Mapping of suspended sediment transport using acoustic methods in a Pantanal tributary.

Generally, fluvial systems are used for different objectives including energy production, water supply, recreation, and navigation. Thus, many impacts must be considered with their use. An understanding of sediment dynamics in fluvial systems is often of value for a variety of objectives, given that erosion and depositional processes can change the fluvial system morphology and can substantially alter the fluvial environment. In this sense, sediment monitoring is important because it helps to explain and quantify sediment dynamics in the environment. Hence, this study presents an innovative sediment monitoring technique: the use of the acoustic Doppler current profiler, commonly used to obtain discharge measurements, to obtain suspended sediment concentration (SSC). This paper aims to describe the application of additional corrections to the ADP-M9 signal to obtain SSC from measurement campaigns that used the ADP only for discharge measurements. The analyses were based on traditional sediment sampling methods and discharge measurements, with the ADP-M9, from 7 field campaigns at the Taquari River, a major tributary from the Alto Paraguay Basin, in the Pantanal Biome, known as the largest freshwater wetland system in the world. The correlation was assessed considering the following: (a) the equipment frequency operation mode (Smart Pulse or Fixed Frequency) and (b) by checking the influence of the sediment attenuation coefficient. Furthermore, extrapolation was conducted in filtered and unmeasured areas of the ADP to map the suspended sediment concentration over the entire cross section. Results indicate that ADP correlations can be an effective tool for estimating SSC in the Taquari River when samples cannot be collected. Correlations could be applied to past and future ADP measurements made at the location where the correlation was created, as long as similar environmental conditions are present as when the correlation was developed. The described technique can expand the amount of sediment data available at a monitoring site even with reduced traditional sampling and by leveraging instruments used for other monitoring purposes.

Use of malaria rapid diagnostic tests by community health workers in Afghanistan: cluster randomised trial.

BACKGROUND: The World Health Organisation (WHO) recommends parasitological diagnosis of malaria before treatment, but use of malaria rapid diagnostic tests (mRDTs) by community health workers (CHWs) has not been fully tested within health services in south and central Asia. mRDTs could allow CHWs to diagnose malaria accurately, improving treatment of febrile illness. METHODS: A cluster randomised trial in community health services was undertaken in Afghanistan. The primary outcome was the proportion of suspected malaria cases correctly treated for polymerase chain reaction (PCR)-confirmed malaria and PCR negative cases receiving no antimalarial drugs measured at the level of the patient. CHWs from 22 clusters (clinics) received standard training on clinical diagnosis and treatment of malaria; 11 clusters randomised to the intervention arm received additional training and were provided with mRDTs. CHWs enrolled cases of suspected malaria, and the mRDT results and treatments were compared to blind-read PCR diagnosis. RESULTS: In total, 256 CHWs enrolled 2400 patients with 2154 (89.8%) evaluated. In the intervention arm, 75.3% (828/1099) were treated appropriately vs. 17.5% (185/1055) in the control arm (cluster adjusted risk ratio: 3.72, 95% confidence interval 2.40-5.77; p < 0.001). In the control arm, 85.9% (164/191) with confirmed Plasmodium vivax received chloroquine compared to 45.1% (70/155) in the intervention arm (p < 0.001). Overuse of chloroquine in the control arm resulted in 87.6% (813/928) of those with no malaria (PCR negative) being treated vs. 10.0% (95/947) in the intervention arm, p < 0.001. In the intervention arm, 71.4% (30/42) of patients with P. falciparum did not receive artemisinin-based combination therapy, partly because operational sensitivity of the RDTs was low (53.2%, 38.1-67.9). There was high concordance between recorded RDT result and CHW prescription decisions: 826/950 (87.0%) with a negative test were not prescribed an antimalarial. Co-trimoxazole was prescribed to 62.7% of malaria negative patients in the intervention arm and 15.0% in the control arm. CONCLUSIONS: While introducing mRDT reduced overuse of antimalarials, this action came with risks that need to be considered before use at scale: an appreciable proportion of malaria cases will be missed by those using current mRDTs. Higher sensitivity tests could be used to detect all cases. Overtreatment with antimalarial drugs in the control arm was replaced with increased antibiotic prescription in the intervention arm, resulting in a probable overuse of antibiotics. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01403350 . Prospectively registered.

Parental attitudes toward newborn screening for Duchenne/Becker muscular dystrophy and spinal muscular atrophy.

INTRODUCTION: Disease inclusion in the newborn screening (NBS) panel should consider the opinions of those most affected by the outcome of screening. We assessed the level and factors that affect parent attitudes regarding NBS panel inclusion of Duchenne muscular dystrophy (DMD), Becker muscular dystrophy (BMD), and spinal muscular atrophy (SMA). METHODS: The attitudes toward NBS for DMD, BMD, and SMA were surveyed and compared for 2 categories of parents, those with children affected with DMD, BMD, or SMA and expectant parents unselected for known family medical history. RESULTS: The level of support for NBS for DMD, BMD, and SMA was 95.9% among parents of children with DMD, BMD, or SMA and 92.6% among expectant parents. CONCLUSIONS: There was strong support for NBS for DMD, BMD, and SMA in both groups of parents. Given advances in diagnostics and promising therapeutic approaches, discussion of inclusion in NBS should continue.

Malaria "diagnosis" and diagnostics in Afghanistan.

In many malaria-endemic areas, including Afghanistan, overdiagnosis of malaria is common. Even when using parasite-based diagnostic tests prior to treatment, clinicians commonly prescribe antimalarial treatment following negative test results. This practice neglects alternative causes of fever, uses drugs unnecessarily, and might contribute to antimalarial drug resistance. We undertook a qualitative study among health workers using different malaria diagnostic methods in Afghanistan to explore perceptions of malaria diagnosis. Health workers valued diagnostic tests for their ability to confirm clinical suspicions of malaria via a positive result, but a negative result was commonly interpreted as an absence of diagnosis, legitimizing clinical diagnosis of malaria and prescription of antimalarial drugs. Prescribing decisions reflected uncertainty around tests and diagnosis, and were influenced by social- and health-system factors. Study findings emphasize the need for nuanced and context-specific guidance to change prescriber behavior and improve treatment of malarial and nonmalarial febrile illnesses.

Midwifery retention and coverage and impact on service utilisation in Afghanistan.

OBJECTIVE: to measure the rate of and determine factors associated with community midwifery education (CME) graduate retention in public sector health care in Afghanistan. DESIGN: cross-sectional. SETTING: performed in public health facilities of 11 Afghan provinces purposively selected by geographic location and security conditions, between October 2011 and April 2012. Facilities were selected by one of two criteria: either a registered deployment site for a CME graduate or randomly selected through population-proportionate sampling. PARTICIPANTS: facility managers and midwives employed in public facilities at the time of data collection. MEASUREMENTS: three quantitative instruments were used: a facility checklist assessed staffing and service volume, and two separate questionnaires for midwives and facility managers, which measured employment duration and perceived barriers to midwife retention. FINDINGS: at 456 surveyed facilities, 570 midwives were interviewed. Overall, 61.3% (n=209/341) of CME graduates deployed in surveyed provinces were working in public sector facilities, whereas 36.8% were working at their assigned site. Facilities without midwife staff had lower average monthly volumes of antenatal care visits (14.6 (SD ± 22.7) versus 71.5 (SD ± 72.5)), family planning visits (10.4 (SD+13.9) versus 56.8 (SD+85.0)), or facility-based deliveries (0.55 (SD ± 2.2) versus 15.7 (SD ± 18.7)). Perceived reasons for leaving employment were insecurity (civil unrest/armed conflict) (46.4%), family disagreement (28.1%), increased workload without compensation (9.9%), and lack of appropriate housing (7.8%). KEY CONCLUSIONS: CME graduate retention in public sector positions was relatively low and significantly impacted by insecurity and cultural issues related to women working outside the home. IMPLICATIONS FOR PRACTICE: culturally appropriate measures are needed to attract and retain skilled female health care providers for rural public facilities in Afghanistan and similar settings. Advocacy to encourage family and community support for midwives working in rural facilities and providing amenities such as housing, education for children, and employment for the accompanying male family member are measures most likely to improve midwife retention.

Factors influencing the retention of midwives in the public sector in Afghanistan: a qualitative assessment of midwives in eight provinces.

OBJECTIVE: to examine factors that affect retention of public sector midwives throughout their career in Afghanistan. DESIGN: qualitative assessment using semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs). SETTING: health clinics in eight provinces in Afghanistan, midwifery education schools in three provinces, and stakeholder organisations in Kabul. PARTICIPANTS: purposively sampled midwifery profession stakeholders in Kabul (n=14 IDIs); purposively selected community midwifery students in Kabul (n=3 FGDs), Parwan (n=1 FGD) and Wardak (n=1 FGD) provinces (six participants per FGD); public sector midwives, health facility managers, and community health workers from randomly selected clinics in eight provinces (n=48 IDIs); midwives who had left the public sector midwifery service (n=5 IDIs). MEASUREMENTS AND FINDINGS: several factors affect a midwife throughout her career in the public sector, including her selection as a trainee, the training itself, deployment to her pre-assigned post, and working in clinics. Overall, appropriate selection is the key to ensuring deployment and retention later on in a midwife's career. Other factors that affect retention of midwives include civil security concerns in rural areas, support of family and community, salary levels, professional development opportunities and workplace support, and inefficient human resources planning in the public sector. KEY CONCLUSIONS: Factors affecting midwife retention are linked to problems within the community midwifery education (CME) programme and those reflecting the wider Afghan context. Civil insecurity and traditional attitudes towards women were major factors identified that negatively affect midwifery retention. IMPLICATIONS FOR PRACTICE: Factors such as civil insecurity and traditional attitudes towards women require a multisectoral response and innovative strategies to reduce their impact. However, factors inherent to midwife career development also impact retention and may be more readily modified.