Effects of Cooking with Liquefied Petroleum Gas or Biomass on Stunting in Infants.

BACKGROUND: Household air pollution is associated with stunted growth in infants. Whether the replacement of biomass fuel (e.g., wood, dung, or agricultural crop waste) with liquefied petroleum gas (LPG) for cooking can reduce the risk of stunting is unknown. METHODS: We conducted a randomized trial involving 3200 pregnant women 18 to 34 years of age in four low- and middle-income countries. Women at 9 to less than 20 weeks' gestation were randomly assigned to use a free LPG cookstove with continuous free fuel delivery for 18 months (intervention group) or to continue using a biomass cookstove (control group). The length of each infant was measured at 12 months of age, and personal exposures to fine particulate matter (particles with an aerodynamic diameter of ≤2.5 µm) were monitored starting at pregnancy and continuing until the infants were 1 year of age. The primary outcome for which data are presented in the current report - stunting (defined as a length-for-age z score that was more than two standard deviations below the median of a growth standard) at 12 months of age - was one of four primary outcomes of the trial. Intention-to-treat analyses were performed to estimate the relative risk of stunting. RESULTS: Adherence to the intervention was high, and the intervention resulted in lower prenatal and postnatal 24-hour personal exposures to fine particulate matter than the control (mean prenatal exposure, 35.0 µg per cubic meter vs. 103.3 µg per cubic meter; mean postnatal exposure, 37.9 µg per cubic meter vs. 109.2 µg per cubic meter). Among 3061 live births, 1171 (76.2%) of the 1536 infants born to women in the intervention group and 1186 (77.8%) of the 1525 infants born to women in the control group had a valid length measurement at 12 months of age. Stunting occurred in 321 of the 1171 infants included in the analysis (27.4%) of the infants born to women in the intervention group and in 299 of the 1186 infants included in the analysis (25.2%) of those born to women in the control group (relative risk, 1.10; 98.75% confidence interval, 0.94 to 1.29; P = 0.12). CONCLUSIONS: An intervention strategy starting in pregnancy and aimed at mitigating household air pollution by replacing biomass fuel with LPG for cooking did not reduce the risk of stunting in infants. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).

Women's empowerment through homestead food production in rural Bangladesh.

BACKGROUND: Women in rural Bangladesh face multiple, inter-related challenges including food insecurity, malnutrition, and low levels of empowerment. We aimed to investigate the pathway towards empowerment experienced by women participating in a three-year nutrition-sensitive homestead food production (HFP) program, which was evaluated through the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized controlled trial. METHODS: We conducted 44 in-depth interviews and 12 focus group discussions with men and women in both intervention and control communities of the FAARM study site in rural, north-eastern Bangladesh. Using a modified grounded theory approach to data collection and analysis, we developed a framework to explain the pathway towards empowerment among HFP program participants. RESULTS: The analysis and resulting framework identified seven steps towards empowerment: 1) receiving training and materials; 2) establishing home gardens and rearing poultry; 3) experiencing initial success with food production; 4) generating social or financial resources; 5) expanding agency in household decision-making; 6) producing renewable resources (e.g. farm produce) and social resources; and 7) sustaining empowerment. The most meaningful improvements in empowerment occurred among participants who were able to produce food beyond what was needed for household consumption and were able to successfully leverage these surplus resources to gain higher bargaining power in their household. Additionally, women used negotiation skills with their husbands, fostered social support networks with other women, and developed increased self-efficacy and motivation. Meanwhile, the least empowered participants lacked support in critical areas, such as support from their spouses, social support networks, or sufficient space or time to produce enough food to meaningfully increase their contribution and therefore bargaining power within their household. CONCLUSIONS: This study developed a novel framework to describe a pathway to empowerment among female participants in an HFP intervention, as implemented in the FAARM trial. These results have implications for the design of future nutrition-sensitive agriculture interventions, which should prioritize opportunities to increase empowerment and mitigate the barriers identified in our study. TRIAL REGISTRATION: FAARM is registered with ClinicalTrials.gov ( NCT02505711 ).

Impact of a homestead food production program on women's empowerment: Pro-WEAI results from the FAARM trial in Bangladesh.

Nutrition-sensitive agricultural programs have the potential to improve women's and children's nutrition, along with women's empowerment. The project-level Women's Empowerment in Agriculture Index (pro-WEAI) aims to standardize the measurement of women's agency and enable the assessment of impact over typical project timelines. Within the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized controlled trial in rural Habiganj, Sylhet, Bangladesh, we examined quantitative pro-WEAI data collected from a subsample of trial participants and their husbands (n = 885) approximately four months after the end of the intervention. We evaluated the impact of a three-year homestead food production program on men's and women's agency separately by pro-WEAI domain and indicator, using multilevel logistic and linear regression. We show that women in the FAARM intervention group had levels of agency similar to men and much higher than women in the control group (Odds Ratio [OR] 7.7, p < 0.001), corresponding to better gender equity in intervention areas (OR 3.5, p < 0.001). The higher levels of agency among intervention women were driven by greater intrinsic and collective agency but not by instrumental agency. Compared to controls, more women in the intervention group found intimate partner violence unacceptable (OR 3.5, p < 0.001), had greater ownership of assets (OR 2.6, p = 0.001), better control of income (OR 1.8, p = 0.042), higher levels of group membership (OR 14.0, p < 0.001), and membership in groups they considered influential (OR 166.8, p < 0.001). Self-efficacy was greater in intervention areas for both women (OR 3.2, p < 0.001) and men (OR 2.3, p = 0.002). Our results contribute to the development of benchmarks for interpreting pro-WEAI scores across programs. Our assessment of the impact of a homestead food production program on women's agency provides additional rationale for women-led agricultural projects. We plan to build on these findings by examining the role of improved women's agency on the pathway from the intervention to nutritional impacts.

Ethical and human rights considerations related to access to anemia diagnosis.

Important disparities exist in anemia diagnosis globally. We examine individuals' and populations' access to anemia diagnosis, the accuracy of diagnostic tests, and the interpretation of test results through the lens of key ethical considerations. These include the human right to health and the Rawlsian concept of the social contract, as well as ethical principles, such as autonomy, self-liberty, beneficence, and nonmaleficence. We discuss factors that influence individuals' and communities' access to high-quality health services, including geography, gender, age, and socioeconomic status. Geographic and other differences exist in the types of diagnostic equipment and methods used to diagnose anemia, potentially leading to differential classification of anemia across individuals and populations. A diagnosis of anemia also requires follow-up to understand etiology and appropriate treatment. However, this is not done consistently, in clinical care or in population-based surveys. To better understand the problem and track countries' progress, a need exists for disaggregated, longitudinal quantitative and qualitative data on disparities related to anemia. Moving forward, it will be important for countries to improve equitable access to high-quality health services, particularly primary health care services, and to address barriers to the ability of individuals or communities to effectively enjoy the right to health.