Assessing the associations between public works participation, household water and sanitation conditions, and child nutrition in Southern Madagascar: a mediation analysis.

چکیده اصلی

BACKGROUND: The pervasive child undernutrition in Southern Madagascar is exacerbated by inadequate water, sanitation, and hygiene (WASH) infrastructure. Although public-works programs such as high-intensity manual labor (HIMO) have been implemented to develop infrastructure and sustain livelihoods, the multi-dimensional associations between these programs and household-level health and hygiene outcomes remain poorly quantified. This study examined the association of workfare participation with child nutritional status and the role of household WASH conditions as a mediating factor. METHODS: Data were integrated from the 2018 Madagascar Multiple Indicator Cluster Survey (MICS6) and 2021 Demographic and Health Survey Spatial Covariates. To address the potential endogeneity in program participation and in the WASH mediators, we employed a potential-outcomes framework combined with instrumental variable (IV) regressions. This approach allowed for the estimation of both total and mediator-adjusted associations between HIMO participation, WASH practices, and child anthropometric outcomes (Z-scores). Furthermore, a mediation analysis was used to quantify the proportion of this association that could be statistically explained by improvements in WASH infrastructure. RESULTS: Participation in the HIMO program was significantly associated with higher household access to improved sanitation and with shorter water-collection travel time (under 30 min). These improvements were associated with significant increments in the height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height (WHZ) Z-scores. Mediation analysis indicated that 12%-14% of the program's total association with the HAZ and WAZ could be statistically explained by improved sanitation infrastructure. Shorter water-fetching time accounted for the largest mediated share of the association between HIMO participation and WHZ, representing approximately 36% of the total association. CONCLUSIONS: This study provides evidence that HIMO participation is associated with better child nutrition in Southern Madagascar, with improved access to water and sanitation as potential mediating pathways. If subsequent longitudinal or experimental evidence confirms these patterns, public works could be designed as nutrition-sensitive interventions that prioritize essential infrastructure. Expanding these projects also offers a sustainable pathway to closing basic-service gaps and reducing regional malnutrition rates.

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