Abstract: Soil-transmitted helminths (STHs) infect over one billion people worldwide. There is concern that chronic infection with STHs among school-aged children may detrimentally affect their development, including their health, cognition, and education. However, two recent Cochrane reviews examining the impact of deworming drugs for STH on nutrition, hemoglobin, and school performance found that randomized controlled trials (RCTs) in the literature provide an insufficient evidence base to draw reliable conclusions. This study uses a cluster-RCT to add to existing evidence by assessing the impact of a deworming intervention on nutrition, cognition, and school performance among schoolchildren in rural China. The intervention, implemented by local health practitioners in a setting with a baseline infection prevalence of 41.9% (95% confidence interval [CI] = 39.8%, 43.9%) and infection intensity of 599.5 eggs per gram of feces among positive-tested schoolchildren (95% CI = 473.2, 725.8), consisted of distributing a 400-mg dose of albendazole accompanied with educational training about STH infection, treatment, and prevention. The intervention was conducted twice over the course of the study—at baseline in May 2013 and later in November 2013. We found that the deworming intervention reduced both infection prevalence and infection intensity, but these declines in infection were not accompanied by an impact on outcomes of nutrition, cognition, or school performance. Our interpretation is that the impact of deworming was attenuated by the light infection intensity in our sample population. Evidence from future RCTs is needed to assess the effect of deworming on key outcomes in areas with moderate and severe worm infections.

Rising atmospheric carbon dioxide concentrations are anticipated to decrease the zinc and iron concentrations of crops. The associated disease burden and optimal mitigation strategies remain unknown. We sought to understand where and to what extent increasing carbon dioxide concentrations may increase the global burden of nutritional deficiencies through changes in crop nutrient concentrations, and the effects of potential mitigation strategies.

Women empowerment (WE) is increasingly viewed as an important strategy to reduce maternal and child undernutrition,^1–3 which continues to be a major health burden in low- and middle-income countries causing 3.5 million preventable maternal and child deaths, 35% of the disease burden in children younger than 5 years, and 11% of total global disability-adjusted life years.^4,5Global data show that one of the worst affected regions is sub-Saharan Africa (SSA), where about 20% of children are malnourished.^6,7 Benin is no exception, as the prevalence of stunting, wasting, and underweight was 37%, 5%, and 17%, respectively, among children aged 6 to 59 months in the 2006 Benin Demographic and Health Survey (DHS),⁸ while 9% of women had chronic energy deficiency in the 2012 DHS.⁹ Greater rates were observed in rural areas where stunting was found in 40% of children, underweight in 19%, and wasting in 5%, while 10% of women had chronic energy deficiency.^8,9 Additionally, Beninese women and children have a limited dietary diversity score (DDS), with diets predominately composed of starchy staples with little or no animal products and few fresh fruits and vegetables.^10,11 Government, United Nation agencies, and nongovernmental organizations in Benin recognize that the state of maternal and child undernutrition requires multiple types of interventions.¹²

However, women’s low empowerment status in Benin can hinder the improvement in women’s and children’s undernutrition. Indeed, although females accounted for 47% of the economically active population in 2014,¹³ social and civil legislation is strongly influenced by tradition and customs, as women continue to be required to seek their husband’s authorization in certain areas such as family planning or health services.¹⁴ Rural women provided labor to the families’ commercial plots, were responsible for household food production and processing, and also had to work in the cooperative structures set up by the state in addition to their household tasks.¹⁴ In a more recent study of productivity differences by gender in central Benin, researchers noted that female rice farmers are particularly discriminated against with regard to access to land and equipment, resulting in significant negative impacts on their productivity and income.¹⁵ As in other areas of West Africa, women also have the responsibility of caring for children and preparing food for the household,¹⁶ but they may be vulnerable to food insecurity owing to unequal intrahousehold food distribution and their willingness to forego meals in favor of children during times of scarcity.¹⁷ Finally, no study to date has examined links between women’s empowerment and nutrition in Benin.

In addition, the evidence backing the effect of women’s empowerment on maternal and child undernutrition is inconsistent.¹⁸ Using the Women’s Empowerment in Agriculture Index (WEAI), Malapit et al¹⁹ reported positive and significant association between women’s group (WG) membership, control over income, overall empowerment, and women’s health (as measured by body mass index [BMI] and DDS) in Nepal. However, in Ghana, women’s aggregate empowerment and participation in credit decisions were positively correlated with women’s DDS, but not BMI.²⁰ Mixed findings were also observed between women’s empowerment and child anthropometry. Moestue et al²¹ found a positive association between maternal involvement in social groups and length-for-age z score of 1-year-old children, but De Silva and Harpham²²showed a negative association in 6- to 18-month-old children. Shroff et al²³ found positive association between decision-making and child weight-for-age z score (WAZ), but Begum and Sen’s²⁴ analysis of Bangladesh DHS data did not reveal any significant associations. Therefore, information about which domains of WE are associated with nutritional status is limited,²⁰ and this lack of knowledge constrains the set of policy options that can be used to empower women and improve nutrition.

In addition to a limited set of studies in SSA, examinations of the effects of WE on nutrition outcomes are constrained due to interstudy differences in population characteristics, settings, or methods/conceptualizations of WE.^25–27 For example, despite recognition of the complex, multidimensional, and culturally defined nature and influence of empowerment on nutrition,^20,26,28,29 only a few studies considered the multidimensional structure of empowerment domains in Africa or examined the varied relationships between each measure of WE and maternal and child nutrition status.^30,31 Furthermore, in 2012, the International Food Policy Research Institute developed WEAI constructed from 5 prespecified domains of empowerment,³²which may not be equally relevant in all areas. In contrast, in 2015, the United Nations adopted the Sustainable Development Goals (SDG), but the specific indicators for the SDG empowerment targets are largely equality metrics.³³ To address the need for multidimensional and contextual examinations of WE and its influence on maternal and child health outcomes, we draw from the concepts put forward in the WEAI and the SDGs but took an approach more along the lines of the World Bank which gathers indicators, both equity and empowerment related, that can be used in contextually appropriate ways.³⁴ The aims of this study were therefore to first explore the structure and domains of WE in Kalalé district of northern Benin and then to examine the effects of these constructs on nutritional status of women and their children in the region.