Mass deworming to improve developmental health and wellbeing of children in low-income and middle-income countries: a systematic review and network meta-analysis.

BACKGROUND: Soil-transmitted helminthiasis and schistosomiasis, considered among the neglected tropical diseases by WHO, affect more than a third of the world's population, with varying intensity of infection. We aimed to evaluate the effects of mass deworming for soil-transmitted helminths (with or without deworming for schistosomiasis or co-interventions) on growth, educational achievement, cognition, school attendance, quality of life, and adverse effects in children in endemic helminth areas. METHODS: We searched 11 databases up to Jan 14, 2016, websites and trial registers, contacted authors, and reviewed reference lists. We included studies published in any language of children aged 6 months to 16 years, with mass deworming for soil-transmitted helminths or schistosomiasis (alone or in combination with other interventions) for 4 months or longer, that reported the primary outcomes of interest. We included randomised and quasi-randomised trials, controlled before-after studies, interrupted time series, and quasi-experimental studies. We screened in duplicate, then extracted data and appraised risk of bias in duplicate with a pre-tested form. We conducted random-effects meta-analysis and Bayesian network meta-analysis. FINDINGS: We included 52 studies of duration 5 years or less with 1 108 541 children, and four long-term studies 8-10 years after mass deworming programmes with more than 160 000 children. Overall risk of bias was moderate. Mass deworming for soil-transmitted helminths compared with controls led to little to no improvement in weight over a period of about 12 months (0·99 kg, 95% credible interval [CrI] -0·09 to 0·28; moderate certainty evidence) or height (0·07 cm, 95% CrI -0·10 to 0·24; moderate certainty evidence), little to no difference in proportion stunted (eight fewer per 1000 children, 95% CrI -48 to 32; high certainty evidence), cognition measured by short-term attention (-0·23 points on a 100 point scale, 95% CI -0·56 to 0·14; high certainty evidence), school attendance (1% higher, 95% CI -1 to 3; high certainty evidence), or mortality (one fewer per 1000 children, 95% CI -3 to 1; high certainty evidence). We found no data on quality of life and little evidence of adverse effects. Mass deworming for schistosomiasis might slightly increase weight (0·41 kg, 95% CrI -0·20 to 0·91) and has little to no effect on height (low certainty evidence) and cognition (moderate certainty evidence). Our analyses do not suggest indirect benefits for untreated children from being exposed to treated children in the community. We are uncertain about effects on long-term economic productivity (hours worked), cognition, literacy, and school enrolment owing to very low certainty evidence. Results were consistent across sensitivity and subgroup analyses by age, worm prevalence, baseline nutritional status, infection status, impact on worms, infection intensity, types of worms (ascaris, hookworm, or trichuris), risk of bias, cluster versus individual trials, compliance, and attrition. INTERPRETATION: Mass deworming for soil-transmitted helminths with or without deworming for schistosomiasis had little effect. For schistosomiasis, mass deworming might be effective for weight but is probably ineffective for height, cognition, and attendance. Future research should assess which subset of children do benefit from mass deworming, if any, using individual participant data meta-analysis. FUNDING: Canadian Institutes of Health Research and WHO.

A longitudinal study on the role of spirituality in response to the diagnosis and treatment of breast cancer.

This longitudinal study addressed the role of spirituality in women's response to breast cancer. Ninety-three women diagnosed with breast cancer were assessed on various measures of image of God, positive attitude, social well-being and emotional distress at pre-diagnosis, 6 months post-surgery and 1 year post-surgery. As compared to women who dropped out of the study, this sample reported religion to be less important in their daily lives. Path analyses showed evidence of direct and indirect effects of positive and negative images of God on emotional distress in cross-sectional but not longitudinal data. A positive image of God was related to greater concurrent distress while a negative image of God was indirectly related to greater distress through the pathways of social well-being and positive attitude. In the longitudinal path model, a pre-diagnosis measure of religious salience was the only aspect of spirituality that predicted an increase in distress at 1 year post-surgery. The cross-sectional analyses provided limited support for the "religious/spiritual mobilization" hypothesis as put forth by Pargament (The psychology of religion and coping. New York: Guilford Press, 1997). There was also limited support for the mediator variables of positive attitude and social well-being as mechanisms through which spirituality influences adjustment. Finally, there was no support that spirituality acted in a protective manner rather the negative elements of spirituality were more prominent in relation to various aspects of women's adjustment to breast cancer. Such results suggest that women who were less spiritually/religiously involved prior to the onset of breast cancer and who attempt to mobilize these resources under the stress of diagnosis may experience a negative process of spiritual struggle and doubt that, in turn, has implications for their long-term adjustment.