Caused by a lack of basic human rights, stunting plagues many individuals living in low- and middle-income nations throughout the world. Stunting first manifests itself when a child is significantly shorter than the average height for children in a specific area, specifically having a "height-for-age [that] is below two standard deviations from the median of the World Health Organization Child Growth Standards” (Improving Child 7). However, simply lacking height does not immediately raise concern, it could just be genetics, right? But when a large percentage of the child population is over two standard deviations below the median height, it cannot be written off as “genetics.” Studies have found that this stunted growth, the lack of height, is the first visible effect of more serious damage occurring inside the brain (“The Double”).
When a young child, especially in his first twenty four months, experiences a prolonged deprivation of nutrients, his brain is seriously inhibited. So serious, in fact, that not only is the child’s height forever limited, but so is his brain capacity. In other words, when the brain does not develop as it should in the instrumental first few years of a child’s life, there are irreversible, lifelong consequences— the brain will forever lack the ability, the neurons, to operate with the productivity and efficiency that a non-stunted brain works at (Improving Child iv).
The consequences of this underdeveloped brain manifest themselves in a number of ways throughout the lives of those stunted. To start with, according to studies done by the World Bank, the IQ of stunted children is about five to eleven points lower than that of non-stunted children (“The Double”). This quantifies and numerically exemplifies the lack of productivity within a stunted brain: it simply cannot operate at the level of a non-stunted brain. This lack of efficiency extends past the ability to acquire knowledge and solve problem: the lack of efficiency in the brain equates to an inefficiency in the immune system, consequently leading to increased risk and instances of not only illness and but also non-communicable diseases (i.e. diabetes, obesity, etc.) in the stunted population that extends throughout their lifetime. Being sick more often not only equates to an increased amount spent on health care, but also to an increased number of school and work absences. From there, the combination of having both lower attendance rates and brain function than those who are not stunted sets stunted children up for failure: they fall behind in school leading to an overall lower education level than their peers. Having completed less school then results in lower wages which only makes it more likely that the children of those who are stunted will be stunted as well. This intergenerational aspect of stunting only increases the severity of problem of stunting: the cycle, unless broken, will continue to permeate itself throughout societies, overtime decreasing the available human capital in the places that are in most in need of it, thereby increasing the challenge and difficulty for communities to bring themselves out of poverty (Improving Child iv, “Stunting”).
In 2011, five percent of the world’s stunted population of children under five lived in Indonesia. At the time about thirty six percent of Indonesian children under five were stunted (Improving Child 9). This percentage increased, and in 2013 over eight million children under the age of five were stunted, equating to 37.2% of the Indonesian young child population (“The Double”). However, the prevalence of stunted children is not homogenous across society: while forty percent of children living in rural areas are stunted, only thirty-one percent of those living in urban areas are stunted (Improving Child 75). Difficulties faced by rural and urban households are innately different, and therefore, I am focusing on decreasing instances stunting in rural areas where the prevalence is greater.
As previously mentioned, stunting is caused by extended periods of malnutrition. While the most direct and obvious cause of malnutrition is the constant lack of food, or even the lack of quality food, illness also plays an integral role in malnutrition (Improving Child 4). Diarrhea and other illnesses caused by lack of sanitation in households and communities cause the few nutrients that are in the body, the nutrients that are available to a child, to be completely flushed out of the body, as if the child had never consumed them in the first place (“Stunting”). These illnesses inherently waste the little food and nutrients a household has access to while lowering the quality of life and is costly to poor families in other ways. Furthermore, when these illnesses finish depleting the nutrients in a child’s body, they cause a decrease in the child’s appetite, making it difficult and unlikely that the child will not replace the calories lost during illness in a timely manner, calories that are a necessity to their brain development (Improving Child 4).
Communities and households with improved or shared sanitation facilities, which World Health Organization defines as “sanitation facilities that hygienically separate human excreta from human contact.” with “improve” implying only a single household uses a facility as opposed to a number of families using a shared facility, are more likely to have better health outcomes (“Key Terms”). Despite this knowledge, fifty-two percent of the Indonesian rural population lacks improved sanitation, with twenty-one percent lacking access or convenient access to any type of facility and consequently practicing open defecation (“The World,” World Health Organization 82).
It is known that improved and proper sanitation leads to overall better health outcomes; however, how is sanitation connected to instances stunting, if at all? UNICEF states in a report that stunting is “linked to water and sanitation. But evidence on how improving these factors affects nutritional status is still limited. Few programs aiming to improve these factors have the co-objective of improving nutrition of women and children so nutritional status is rarely used as an indicator to gauge their success” (Improving Child 50). My impact evaluation aims to solve this issue by seeking to quantify the correlation between these two items. Furthermore, according to a survey done in Indonesia, there is a large overlap of Indonesian communities that lack proper sanitation and communities that experience high cases of stunting. However, whether this relationship is causal or correlative is unknown as this data was acquired in a survey rather than an impact evaluation. Consequently, we currently are unsure whether or not sanitation directly impacts stunting, or if both are side effects of extreme poverty and do not share a relationship (“Detriments of Stunting”).
Program Theory
My intervention seeks to decrease stunting by increasing sanitation in rural villages throughout certain regions in Indonesia. By improving and increasing the number of improved sanitation facilities in villages, instances of illnesses such as diarrhea will decrease, thereby decreasing the cases of stunting. Specifically, we will increase the number of proper sanitation facilities in each village so that there will be twenty public pit latrines up to standard in each treatment village. In order to ensure that treatment latrine systems are effective and identical to each other, all treatment latrine systems will meet the standards set forth by UNICEF for a proper latrine by “having (1) a pit with a depth of more than 1.5m; (2) a superstructure, (3) a roof; (4) a cement slab; (5) a pit-hole cover; and (6) a hand washing facility” (Cha and Lee).
After collecting the initial survey data recipients of the treatment and the control group have been confirmed, the required number of proper latrines will be built in treatment villages, using a computer program with locations of households in order to maximize the effect of the latrines by minimizing the average distance from households to a latrine. Additionally, latrines will be placed downhill from water sources as to avoid contamination of water. Villagers will be hired to implement and build the new latrine systems as quickly as they can using native materials when possible and when not, materials will be provided by the intervention. In each village in which the experiment is taking place, a team of surveyors will be stationed to check the height, weight, and age of the children every six months after the completion of the latrine for 2 years. Theoretically, over time, the instances of stunting in the treatment group will decrease as the proper latrines will reduce childhood diarrhea and consequently the few nutrients that are present in these children’s bodies won’t be expunged at once.
The inputs of the program are the sanitation facilities, with the activity being people use proper latrines. The output will be less open fecal matter in society that is a breeding ground for diseases, which causes the output of less disease. The final outcome will be a decrease in the instances of stunting leading to better overall productivity and health in society.
Program Design
This intervention will be taking place throughout Indonesia, specifically throughout villages in rural and impoverished areas. After looking at previous surveys, such as the Indonesian Family Life Survey (IFLS), and Indonesian census data to create an initial list of villages that might qualify to take part in this intervention, our own surveys will take place to ensure that villages meet this initial criteria: a) villages have less than 10 proper community latrines with less than twenty percent of households having personal, improved latrines, b) large enough population for within village randomization, and c) no other intervention or program, especially those aiming to improve water, sanitation, health, or nutrition, may currently be in place or may start within the next two years. These surveys will determine whether or not villages are candidates for the trial because in order for there to be a successful differentiation between the treatment and control, both groups must lack proper sanitation before the intervention. Furthermore, the population of the village must be large enough that a statistically significantly number of children under age of two are always present in society, once again, because this is an impact evaluation and we are interested in seeing a statistical significant effect. Finally, there must not be any other intervention going on that could potentially affect the issue we are aiming to impact, as that would leave inconclusive results and an unknown as to whether the treatment of this program worked or if stunting instances decreased due to some other intervention.
Randomization will occur by village, with each village being named to either the treatment group (better sanitation facilities) or the control group (no change). Once the necessary number of qualified villages has been chosen, each village will be given a number, and we will use a random number generator to decide which group each village will belong to. Within each village, a census survey will be taken to find households with a child between the ages of three months and twenty-four months, and from there qualifying households will be numbered. Once again, we will use a random number generator will create a list of all households in random order. We will start going down the list to survey households until we reach the amount of surveys needed. If a household is no longer available to partake in the survey, they will be skipped and the next household at the end of the list will be included.
Because the most current information on stunting in rural Indonesia states that forty percent of children under the age of five are stunted, forty percent will be the expected mean of the control group (Improving Child 75). While the actual percent of stunted children number might be different in our villages (data which we will find out during the collection baseline data in both the control and treatment villages), we are using forty percent as the mean to calculate the number of treatment and control groups needed to gain statistical significance with data found. Because the stunting percentages range from about twenty percent to fifty-eight percent across different provinces in Indonesia, I am assuming a standard deviation of ten percent, implying that in any given village, the stunting instances will most likely be within one standard deviation (thirty and fifty percent), with a few instances being within two standard deviations (twenty and sixty percent), which is representative of the data collected in a 2013 study (Shrimpton and Rokx 16).
Using these numbers, in order to have a statistical power of eighty percent when looking for an effect size of 0.1, the mean would drop from forty percent to thirty-nine percent, 327 villages would need to be in the treatment group with another 327 villages in the control. Within each village there must be over one hundred households with a child between ages three months and twenty-four, so that we are able to randomly survey the one hundred households needed in order to gain sufficient statistical power.
Randomization will be occurring at the level of the village, as opposed household, in an attempt to limit a spillover effect. The addition of proper latrines in households improves sanitation not only for a members of said household, but also the community as a whole; thus, if the trial was randomized by households, children in the control group may be affected by the treatment, decreasing the difference between the treatment and control groups. This would make the treatment appear less effective than it actually was. Therefore, we will be building public latrines and randomizing by the village.
However, while randomizing at the level of the village will decrease the spillover effect, because this is an intervention in the real world rather than in a contained lab setting, chances that there will be some mixing between control and treatment groups is high. We, the researchers, cannot isolate villages and prevent interactions between people from treated and not treated villages. Because we are hoping improved sanitation will result in less illness thereby causing a decrease in instances stunting, interaction of treated communities with non-treated communities has the potential to reintroduce illnesses into the treated community that otherwise would not be there. However, this could also work in the reverse direction: the decrease in overall open fecal matter could lead to a decrease in the negative effects that would normally be in the control. Simply put, interactions between villagers have the potential to minimize the effects of the treatment by not only increasing illness in the treatment but also decreasing illness in the control. However, because we are aware of it, we can take this into consideration when analyzing the data.
Furthermore depending on other ways any two villages are too each other there is the possibility for side effects. For example, say a second village is downstream from the first village, and the second village gets their water from this stream. If the second group is a treatment, but the first is not, the water source of the second could potentially remain compromised despite the fact that the group is treated. This could also occur the other way if the treatment group is upstream and because of the treatment, stops defecating in the water, thereby making the water source of the second village clean, positively impacting them. However, the purpose of the randomization process is that these potential effects on data might be mitigated throughout the overall results.
While having a spillover or contamination effect makes it slightly more difficult to analyze data and see if our program is, in fact, successful, these effects show us how the world actually works, and what other impacts our program could potentially have. In other words, so long that we are aware of the spillover effect, we can use it to our advantage to see the full impact of the program.
Because an outside program is entering a society and changing their way of life, though it may be for the better, there is potential for adverse effects. One of which is increased tensions between villages. Giving villages that already dislike each other or are competing with each other different roles in the intervention could raise the already existing tension should the control find out that the other village got improved sanitation facilities whereas they did not. Depending on the current situation, this added tension could cause significant problems in terms of communication, travel, and trade between villages. This could potentially add economic strain on either or both of the villages which would create a negative effect in society. In order to prevent adverse effects, not be publicized in hopes to avoid discontent among non-treated villages. Furthermore, if tension does arise, the overseers of the project in the villages, along with other influential leaders, will be tasked with explaining to the non-treated village how treatment of their neighbors positively affects them as well.
Monitoring and Evaluation Plan
In order to determine success, the measurement that is important is we will be looking at the number of instances stunting. Because stunting is an absolute, either a child is below two standard deviations of the average height-for-age or he is not, we will be collecting information on the percentage of stunted children within both the treated and non-treated villages and consequently comparing those percentages in order to determine whether or not our program is successful.
Baseline data will be taken at both the village and household levels. On the village level, information such as number of sanitation facilities, overall population, and general geographic surroundings will be taken. A general census will be taken in order to find households with children aged between three and twenty-four months. Through the randomization process previously discussed households will be chosen to be surveyed a lot more at a much greater depth.
General questions about the household will first be asked: number of members living in household, income of household, assets of household, occupation of working members in household, level of education of members in household, number of meals consumed in the past day/week by each household member, what specifically did each family member consume in the past week, illnesses, length of illness, and other information regarding health and lifestyle of the household.
The family will then be questioned on its current water and sanitation practices. Where do they get their water? Is it treated at all? How so? How far away is water? What kind of sanitation facility do they use? Improved? Shared? Unimproved? Open defecation? If the answer is any item except “improved” a series of follow up questions will be asked regarding the distance closest shared facility? Whether or not one uses the shared facility? How often? If not, why not? Location of unimproved or open defecation in relation to household? Distance between water source and sanitation facility?
From there, questions will then be asked regarding the child under the age of two. First and foremost the child’s height and then weight will be measured in order to see whether or not he is stunted. From there, other health concerns will be assessed. Items such as birth weight and height, the last time child had an illness and how long it lasted, about how many times has the child been sick throughout its life, etc. will be asked of the parent/guardian answering the questionnaire. Furthermore, questions will be asked regarding the child’s nutrition intake. For example, “Did the mother breastfeed him, and if so, for how long?” and “How often and what exactly does the child eat?”
After baseline data is acquired and the sanitation facilities have been in place for a year, surveyors will go through the process of acquiring data again; however, after the baseline year, two different sets of data will be collected. First, surveyors will return to the households who made up the baseline data and will ask them the same series of questions. This will be to observe the overall health impacts on specific households, removing household variance as an error. While this information will be important in determining whether or not there was latrine usage, chances that a child will go from being stunted to not in a year are slim as stunting is irreversible damage to the brain. Therefore, in order to determine whether or not improved latrines impact stunting, a new census will be taken and one hundred households in the village with a child between three months and twenty-four months will be randomly chosen. These households will be asked the same series of questions that were answered in the baseline data survey. This process will repeat itself one more time after another year has passed, so by the time the program is done there will be data on each village for three consecutive years.
The reason will we choose new households to be surveyed throughout time is because we are looking to see what impact sanitation facilities have on the stunting prevalence in a village. However, because the conditions and way in which a child lives from the first day he was born highly impacts stunting, in order to see whether or not the facilities actually decrease the number of stunted children we need to observe and see the impact of those children who only lived with the treatment in place.
In terms of monitoring the project, two members of each village will be trained and hired as overseers to the project. First they will be educated on the use and upkeep of pit latrines so that they can ensure that the new and improved sanitation facilities remain clean and that the maintenance that needs to be taken care of in order to keep the improved sanitation facilities improved and doing their jobs. Furthermore, these two members will also be tasked with informing their community about the importance of proper sanitation by spreading the word of the availability of proper facilities and the added health benefits.
There is the potential that the program itself is unsuccessful, meaning that percentage of stunted children does not decrease in the treatment villages. There are two potential scenarios that could result with no change. First of all, our hypothesis may be incorrect and there simply is not be a causative relationship between sanitation and stunting. The other option, however, is that the implementation of the project (i.e. the number and location of latrine systems per village) was unsuccessful in getting people to use improved sanitation. Because we know of other positive health benefits that are associated with improved sanitation, we can see whether or not the issue was in the theory or the implementation. We will be able to check this by assessing other health aspects that are commonly associated with better sanitation. If treated communities lack the positive health benefits that are known to come with better sanitation, then we can assume that our theory is inconclusive because sanitation was not actually improved so we do not know whether or not improved sanitation results in less instances stunting. However, if there are better overall health effects but little or no effects on stunting prevalence in treated groups, then we can assume that our hypothesis was incorrect and proper sanitation does not lead to decrease in stunting.
Cost Effective Analysis
The suspected cost to build a single pit latrine is about US $7.20 plus the cost to build the structure and roof, so all together, about $10.00, with about US $1.50 required each year in order to keep the pit latrine up to standards (Cha and Lee,Wash cost effect). According to a study done in the Democratic Republic of the Congo, it takes approximately 10 days for two people to build a pit latrine from start to finish (Cha and Lee). Because we will be building latrines in 327 villages, it will take approximately 196,200 single days of work, or 4,360 months, to build the latrines. The Indonesian minimum wage is US $234.50 per month so the overall cost of paying workers to build the latrines will be approximately US $1.02 million, or US $78.00 per worker per latrine (“Trading Economics”). Furthermore, in each village two overseers will have to be paid US $2,808.00 per year in order to maintain the quality of latrines. The one added cost to the program that I could not find is the cost of the surveyors and monitors. Because this is an impact evaluation, we will want to be collecting data to see whether or not this program actually impacts the world as we suspect it will. Collecting the data will most likely be expensive; however, seeing as there lacks data that directly connects sanitation and stunting, gathering this information is even more important. Should our hypothesis be correct, we will be generating new knowledge on how to decrease stunting.
Overall the cost of the program itself is not expensive compared to the suspected impact. The proper sanitation will not only lead to a decrease in stunting but also is associated with better overall health incomes. These pit latrines impact everyone in the village and will increase the human capital. Furthermore, it is estimated Indonesia loses between two to three percent of its GDP per year due to stunting loses (“The Double”). Set aside the improvements in basic human rights, this cost to build the latrines is tiny compared to the three percent of Indonesia’s GDP of 932.4 billion USD lost to stunting each year (“The World”). In other economical terms, a WHO study in 2012 found that there is an average return of US $5.50 for ever dollar invested in sanitation due to “lower health costs, more productivity, and fewer premature deaths” (“Sanitation”).
Furthermore, if proven successful, an enormous amount of money will be saved when it comes to food. If illness is no longer wasting food entering into children’s bodies, families will be getting more out of the cost for food that they are spending. Additionally, other programs that come later that are also seeking to find a solution for stunting will not have to combat illness and the loss of food because of nutrients. In conclusion, implementing this program is not only a cost effective endeavor itself, but it also increases the cost effectiveness of future programs.
External Validity Analysis
Child stunting, however, is not an issue that only Indonesians face; it is prevalent in and destroying many societies, especially those low income or middle income nations similar to Indonesia. As previously discussed, the effects of stunting are not only detrimental to the immediate family and child but also the community as a whole. Stunted growth of children stunts the growth of a society; it limits the potential for human capital and consequently prevents a society from moving out of poverty.
Similar to the overlap of Indonesian regions with the worst sanitation and those with the highest instances stunting, many of the countries with the most stunting instances also have the least number of people using proper sanitation. Just a few of the countries that fall in this category are Nigeria, Democratic Republic of the Congo, and Sierra Leone (Improving Child 9, Sanitation 2017).
The exact solution may work in other rural villages throughout the world if the overall standards and way of life is similar to that of Indonesia. If a rural village in another country is more rural, covers a larger area, and is less dense, placing public sanitation facilities will have less of an impact if the location of the facility is not convenient enough due to the spread outness of the village. On the opposite issue, if a rural village in another area is more dense than those tested in Indonesia despite still being considered “rural”, the number of facilities might not be able to sustain the population. Furthermore, if families and cultures are comfortable using the restroom in a unsanitary, yet specific and convenient way, if a new way takes added effort, they might not choose to make that added effort despite the highly positive effects.
However, in urban areas, this specific design will not work: one simply cannot increase the number of latrines or sanitation facilities in urban areas where the high density of people prohibits the building of these facilities. Furthermore, if we could implement pit latrines, a larger number of people would be using them making the system less effective. However, if an increase in sanitation does lead to a decrease in stunting, researchers and engineers have even more reason to focus even more efforts to find a solution of proper sanitation.
Conclusion
In conclusion, we hope that by doing an impact evaluation on the relationship between improved sanitation and stunting, we will be able to change the approach to solving the problem of stunting. If this intervention is proven successful, it will set a precedence for more sustainable ways to tackle the issue of stunting throughout the world. Knowing that improved sanitation decreases the stunting prevalence in a society is even more reason for NGOs and engineers to focus on finding a solution to the sanitation problem throughout the world, even if it is not the same as the one we used in this intervention. Furthermore, proper sanitation is a more sustainable solution to stunting than simply providing higher quality food because its consumption rate no where near that of food. We hope that our intervention leads to a revolution in the way that people go about searching for solutions not only concerning stunting, but also in