making, particularly in urban contexts. As more women get involved in decisions to build toilets, highlighting this norm may encourage gender-equitable engagement in sanitation-related decisions in low-resource settings.

On willingness to pay for Covid-19 vaccines: a case study from India.

In this paper, using survey data from 1251 respondents from peri-urban parts in the Bhopal district of India, we estimated the willingness-to-pay (WTP) for hypothetical Covid-19 vaccines. We use open-ended questions along with the discrete choice contingent valuation method for two vaccines, one with full efficacy and the other with 70% efficacy. While no major evidence of vaccine hesitancy was observed, we found a WTP of about Rs. 141 ($1.9) for the former type vaccine and about Rs. 116 ($1.6) for the latter. From the contingent valuation method, we found about 71.9% were not willing to spend Rs. 200 ($2.7) or more for the fully effective vaccine, while this figure goes up to 77.8% for the one with 70% efficacy. Estimations from linear and probit regressions suggest that economic indicators were the most important predictors of WTP. Usage of public transport, the number of days that the respondent stepped out for work, and the presence of comorbid individuals in the household were positively associated with the WTP, while pandemic-induced income reduction was negatively correlated. The findings lend support toward the requirement of highly subsidized vaccines, and hence back the recent policy announcement toward the supply of free vaccines to all states.

Norms and Social Network-Centric Behavior Change Intervention (Nam Nalavazhvu) for Improved Toilet Usage in Peri-Urban Communities of Tamil Nadu: Protocol for a Cluster-Randomized Controlled Trial.

BACKGROUND: Inconsistent toilet usage is a continuing challenge in India. Despite the impact of social expectations on toilet usage, few programs and studies have developed theoretically grounded norm-centric behavior change interventions to increase toilet use in low-income settings. OBJECTIVE: The objective of this paper is to detail the rationale and design of an ex ante, parallel cluster-randomized trial evaluating the impact of a demand-side, norm-centric behavior change intervention on exclusive toilet use and maintenance in peri-urban Tamil Nadu, India. METHODS: Following formative research, we developed an evidence-based norm-centric behavior change intervention called Nam Nalavazhvu (Tamil for "our well-being"). The multilevel intervention aims to improve toilet usage by shifting empirical expectations or beliefs about other relevant people's sanitation practices. It also provides action-oriented information to aid individuals to set goals and overcome barriers to own, consistently use, and maintain their toilets. This trial includes 76 wards in the Pudukkottai and Karur districts, where half were randomly assigned to receive the intervention and the remaining served as counterfactuals. RESULTS: We enrolled wards and conducted a baseline survey among randomly selected individuals in all 76 wards. The 1-year behavior change intervention is currently ongoing. At the endline, we will collect relevant data and compare results between study arms to determine the impacts of the Nam Nalavazhvu intervention on sanitation-related behavioral, health, and well-being outcomes and potential moderators. This study is powered to detect differences in the prevalence of exclusive toilet use between study arms. We are also conducting a process evaluation to understand the extent to which the intervention was implemented as designed, given the special pandemic context. CONCLUSIONS: Findings from this trial will inform norm-centric behavior change strategies to improve exclusive toilet usage. TRIAL REGISTRATION: ClinicalTrials.gov NCT04269824; https://www.clinicaltrials.gov/ct2/show/NCT04269824. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24407.

Awareness, Risk Perception, and Stress during the COVID-19 Pandemic in Communities of Tamil Nadu, India.

The health and economic consequences of the COVID-19 pandemic is expected to disproportionately impact residents of lower-middle income countries. Understanding the psychological impact of the pandemic is important to guide outreach interventions. In this study, we examined people's awareness of COVID-19 symptoms, risk perception, and changes in behaviors and stress levels during the lockdown in peri-urban Tamil Nadu India. Field workers conducted phone call surveys (included n = 2044) in 26 communities from 20-25 May 2020. The majority perceived no (60%) or low (23%) level of risk of personally contracting coronavirus. Common fears were related to health and economic concerns, including loss of income (62%), inability to travel freely (46%), and becoming sick (46%). Residents were well aware of the common symptoms of COVID-19, such as fever (66%) and dry cough (57%), but not the asymptomatic transmission (24%). The majority experienced increased stress about finance (79%) and the lockdown (51%). Our findings emphasize the need to develop context-adequate education and communication programs to raise vigilance about asymptomatic transmission and to sustain preventative behaviors. The evidence on fear and changes in stress levels could inform designing coping strategies and programs focused on mental well-being.

Women are more likely to expect social sanctions for open defecation: Evidence from Tamil Nadu India.

Social sanctions can be effective for sustaining beneficial norms by harnessing the power of social pressure and peer monitoring. Yet, field evidence regarding how norms might be linked to perceived risk of sanction is limited. In this study, we focused on communities located in peri-urban areas of Tamil Nadu, India, and examined how people's perceived prevalence of a socially desirable behavior (i.e., toilet use) relates to the perceived risk of sanctions for deviating from this behavior (i.e., open defecation) in the sanitation domain. Cross-sectional data from 2427 participants in 75 communities revealed that the majority (77%, n = 1861) perceived the risk of informal sanctions related to open defecation. Among those, verbal reprimand was the most common (60%), followed by advice (30%) and gossip (7%). Results from multilevel logistic regression indicated that those who believed toilet use was prevalent in their community were more likely to perceive the risk of social sanctions for open defecation. Moderation analysis revealed that this relationship was robust among women, but attenuated among men. Our findings suggest that women are more likely to expect social sanctions if they deviate from what is perceived as the prevalent sanitation behavior (e.g., toilet use) in their community. Open defecation practices are known to cause psychosocial stress among women due to their experiences with sanitation insecurity, which may include fear of disapproval from community members. Our results highlight the need for gendered intervention strategies when sanitation programs leverage social influence for behavior change.

Sanitation Practices during Early Phases of COVID-19 Lockdown in Peri-Urban Communities in Tamil Nadu, India.

In countries without adequate access to improved sanitation, government-imposed restrictions during the COVID-19 pandemic can impact toilet usage. In India, where millions have recently transitioned to using a toilet, pandemic-related barriers to use might increase open defecation practices. We assessed changes in reported defecation practices in peri-urban communities in Tamil Nadu. Field assistants conducted phone surveys in 26 communities in two districts from May 20, 2020 to May 25, 2020. They asked respondents about their access to a toilet, whether they or a family member left their house to defecate in the past week, and whether specific practices had changed since the lockdown. Among 2,044 respondents, 60% had access to a private toilet, 11% to a public or community toilet, whereas 29% lacked access to any toilet facility. In our study, 92% of the respondents did not change their defecation behaviors in the 2 months following the pandemic-related lockdown. About a third (27%) reported that they or a family member left their house daily to defecate amid lockdown measures. A majority of those with private toilets (91%) or with public toilets (69%) continued using them. Respondents with private toilet access were more likely to report an increased frequency of handwashing with soap (prevalence ratio [PR]: 1.78, 95% CI: 1.04-3.05) since the lockdown. The lack of private toilets contributes to the need to leave the house amid a lockdown. Maintaining shared toilets require disinfection protocols and behavioral precautions to limit the risk of fomite transmission. Robust urban COVID-19 control strategies should include enhanced sanitation facility management and safe usage messaging.

Bias in the perceived prevalence of open defecation: Evidence from Bihar, India.

People often form perceptions about how prevalent a behavior is in a social group. However, these perceptions can be inaccurate and biased. While persistent undesirable practices in low-income countries have drawn global attention, evidence regarding people's perception of how prevalent these practices are is scarce. Among those harmful practices, open defecation in India remains a significant public health concern, where it perpetuates the vicious cycle of disease and poverty. In this study, we focus on measuring the perceived prevalence of open defecation among respondents in Bihar, India. We examined the bias in perceived prevalence, which is defined as a pattern of deviation from the actual prevalence of open defecation. Results showed that respondents who defecate in the open overestimate the prevalence of open defecation, whereas those who consistently use toilets underestimate it. This finding suggests a false consensus bias in the perceived prevalence of open defecation. Scholars, policymakers, and program implementers who seek to correct misperceptions about open defecation by broadcasting real prevalence should be aware of biases in the perceived prevalence and address them in behavior change interventions.

COVID-19 and the case for global development.

COVID-19 accentuates the case for a global, rather than an international, development paradigm. The novel disease is a prime example of a development challenge for all countries, through the failure of public health as a global public good. The COVID-19 pandemic has highlighted the falsity of any assumption that the global North has all the expertise and solutions to tackle global challenges, and has further highlighted the need for multi-directional learning and transformation in all countries towards a more sustainable and equitable world. We illustrate our argument for a global development paradigm by examining the implications of the COVID-19 pandemic across four themes or 'vignettes': global value chains, digitalisation, debt, and climate change. We conclude that development studies must adapt to a very different context from when the field emerged in the mid-20th century.