Not Only How Much But How: The Importance Of Diversifying Funding Streams In A Reimagined Public Health System.

Revenue diversification may be a synergistic strategy for transforming public health, yet few national or trend data are available. This study quantified and identified patterns in revenue diversification in public health before and during the COVID-19 pandemic. We used National Association of County and City Health Officials' National Profile of Local Health Departments study data for 2013, 2016, 2019, and 2022 to calculate a yearly diversification index for local health departments. Respondents' revenue portfolios changed fairly little between 2016 and 2022. Compared with less-diversified local health departments, well-diversified departments reported a balanced portfolio with local, state, federal, and clinical sources of revenue and higher per capita revenues. Less-diversified local health departments relied heavily on local sources and saw lower revenues. The COVID-19 period exacerbated these differences, with less-diversified departments seeing little revenue growth from 2019 to 2022. Revenue portfolios are an underexamined aspect of the public health system, and this study suggests that some organizations may be under financial strain by not having diverse revenue portfolios. Practitioners have ways of enhancing diversification, and policy attention is needed to incentivize and support revenue diversification to enhance the financial resilience and sustainability of local health departments.

An evaluation of the EASY instrument in a cross-sectional study.

BACKGROUND: The purpose of this paper is to evaluate the impact of modifying the published scoring system to address identified potential weaknesses in the published scoring system for the Evaluation of Activity Surveys in Youth (EASY). A secondary purpose was to evaluate the EASY on children in Grades 1-5. The EASY is a self-report physical activity instrument for youth. METHODS: Original EASY survey results were collected at one time point from an online panel from participants across the United States as part of a larger cross-sectional University of Minnesota project looking at children's specific activity and sports participation between June and August 2019. Data was evaluated using three common scoring methods: simple summation, mean, and transformed summation. Data was compared by Grades 1-5 and 6-8. RESULTS: The summary statistics of the scores show that there is no statistically significant difference across the scoring methods by population. A paired t-test evaluation of the different scoring methods shows that while the scores are very similar within methodology (simple summation, mean, transformed sum) they are all statistically significantly different from one another, which demonstrates that for any given individual the specific scoring methodology used can result in meaningful differences. The transformed sum provided the strongest methodologic result. Analysis also concluded that administering the scale by proxy to children from grades 1-5 resulted in similar responses to those in Grades 6-8 broadening the appropriate populations able to use this scale. CONCLUSION: The transformed sum is the preferred scoring method. TRIAL REGISTRATION: Not applicable.

Using a web platform for equitable distribution of COVID-19 monoclonal antibodies: a case study in resource allocation.

While medical countermeasures in COVID-19 have largely focused on vaccinations, monoclonal antibodies (mAbs) were early outpatient treatment options for COVID-positive patients. In Minnesota, a centralized access platform was developed to offer access to mAbs that linked over 31,000 patients to care during its operation. The website allowed patients, their representative, or providers to screen the patient for mAbs against Emergency Use Authorization (EUA) criteria and connect them with a treatment site if provisionally eligible. A validated clinical risk scoring system was used to prioritize patients during times of scarcity. Both an ethics and a clinical subject matter expert group advised the Minnesota Department of Health on equitable approaches to distribution across a range of situations as the pandemic evolved. This case study outlines the implementation of this online platform and clinical outcomes of its users. We assess the impact of referral for mAbs on hospitalizations and death during a period of scarcity, finding in particular that vaccination conferred a substantially larger protection against hospitalization than a referral for mAbs, but among unvaccinated users that did not get a referral, chances of hospitalization increased by 4.1 percentage points.

Determinants of undernutrition and overnutrition among reproductive-age women in Bangladesh: Trend analysis using spatial modeling.

BACKGROUND: Bangladesh is facing a dual burden of malnutrition, with high rates of undernutrition and increasing rates of overnutrition. The complex scenario of malnutrition in Bangladesh varies across different regions, making it a challenging public health concern to address. OBJECTIVES: This study analyzes the spatial and temporal dependence of underweight and overweight Bangladeshi women of reproductive age. METHODS: Nationally representative cross-sectional data from the Bangladesh Demographic and Health Surveys in 2014 and 2017-18 were utilized to study the changes in weight status in 15-49-year-old women who were either underweight or overweight. A Bayesian geo-additive regression model was used to account for non-linear and linear effects of continuous and categorical covariates and to incorporate spatial effects of geographical divisions. RESULTS: The prevalence of overweight or obese women in rural, city corporations, and other urban areas increased significantly over the four years from 2014 to 2017-18. Women in the categories 'richer' and 'richest' were more likely to be overweight or obese. Women from Sylhet were more likely to be underweight in both survey years; however, the spatial effects were significant for underweight women in Mymensingh for the year 2017-18. Women in Rajshahi and Khulna were more likely to be overweight or obese in 2014, and women from Barishal and Chittagong were more likely to be overweight in the year 2017-18. CONCLUSIONS: Underweight and overweight statuses in women vary unevenly across Bangladesh, with a substantially higher prevalence of overweight or obese women in more urbanized areas. The growing burden of overweight and obesity among Bangladeshi women should be addressed with interventions aimed at those in the reproductive age group.

Spatial distribution of stunting and wasting in 6-59 months children in Nepal: analysis using a Bayesian distributional bivariate probit model.

The combined burden of stunting and wasting in children under five years is a serious public health concern. The present study aimed to estimate the joint burden of stunting and wasting among children aged 6-59 months and explore its spatial variation across Nepal. The 2016 Nepal Demographic and Health Survey data was used to study acute and chronic childhood malnutrition. A Bayesian distributional bivariate probit geoadditive model was designed to study the linear association and geographical variation of stunting and wasting among 6-59 months, children. Child-related factors such as low birth weight, fever in the last 2 weeks preceding the survey and fourth or greater birth order were associated with a higher likelihood of stunting. The likelihood of a child being stunted was significantly less in the wealthiest households, having improved toilet facilities, and if mothers were overweight. Children from severely food insecure households were significantly more likely, and children from poorer households were significantly less likely to suffer both acute and chronic malnutrition simultaneously. Results from spatial effect showed that children from Lumbini and Karnali had a higher burden of stunting, and the likelihood that achild would have been wasted was significantly higher in Madhesh and Province 1. Immediate nutritional efforts are vital in low-income and severely food insecure households to lessen the risk of stunting and wasting in under children. Disproportionate geographic variations in stunting and wasting warrant sub-regional-specific nutrition intervention to achieve nutrition targets and reduce the burden of childhood malnutrition across the country.

Cardiovascular disease risk factors distribution and clustering across different geographic levels in Nepal.

BACKGROUND: In an effort to reduce the burgeoning problem of cardiovascular diseases (CVD), it is imperative to understand the variation of risk factors across different geographic regions. This study aims to shed light on examining the leading risk factors of CVD and it's clustering across Nepal. METHODS: Data from a nationally representative survey were analyzed to estimate the distribution of four major risk factors (high blood pressure, overweight, obesity, and smoking) of cardiovascular diseases. Similarly, this study also assessed the intra-cluster correlation coefficients (ICCs) of CVD risk factors at the household, community (urban/rural), district, and province level. RESULTS: This study included 14 418 adult population with age of 15 years and above of which 41.7% were male and 58.3% were female. Higher prevalence of all four CVD risk factors was found in the richest quintile, people living in hilly region, most noticeably among residents of metropolitan city and in Gandaki, Bagmati, and Province 1. The ICC decreased as the socio-geographic clustering units decreased in size from province, district, and household level clustering. The ICC was highest at province level for "province 1" for raised blood pressure than other provinces. CONCLUSIONS: Risk factors of CVD in Nepal are concentrated prominent in highly urbanized areas and ICC is low as the level of geography decreased from province, district, and household. The findings can be applied in directing prevention activities at different levels to mitigate the higher burden of risk factors of CVD in Nepal.

Transitioning Wastewater Treatment Plants toward Circular Economy and Energy Sustainability.

Aging infrastructure, increasing environmental regulations, and receiving water environment issues stem the need for advanced wastewater treatment processes across the world. Advanced wastewater treatment systems treat wastewater beyond organic carbon removal and aim to remove nutrients and recover valuable products. While the removal of major nutrients (carbon, nitrogen, and phosphorus) is essential for environmental protection, this can only be achieved through energy-, chemical-, and cost-intensive processes in the industry today, which is an unsustainable trend, considering the global population growth and rapid urbanization. Two major routes for developing more sustainable and circular-economy-based wastewater treatment systems would be to (a) innovate and integrate energy- and resource-efficient anaerobic wastewater treatment systems and (b) enhance carbon capture to be diverted to energy recovery schemes. This Mini-Review provides a critical evaluation and perspective of two potential process routes that enable this transition. These process routes include a bioelectrochemical energy recovery scheme and codigestion of organic sludge for biogas generation in anaerobic digesters. From the analysis, it is imperative that integrating both concepts may even result in more energy- and resource-efficient wastewater treatment systems.

Impact of high-risk fertility behaviours on underfive mortality in Asia and Africa: evidence from Demographic and Health Surveys.

BACKGROUND: Maternal age < 18 or > 34 years, short inter-pregnancy birth interval, and higher birth order are considered to be high-risk fertility behaviours (HRFB). Underfive mortality being disproportionately concentrated in Asia and Africa, this study analyses the association between HRFB and underfive mortality in selected Asian and African countries. METHODS: This study used Integrated Public Microdata Series-Demographic and Health Surveys (IPUMS-DHS) data from 32 countries in sub-Saharan Africa, Middle East, North Africa and South Asia from 1986 to 2017 (N = 1,467,728). Previous evidence hints at four markers of HRFB: women's age at birth of index child < 18 or > 34 years, preceding birth interval < 24 months and child's birth order > 3. Using logistic regression, we analysed change in the odds of underfive mortality as a result of i) exposure to HRFB individually, ii) exposure to any single HRFB risk factor, iii) exposure to multiple HRFB risk factors, and iv) exposure to specific combinations of HRFB risk factors. RESULTS: Mother's age at birth of index child < 18 years and preceding birth interval (PBI) < 24 months were significant risk factors of underfive mortality, while a child's birth order > 3 was a protective factor. Presence of any single HRFB was associated with 7% higher risk of underfive mortality (OR 1.07; 95% CI 1.04-1.09). Presence of multiple HRFBs was associated with 39% higher risk of underfive mortality (OR 1.39; 95% CI 1.36-1.43). Some specific combinations of HRFB such as maternal age < 18 years and preceding birth interval < 24 month significantly increased the odds of underfive mortality (OR 2.07; 95% CI 1.88-2.28). CONCLUSION: Maternal age < 18 years and short preceding birth interval significantly increase the risk of underfive mortality. This highlights the need for an effective legislation to curb child marriages and increased public investment in reproductive healthcare with a focus on higher contraceptive use for optimal birth spacing.

Spatial distribution of various forms of malnutrition among reproductive age women in Nepal: A Bayesian geoadditive quantile regression approach.

Addressing both the under-and over-nutritional status of women is an eminent challenge for developing countries like Nepal. This paper examined a critical analysis of factors associated with various forms of malnutrition using Bayesian geoadditive quantile regression approach and assessed spatial variations of malnutrition among Nepalese women using Asian cut-off values. Data drawn from the 2016 Nepal Demographic and Health Survey was utilized to assess the spatial distributions of underweight, overweight and obesity at the provincial level. Spatial and nonlinear components were estimated using Markov random fields and Bayesian P-splines, respectively. The analysis of 4,338 women confirmed that women living in extremely urbanized areas and in Province 1, Province 3, and Province 4 were more likely to be overweight/obese. Similarly, the likelihood of being underweight was prominently high among women residing in rural municipality and women residing in Province 2 and Province 7. Women from the richest and richer quintiles, and with primary education were more likely to be obese. Furthermore, currently-working women and women having access to protected water source were less likely to be obese while improved toilet and access to electricity facility were associated with obesity. Women with access to newspaper and radio were less prone to obesity. Inconsistent distribution of under- and over-nutrition existed in Nepal, given that the high prevalence of overweight/obesity among women living in metropolitan and undernutrition among rural women. Specific intervention measures, addressing location-specific nutrition issues are urgent. Rigorous implementation of strategies incorporated in the national nutrition plan is called for to curb the burden of overweight/obesity. Involving mass media to promote healthier lifestyle and nutritious food could be advantageous at the population level, especially in rural municipalities.

Behavioral factors associated with utilization of healthcare services among elderly in Pakistan: evidence from a nationally representative survey.

BACKGROUND: In Pakistan, health system is facing unprecedented challenges to deal with the healthcare demand of the growing ageing population. Using conceptual framework, this study aims to analyze the factors associated with the utilization of healthcare services in private and public hospitals by the elderly population. METHODS: This study used a sample of 5319 individuals aged 60 and above extracted from the Pakistan Social and Living Standards Measurement Survey 2014-15. We followed the Anderson's Behavioral model of healthcare utilization. The behavioral factors, including predisposing, enabling and need factors, associated with the use of healthcare care were analyzed using exploratory data analysis and binary logistic regressions. The utilization of healthcare service in the study refers to the visits to private and government hospital. RESULTS: Out of total 5319 participants around three-fourth or 72.4% of participants visited private hospitals for their healthcare needs. Multivariate analysis showed that older age-group (80 years and above) and participants from urban were 1.35 and 1.53 times more likely to avail healthcare service in private hospitals, respectively. The elderly persons from Khyber Pakhtunkhwa were three times (AOR: 3.29, 95%CI 2.5-4.8) more likely to visit government hospitals than their peers in Punjab. Participants who attended school (AOR: 1.21, 95%CI 0.82-1.31) were more likely to utilize healthcare service in private hospitals. Elders from rich (AOR: 1.04, 95%CI 0.84-1.13) and richest (AOR: 1.29, 95%CI 0.89-1.87) wealth quintiles were more likely to use healthcare in private hospitals. The likelihood of the utilization of healthcare service in private hospitals was 1.7 times higher for three or more consulting visits than the single visit, and 1.5 times higher in the public hospital. CONCLUSIONS: Our findings underscore a dire need for expanding the outreach of healthcare services for the elderly population. It calls for effective implementation of policies which aim at improving equitable access to private healthcare services, and upgrading of government hospitals Moreover, the knowledge generated through this research may be employed to make social protection programs more responsive to age-related healthcare needs, and focused on caregiving for elderly living without spouse.

Assessing the prevalence trend of childhood pneumonia associated with indoor air pollution in Pakistan.

The indoor air pollution (IAP) is one of the leading risk factors of childhood pneumonia in developing countries. This study makes the first attempt to examine the prevalence trend of pneumonia among under-five children in Pakistan in association with IAP-related factors, using bivariate and multivariate statistical methods. Three waves of Pakistan Demographic Health Survey for 2006-2007, 2012-2013, and 2017-2018 were used. Our study findings showed a steady decline in the prevalence of pneumonia synchronized with the decreased use of polluting fuel during the last decade (2006-2017). In bivariate regression, odd ratios of childhood pneumonia were 1.27 and 1.21 times higher in overcrowded houses in 2006-2007 and 2012-2013, respectively, and 1.25 times higher in families relying on biomass for cooking in 2017-2018. In the multivariate model, polluting fuel and overcrowded homes had higher adjusted odd ratios of pneumonia in all survey years, and children age 37-48 months, older mothers, and large birth sized children had lower AOR of pneumonia in 2006-2007 and 2012-2013. Countrywide promotion of IAP mitigation measures such as sponsoring cleaner fuels, separate place for cooking, and lessening home overcrowding may play a vital role in alleviating the prevalence of childhood pneumonia.

Wetlands for environmental protection.

This article presents an update on the research and practical demonstration of wetland-based treatment technologies for protecting water resources and environment covering papers published in 2019. Wetland applications in wastewater treatment, stormwater management, and removal of nutrients, metals, and emerging pollutants including pathogens are highlighted. A summary of studies focusing on the effects of vegetation, wetland design and operation strategies, and process configurations and modeling, for efficient treatment of various municipal and industrial wastewaters, is included. In addition, hybrid and innovative processes with wetlands as a platform treatment technology are presented.

Health system's readiness to provide cardiovascular, diabetes and chronic respiratory disease related services in Nepal: analysis using 2015 health facility survey.

BACKGROUND: The burgeoning rise of non-communicable diseases (NCDs) is posing serious challenges in resource constrained health facilities of Nepal. The main objective of this study was to assess the readiness of health facilities for cardiovascular diseases (CVDs), diabetes and chronic respiratory diseases (CRDs) services in Nepal. METHODS: This study utilized data from the Nepal Health Facility Survey 2015. General readiness of 940 health facilities along with disease specific readiness for CVDs, diabetes, and CRDs were assessed using the Service Availability and Readiness Assessment manual of the World Health Organization. Health facilities were categorized into public and private facilities. RESULTS: Out of a total of 940 health facilities assessed, private facilities showed higher availability of items of general service readiness except for standard precautions for infection prevention, compared to public facilities. The multivariable adjusted regression coefficients for CVDs (ß = 2.87, 95%CI: 2.42-3.39), diabetes (ß =3.02, 95%CI: 2.03-4.49), and CRDs (ß = 15.95, 95%CI: 4.61-55.13) at private facilities were higher than the public facilities. Health facilities located in the hills had a higher readiness index for CVDs (ß = 1.99, 95%CI: 1.02-1.39). Service readiness for CVDs (ß = 1.13, 95%CI: 1.04-1.23) and diabetes (ß = 1.78, 95%CI: 1.23-2.59) were higher in the urban municipalities than in rural municipalities. Finally, disease-related services readiness index was sub-optimal with some degree of variation at the province level in Nepal. Compared to province 1, province 2 (ß = 0.83, 95%CI: 0.73-0.95) had lower, and province 4 (ß =1.24, 95%CI: 1.07-1.43) and province 5 (ß =1.17, 95%CI: 1.02-1.34) had higher readiness index for CVDs. CONCLUSION: This study found sub-optimal readiness of services related to three NCDs at the public facilities in Nepal. Compared to public facilities, private facilities showed higher readiness scores for CVDs, diabetes, and CRDs. There is an urgent need for policy reform to improve the health services for NCDs, particularly in public facilities.

Severe acute malnutrition and its associated factors among children under-five years: a facility-based cross-sectional study.

BACKGROUND: Despite consistent efforts to enhance child nutrition, poor nutritional status of children continues to be a major public health problem in Nepal. This study identified the predictors of severe acute malnutrition (SAM) among children aged 6 to 59 months in the two districts of Nepal. METHODS: We used data from a cross-sectional study conducted among 6 to 59 months children admitted to the Outpatient Therapeutic Care Centers (OTCC). The nutritional status of children was assessed using mid-upper arm circumference (MUAC) measurement. To determine which variables predict the occurrence of SAM, adjusted odds ratio was computed using multivariate logistic regression and p-value < 0.05 was considered as significant. RESULTS: Out of 398 children, 5.8% were severely malnourished and the higher percentage of female children were malnourished. Multivariate analysis showed that severe acute malnutrition was significantly associated with family size (five or more members) (Adjusted Odds Ratio [AOR]: 3.96; 95% Confidence Interval [CI]: 1.23-12.71). Children from severely food insecure households (AOR: 4.04; 95% CI: 1.88-10.53) were four times more likely to be severely malnourished. Higher odds of SAM were found among younger age-group (AOR: 12.10; 95% CI: 2.06-71.09) children (0-12 vs. 24-59 months). CONCLUSIONS: The findings of this study indicated that household size, household food access, and the child's age were the major predictors of severe acute malnutrition. Engaging poor families in kitchen gardening to ensure household food access and nutritious diet to the children, along with health education and promotion to the mothers of young children are therefore recommended to reduce child undernutrition.

Food insecurity and dietary diversity among lactating mothers in the urban municipality in the mountains of Nepal.

BACKGROUND: Adequate nutrition is essential during the lactation period for better maternal and child health outcomes. Although food insecurity and dietary monotony (defined as less diverse diet), two important determinants of undernutrition, are endemic in the rural mountains of Nepal, insufficiently examined and assessed for risk factors in mothers during lactation, a life stage of high nutritional demand. This study aimed to assess the status and factors associated with food insecurity and dietary diversity among lactating mothers residing in the mountains of Nepal. METHODS: A community-based cross-sectional study was conducted in an urban municipality in the mountainous Bajhang District of far-western Nepal. The sampling frame and strategy led to 417 randomly selected lactating mothers. Household Food Insecurity Access Scale (HFIAS) and the tool "Minimum Dietary Diversity for Women" developed by the Food and Agriculture Organization were used to measure food insecurity and dietary diversity, respectively. Additional information on socio-demographics and risk factors were collected. Multivariable logistics regression assessed correlates of study outcomes. RESULTS: Overall, 54% of the households were food insecure, and over half (53%) of the mothers had low dietary diversity. Food insecurity status (mild food insecurity AOR = 10.12, 95% CI = 4.21-24.34; moderate food insecurity AOR = 8.17, 95% CI = 3.24-20.59, and severe food insecurity AOR = 10.56, 95% CI = 3.92-28.43) were associated with higher odds of dietary monotony. Likewise, participants with lower dietary diversity were 8.5 times more likely to be food insecure than those with higher dietary diversity (AOR = 8.48, 95% CI = 3.76-19.14). The monthly income of the family was positively associated with food insecurity. Participants' (AOR = 3.92 95%CI = 1.76-8.71) or spouses' (AOR = 2.90, 95% CI = 1.07-7.85) unemployment was associated with higher odds of being food insecure. Likewise, owning a cultivable land (AOR = 0.49, 95% CI = 0.28-0.84) and participant's unemployment status (AOR = 5.92, 95% CI = 3.02-11.63), were significantly associated with increased odds of dietary monotony. CONCLUSION: The observed food insecurity and poor dietary diversity among lactating mothers, the correlates associated with these outcomes, may help local stakeholders to identify local health needs and subgroups for targeted interventions. Socioeconomically disadvantaged mothers should be specifically targeted for relevant programs and policies.

Prevalence of American Heart Association defined ideal cardiovascular health metrics in Nepal: findings from a nationally representative cross-sectional study.

BACKGROUND: The ever-increasing burden of non-communicable diseases (NCDs) is posing a serious health challenge for Nepal. This study examines the status of ideal cardiovascular health (ICH) and its associated determinants in Nepal using the American Heart Association (AHA) definition of ICH metrics. METHODS: The AHA has defined ICH as having five to seven of the ideal health metrics. A representative sample from the NCD risk factors STEPS survey 2013 were drawn to analyse the prevalence and sociodemographic determinants of ideal, intermediate and poor cardiovascular health in Nepal. Multivariable logistic regression was used to measure the determinants of ICH. RESULTS: More than half of the participants had ICH metrics (51.6%), with the 45-69 y age group having the lowest prevalence of ICH (28%) and females having better cardiovascular health compared with their male counterparts (60.6% vs 41.7%). The prevalence of low intake of fruit and vegetables, tobacco smoking and elevated blood pressure were quite high (99%, 18.8% and 31.4%, respectively). The status of ICH declined with age: individuals 15-29 y of age had 6 times (95% confidence interval [CI] 4.80-8.60) higher odds of having ICH compared with those who were 45-69 y, and it was low among urban residents (referent: rural; adjusted odds ratio 0.77 [95% CI 0.58-1.01]). CONCLUSIONS: Nearly half of the participants had ICH, which declined with ageing. Further, urban residents had poor cardiovascular health. This highlights the need for a comprehensive population-based intervention targeting elderly and urban residents to improve overall cardiovascular health.

Wetlands for wastewater treatment.

This article presents an update on the research and practical demonstration of wetland treatment technologies for wastewater treatment. Applications of wetlands in wastewater treatment (as an advanced treatment unit or a decentralized system) and stormwater management or treatment for nutrient and pollutant removal (metals, industrial and emerging pollutants including pharmaceutical compounds and pathogens) are highlighted. A summary of studies involving the effects of vegetation, wetland design and operation, and configurations for efficient treatment of various municipal and industrial wastewaters is also included. PRACTITIONER POINTS: Provides an update on current research and development of wetland technologies for wastewater treatment. Effects of vegetation, pathogens removal, heavy metals and emerging pollutants removal are included. Wetland design and operation is a key factor to improve water quality of wetland effluent.

The effect of maternal health service utilization in early initiation of breastfeeding among Nepalese mothers.

Background: The World Health Organization (WHO) recommends early initiation of breastfeeding and exclusive breastfeeding for six months. Understanding the association of maternal health services and early initiation of breastfeeding might be useful on prioritizing the health services to promote early breastfeeding practices. The purpose of this study was to examine the association between utilization of maternal health services and early initiation of breastfeeding among Nepalese mothers. Methods: Nationally representative data from the 2016 Nepal Demographic Health Survey (NDHS) was used to determine the association between early initiation of breastfeeding and variables related to maternal health services utilization. Association was measured by using Chi-square test followed by calculation of adjusted odds ratio (AOR) and 95% confidence intervals (CI) using multivariable logistic regression analysis. Results: Out of 1,978 children, 55% were breastfed within an hour of birth. Early initiation of breastfeeding was associated among mothers who delivered at the health facilities (AOR 2.22; 95% CI 1.36, 3.60). Mothers who had a vaginal birth (AOR 6.70; 95% CI 4.30, 10.42) were significantly more likely to breastfeed within an hour of birth compared to mothers who had caesarean delivery. The odds of initiating early breastfeeding were higher among mothers from Province 5 (AOR 1.59; CI 1.02, 2.48), Province 6 (AOR 2.58; 95% CI 1.41,4.69) and Province 7 (AOR 2.30; CI 1.36, 3.87). Conclusions: Health facility delivery and a vaginal delivery were strongly associated with early initiation of breastfeeding. It is vital to intensify maternal health service up to the community to aware pregnant women to utilize maternal health services to improve breastfeeding practices. Skilled Birth Attendant (SBA) training should include comprehensive breastfeeding counselling package to motivate mothers to initiate early breastfeeding especially for mothers having caesarean delivery.

Accomplishing a N-E-W (nutrient-energy-water) synergy in a bioelectrochemical nitritation-anammox process.

This study reports an investigation of the concept, application and performance of a novel bioelectrochemical nitritation-anammox microbial desalination cell (MDC) for resource-efficient wastewater treatment and desalination. Two configurations of anammox MDCs (anaerobic-anammox cathode MDC (AnAmoxMDC) and nitration-anammox cathode MDC (NiAmoxMDC)) were compared with an air cathode MDC (CMDC), operated in fed-batch mode. Results from this study showed that the maximum power density produced by NiAmoxMDC (1,007 mW/m3) was higher than that of AnAmoxMDC (444 mW/m3) and CMDC (952 mW/m3). More than 92% of ammonium-nitrogen (NH4+-N) removal was achieved in NiAmoxMDC, significantly higher than AnAmoxMDC (84%) and CMDC (77%). The NiAmoxMDC performed better than CMDC and AnAmoxMDC in terms of power density, COD removal and salt removal in desalination chamber. In addition, cyclic voltammetry analysis of anammox cathode showed a redox peak centered at -140 mV Vs Ag/AgCl confirming the catalytic activity of anammox bacteria towards the electron transfer process. Further, net energy balance of the NiAmoxMDC was the highest (NiAmoxMDC-0.022 kWh/m3 >CMDC-0.019 kWh/m3 >AnAmoxMDC-0.021 kWh/m3) among the three configurations. This study demonstrated, for the first time, a N-E-W synergy for resource-efficient wastewater treatment using nitritation-anammox process.