Barriers to post-abortion care service provision: A cross-sectional analysis in Burkina Faso, Kenya and Nigeria

Despite several political commitments to ensure the availability of and access to post-abortion care services, women in sub-Saharan Africa still struggle to access quality post-abortion care, and with devastating social and economic consequences. Expanding access to post-abortion care while eliminating barriers to utilization could significantly reduce abortions-related morbidity and mortality. We describe the barriers to providing and utilizing post-abortion care across health facilities in Burkina Faso, Kenya, and Nigeria. This paper draws on three data sources: health facility assessment data, patient-exit interview data, and qualitative interviews conducted with healthcare providers and policymakers. All data were based on a cross-sectional survey of a nationally representative sample of health facilities conducted between November 2018 and February 2019. Data on post-abortion care service indicators were collected, including staffing levels and staff training, availability of post-abortion care supplies, equipment and commodities. Patient-exit interviews focused on patients treated for post-abortion complications. In-depth interviews were conducted with healthcare providers within a sample of the study health facilities and national or local decision-makers in sexual and reproductive health. Few primary-level facilities in Burkina Faso (15%), Kenya (46%), and Nigeria (20%) had staff trained on post-abortion care. Only 16.6% of facilities in Kenya had functional operating theaters or MVA rooms, Burkina Faso (20.3%) and Nigeria (50.7%). Primary facilities refer post-abortion care cases to higher-level facilities despite needing to be more adequately equipped to facilitate these referrals. Several challenges that impede the provision of quality and comprehensive post-abortion care across the three countries. The absence of post-abortion care training, equipment, and inadequate referral capacity was among the critical reasons for the lack of services. There is a need to strengthen post-abortion care services across all levels of the health system, but especially at lower-level facilities where most patients seek care first.

Economic vulnerabilities, mental health, and coping strategies among Tanzanian youth during COVID-19

BACKGROUND

The COVID-19 pandemic has exacerbated struggles for youth living in poor households. Youth in rural Tanzania are particularly vulnerable given widespread poverty, lack of formal sector employment opportunities, and health risks. We examine influences of the pandemic on economic insecurity and mental health and explore the coping strategies employed by youth and their households.

METHODS

We conducted mixed-method data collection with youth (N = 760 quantitative and N = 44 qualitative interviews) and households (n = 542) via mobile phone among a sub-set of a cohort from an on-going longitudinal sample in two rural regions in Tanzania. In addition to phone interviews, we collected data bi-weekly via SMS messaging. We present mixed-methods, descriptive analysis of the outcomes and longitudinally compare quantitative outcomes pre- and post-COVID-19, within the same individuals.

RESULTS

Adverse economic impacts were most salient, and to cope, youth engaged in more labor and domestic chores. Compared to prior the COVID-19 pandemic, youth reported spending more time caring for elderly or sick household members and gathering firewood or nuts.

CONCLUSIONS

These findings underscore the potential opportunity to promote policies and programs which address risks youth face. Recommended measures include expansion and adaptation of social protection policies, strengthened food and nutrition surveillance and referral systems, and scaling up community-based mental health programming.

Donor coordination to support universal health coverage in Malawi

Development assistance is a major source of financing for health in least developed countries. However, persistent aid fragmentation has led to inefficiencies and health inequities and constrained progress towards Universal Health Coverage (UHC). Malawi is a case study for this global challenge, with 55% of total health expenditure funded by donors and fragmentation across 166 financing sources and 265 implementing partners. This often leads to poor coordination and misalignment between government priorities and donor projects. To address these challenges, the Malawi Ministry of Health (MoH) has developed and implemented an architecture of aid coordination tools and processes. Using a case study approach, we documented the iterative development, implementation and institutionalization of these tools, which was led by the MoH with technical assistance from the Clinton Health Access Initiative. We reviewed the grey literature, including relevant policy documents, planning tools and databases of government/partner funding commitments, and drew upon the authors' experiences in designing, implementing and scaling up these tools. Overall, the iterative use and revision of these tools by the Government of Malawi across the national and subnational levels, including integration with the government's public financial management system, was critical to successful uptake. The tools are used to inform government and partner resource allocation decisions, assess financing and gaps for national and district plans and inform donor grant applications. As Malawi has launched the Health Sector Strategic Plan 2023-2030, these tools are being adapted for the 'One Plan, One Budget and One Report' approach. However, while the tools are an incremental mechanism to strengthen aid alignment, success has been constrained by the larger context of power imbalances and misaligned incentives between the donor community and the Government of Malawi. Reform of the aid architecture is therefore critical to ensure that these tools achieve maximum impact in Malawi's journey towards UHC.

Reduced efficacy of single-dose albendazole against Ascaris lumbricoides, and Trichuris trichiura, and high reinfection rate after cure among school children in southern Ethiopia: a prospective cohort study

BACKGROUND

Mass drug administration (MDA) program of albendazole to at-risk populations as preventive chemotherapy is the core public health intervention to control soil-transmitted helminths (STHs). Achieving this goal relies on drug effectiveness in reducing the parasite reservoirs in the community and preventing reinfection. We assessed the efficacy of albendazole against STH parasite infection and reinfection status after cure.

METHODS

A total of 984 schoolchildren infected with at least one type of STH parasite (hookworm, Ascaris lumbricoides, Trichuris trichiura) in southern Ethiopia were enrolled and received albendazole and praziquantel in MDA campaign conducted from January to March 2019. Stool exams at week-4 and at week-8 of post-MDA were done using Kato Katz technique. The primary outcome was efficacy assessed by cure rate (CR) and fecal egg reduction rates (ERRs) at four weeks of post-MDA. The secondary outcome was reinfection status defined as parasite egg positivity at eight weeks among those who were cured at 4 weeks of post-MDA. Group comparisons in CR and related factors were assessed with chi-square or Fisher's exact tests. Predictors of CR were examined through univariate and multivariate regression analyses.

RESULTS

The overall CR and ERR for hookworm infection were 97.2% (95% CI 94.6-99.4) and 97.02%, respectively. The overall CR and ERR for A. lumbricoides were 71.5% (95% CI 68.3-74.6) and 84.5% respectively. The overall CR and ERR and for T. trichiura were 49.5% (95% CI 44.8-54.2) and 68.3%, respectively. The CR among moderate T. trichiura infection intensity was 28.6%. Among children cured of hookworm, A. lumbricoides and T. trichiura at week 4 post-MDA, 4.6%, 18.3% and 52.4% became reinfected at week-8 post-MDA, respectively. Significantly lower CR (36.6%) and higher reinfection after cure (60.6%) among A. lumbricoides and T. trichiura coinfected children than A. lumbricoides only (CR = 69.6%, reinfection rate = 15.1%) or T. trichiura only infected children (CR = 55.6%, reinfection rate = 47.1%) was observed. Pre-treatment coinfection with ≥ two types of STH parasites was significantly associated with re-infection after cure.

CONCLUSION

Albendazole MDA is efficacious against hookworm but has reduced efficacy against A. lumbricoides and is not effective against T. trichiura. The low drug efficacy and high reinfection rate after cure underscore the need for alternative treatment and integration of other preventive measures to achieve the target of eliminating STHs as a public health problem by 2030.

Efficacy and safety of praziquantel treatment against Schistosoma mansoni infection among pre-school age children in southern Ethiopia

BACKGROUND

Preventive chemotherapy with a single dose of praziquantel given to an all-at-risk population through mass drug administration is the cornerstone intervention to control and eliminate schistosomiasis as a public health problem. This intervention mainly targets school age children, and pre-school age children (pre-SAC) are excluded from receiving preventive chemotherapy, partly due to scarcity of data on praziquantel treatment outcomes.

METHODS

We conducted active efficacy and safety surveillance of praziquantel treatment among 240 Schistosoma mansoni-infected pre-SAC who received a single dose of praziquantel (40 mg/kg) in southern Ethiopia. The study outcomes were egg reduction rates (ERR) and cure rates (CRs) four weeks after treatment using the Kato-Katz technique and treatment-associated adverse events (AEs) that occurred within 8 days post-treatment.

RESULTS

The overall ERR was 93.3% (WHO reference threshold ≥ 90%), while the CR was 85.2% (95% CI = 80.0-89.5%). Baseline S. mansoni infection intensity was significantly associated with CRs, 100% among light infected than moderate (83.4%) or heavy (29.4%) infected children. An increase of 100 in baseline S. mansoni egg count per gram of stool resulted in a 26% (95% CI: 17%, 34%) reduction in the odds of cure. The incidence of experiencing at least one type of AE was 23.1% (95% CI: 18.0%, 29.0%). Stomachache, diarrhea, and nausea were the most common AEs. AEs were mild-to-moderate grade and transient. Pre-treatment moderate (ARR = 3.2, 95% CI: 1.69, 6.14) or heavy infection intensity (ARR = 6.5, 95% CI: 3.62, 11.52) was a significant predictor of AEs (p < 0.001). Sex, age, or soil-transmitted helminth coinfections were not significant predictors of CR or AEs.

CONCLUSIONS

Single-dose praziquantel is tolerable and effective against S. mansoni infection among pre-SAC, and associated AEs are mostly mild-to-moderate and transient. However, the reduced CR in heavily infected and AEs in one-fourth of S. mansoni-infected pre-SAC underscores the need for safety and efficacy monitoring, especially in moderate-to-high infection settings. Integrating pre-SACs in the national deworming programs is recommended to accelerate the elimination of schistosomiasis as a public health problem.

Exploring challenges and recommendations for verbal autopsy implementation in low-/middle-income countries: a cross-sectional study of Iringa Region-Tanzania

BACKGROUND

Verbal autopsy (VA) plays a vital role in providing cause-of-death information in places where such information is not available. Many low-/middle-income countries (LMICs) including Tanzania are still struggling to yield quality and adequate cause-of-death data for Civil Registration and Vital Statistics (CRVS).

OBJECTIVE

To highlight challenges and recommendations for VA implementation to support LMICs yield quality and adequate mortality statistics for informed decisions on healthcare interventions.

DESIGN

Cross-sectional study.

STUDY SETTING

Iringa region in Tanzania.

PARTICIPANTS

41 people including 33 community health workers, 1 VA national coordinator, 5 national task force members, 1 VA regional coordinator and 1 member of the VA data management team.

RESULTS

The perceived challenges of key informants include a weak death notification system, lengthy VA questionnaire, poor data quality and inconsistent responses, lack of clarity in the inclusion criteria, poor commitment to roles and responsibilities, poor coordination, poor financial mechanism and no or delayed feedback to VA implementers. Based on these findings, we recommend the following strategies for effective adaptation and use of VAs: (1) reinforce or implement legislative procedures towards the legal requirement for death notification. (2) Engage key stakeholders in the overall implementation of VAs. (3) Build capacity for data collection, monitoring, processing and use of VA data. (4) Improve the VA questionnaire and quality control mechanism for optimal use in data collection. (5) Create sustainable financing mechanisms and institutionalisation of VA implementation. (6) Integrating VA Implementation in CRVS.

CONCLUSION

Effective VA implementation demands through planning, stakeholder engagement, upskilling of local experts and fair compensation for interviewers. Such coordinated endeavours will overcome systemic, technical and behavioural challenges hindering VA's successful implementation.

Molecular characterization of a galactomannan extracted from Tara (Caesalpinia spinosa) seeds

Tara gum (TG) is a polysaccharide extracted from the seeds of a South American tree called Tara (Caesalpinia spinosa). TG is a galactomannan with many applications in the food industry, mainly as an emulsifier and stabilizer agent. In addition, it is also used in the paper and cosmetic industries. In the present study, we performed a molecular characterization based on chemical composition and physicochemical properties to understand the properties behind TG applications. TG was extracted and purified from Tara seeds distributed in different ecoregions of Bolivia. The monosaccharide composition analysis was determined by high-performance anion-exchange chromatography/pulsed amperometric detection (HPAEC-PAD). At the same time, their molecular characteristics, such as molar mass, root-mean-square radius, hydrodynamic radius, conformation, and densities, were studied by asymmetrical flow field-flow fractionation coupled to multi-angle light scattering refractive index (AF4-MALS-dRI), also the specific refractive index increment (dn/dc) was determined for the first time using AF4 for TG. The results revealed that the gum samples are galactomannans composed of mannose (Man) and galactose (Gal) in a ratio of 3.37 (Man/Gal), with an average molar mass range from 2.460 × 107 to 3.699 × 107 Da, distributed in a single population. The root-mean-square radius range from 260.4 to 281.6 nm, and dn/dc is 0.1454. The Kratky plots based on 14 scattering angles indicated that the conformation of all samples corresponds to random coil monodisperse, while their gyration radius/hydrodynamic radius ratio (ρ) is high. All these results suggest that the chains have a low branched density, consistent with the Gal/Man composition. To the best of our knowledge, we report for the first time an integrated physicochemical study of TG relevant to developing emulsifier and stabilizer formulations.

Insights into the rapid metabolism of Geobacillus sp. LC300: unraveling metabolic requirements and optimal growth conditions

This study investigated the metabolism of Geobacillus sp. LC300, a promising biorefinery host organism with high substrate utilization rates. A new defined medium was designed and tested that allows for exponential growth to elevated cell densities suitable for quantitative physiological studies. Screening of the metabolic requirements of G. sp. LC300 revealed prototrophy for all essential amino acids and most vitamins and only showed auxotrophy for vitamin B12 and biotin. The effect of temperature and pH on growth rate was investigated, adjusting the optimal growth temperature to several degrees lower than previously reported. Lastly, studies on carbon source utilization revealed a capability for fast growth on several common carbon sources, including monosaccharides, oligosaccharides, and polysaccharides, and the highest ever reported growth rate in defined medium on glucose (2.20 h-1) or glycerol (1.95 h-1). These findings provide a foundation for further exploration of G. sp. LC300's physiology and metabolic regulation, and its potential use in bioproduction processes.

Association of recent respiratory illness and influenza with acute myocardial infarction among the Bangladeshi population: A case-control study

Current evidence suggests that recent acute respiratory infections and seasonal influenza may precipitate acute myocardial infarction (AMI). This study examined the potential link between recent clinical respiratory illness (CRI) and influenza, and AMI in Bangladesh. Conducted during the 2018 influenza season at a Dhaka tertiary-level cardiovascular (CV) hospital, it included 150 AMI cases and two control groups: 44 hospitalized cardiac patients without AMI and 90 healthy individuals. Participants were matched by gender and age groups. The study focused on self-reported CRI and laboratory-confirmed influenza ascertained via quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) within the preceding week, analyzed using multivariable logistic regression. Results showed that cases reported CRI, significantly more frequently than healthy controls (27.3% vs. 13.3%, adjusted odds ratio (aOR): 2.21; 95% confidence interval (CI): 1.05-4.06), although this was not significantly different from all controls (27.3% vs. 22.4%; aOR: 1.19; 95% CI: 0.65-2.18). Influenza rates were insignificantly higher among cases than controls. The study suggests that recent respiratory illnesses may precede AMI onset among Bangladeshi patients. Infection prevention and control practices, as well as the uptake of the influenza vaccine, may be advocated for patients at high risk of acute CV events.

Adolescents' experience of mistreatment and abuse during childbirth: a cross-sectional community survey in a low-income informal settlement in Nairobi, Kenya

BACKGROUND

Adolescent girls in Africa have poorer maternal health outcomes than older women partly because they are less likely to access antenatal and facility-based delivery care. Mistreatment and abuse of adolescents during facility-based childbirth can further negatively impact their use of maternal healthcare services. Yet studies on this topic are limited. As a result, patterns of mistreatment and abuse, their association with care satisfaction, and the intention to use health facilities for future births or recommend facilities to others are poorly understood. This study estimates the prevalence of mistreatment and abuse of adolescent girls during facility-based childbirth in low-income settlements in an urban area. It also examines whether experiencing mistreatment and abuse during facility-based childbirth is associated with care satisfaction, willingness to recommend the facility to others, and intention to use the facility for subsequent childbirths.

METHODS

We used cross-sectional data collected from 491 adolescent mothers recruited through a household listing in an informal settlement in Nairobi, Kenya. Girls self-reported their experience of physical and verbal abuse, stigma and discrimination, lack of privacy, detainment (baby or mother detained in the clinic due to inability to pay user fees), neglect and abandonment during childbirth. Descriptive statistics were used to summarise the categorical variables while binary logistic regression models were used to examine the association between experience of mistreatment and abuse and care satisfaction, willingness to recommend the facility to others and intention to use the facility for subsequent childbirths.

RESULTS

About one-third of adolescent mothers (32.2%) reported physical abuse, verbal abuse or stigma and discrimination from health providers. 1 in 10 reported neglect and abandonment during childbirth, and about a quarter (24%) reported a lack of privacy. Detainment was reported by approximately 17% of girls. Report of any physical abuse, verbal abuse, and stigma and discrimination was significantly associated with a lower likelihood of satisfaction with care (Adjusted Odds ration (AOR) 0.24; 95% CI 0.15 to 0.38), intention to use the facility for future births (AOR 0.32; 95% CI 0.22 to 0.48) and willingness to recommend the facility to others (AOR 0.23; 95% CI 0.15 to 0.36). Neglect and abandonment during childbirth, and lack of privacy were significantly associated with lower odds of being satisfied with the care, intention to use the facility for future births, and the willingness to recommend the facility to others. Experience of detention was associated with a lower likelihood of intention to use the facility for future births (AOR 0.55; 95% CI 0.34 to 90), but not with the willingness to recommend the facility to others or overall satisfaction with care.

CONCLUSIONS

Mistreatment and abuse of adolescent girls during childbirth are common in the study setting and are associated with lower levels of satisfaction with care, intention to use the facility for future births, or recommend it to others. Preservice and in-service training of health workers in the study setting should address the need for respectful care for adolescents.

Comparative Safety Surveillance of Triple (IDA) Versus Dual Therapy (DA) in Mass Drug Administration for Elimination of Lymphatic Filariasis in Kenya: A Cohort Event Monitoring Study

INTRODUCTION

Dual diethylcarbamazine and albendazole (DA) therapy is the standard mass drug administration (MDA) regimen for lymphatic filariasis in Kenya. Following the recent World Health Organization recommendation, Kenya piloted triple therapy with ivermectin, diethylcarbamazine, and albendazole (IDA) in MDA.

OBJECTIVE

We conducted a community-based, observational, cohort event monitoring study to compare the types, frequency, severity, and predictors of adverse events following dual versus triple therapy in 20,421 eligible residents.

METHODS

Residents in Kilifi (n = 10,010) and Mombasa counties (n = 10,411) received DA and IDA through MDA campaigns, respectively. Adverse events were actively monitored through house-to-house visits on days 1, 2, and 7 after MDA. Any clinical events reported before and after MDA were cross-checked and verified to differentiate pre-existing events from MDA-associated adverse events.

RESULTS

Overall, 5807 and 3102 adverse events were reported by 2839 and 1621 individuals in the IDA and DA groups, respectively. The incidence of experiencing one or more adverse events was significantly higher (p < 0.0001) in the IDA group (27.3%; 95% confidence interval [CI] 26.4-28.2) than in the DA group (16.2%; 95% CI 15.5-16.9). Dizziness (15.9% vs 5.9%) and drowsiness (10.1% vs 2.6%) were the most common adverse events and significantly higher in the IDA group compared with the DA group (p < 0.0001). Most adverse events were mild or moderate with a few severe cases (IDA = 0.05%; 95% CI 0.35-0.78, DA = 0.03%; 95% CI 0.14-0.60). Female sex, obesity, taking three or more diethylcarbamazine or ivermectin tablets, and having pre-existing clinical symptoms were significant predictors of adverse events following IDA treatment.

CONCLUSIONS

Ivermectin, diethylcarbamazine, and albendazole as a combination is as safe and well tolerated as DA to use in MDA campaigns with no serious life-threatening adverse events. Systemic mild-to-moderate adverse events with a few severe cases and transient adverse events are more common with IDA treatment than with DA treatment. Hence, integrating pharmacovigilance into a MDA program is recommended for the timely detection and management of adverse events.

Naïve, uninformed and sexually abused: circumstances surrounding adolescent pregnancies in Malawi

BACKGROUND

Pregnancy and childbearing in adolescence could negatively affect girls' health and socio-economic wellbeing across the life course. Previous studies on drivers of adolescent pregnancy in Africa have not fully considered the perspectives of parents/guardians vis-à-vis pregnant and parenting adolescents. Our study addresses this gap by examining pregnant and parenting adolescents' and parents/guardians' narratives about factors associated with early and unintended pregnancy.

METHODOLOGY

The descriptive study draws on qualitative data collected as part of a larger mixed-methods cross-sectional survey on the lived experiences of pregnant and parenting adolescents. Data were collected between March and May 2021 in Blantyre, Malawi, using semi-structured interview guides. We interviewed 18 pregnant and parenting adolescent girls, 10 parenting adolescent boys, and 16 parents/guardians of pregnant and parenting adolescents. Recorded interviews were transcribed verbatim into the English language by bilingual transcribers. We used the inductive-thematic analytical approach to summarize the data.

FINDINGS

The data revealed several interconnected and structural reasons for adolescents' vulnerability to early and unintended pregnancy. These include adolescents' limited knowledge and access to contraceptives, poverty, sexual violence, school dropout, COVID-19 school closures, and being young and naively engaging in unprotected sex. While some parents agreed that poverty and school dropout or COVID-19 related school closure could lead to early pregnancies, most considered stubbornness, failure to adhere to abstinence advice and peer influence as responsible for adolescent pregnancies.

CONCLUSION

Our findings contribute to the evidence on the continued vulnerability of girls to unintended pregnancy. It highlights how parents and adolescents hold different views on reasons for early and unintended pregnancy, and documents how divergent views between girls and their parents may contribute to the lack of progress in reducing adolescent childbearing. Based on these findings, preventing unintended pregnancies will require altering community attitudes about young people's use of contraceptives and engaging parents, education sector, civil society organizations and community and religious leaders to develop comprehensive sexuality education programs to empower in- and out-of school adolescents.

Lived experiences of pregnant and parenting adolescents in Africa: A scoping review

BACKGROUND

Previous studies have not synthesized existing literature on the lived experiences of pregnant and parenting adolescents (aged 10-19) in Africa. Such evidence synthesis is needed to inform policies, programs, and future research to improve the well-being of the millions of pregnant or parenting adolescents in the region. Our study fills this gap by reviewing the literature on pregnant and parenting adolescents in Africa. We mapped existing research in terms of their substantive focus, and geographical distribution. We synthesized these studies based on thematic focus and identified gaps for future research.

METHODS

We used a three-step search strategy to find articles, theses, and technical reports reporting primary research published in English between January 2000 and June 2021 in PubMed, Jstor, AJOL, EBSCO Host, and Google Scholar. Three researchers screened all articles, including titles, abstracts, and full text, for eligibility. Relevant data were extracted using a template designed for the study. Overall, 116 studies met the inclusion criteria and were included in the study. Data were analyzed using descriptive and thematic analyses.

RESULTS

Research on pregnant and parenting adolescents is limited in volume and skewed to a few countries, with two-fifths of papers focusing on South Africa (41.4%). Most of the studies were African-led (81.9%), received no funding (60.3%), adopted qualitative designs (58.6%), and were published between 2016 and 2021 (48.3%). The studies highlighted how pregnancy initiates a cycle of social exclusion of girls with grave implications for their physical and mental health and social and economic well-being. Only 4.3% of the studies described an intervention. None of these studies employed a robust research design (e.g., randomized controlled trial) to assess the intervention's effectiveness. Adolescent mothers' experiences (26.7%) and their education (36.2%) were the most studied topics, while repeat pregnancy received the least research attention.

CONCLUSION

Research on issues affecting pregnant and parenting adolescents is still limited in scope and skewed geographically despite the large burden of adolescent childbearing in many African countries. While studies have documented how early pregnancy could result in girls' social and educational exclusion, few interventions to support pregnant and parenting adolescents exist. Further research to address these gaps is warranted.

Correlation of N-acetyltransferase 2 genotype and acetylation status with plasma isoniazid concentration and its metabolic ratio in ethiopian tuberculosis patients

Unfavorable treatment outcomes for tuberculosis (TB) treatment might result from altered plasma exposure to antitubercular drugs in TB patients. The present study investigated the distribution of the N-Acetyltransferase 2 (NAT2) genotype, isoniazid acetylation status, genotype-phenotype concordance of NAT2, and isoniazid plasma exposure among Ethiopian tuberculosis patients. Blood samples were collected from newly diagnosed TB patients receiving a fixed dose combination of first-line antitubercular drugs daily. Genotyping of NAT2 was done using TaqMan drug metabolism assay. Isoniazid and its metabolite concentration were determined using validated liquid chromatography-tandem mass spectrometry (LC-MS/MS). A total of 120 patients (63 male and 57 female) were enrolled in this study. The mean daily dose of isoniazid was 4.71 mg/kg. The frequency of slow, intermediate, and fast NAT2 acetylators genotypes were 74.2%, 22.4%, and 3.3% respectively. The overall median isoniazid maximum plasma concentration (Cmax) was 4.77 µg/mL and the AUC0-7 h was 11.21 µg.h/mL. The median Cmax in slow, intermediate, and fast acetylators were 5.65, 3.44, and 2.47 μg/mL, respectively. The median AUC0-7 h hour in slow, intermediate, and fast acetylators were 13.1, 6.086, and 3.73 mg•h/L, respectively. The majority (87.5%) of the study participants achieved isoniazid Cmax of above 3 µg/mL, which is considered a lower limit for a favorable treatment outcome. There is 85% concordance between the NAT2 genotype and acetylation phenotypes. NAT2 genotype, female sex, and dose were independent predictors of Cmax and AUC0-7 h (p < 0.001). Our finding revealed that there is a high frequency of slow NAT2 genotypes. The plasma Cmax of isoniazid was higher in the female and slow acetylators genotype group. The overall target plasma isoniazid concentrations in Ethiopian tuberculosis patients were achieved in the majority of the patients. Therefore, it is important to monitor adverse drug reactions and the use of a higher dose of isoniazid should be closely monitored.

Correlates of intimate partner violence among pregnant and parenting adolescents: a cross-sectional household survey in Blantyre District, Malawi

BACKGROUND

Despite efforts from the government and developmental partners to eliminate gender-based violence, intimate partner violence (IPV) remains a pervasive global health and human rights problem, affecting up to 753 million women and girls globally. Few studies on IPV have focused on pregnant and parenting adolescent (PPA) girls in Africa, although the region has the highest rates of adolescent childbearing. This limited attention results in the neglect of pregnant and parenting adolescents in policies and interventions addressing IPV in the region. Our study examined IPV prevalence and its individual, household, and community-level correlates among pregnant and parenting adolescent girls (10-19 years) in Blantyre District, Malawi.

METHODS

We collected data from a cross-section of pregnant and parenting adolescent girls (n = 669) between March and May 2021. The girls responded to questions on socio-demographic and household characteristics, lifetime experience of IPV (i.e., sexual, physical, and emotional violence), and community-level safety nets. We used multilevel mixed-effect logistic regression models to examine the individual, household, and community-level factors associated with IPV.

RESULTS

The lifetime prevalence of IPV was 39.7% (n = 266), with more girls reporting emotional (28.8%) than physical (22.2%) and sexual (17.4%) violence. At the individual level, girls with secondary education (AOR: 1.72; 95% CI: 1.16-2.54), who engaged in transactional sex (AOR: 2.29; 95% CI: 1.35-3.89), and accepted wife-beating (AOR: 1.97; 95% CI: 1.27-3.08) were significantly more likely to experience IPV compared to those with no education/primary education, who never engaged in transactional sex and rejected wife beating. Girls aged 19 (AOR: 0.49; 95% CI: 0.27-0.87) were less likely to report IPV than those aged 13-16. At the household level, girls with fair and poor partner support had higher odds of experiencing IPV, but the effect size did not reach a significant level in the parsimonious model. A high perception of neighborhood safety was associated with a lower likelihood of experiencing IPV (AOR: 0.81; 95% CI: 0.69-0.95).

CONCLUSION

Intimate partner violence is rife among pregnant and parenting adolescent girls in Malawi, underscoring the need for appropriate interventions to curb the scourge. Interventions addressing IPV need to target younger adolescents, those engaging in transactional sex, and those having weaker community-level safety nets. Interventions to change social norms that drive the acceptance of gender-based violence are also warranted.

Implementation of the Afya conditional cash transfer intervention to retain women in the continuum of care: a mixed-methods process evaluation

OBJECTIVES

We report the results of a mixed-methods process evaluation that aimed to provide insight on the Afya conditional cash transfer (CCT) intervention fidelity and acceptability.

INTERVENTION, SETTING AND PARTICIPANTS

The Afya CCT intervention aimed to retain women in the continuum of maternal healthcare including antenatal care (ANC), delivery at facility and postnatal care (PNC) in Siaya County, Kenya. The cash transfers were delivered using an electronic card reader system at health facilities. It was evaluated in a trial that randomised 48 health facilities to intervention or control, and which found modest increases in attendance for ANC and immunisation appointments, but little effect on delivery at facility and PNC visits.

DESIGN

A mixed-methods process evaluation was conducted. We used the Afya electronic portal with recorded visits and payments, and reports on use of the electronic card reader system from each healthcare facility to assess fidelity. Focus group interviews with participants (N=5) and one-on-one interviews with participants (N=10) and healthcare staff (N=15) were conducted to assess the acceptability of the intervention. Data analyses were conducted using descriptive statistics and qualitative content analysis, as appropriate.

RESULTS

Delivery of the Afya CCT intervention was negatively affected by problems with the electronic card reader system and a decrease in adherence to its use over the intervention period by healthcare staff, resulting in low implementation fidelity. Acceptability of cash transfers in the form of mobile transfers was high for participants. Initially, the intervention was acceptable to healthcare staff, especially with respect to improvements in attaining facility targets for ANC visits. However, acceptability was negatively affected by significant delays linked to the card reader system.

CONCLUSIONS

The findings highlight operational challenges in delivering the Afya CCT intervention using the Afya electronic card reader system, and the need for greater technology readiness before further scale-up.

TRIAL REGISTRATION NUMBER

NCT03021070.

The impact of unconditional cash transfers on morbidity and health-seeking behaviour in Africa: evidence from Ghana, Malawi, Zambia and Zimbabwe

Unconditional cash transfers have demonstrated widespread, positive impacts on consumption, food security, productive activities and schooling. However, the evidence to date on cash transfers and health-seeking behaviours and morbidity is not only mixed, but the evidence base is biased towards conditional programmes from Latin America and is more limited in the context of Africa. Given contextual and programmatic design differences between the regions, more evidence from Africa is warranted. We investigate the impact of unconditional cash transfers on morbidity and health-seeking behaviour using data from experimental and quasi-experimental study designs of five government cash transfer programs in Ghana, Malawi, Zambia and Zimbabwe. Programme impacts were estimated using difference-in-differences models with longitudinal data. The results indicate positive programme impacts on health seeking when ill and on health expenditures. Our findings suggest that while unconditional cash transfers can improve health seeking when ill, morbidity impacts were mixed. More research is needed on longer-term impacts, mechanisms of impact and moderating factors. Additionally, taken together with existing evidence, our findings suggest that when summarizing the impacts of cash transfers on health, findings from conditional and unconditional programmes should be disaggregated.

Antiretroviral therapy uptake and predictors of virological failure in patients with HIV receiving first-line and second-line regimens in Johannesburg, South Africa: a retrospective cohort data analysis

OBJECTIVE

This study described the demographics, treatment information and identified characteristics associated with virological failure and being lost to follow-up (LTFU) for patients with HIV on first-line and second-line antiretroviral therapy (ART) regimens in a large South African cohort.

DESIGN

A quantitative retrospective cohort study using secondary data analysis.

SETTING

Seven Johannesburg inner city facilities.

PARTICIPANTS

Unique records of 123 002 people with HIV receiving ART at any point in the period 1 April 2004 to 29 February 2020 were included.

MEASURES

Demographic characteristics, ART status, CD4 count information and retention status were collected and analysed as covariates of outcomes (viral load (VL) and LTFU).

RESULTS

Of the total study patients, 95% (n=1 17 260) were on a first-line regimen and 5% (n=5742) were on a second-line regimen. Almost two-thirds were female (64%, n=79 226). Most patients (60%, n=72 430) were initiated on an efavirenz-based, tenofovir disoproxil fumarate-based and emtricitabine-based regimen (fixed-dose combination). 91% (n=76 737) achieved viral suppression at least once since initiating on ART and 60% (n=57 981) remained in care as at the end of February 2020. Patients from the community health centre and primary healthcare clinics were not only more likely to be virally suppressed but also more likely to be LTFU. Patients on second-line regimens were less likely to reach viral suppression (adjusted OR (aOR)=0.26, CI=0.23 to 0.28) and more likely to be LTFU (aOR=1.21, CI=1.09 to 1.35). Being older (≥25 years) and having a recent CD4 cell count≥100 cells/µL were predictors of viral suppression and retention in patients on ART.

CONCLUSION

Patients on first-line regimens had higher VL suppression rates and were more likely to remain in care than those on a second-line regimen. Being younger and having low CD4 cell counts were associated with poor outcomes, suggesting priority groups for ART adherence support.

Effectiveness of conditional cash transfers (Afya credits incentive) to retain women in the continuum of care during pregnancy, birth and the postnatal period in Kenya: a cluster-randomised trial

OBJECTIVES

Given high maternal and child mortality rates, we assessed the impact of conditional cash transfers (CCTs) to retain women in the continuum of care (antenatal care (ANC), delivery at facility, postnatal care (PNC) and child immunisation).

DESIGN

We conducted an unblinded 1:1 cluster-randomised controlled trial.

SETTING

48 health facilities in Siaya County, Kenya were randomised. The trial ran from May 2017 to December 2019.

PARTICIPANTS

2922 women were recruited to the control and 2522 to the intervention arm.

INTERVENTIONS

An electronic system recorded attendance and triggered payments to the participant's mobile for the intervention arm (US$4.5), and phone credit for the control arm (US$0.5). Eligibility criteria were resident in the catchment area and access to a mobile phone.

PRIMARY OUTCOMES

Primary outcomes were any ANC, delivery, any PNC between 4 and 12 months after delivery, childhood immunisation and referral attendance to other facilities for ANC or PNC. Given problems with the electronic system, primary outcomes were obtained from maternal clinic books if participants brought them to data extraction meetings (1257 (50%) of intervention and 1053 (36%) control arm participants). Attendance at referrals to other facilities is not reported because of limited data.

RESULTS

We found a significantly higher proportion of appointments attended for ANC (67% vs 60%, adjusted OR (aOR) 1.90; 95% CI 1.36 to 2.66) and child immunisation (88% vs 85%; aOR 1.74; 95% CI 1.10 to 2.77) in intervention than control arm. No intervention effect was seen considering delivery at the facility (90% vs 92%; aOR 0.58; 95% CI 0.25 to 1.33) and any PNC attendance (82% vs 81%; aOR 1.25; 95% CI 0.74 to 2.10) separately. The pooled OR across all attendance types was 1.64 (1.28 to 2.10).

CONCLUSIONS

Demand-side financing incentives, such as CCTs, can improve attendance for appointments. However, attention needs to be paid to the technology, the barriers that remain for delivery at facility and PNC visits and encouraging women to attend ANC visits within the recommended WHO timeframe.

TRIAL REGISTRATION

NCT03021070.

Transcriptomic Analysis of Quinoa Reveals a Group of Germin-Like Proteins Induced by Trichoderma

Symbiotic strains of fungi in the genus Trichoderma affect growth and pathogen resistance of many plant species, but the interaction is not known in molecular detail. Here we describe the transcriptomic response of two cultivars of the crop Chenopodium quinoa to axenic co-cultivation with Trichoderma harzianum BOL-12 and Trichoderma afroharzianum T22. The response of C. quinoa roots to BOL-12 and T22 in the early phases of interaction was studied by RNA sequencing and RT-qPCR verification. Interaction with the two fungal strains induced partially overlapping gene expression responses. Comparing the two plant genotypes, a broad spectrum of putative quinoa defense genes were found activated in the cultivar Kurmi but not in the Real cultivar. In cultivar Kurmi, relatively small effects were observed for classical pathogen response pathways but instead a C. quinoa-specific clade of germin-like genes were activated. Germin-like genes were found to be more rapidly induced in cultivar Kurmi as compared to Real. The same germin-like genes were found to also be upregulated systemically in the leaves. No strong correlation was observed between any of the known hormone-mediated defense response pathways and any of the quinoa-Trichoderma interactions. The differences in responses are relevant for the capabilities of applying Trichoderma agents for crop protection of different cultivars of C. quinoa.

Effectiveness of school-based interventions in delaying sexual debut among adolescents in sub-Saharan Africa: a protocol for a systematic review and meta-analysis

INTRODUCTION

Early sexual debut is associated with poor sexual and reproductive health outcomes across the life course. A majority of interventions aimed at delaying sexual debut among adolescents in sub-Saharan Africa (SSA) have been implemented in schools with mixed findings on the effectiveness of such interventions. This systematic review will summarise and synthesise existing evidence on the effectiveness of school-based interventions in delaying sexual debut among adolescents aged 10-19 years.

METHODS AND ANALYSIS

We will conduct a comprehensive database search of peer-reviewed studies published in PubMed, Scopus, Science Direct, Web of Science, HINARI and EBSCO (PsycINFO, Global Health, CINAHL) and in Cochrane library, National Institute of Health and Turning Research into Practice databases for ongoing studies yet to be published. All studies conducted in SSA between January 2009 and December 2020, regardless of the study design, will be included. Two authors will independently screen all retrieved records and relevant data on sexual debut extracted.Data will be pooled using the random effects model. Dichotomous outcomes will be reported as risk ratios and continuous data as mean difference at 95% CI. Heterogeneity will be assessed using the I² statistic. Findings will be presented in tables and charts, while providing a description of all included studies, themes and concepts drawn from literature.

ETHICS AND DISSEMINATION

Ethical approval is not required. The findings will be disseminated through peer-reviewed publications, presentations at relevant conferences and other convening focusing on adolescent sexual and reproductive health.

Disability status and multi-dimensional personal well-being among adolescents in the Southern Highlands Region of Tanzania: results of a cross-sectional study

OBJECTIVE

Examine how disability status among adolescents is associated with the following domains of personal well-being: schooling, livelihoods, health, violence and psychosocial well-being. It is hypothesised that adolescents with a disability will have greater deficits in these areas of well-being compared with their healthier counterparts.

DESIGN

Cross-sectional data from 2018 were obtained from the second round of an on-going study of adolescents living in poor households in two regions of the Southern Highlands of Tanzania (Iringa and Mbeya). We use the Washington Group (WG) Short Set indicators to measure disability and undertook logistic and linear multivariate regressions to understand the association between disability and the outcomes of interest.

PARTICIPANTS

The sample included 2274 participants aged 15-20 years living in households participating in a government social protection programme targeted to households living in extreme poverty.

RESULTS

Overall, 310 participants (14%) were classified as having disabilities. Outcomes not associated with disability status included literacy, schooling, livelihoods and self-efficacy. Adolescents with disabilities were less likely to report good or very good health (adjusted OR (aOR)=0.39, 95% CI 0.29 to 0.52) and had increased odds of reporting depressive symptoms in (aOR=1.46, 95% CI 1.11 to 1.90), emotional violence (aOR=2.18, 95% CI 1.49 to 3.20) and physical violence (aOR=1.71, 95% CI 1.13 to 2.59), compared with those without disabilities. Reports of depression were higher among men, and violence was more prevalent among women. Patterns of association were generally similar between men and women, although the association of disability with markers of well-being reached statistical significance more often among men.

CONCLUSION

This study highlights areas where adolescents with disabilities are falling behind their peers in terms of personal well-being. These findings suggest that interventions may be needed to mainstream disability in programmes and policies aiming to improve well-being, mental health and violence prevention among adolescents.

TRIAL REGISTRATION NUMBER

Pan African Clinical Trial Registry (PACTR201804003008116).

COVID-19: From health crises to food security anxiety and policy implications

Like the rest of the world, African countries are reeling from the health, economic and social effects of COVID-19. The continent's governments have responded by imposing rigorous lockdowns to limit the spread of the virus. The various lockdown measures are undermining food security, because stay at home orders have among others, threatened food production for a continent that relies heavily on agriculture as the bedrock of the economy. This article draws on quantitative data collected by the GeoPoll, and, from these data, assesses the effect of concern about the local spread and economic impact of COVID-19 on food worries. Qualitative data comprising 12 countries south of the Sahara reveal that lockdowns have created anxiety over food security as a health, economic and human rights/well-being issue. By applying a probit model, we find that concern about the local spread of COVID-19 and economic impact of the virus increases the probability of food worries. Governments have responded with various efforts to support the neediest. By evaluating the various policies rolled out we advocate for a feminist economics approach that necessitates greater use of data analytics to predict the likely impacts of intended regulatory relief responses during the recovery process and post-COVID-19.

The presence of antibiotic-resistant Staphylococcus spp. and Escherichia coli in smallholder pig farms in Uganda

BACKGROUND

The development of antimicrobial resistance is of global concern, and is commonly monitored by the analysis of certain bacteria. The aim of the present study was to study the antibiotic susceptibility in isolates of Staphylococcus spp. and Escherichia (E.) coli obtained from healthy pigs originating from nineteen herds enrolled in a study on herd health management in Lira district, northern Uganda. Skin and nasal swabs were analyzed for the presence of Staphylococcus spp., and selectively cultivated to investigate the presence of methicillin-resistant Staphylococcus (S.) aureus (MRSA), and rectal swabs were analyzed for the presence of E. coli. Antibiotic susceptibility was tested by broth micro-dilution. Information on the antibiotic usage and treatment regimens during the previous year was gathered using structured interviews and longitudinal data.

RESULTS

In Staphylococcus spp., resistance to penicillin (10/19 isolates; 53%), fusidic acid (42%) and tetracycline (37%) were most commonly found. In E. coli, resistance to sulfamethoxazole (46/52 isolates; 88%), tetracycline (54%) and trimethoprim (17%) was most frequent. Methicillin-resistant S. aureus was found in one sample (1/50; 2%). Multi-drug resistant isolates of Staphylococcus spp. and E. coli were found in 54 and 47% of the herds, respectively. At the herd level, no associations could be made between antibiotic resistance and herd size or treatment regimens for either of the bacteria.

CONCLUSION

In conclusion, resistance to important antibiotics frequently used in animals in Uganda was common, and the presence of MRSA was demonstrated, in Ugandan pig herds.

Challenges and facilitators of implementation of an information communication and technology (ICT)-based human resources management tool in the government health sector in Bangladesh: protocol for an exploratory qualitative research study

INTRODUCTION

To improve human resources for health (HRH) management in Bangladesh, the directorate general of health services (DGHS) introduced a new information and communications technology (ICT) tool, named 'human resources information system (HRIS)', to process real-time HRH data of all facilities under the DGHS. However, synchronisation is a major concern since multiple authorities are involved in the implementation of the tool at different tiers of the health system. Introducing ICT tools in healthcare organisations has always proved challenging as evidence from low-income and middle-income countries suggests. The knowledge gap in terms of factors that support or constrain the successful implementation of the HRIS in Bangladesh will be investigated in this exploratory study to identify ways of engaging the key stakeholders in a better way for an effective use of the tool.

METHODS AND ANALYSIS

Desk review and qualitative data collection methods will be used to address the study objectives. Key informant interviews and in-depth interviews will be conducted to explore perspectives of policy-makers, programme managers, service providers and other stakeholders to understand the barriers to implementing HRIS in the context of Bangladesh. We plan to organise stakeholder consultation workshops to validate the qualitative study findings and to seek suggestions for ensuring a successful implementation of the HRIS. Framework analysis will be applied to analyse qualitative data, and an outline with the definitions of a priori codes guided by the policy engagement framework will be prepared. Besides, emerging themes will also be identified. A data display matrix will be prepared to summarise and interpret the findings for policy review.

ETHICS AND DISSEMINATION

The research review committee and the ethical review committee of icddr,b have approved the research protocol. Findings from the study will be communicated through national and international forums, conferences, policy briefs and peer-reviewed journal publications.

Postneonatal under-5 mortality in peri-urban and rural Eastern Uganda, 2005-2015

INTRODUCTION

Community and individual sociodemographic characteristics play an important role in child survival. However, a question remains how urbanisation and demographic changes in sub-Saharan Africa affect community-level determinants for child survival.

METHODS

Longitudinal data from the Iganga/Mayuge Health and Demographic Surveillance Site was used to obtain postneonatal under-5 mortality rates between March 2005 and February 2015 in periurban and rural areas separately. Multilevel survival analysis models were used to identify factors associated with mortality.

RESULTS

There were 43 043 postneonatal under-5 children contributing to 116 385 person years of observation, among whom 1737 died. Average annual crude mortality incidence rate (IR) differed significantly between periurban and rural areas (9.0 (8.1 to 10.0) per 1000 person-years vs 18.1 (17.1 to 19.0), respectively). In periurban areas, there was evidence for decreasing mortality from IR=11.3 (7.7 to 16.6) in 2006 to IR=4.5 (3.0 to 6.9) in 2015. The mortality fluctuated with no evidence for reduction in rural areas (IR=19.0 (15.8 to 22.8) in 2006; IR=15.5 (13.0 to 18.6) in 2015). BCG vaccination was associated with reduced mortality in periurban and rural areas (adjusted rate ratio (aRR)=0.45; 95% CI 0.30 to 0.67 and aRR=0.56; 95% CI 0.41 to 0.76, respectively). Maternal education level within the community was associated with reduced mortality in both periurban and rural sites (aRR=0.83; 95% CI 0.70 to 0.99; aRR=0.90; 95% CI 0.81 to 0.99). The proportion of households in the poorest quintile within the community was associated with mortality in rural areas only (aRR=1.08; 95% CI 1.00 to 1.18). In rural areas, a large disparity existed between the least poor and the poorest (aRR=0.50; 95% CI 0.27 to 0.92).

CONCLUSION

We found evidence for a mortality decline in peri-urban but not rural areas. Investments in the known key health (eg, vaccination) and socio-economic interventions (education, and economic development) continue to be crucial for mortality declines. Focused strategies to eliminate the disparity between wealth quintiles are also warranted. There may be equitable access to health services in peri-urban areas but improved metrics of socioeconomic position suitable for peri-urban residents may be needed.

Prevalence, Intensity, and Correlates of Schistosomiasis and Soil-Transmitted Helminth Infections after Five Rounds of Preventive Chemotherapy among School Children in Southern Ethiopia

Preventive chemotherapy (PC) is a WHO-recommended strategy to control and eliminate schistosomiasis and soil-transmitted helminths (STHs). We assessed the prevalence, intensity, and correlates of schistosomiasis and STH infection after five rounds of PC in southern Ethiopia. A total of 3162 school children from four schools in Wondo Gennet and Hawella Tula districts were screened for Schistosoma mansoni and STHs infection. The overall prevalence of S. mansoni infection was 25.8% (range between schools 11.6% to 54.1%), with light (19.1%), moderate (5.3%), and heavy (1.4%) infection intensities. A total of 61.6% S. mansoni-infected children were STH co-infected. The overall prevalence of STHs infection was 54.7% (range between schools 30.6-71.0%), with moderate-to-heavy intensity infections being 16.3%. Ascaris lumbricoides was the most prevalent 45% (95% CI, 43.5-47) followed by Trichuris trichiura 25.3% (95% CI, 23.8-26.9) and hookworm 6.1% (95% CI, 5.3-7). A total of 33.7% of STHs-infected children had A. lumbricoides and T. trichiura co-infections. S. mansoni infection was significantly associated with school and STHs co-infection (p < 0.001). STH infection was correlated with school and younger age (p < 0.001). Despite repeated PC, S. mansoni and STH infection remain significant health problems, and the WHO target to control schistosomiasis and eliminate STH by 2020 may not be achieved. Intensified control and prevention measures, including drug efficacy surveillance, is recommended.

Responsiveness of health care services towards the elderly in Tanzania: does health insurance make a difference? A cross-sectional study

BACKGROUND

Responsiveness has become an important health system performance indicator in evaluating the ability of health care systems to meet patients' expectations. However, its measurement in sub-Saharan Africa remains scarce. This study aimed to assess the responsiveness of the health care services among the insured and non-insured elderly in Tanzania and to explore the association of health insurance (HI) with responsiveness in this population.

METHODS

A community-based cross-sectional study was conducted in 2017 where a pre-tested household survey, administered to the elderly (60 + years) living in Igunga and Nzega districts, was applied. Participants with and without health insurance who attended outpatient and inpatient health care services in the past three and 12 months were selected. Responsiveness was measured based on the short version of the World Health Organization (WHO) multi-country responsiveness survey study, which included the dimensions of quality of basic amenities, choice, confidentiality, autonomy, communication and prompt attention. Quantile regression was used to assess the specific association of the responsiveness index with health insurance adjusted for sociodemographic factors.

RESULTS

A total of 1453 and 744 elderly, of whom 50.1 and 63% had health insurance, used outpatient and inpatient health services, respectively. All domains were rated relatively highly but the uninsured elderly reported better responsiveness in all domains of outpatient and inpatient care. Waiting time was the dimension that performed worst. Possession of health insurance was negatively associated with responsiveness in outpatient (- 1; 95% CI: - 1.45, - 0.45) and inpatient (- 2; 95% CI: - 2.69, - 1.30) care.

CONCLUSION

The uninsured elderly reported better responsiveness than the insured elderly in both outpatient and inpatient care. Special attention should be paid to those dimensions, like waiting time, which ranked poorly. Further research is necessary to reveal the reasons for the lower responsiveness noted among insured elderly. A continuous monitoring of health care system responsiveness is recommended.

Midwives' challenges and factors that motivate them to remain in their workplace in the Democratic Republic of Congo-an interview study

BACKGROUND

The Democratic Republic of Congo (DRC) has high maternal mortality and a low number of midwives, which undermines the achievement of goal 3 of the Sustainable Development Goals (SDGs) for 2030, specifically the health of the mother and newborn. Scaling up the midwifery workforce in relation to number, quality of healthcare, and retention in service is therefore critical. The aim of this study was to investigate midwives' challenges and factors that motivate them to remain in their workplace in the DRC.

METHODS

Data were collected in two out of 26 provinces in the DRC through ten focus group discussions with a total of 63 midwives working at ten different healthcare facilities. Transcribed discussions were inductively analysed using content analysis.

RESULTS

The midwives' challenges and the factors motivating them to remain in their workplace in the DRC are summarised in one main category-Loving one's work makes it worthwhile to remain in one's workplace, despite a difficult work environment and low professional status-consisting of three generic categories: Midwifery is not just a profession; it's a calling is described in the subcategories Saving lives through midwifery skills, Building relationships with the women and the community, and Professional pride; Unsupportive organisational system is expressed in the subcategories Insufficient work-related security and No equitable remuneration system, within Hierarchical management structures; and Inadequate pre-conditions in the work environment includes the subcategories Lack of resources and equipment and Insufficient competence for difficult working conditions.

CONCLUSION

Midwives in the DRC are driven by a strong professional conscience to provide the best possible care for women during childbirth, despite a difficult work environment and low professional status. To attract and retain midwives and ensure that they are working to their full scope of practice, we suggest coordinated actions at the regional and national levels in the DRC and in other low-income countries with similar challenges, including (i) conducting midwifery education programmes following international standards, (ii) prioritising and enforcing policies to include adequate remuneration for midwives, (iii) involving midwives' associations in policy and planning about the midwifery workforce, and (iv) ensuring that midwives' working environments are safe and well equipped.

Complement opsonization of HIV affects primary infection of human colorectal mucosa and subsequent activation of T cells

HIV transmission via genital and colorectal mucosa are the most common routes of dissemination. Here, we explored the effects of free and complement-opsonized HIV on colorectal tissue. Initially, there was higher antiviral responses in the free HIV compared to complement-opsonized virus. The mucosal transcriptional response at 24 hr revealed the involvement of activated T cells, which was mirrored in cellular responses observed at 96 hr in isolated mucosal T cells. Further, HIV exposure led to skewing of T cell phenotypes predominantly to inflammatory CD4+ T cells, that is Th17 and Th1Th17 subsets. Of note, HIV exposure created an environment that altered the CD8+ T cell phenotype, for example expression of regulatory factors, especially when the virions were opsonized with complement factors. Our findings suggest that HIV-opsonization alters the activation and signaling pathways in the colorectal mucosa, which promotes viral establishment by creating an environment that stimulates mucosal T cell activation and inflammatory Th cells.

An experimental assessment of algal calcification as a potential source of atmospheric CO2

Marine vegetated ecosystems such as seagrass meadows are increasingly acknowledged as important carbon sinks based on their ability to capture and store atmospheric carbon dioxide, thereby contributing to climate change mitigation. Most studies on carbon storage in marine ecosystems have focused on organic carbon, leaving inorganic carbon processes such as calcification unaccounted for, despite of their critical role in the global carbon budget. This is probably because of uncertainties regarding the role of calcification in marine carbon budgets as either atmospheric CO2 source or sink. Here, we conducted a laboratory experiment to investigate the influence of a calcifying alga (Corallina officinalis L.) on seawater carbon content, using a non-calcifying alga (Ulva lactuca L.) as a control. In a first part, algae were incubated separately while measuring changes in seawater pH, total alkalinity (TA) and total dissolved inorganic carbon (DIC). The amount of carbon used in photosynthetic uptake and production of CaCO3 was then calculated. In a second, directly following, part the algae were removed and DIC levels were allowed to equilibrate with air until the pH stabilized and the loss of CO2 to air was calculated as the difference in total DIC from the start of part one, to the end of the second part. The results showed that C. officinalis caused a significant and persistent reduction in total dissolved inorganic carbon (DIC), TA and seawater pH, while no such permanent changes were caused by U. lactuca. These findings indicate that calcification can release a significant amount of CO2 to the atmosphere and thereby possibly counteract the carbon sequestration in marine vegetated ecosystems if this CO2 is not re-fixed in the system. Our research emphasises the importance of considering algal calcification in future assessments on carbon storage in coastal areas.

Relative importance of prenatal and postnatal determinants of stunting: data mining approaches to the MINIMat cohort, Bangladesh

INTRODUCTION

WHO has set a goal to reduce the prevalence of stunted child growth by 40% by the year 2025. To reach this goal, it is imperative to establish the relative importance of risk factors for stunting to deliver appropriate interventions. Currently, most interventions take place in late infancy and early childhood. This study aimed to identify the most critical prenatal and postnatal determinants of linear growth 0-24 months and the risk factors for stunting at 2 years, and to identify subgroups with different growth trajectories and levels of stunting at 2 years.

METHODS

Conditional inference tree-based methods were applied to the extensive Maternal and Infant Nutrition Interventions in Matlab trial database with 309 variables of 2723 children, their parents and living conditions, including socioeconomic, nutritional and other biological characteristics of the parents; maternal exposure to violence; household food security; breast and complementary feeding; and measurements of morbidity of the mothers during pregnancy and repeatedly of their children up to 24 months of age. Child anthropometry was measured monthly from birth to 12 months, thereafter quarterly to 24 months.

RESULTS

Birth length and weight were the most critical factors for linear growth 0-24 months and stunting at 2 years, followed by maternal anthropometry and parental education. Conditions after birth, such as feeding practices and morbidity, were less strongly associated with linear growth trajectories and stunting at 2 years.

CONCLUSION

The results of this study emphasise the benefit of interventions before conception and during pregnancy to reach a substantial reduction in stunting.

Spatial analysis of HIV-TB co-clustering in Uganda

BACKGROUND

Tuberculosis (TB) is the leading cause of death for individuals infected with Human immunodeficiency virus (HIV). Conversely, HIV is the most important risk factor in the progression of TB from the latent to the active status. In order to manage this double epidemic situation, an integrated approach that includes HIV management in TB patients was proposed by the World Health Organization and was implemented in Uganda (one of the countries endemic with both diseases). To enable targeted intervention using the integrated approach, areas with high disease prevalence rates for TB and HIV need to be identified first. However, there is no such study in Uganda, addressing the joint spatial patterns of these two diseases.

METHODS

This study uses global Moran's index, spatial scan statistics and bivariate global and local Moran's indices to investigate the geographical clustering patterns of both diseases, as individuals and as combined. The data used are TB and HIV case data for 2015, 2016 and 2017 obtained from the District Health Information Software 2 system, housed and maintained by the Ministry of Health, Uganda.

RESULTS

Results from this analysis show that while TB and HIV diseases are highly correlated (55-76%), they exhibit relatively different spatial clustering patterns across Uganda. The joint TB/HIV prevalence shows consistent hotspot clusters around districts surrounding Lake Victoria as well as northern Uganda. These two clusters could be linked to the presence of high HIV prevalence among the fishing communities of Lake Victoria and the presence of refugees and internally displaced people camps, respectively. The consistent cold spot observed in eastern Uganda and around Kasese could be explained by low HIV prevalence in communities with circumcision tradition.

CONCLUSIONS

This study makes a significant contribution to TB/HIV public health bodies around Uganda by identifying areas with high joint disease burden, in the light of TB/HIV co-infection. It, thus, provides a valuable starting point for an informed and targeted intervention, as a positive step towards a TB and HIV-AIDS free community.

Comparison of engineered Escherichia coli AF1000 and BL21 strains for (R)-3-hydroxybutyrate production in fed-batch cultivation

Accumulation of acetate is a limiting factor in recombinant production of (R)-3-hydroxybutyrate (3HB) by Escherichia coli in high-cell-density processes. To alleviate this limitation, this study investigated two approaches: (i) deletion of phosphotransacetylase (pta), pyruvate oxidase (poxB), and/or the isocitrate lyase regulator (iclR), known to decrease acetate formation, on bioreactor cultivations designed to achieve high 3HB concentrations. (ii) Screening of different E. coli strain backgrounds (B, BL21, W, BW25113, MG1655, W3110, and AF1000) for their potential as low acetate-forming, 3HB-producing platforms. Deletion of pta and pta-poxB in the AF1000 strain background was to some extent successful in decreasing acetate formation, but also dramatically increased excretion of pyruvate and did not result in increased 3HB production in high-cell-density fed-batch cultivations. Screening of the different E. coli strains confirmed BL21 as a low acetate-forming background. Despite low 3HB titers in low-cell-density screening, 3HB-producing BL21 produced five times less acetic acid per mole of 3HB, which translated into a 2.3-fold increase in the final 3HB titer and a 3-fold higher volumetric 3HB productivity over 3HB-producing AF1000 strains in nitrogen-limited fed-batch cultivations. Consequently, the BL21 strain achieved the hitherto highest described volumetric productivity of 3HB (1.52 g L⁻¹ h⁻¹) and the highest 3HB concentration (16.3 g L⁻¹) achieved by recombinant E. coli. Screening solely for 3HB titers in low-cell-density batch cultivations would not have identified the potential of this strain, reaffirming the importance of screening with the final production conditions in mind.

AMBIsome Therapy Induction OptimisatioN (AMBITION): High dose AmBisome for cryptococcal meningitis induction therapy in sub-Saharan Africa: economic evaluation protocol for a randomised controlled trial-based equivalence study

INTRODUCTION

Cryptococcal meningitis is responsible for around 15% of all HIV-related deaths globally. Conventional treatment courses with amphotericin B require prolonged hospitalisation and are associated with multiple toxicities and poor outcomes. A phase II study has shown that a single high dose of liposomal amphotericin may be comparable to standard treatment. We propose a phase III clinical endpoint trial comparing single, high-dose liposomal amphotericin with the WHO recommended first-line treatment at six sites across five counties. An economic analysis is essential to support wide-scale implementation.

METHODS AND ANALYSIS

Country-specific economic evaluation tools will be developed across the five country settings. Details of patient and household out-of-pocket expenses and any catastrophic healthcare expenditure incurred will be collected via interviews from trial patients. Health service patient costs and related household expenditure in both arms will be compared over the trial period in a probabilistic approach, using Monte Carlo bootstrapping methods. Costing information and number of life-years survived will be used as the input to a decision-analytic model to assess the cost-effectiveness of a single, high-dose liposomal amphotericin to the standard treatment. In addition, these results will be compared with a historical cohort from another clinical trial.

ETHICS AND DISSEMINATION

The AMBIsome Therapy Induction OptimisatioN (AMBITION) trial has been evaluated and approved by the London School of Hygiene and Tropical Medicine, University of Botswana, Malawi National Health Sciences, University of Cape Town, Mulago Hospital and Zimbabwe Medical Research Council research ethics committees. All participants will provide written informed consent or if lacking capacity will have consent provided by a proxy. The findings of this economic analysis, part of the AMBITION trial, will be disseminated through peer-reviewed publications and at international and country-level policy meetings.

TRIAL REGISTRATION

ISRCTN 7250 9687; Pre-results.

Abortion in Zimbabwe: A national study of the incidence of induced abortion, unintended pregnancy and post-abortion care in 2016

BACKGROUND

Zimbabwe has the highest contraceptive prevalence rate in sub-Saharan Africa, but also one of the highest maternal mortality ratios in the world. Little is known, however, about the incidence of abortion and post-abortion care (PAC) in Zimbabwe. Access to legal abortion is rare, and limited to circumstances of rape, incest, fetal impairment, or to save the woman's life.

OBJECTIVES

This paper estimates a) the national provision of PAC, b) the first-ever national incidence of induced abortion in Zimbabwe, and c) the proportion of pregnancies that are unintended.

METHODS

We use the Abortion Incidence Complications Method (AICM), which indirectly estimates the incidence of induced abortion by obtaining a national estimate of PAC cases, and then estimates what proportion of all induced abortions in the country would result in women receiving PAC. Three national surveys were conducted in 2016: a census of health facilities with PAC capacity (n = 227), a prospective survey of women seeking abortion-related care in a nationally-representative sample of those facilities (n = 127 facilities), and a purposive sample of experts knowledgeable about abortion in Zimbabwe (n = 118). The estimate of induced abortion, along with census and Demographic Health Survey data was used to estimate unintended pregnancy.

RESULTS

There were an estimated 25,245 PAC patients treated in Zimbabwe in 2016, but there were critical gaps in their care, including stock-outs of essential PAC medicines at half of facilities. Approximately 66,847 induced abortions (uncertainty interval (UI): 54,000-86,171) occurred in Zimbabwe in 2016, which translates to a national rate of 17.8 (UI: 14.4-22.9) abortions per 1,000 women 15-49. Overall, 40% of pregnancies were unintended in 2016, and one-quarter of all unintended pregnancies ended in abortion.

CONCLUSION

Zimbabwe has one of the lowest abortion rates in sub-Saharan Africa, likely due to high rates of contraceptive use. There are gaps in the health care system affecting the provision of quality PAC, potentially due to the prolonged economic crisis. These findings can inform and improve policies and programs addressing unsafe abortion and PAC in Zimbabwe.

Challenges to implementing national comprehensive sexuality education curricula in low- and middle-income countries: Case studies of Ghana, Kenya, Peru and Guatemala

School-based comprehensive sexuality education (CSE) can help adolescents achieve their full potential and realize their sexual and reproductive health and rights. This is particularly pressing in low- and middle-income countries (LMICs), where high rates of unintended pregnancy and STIs among adolescents can limit countries' ability to capitalize on the demographic dividend. While many LMICs have developed CSE curricula, their full implementation is often hindered by challenges around program planning and roll-out at the national and local level. A better understanding of these barriers, and similarities and differences across countries, can help devise strategies to improve implementation; yet few studies have examined these barriers. This paper analyzes the challenges to the implementation of national CSE curricula in four LMICs: Ghana, Kenya, Peru and Guatemala. It presents qualitative findings from in-depth interviews with central and local government officials, civil society representatives, and community level stakeholders ranging from religious leaders to youth representatives. Qualitative findings are complemented by quantitative results from surveys of principals, teachers who teach CSE topics, and students aged 15-17 in a representative sample of 60-80 secondary schools distributed across three regions in each country, for a total of around 3000 students per country. Challenges encountered were strikingly similar across countries. Program planning-related challenges included insufficient and piecemeal funding for CSE; lack of coordination of the various efforts by central and local government, NGOs and development partners; and inadequate systems for monitoring and evaluating teachers and students on CSE. Curriculum implementation-related challenges included inadequate weight given to CSE when integrated into other subjects, insufficient adaptation of the curriculum to local contexts, and limited stakeholder participation in curriculum development. While challenges were similar across countries, the strategies used to overcome them were different, and offer useful lessons to improve implementation for these and other low- and middle-income countries facing similar challenges.

Predicting mortality with the international classification of disease injury severity score using survival risk ratios derived from an Indian trauma population: A cohort study

Background

Trauma is predicted to become the third leading cause of death in India by 2020, which indicate the need for urgent action. Trauma scores such as the international classification of diseases injury severity score (ICISS) have been used with great success in trauma research and in quality programmes to improve trauma care. To this date no valid trauma score has been developed for the Indian population.

Study design

This retrospective cohort study used a dataset of 16047 trauma-patients from four public university hospitals in urban India, which was divided into derivation and validation subsets. All injuries in the dataset were assigned an international classification of disease (ICD) code. Survival Risk Ratios (SRRs), for mortality within 24 hours and 30 days were then calculated for each ICD-code and used to calculate the corresponding ICISS. Score performance was measured using discrimination by calculating the area under the receiver operating characteristics curve (AUROCC) and calibration by calculating the calibration slope and intercept to plot a calibration curve.

Results

Predictions of 30-day mortality showed an AUROCC of 0.618, calibration slope of 0.269 and calibration intercept of 0.071. Estimates of 24-hour mortality consistently showed low AUROCCs and negative calibration slopes.

Conclusions

We attempted to derive and validate a version of the ICISS using SRRs calculated from an Indian population. However, the developed ICISS-scores overestimate mortality and implementing these scores in clinical or policy contexts is not recommended. This study, as well as previous reports, suggest that other scoring systems might be better suited for India and other Low- and middle-income countries until more data are available.

Environmental risk assessment of pesticides in the River Madre de Dios, Costa Rica using PERPEST, SSD, and msPAF models

This study assesses the ecological risks (ERA) of pesticides to aquatic organisms in the River Madre de Dios (RMD), which receives surface runoff water from banana, pineapple, and rice plantations on the Caribbean coast of Costa Rica. Water samples collected over 2 years at five sites in the RMD revealed a total of 26 pesticides. Their toxicity risk to aquatic organisms was assessed using three recent ERA models. (1) The PERPEST model showed a high probability (>50 %) of clear toxic effects of pesticide mixtures on algae, macrophytes, zooplankton, macroinvertebrates, and community metabolism and a low probability (<50 %) of clear effects on fish. (2) Species sensitivity distributions (SSD) showed a moderate to high risk of three herbicides: ametryn, bromacil, diuron and four insecticides: carbaryl, diazinon, ethoprophos, terbufos. (3) The multi-substance potentially affected fraction (msPAF) model showed results consistent with PERPEST: high risk to algae (maximum msPAF: 73 %), aquatic plants (61 %), and arthropods (25 %) and low risk to fish (0.2 %) from pesticide mixtures. The pesticides posing the highest risks according to msPAF and that should be substituted with less toxic substances were the herbicides ametryn, diuron, the insecticides carbaryl, chlorpyrifos, diazinon, ethoprophos, and the fungicide difenoconazole. Ecological risks were highest near the plantations and decreased progressively further downstream. The risk to fish was found to be relatively low in these models, but water samples were not collected during fish kill events and some highly toxic pesticides known to be used were not analyzed for in this study. Further sampling and analysis of water samples is needed to determine toxicity risks to fish during peaks of pesticide mixture concentrations. The msPAF model, which estimates the ecological risks of mixtures based on their toxic modes of action, was found to be the most suitable model to assess toxicity risks to aquatic organisms in the RMD. The PERPEST model was found to be a strong tool for screening risk assessments. The SSD approach is useful in deriving water quality criteria for specific pesticides. This study, through the application of three ERA models, clearly shows that pesticides used in plantations within the RMD watershed are expected to have severe adverse effects on most groups of aquatic organisms and that actions are urgently needed to reduce pesticide pollution in this high biodiversity ecosystem.

Assessing the ecological impact of banana farms on water quality using aquatic macroinvertebrate community composition

In Costa Rica, considerable effort goes to conservation and protection of biodiversity, while at the same time agricultural pesticide use is among the highest in the world. Several protected areas, some being wetlands or marine reserves, are situated downstream large-scale banana farms, with an average of 57 pesticide applications per year. The banana industry is increasingly aware of the need to reduce their negative environmental impact, but few ecological field studies have been made to evaluate the efficiency of proposed mitigation strategies. This study compared the composition of benthic macroinvertebrate communities up- and downstream effluent water from banana farms in order to assess whether benthic invertebrate community structure can be used to detect environmental impact of banana farming, and thereby usable to assess improvements in management practises. Aquatic invertebrate samples were collected at 13 sites, using kick-net sampling, both up- and downstream banana farms in fast flowing streams in the Caribbean zone of Costa Rica. In total, 2888 invertebrate specimens were collected, belonging to 15 orders and 48 families or taxa. The change in community composition was analysed using multivariate statistics. Additionally, a biodiversity index and the Biological Monitoring Working Party (BMWP) score system was applied along with a number of community composition descriptors. Multivariate analyses indicated that surface waters immediately up- and downstream large-scale banana farms have different macroinvertebrate community compositions with the most evident differences being higher dominance by a single taxa and a much higher total abundance, mostly of that same taxon. Assessment of macroinvertebrate community composition thus appears to be a viable approach to detect negative impact from chemical-intensive agriculture and could become an effective means to monitor the efficacy of changes/proposed improvements in farming practises in Costa Rica and similar systems.

Quantifying the connections-linkages between land-use and water in the Kathmandu Valley, Nepal

Land development without thoughtful water supply planning can lead to unsustainability. In practice, management of our lands and waters is often unintegrated. We present new land-use, ecological stream health, water quality, and streamflow data from nine perennial watersheds in the Kathmandu Valley, Nepal, in the 2016 monsoon (i.e., August and September) and 2017 pre-monsoon (i.e., April and May) periods. Our goal was to improve understanding of the longitudinal linkages between land-use and water. At a total of 38 locations, the Rapid Stream Assessment (RSA) protocol was used to characterize stream ecology, basic water quality parameters were collected with a handheld WTW multi-parameter meter, and stream flow was measured with a SonTek FlowTracker Acoustic Doppler Velocimeter. A pixel-based supervised classification method was used to create a 30-m gridded land use coverage from a Landsat 8 image scene captured in the fall of 2015. Our results indicated that land-use had a statistically significant impact on water quality, with built land-uses (high and low) having the greatest influence. Upstream locations of six of the nine watersheds investigated had near natural status (i.e., river quality class (RQC) 1) and water could be used for all purposes (after standard treatments as required). However, downstream RSA measurements for all nine watersheds had RQC 5 (i.e., most highly impaired). Generally, water quality deteriorated from monsoon 2016 to pre-monsoon 2017. Our findings reinforce the importance of integrated land and water management and highlight the urgency of addressing waste management issues in the Kathmandu Valley.

Quality of pediatric anesthesia: A cross-sectional study of a university hospital in a low-income country

Objective

To evaluate the quality of pediatric anesthesia in a university hospital in Dar es Salaam, Tanzania.

Method

A cross-sectional study conducted using a new tool that was developed from the literature and WHO recommendations including 28 parameters as standards for pediatric anesthesia. These 28 parameters consisted of 17 structure parameters of the equipment and medicines that should be present in theatre before any surgery starts, and 11 process parameters of actions taken by staff. Adverse events occurring during the anesthesia were recorded.

Results

30 patients were included, aged between 1.5 months to 5 years with a mean of 2.4 years. 26 of the patients underwent elective surgery and 4 patients emergency surgery. Nine parameters were always present and one parameter (bag and mask) was not available for any of the patients. The structure index ranged from 71% to 94% with a mean of 84%. The process index had a mean score of 71% with a range from 50% to 90%: lower than the structure index (p<0.001). With the structure and process index combined the average score was 79% with a low of 67% and high of 89%. 70 adverse events were observed with a range from 0 to 7 adverse events per patient. The most common adverse event was hypoxia at extubation in 20 (69%) patients. Nine patients had an episode of severe hypoxia at extubation.

Conclusion

Pediatric anesthesia in low resource settings suffers from deficiencies in the structures and processes of providing good quality care. Improvement efforts may be best focused on improving the consistency and quality of the process of care and a reduction in adverse events rather than the structures available. Use of the assessment tool developed for this research could be useful for systematic quality-improvement efforts and to assess the needs in different settings.

Outdoor thermal comfort in public space in warm-humid Guayaquil, Ecuador

The thermal environment outdoors affects human comfort and health. Mental and physical performance is reduced at high levels of air temperature being a problem especially in tropical climates. This paper deals with human comfort in the warm-humid city of Guayaquil, Ecuador. The main aim was to examine the influence of urban micrometeorological conditions on people's subjective thermal perception and to compare it with two thermal comfort indices: the physiologically equivalent temperature (PET) and the standard effective temperature (SET*). The outdoor thermal comfort was assessed through micrometeorological measurements of air temperature, humidity, mean radiant temperature and wind speed together with a questionnaire survey consisting of 544 interviews conducted in five public places of the city during both the dry and rainy seasons. The neutral and preferred values as well as the upper comfort limits of PET and SET* were determined. For both indices, the neutral values and upper thermal comfort limits were lower during the rainy season, whereas the preferred values were higher during the rainy season. Regardless of season, the neutral values of PET and SET* are above the theoretical neutral value of each index. The results show that local people accept thermal conditions which are above acceptable comfort limits in temperate climates and that the subjective thermal perception varies within a wide range. It is clear, however, that the majority of the people in Guayaquil experience the outdoor thermal environment during daytime as too warm, and therefore, it is important to promote an urban design which creates shade and ventilation.

Sweet attraction: sugarcane pollen-associated volatiles attract gravid Anopheles arabiensis

BACKGROUND

Anopheles arabiensis is a key vector for the transmission of human malaria in sub-Saharan Africa. Over the past 10,000 years, humans have successfully cultivated grasses and altered the landscape, creating An. arabiensis favourable environments that contain excellent habitats for both larvae and adults. Sugarcane is the most expanding agricultural system in sub-Saharan Africa, and is linked to the increased threat of malaria in rural communities. The prolific production and wind dispersal of sugarcane pollen, together with standing pools of water, often provide, as a result of irrigation, a nutrient-rich environment for the offspring of gravid malaria mosquitoes.

RESULTS

In the present study, sugarcane pollen-associated volatiles from two cultivars are shown to attract gravid An. arabiensis in a still air two-port olfactometer and stimulate egg laying in an oviposition bioassay. Through combined gas chromatography and electroantennographic detection, as well as combined gas chromatography and mass spectrometric analyses, we identified the bioactive volatiles and generated a synthetic blend that reproduced the full behavioural repertoire of gravid mosquitoes in the Y-tube assay. Two subtractive odour blends, when compared with the full blend, were significantly more attractive. These three and four-component subtractive blends share the compounds (1R)-(+)-α-pinene, nonanal and benzaldehyde, of which, (1R)-(+)-α-pinene and nonanal are found in the attractive odour blends from rice plants and maize pollen. In pairwise comparisons, the rice synthetic odour blend was more attractive to gravid mosquitoes than either of the pollen blends, whereas the pollen blends did not differ in attraction.

CONCLUSIONS

The attraction of gravid females to sugarcane pollen volatiles demonstrated in this study, together with the previously found grass-associated volatiles, raise the potential of developing a bioactive chimeric blend to attract gravid malaria mosquitoes. This is discussed in relation to the development of novel and cost-effective vector control measures.

Mapping regional livelihood benefits from local ecosystem services assessments in rural Sahel

Most current approaches to landscape scale ecosystem service assessments rely on detailed secondary data. This type of data is seldom available in regions with high levels of poverty and strong local dependence on provisioning ecosystem services for livelihoods. We develop a method to extrapolate results from a previously published village scale ecosystem services assessment to a higher administrative level, relevant for land use decision making. The method combines remote sensing (using a hybrid classification method) and interviews with community members. The resulting landscape scale maps show the spatial distribution of five different livelihood benefits (nutritional diversity, income, insurance/saving, material assets and energy, and crops for consumption) that illustrate the strong multifunctionality of the Sahelian landscapes. The maps highlight the importance of a diverse set of sub-units of the landscape in supporting Sahelian livelihoods. We see a large potential in using the resulting type of livelihood benefit maps for guiding future land use decisions in the Sahel.

The eBioKit, a stand-alone educational platform for bioinformatics

Bioinformatics skills have become essential for many research areas; however, the availability of qualified researchers is usually lower than the demand and training to increase the number of able bioinformaticians is an important task for the bioinformatics community. When conducting training or hands-on tutorials, the lack of control over the analysis tools and repositories often results in undesirable situations during training, as unavailable online tools or version conflicts may delay, complicate, or even prevent the successful completion of a training event. The eBioKit is a stand-alone educational platform that hosts numerous tools and databases for bioinformatics research and allows training to take place in a controlled environment. A key advantage of the eBioKit over other existing teaching solutions is that all the required software and databases are locally installed on the system, significantly reducing the dependence on the internet. Furthermore, the architecture of the eBioKit has demonstrated itself to be an excellent balance between portability and performance, not only making the eBioKit an exceptional educational tool but also providing small research groups with a platform to incorporate bioinformatics analysis in their research. As a result, the eBioKit has formed an integral part of training and research performed by a wide variety of universities and organizations such as the Pan African Bioinformatics Network (H3ABioNet) as part of the initiative Human Heredity and Health in Africa (H3Africa), the Southern Africa Network for Biosciences (SAnBio) initiative, the Biosciences eastern and central Africa (BecA) hub, and the International Glossina Genome Initiative.

Arsenic concentrations in local aromatic and high-yielding hybrid rice cultivars and the potential health risk: a study in an arsenic hotspot

The presence of high levels of arsenic (As) in rice fields has negative effects on the health of those consuming rice as their subsistence food. This study determined the variation in total As concentration in local aromatic rice (LAR) (kalijira) and two high-yielding varieties (HYVs) (BRRI dhan 32 and BRRI dhan 28) grown in paddy fields in Matlab, Bangladesh, an As hotspot with elevated As levels in groundwater. Mature rice grain samples and soil samples were collected from different paddy fields, and the As concentrations in both the de-husked grains and the husks of the three rice cultivars were analysed to identify the safest of the three cultivars for human consumption. The results showed that the total As concentration was higher (0.09-0.21 mg As kg^-1) in the de-husked grains of LAR than in the husks, while the opposite was found for the HYV rice. Moreover, the As concentration in soil samples was 2 to 5-fold higher for the LAR than for the HYVs, but the As accumulation factor (AF) was lower in the LAR (0.2-0.4%) than in the HYVs (0.9-1%). Thus, LAR can be considered the safest of the three cultivars for human consumption owing to its low AF value. Furthermore, due to the low AF, growing LAR instead of HYVs in soils with slightly elevated As levels could help improve the food safety level in the food chain.

An Exploration of Human Well-Being Bundles as Identifiers of Ecosystem Service Use Patterns

We take a social-ecological systems perspective to investigate the linkages between ecosystem services and human well-being in South Africa. A recent paper identified different types of social-ecological systems in the country, based on distinct bundles of ecosystem service use. These system types were found to represent increasingly weak direct feedbacks between nature and people, from rural "green-loop" communities to urban "red-loop" societies. Here we construct human well-being bundles and explore whether the well-being bundles can be used to identify the same social-ecological system types that were identified using bundles of ecosystem service use. Based on national census data, we found three distinct well-being bundle types that are mainly characterized by differences in income, unemployment and property ownership. The distribution of these well-being bundles approximates the distribution of ecosystem service use bundles to a substantial degree: High levels of income and education generally coincided with areas characterised by low levels of direct ecosystem service use (or red-loop systems), while the majority of low well-being areas coincided with medium and high levels of direct ecosystem service use (or transition and green-loop systems). However, our results indicate that transformations from green-loop to red-loop systems do not always entail an immediate improvement in well-being, which we suggest may be due to a time lag between changes in the different system components. Using human well-being bundles as an indicator of social-ecological dynamics may be useful in other contexts since it is based on socio-economic data commonly collected by governments, and provides important insights into the connections between ecosystem services and human well-being at policy-relevant sub-national scales.