Factors Influencing the Integration of Traditional Medicine and Mainstream Medicine in Mental Health Services in West Africa: A Systematic Review Using Narrative Synthesis.

This study explored the enablers and obstacles to the integration of traditional medicine and mainstream medicine in mental health services in West Africa. This study is a systematic review conducted in accordance with the relevant parts of the Preferred Reporting Items for Systematic reviews and Meta-analyses. Keywords searches were done in databases, and other reference lists were also searched. The Rainbow model of integrated care and a thematic analysis framework were used to account for the factors influencing the integration of traditional medicine and mainstream medicine in mental health services in West Africa. A total of 12 studies met the eligibility criteria after the evaluation of 6413 articles from databases and reference lists. The themes of: policy and implementation; different conceptualisation of mental health/referrals; trust issues, and education and training, were enablers or obstacles of integration depending on how they worked to facilitate or hinder integration. There was an indication of little integration of TM and MM at the macro, meso and micro levels in mental health services in West Africa. Though the study does cover all the West African states evenly, it is recommended that policy-makers and stakeholders interested in integration should ensure integration activities, especially policies, cut across all the levels of the rainbow model of integrated care and are planned and aligned at the macro, meso and micro levels instead of using ad hoc measures, informal initiatives or placing TM services in MM mental health services, which do not amount to integration.

Partial denitrifying phosphorus removal coupling with anammox (PDPRA) enables synergistic removal of C, N, and P nutrients from municipal wastewater: A year-round pilot-scale evaluation.

Applying anaerobic ammonium oxidation (anammox) in municipal wastewater treatment plants (MWWTPs) can unlock significant energy and resource savings. However, its practical implementation encounters significant challenges, particularly due to its limited compatibility with carbon and phosphorus removal processes. This study established a pilot-scale plant featuring a modified anaerobic-anoxic-oxic (A2O) process and operated continuously for 385 days, treating municipal wastewater of 50 m3/d. For the first time, we propose a novel concept of partial denitrifying phosphorus removal coupling with anammox (PDPRA), leveraging denitrifying phosphorus-accumulating organisms (DPAOs) as NO2- suppliers for anammox. 15N stable isotope tracing revealed that the PDPRA enabled an anammox reaction rate of 6.14 ± 0.18 µmol-N/(L·h), contributing 57.4 % to total inorganic nitrogen (TIN) removal. Metagenomic sequencing and 16S rRNA amplicon sequencing unveiled the co-existence and co-prosperity of anammox bacteria and DPAOs, with Candidatus Brocadia being highly enriched in the anoxic biofilms at a relative abundance of 2.46 ± 0.52 %. Finally, the PDPRA facilitated the synergistic conversion and removal of carbon, nitrogen, and phosphorus nutrients, achieving remarkable removal efficiencies of chemical oxygen demand (COD, 83.5 ± 5.3 %), NH4+ (99.8 ± 0.7 %), TIN (77.1 ± 3.6 %), and PO43- (99.3 ± 1.6 %), even under challenging operational conditions such as low temperature of 11.7 °C. The PDPRA offers a promising solution for reconciling the mainstream anammox and the carbon and phosphorus removal, shedding fresh light on the paradigm shift of MWWTPs in the near future.

Aerobic and anoxic utilization of organic matter for flexible nitrite supply in nutrient conversion pathways based on anaerobic ammonium oxidation: Microbial interactive mechanism.

This study investigated nutrient conversion pathways and corresponding interactive mechanisms in a mainstream partial-nitritation (PN)/anaerobic ammonium oxidation (anammox)/partial-denitrification-(PD)-enhanced biological phosphorus-removal (EBPR) (PN/A/PD-EBPR) process. A laboratory-scale sequencing batch reactor was operated for 301 days under different operational strategies. Mainstream PN/A/PD-EBPR was successfully operated with aerobic and anoxic utilization of organic matter. Aerobic utilization of organic matter was an effective strategy for conversion to denitrifying polyphosphate-accumulating organism-based phosphorus removal, referring to a biological reaction that outperformed nitrite-oxidizing bacteria. Aerobically adsorbed organic matter could be used as a carbon source for PD, which further enhanced nitrogen removal by PN/A. Ultimately, the interaction between complex nutrient conversion pathways served to achieve stable performance. High-throughput sequencing results elucidated the core microbe functioning in the mainstream PN/A/PD-EBPR process with respect to various nutrients. The outcomes of this study will be beneficial to those attempting to implement mainstream PN/A/PD-EBPR.

Hydraulic retention time optimization achieved unexpectedly high nitrogen removal rate in pilot-scale anaerobic/aerobic/anoxic system for low-strength municipal wastewater treatment.

Applications of post-denitrification processes are subjected to low reaction rates caused by a lack of carbon resources. To offer a solution for reaction rate promotion, this research found a pilot-scale anaerobic/aerobic/anoxic bioreactor treating 55-120 m3/d low-strength municipal wastewater for 273 days. A short hydraulic retention time (HRT, 5-6 h) and a high nitrogen removal rate (63.2 ± 9.3 g-N/m3·d) were achieved using HRT optimization. The effluent total nitrogen concentration was maintained at 5.8 ± 1.4 mg/L while operating at a high nitrogen loading rate of 86.2 ± 12.8 g-N/m3·d. The short aeration (1.25-1.5 h) minimized the Glycogen loss. The endogenous denitrification rate increased to above 1.0 mg/(g-VSS·h). The functional genus Ca. Competibacter enriched to 2.3 %, guaranteeing the efficient post-denitrification process. Dechloromonas rose to 1.1 %, aiding in the synchronous phosphorus removal. These findings offered fresh insights into AOA processes to achieve energy/cost-saving wastewater treatment.

Simultaneous nitrogen and phosphorus removal through an integrated partial-denitrification/anammox process in a single UAFB system.

With the aim of obtaining enhanced nitrogen removal and phosphate recovery in mainstream sewage, we examined an integrated partial-denitrification/anaerobic ammonia oxidation (PD/A) process over a period of 189 days to accomplish this goal. An up-flow anaerobic fixed-bed reactor (UAFB) used in the integrated PD/A process was started up with anammox sludge inoculated and the influent composition controlled. Results showed that the system achieved a phosphorus removal efficiency of 82% when the influent concentration reached 12.0 mg/L. Batch tests demonstrated that stable and efficient removal of chemical oxygen demand (COD), nitrogen, and phosphorus was achieved at a COD/NO3--N ratio of 3.5. Scanning electron microscope (SEM) and X-ray diffraction (XRD) analysis indicated that hydroxyapatite was the main crystal in the biofilm. Furthermore, substrate variation along the axial length of UAFB indicated that partial denitrification and anammox primarily took place near the reactor's bottom. According to a microbiological examination, 0.4% of the PD/A process's microorganisms were anaerobic ammonia oxidizing bacteria (AnAOB). Ca. Brocadia, Ca. Kuenenia, and Ca. Jettenia served as the principal AnAOB generals in the system. Thauera, Candidatus Accumulibacter, Pseudomonas, and Acinetobacter, which together accounted for 27% of the denitrifying and phosphorus-accumulating bacteria, were helpful in advanced nutrient removal. Therefore, the combined PD/A process can be a different option in the future for sewage treatment to achieve contemporaneous nutrient removal.

Metagenomics insight into the long-term effect of ferrous ions on the mainstream anammox system.

Anaerobic ammonium oxidation (anammox) bacteria have a high requirement for iron for their growth and metabolism. However, it remains unclear whether iron supplementation can sustain the stability of mainstream anammox systems at varying temperatures. Here, we investigated the long-term effects of Fe2+ on the mainstream anammox systems. Our findings revealed that the nitrogen removal efficiency (NRE) of the anammox system supplemented with 5 mg/L Fe2+ decreased from 76.5 ± 0.76% at 35 °C to 39.0 ± 9.9% at 25 °C. Notably, higher dosages of Fe2+ (15 mg/L and 30 mg/L) inhibited the anammox system, resulting in NREs of 15.9 ± 8.1% and 2.5 ± 1.1% at 25 °C, respectively. The results of microbial communities and function profiles suggested that the high Fe2+ dosage seriously affected the iron assimilation and utilization in the mainstream anammox system. This was evident from the decreased abundance of genes associated with Fe(II) transport and uptake, which in turn hindered the biosynthesis of intracellular iron-cofactors, resulting in decrease in the absolute abundance of Candidatus Brocadia, a key anammox bacterium, as well as a decline in NRE. Furthermore, our results showed that the anammox process was more susceptible to iron supplementation at 25 °C compared to 35 °C, which may be due to the oxidative stress reactions induced by combined lowered temperature and a high Fe2+ dosage. Overall, these findings offer a deeper understanding of the effect of iron in mainstream anammox systems, which can contribute to improved stability maintenance and effectiveness of anammox processes.

Partial Nitritation/Anammox and biological phosphorus removal integration in a single bioreactor under mainstream conditions.

Anammox-based nitrogen removal and enhanced biological phosphorus removal (EBPR) are increasingly applied for nutrient removal from wastewater, but are typically operated in separate reactors. Here, a novel process for integrated partial nitritation/anammox (PN/A) and EBPR in a single reactor employing integrated fixed film activated sludge was tested. The reactor was fed with mainstream municipal wastewater (5.4 ± 1.3 g COD/g N) at 20 °C for 243 days. Robust ammonium, total inorganic nitrogen, and orthophosphate removal efficiencies of 94 ± 4 %, 87 ± 7 % and 92 ± 7 % were achieved. Nitrite-oxidizing organisms suppression and ammonia-oxidizing organisms retention were achieved via solids retention time control, intermittent aeration, and suspended versus attached biomass population segregation. The contribution of anammox to nitrogen removal increased from 24 % to 74 %. In parallel, a substantial enrichment of Tetrasphaera polyphosphate accumulating organisms was observed. This work demonstrates a novel intensified bioprocess coupling PN/A and EBPR in the same reactor for efficient nutrient removal from wastewater.

Ultra-high nitrogen removal from real municipal wastewater using selective enhancement of glycogen accumulating organisms (GAOs) in a partial nitrification-anammox (PNA) system.

Integrating endogenous denitrification (ED) into partial nitrification-anammox (PNA) systems by adequately utilizing organics in municipal wastewater is a promising approach to improve nitrogen removal efficiency (NRE). In this study, a novel strategy to inhibit phosphorus-accumulating organisms (PAOs) by inducing phosphorus release and exclusion was adopted intermittently, optimizing organics allocation between PAOs and glycogen-accumulating organisms (GAOs). Enhanced ED-synergized anammox was established to treat real municipal wastewater, achieving an NRE of 97.5±2.2% and effluent total inorganic nitrogen (TIN) of less than 2.0 mg/L. With low poly-phosphorus (poly-P) levels (poly-P/VSS below 0.01 (w/w)), glycogen accumulating metabolism (GAM) acquired organics exceeded that of phosphorus accumulating metabolism (PAM) and dominated endogenous metabolism. Ca. Competibacter (GAO) dominated the community following phosphorus-rich supernatant exclusion, with abundance increasing from 3.4% to 5.7%, accompanied by enhanced ED capacity (0.2 to 1.4 mg N/g VSS /h). The enriched subgroups (GB4, GB5) of Ca. Competibcater established a consistent nitrate cycle with anammox bacteria (AnAOB) through endogenous partial denitrification (EPD) at a ∆NO2--N/∆NH4+-N of 0.91±0.11, guaranteeing the maintenance of AnAOB abundance and performance. These results provide new insights into the flexibility of PNA for the energy-efficient treatment of low-strength ammonium wastewater.

Achieving phosphorus recovery at pilot-scale anaerobic anoxic/nitrifying-induced crystallization (A2N-IC) process: Performance, assessment, and challenges.

A pilot-scale anaerobic-anoxic/nitrifying/induced crystallization (A2N-IC) process was established for phosphorus (P) recovery and nutrient removal from municipal wastewater with a treatment capacity of 80 m3d-1. Results show that the A2N-IC process can operate stably on a pilot scale; the recovery efficiency of influent P reached 62.2%, and the total P removal efficiency of the IC section was 65.4%. The IC section had little effect on the removal of chemical oxygen demand (COD) and nitrogen (N), and the P removal efficiency was improved. Soluble non-reactive P (sNRP) was the key factor affecting P recovery efficiency. Although P recovery increases the construction and maintenance costs, the process can be profitable if a market for P recovery products is established. To improve the P recovery efficiency, attention should be paid to the effects of sNRP and dissolved organic matter (DOM) on P recovery, and P-rich sludge should be considered.

The phosphorus harvest from low-temperature mainstream wastewater through iron phosphate crystallization in a pilot-scale partial nitritation/anammox reactor.

The phosphorus harvest along nitrogen removal in the partial nitritation/anammox (PNA) reactor is promising for saving space and simplifying the management of mainstream wastewater treatment facilities. In this study, the phosphorus recovery from the low-temperature mainstream wastewater was explored through iron phosphate crystallization in a pilot-scale PNA reactor. With the COD-alleviated municipal wastewater as the influent, the ammonium concentration of about 50 mg/L and the phosphorus concentration ranged from 5.4 to 7.1 mg/L, under the temperature of 15 °C and the addition of external ferrous iron of 14 mg/L, the achieved nitrogen removal efficiency and the phosphorus removal efficiency were 37.6 % and 62.7 %, respectively. The good settleability of sludge indicated that the formed iron phosphate was well combined with the biomass. The quantitative analysis confirmed that the main iron phosphate in dry sludge was graftonite, and qualitative analysis confirmed that the equivalent of P2O5 content in the sludge was 5.8 %, which was suitable as fertilizer on agricultural land to realize the direct recycle of discharged phosphorus. In all, this study proposed a pioneering scheme to realize the nitrogen removal and phosphorus cycle in human society and given a meaningful reference for further research and application.

Enhanced nutrient removal from mainstream sewage via denitrifying dephosphatation, endogenous denitrification and anammox in a novel continuous flow process.

It is a challenging subject to realize nitrogen and phosphorus elimination synchronously from limited-carbon sewage through conventional biological processes. Herein, a novel continuous flow anaerobic/oxic/anoxic/oxic (AOA-O) process, which integrated denitrifying dephosphatation, endogenous denitrification and anammox in the anoxic zone, was developed to enhance nutrient elimination from low carbon/nitrogen sewage (3.4 in average). After the long-term operation (280 days), a satisfactory nutrient removal performance (effluent PO43--P: 0.2 mg P/L, total inorganic nitrogen (TIN):8.9 mg N/L) was obtained. Mass balance indicated that anammox contributed to 26.1% TIN removal and denitrifying dephosphatation contributed to 25.6% phosphorus removal, respectively. The cooperation of anammox bacteria retained in biofilms and endogenous denitrifying bacteria in flocculent sludge was responsible for the enhanced nutrient removal in the anoxic zone. Dechloromonas carried out phosphorus uptake both under oxic conditions and anoxic conditions. This study can broaden the application prospect of mainstream anammox.

A review on the integration of mainstream P-recovery strategies with enhanced biological phosphorus removal.

Phosphorus (P), an essential nutrient for all organisms, urgently needs to be recovered due to the increasing demand and scarcity of this natural resource. Recovering P from wastewater is a feasible and promising way widely studied nowadays due to the need to remove P in wastewater treatment plants (WWTPs). When enhanced biological P removal (EBPR) is implemented, an innovative option is to recover P from the supernatant streams obtained in the mainstream water line, and then combine it with liquor-crystallisation recovery processes, being the final recovered product struvite, vivianite or hydroxyapatite. The basic idea of these mainstream P-recovery strategies is to take advantage of the ability of polyphosphate accumulating organisms (PAO) to increase P concentration under anaerobic conditions when some carbon source is available. This work shows the mainstream P-recovery technologies reported so far, both in continuous and sequenced batch reactors (SBR) based configurations. The amount of extraction, as a key parameter to balance the recovery efficiency and the maintenance of the EBPR of the system, should be the first design criterion. The maximum value of P-recovery efficiency for long-term operation with an adequate extraction ratio would be around 60%. Other relevant factors (e.g. COD/P ratio of the influent, need for an additional carbon source) and operational parameters (e.g. aeration, SRT, HRT) are also reported and discussed.

Enhanced simultaneous nitrogen and phosphorus removal from low COD/TIN domestic wastewater through nitritation-denitritation coupling improved anammox process with an optimal Anaerobic/Oxic/Anoxic strategy.

Advanced nitrogen and phosphorus removal in a single-stage suspending-sludge system was achieved by employing a novel Anaerobic/Oxic/Anoxic (AOA) strategy over 200 days. Satisfactory total inorganic nitrogen (TIN) removal efficiency of 90.4% was achieved and effluent phosphorus was below 0.5 mg/L when treating domestic wastewater with the chemical oxygen demand (COD)/TIN as low as 2.98 ± 1.26. Stable nitritation was maintained with the ammonia residual and low dissolved oxygen of 0.2-0.5 mg/L at aerobic stage following by a post anoxic stage. The much higher activity of ammonia oxidation bacteria (12.99 mgN/gVSS/h) was achieved than the nitrite oxidation bacteria (0.09 mgN/gVSS/h). Notably, improved anammox performance was obtained without initial inoculation, contributing 47.4% to TIN removal. The abundance of Nitrosomonas increased from 0.12% to 0.95% (P < 0.001) and self-enrichment of anammox bacteria Ca. Brocadia was confirmed. It provided new insight into the advanced nutrient removal with comprehensible regulation and less aeration requirement.

Simultaneous enhanced biological phosphorus removal and semi-nitritation (EBPR-SN) followed by anammox process treating municipal wastewater at seasonal temperatures: From summer to winter.

This work investigated the feasibility of a novel simultaneous enhanced biological phosphorus removal and semi-nitritation (EBPR-SN) plus anammox process treating real municipal wastewater from summer to winter (28.1- 15.3 °C). Two lab-scale sequential reactors were used in this study, namely EBPR-SN and Anammox sequencing batch reactors (SBRs). Long-term operation suggested that ammonium oxidizing bacteria abundance decreased from 1.67% to 0.89% whereas nitrite oxidizing bacteria decreased to nearly undetected in the EBPR-SN SBR, maintaining the stable nitritation (nitrite accumulation ratio: 98.3 ± 1.0%). Lowering airflow rate was effective to retain nitritation with temperature decrease. Reliable nutrient removal was still maintained in winter (16.4 ± 0.7 °C), i.e. the removal efficiencies for nitrogen and phosphorus were 80.0 ± 3.5% and 95.4 ± 5.2%, respectively, with short aerobic HRT (6.4 h) and low dissolved oxygen (0.2-1.5 mg/L). The percentage of anammox contribution to nitrogen-removal increased with temperature decrease, although Candidatus Brocadia abundance decreased. Additionally, the protection of extracellular polymeric substances was important to the successful performance.

A novel SNPR process for advanced nitrogen and phosphorus removal from mainstream wastewater based on anammox, endogenous partial-denitrification and denitrifying dephosphatation.

For achieving energy-efficient wastewater treatment, a novel simultaneous nitrogen and phosphorus removal (SNPR) process, which integrated anammox, endogenous partial-denitrification and denitrifying dephosphatation in a sequencing batch reactor with granular sludge was developed to treat mainstream wastewater. After 200 days of operation, a simultaneous high-level nitrogen and phosphorus removal of 93.9% and 94.2%, respectively was achieved with an average influent C/N ratio of 2.9. Anammox pathway contributed 82.9% of the overall nitrogen removal because of the stable nitrite production from nitrate via endogenous partial-denitrification. In addition, phosphorus was mainly removed via denitrifying dephosphatation utilizing nitrate as the electron acceptor, resulting in a significant saving of carbon sources and oxygen demands. Further, adsorption/precipitation of phosphorus occurred in this novel SNPR process, which displaced the energy source to the metabolism of glycogen accumulating organisms (GAOs) for nitrite production and alleviated competition between phosphorus accumulating organisms (PAOs) and anammox for electron acceptor. Using 16S rRNA gene amplicon sequencing analysis, the study found that anammox bacteria (8.4%), GAOs (1.5%) and PAOs (1.1%) co-existed in this system, potentially resulting in simultaneous endogenous partial-denitrification, anammox and denitrifying dephosphatation. The above results demonstrated that the novel SNPR process is a promising technique for energy-efficient wastewater treatment.

Achieving mainstream nitrogen and phosphorus removal through Simultaneous partial Nitrification, Anammox, Denitrification, and Denitrifying Phosphorus Removal (SNADPR) process in a single-tank integrative reactor.

Simultaneous partial Nitrification, Anammox, and Denitrification (SNAD) is a promising and energy-efficient nitrogen removal process, which is powerless to eliminate phosphorus and confronted the problem of excessive effluent nitrate once applied in municipal sewage treatment characterized with high C/N ratio (≥2). Herein, by coupling SNAD with denitrifying phosphorus removal (DPR) process in a single-tank reactor, a novel integrative process (termed as SNADPR) was designed to treat municipal sewage. The removal efficiencies of TN, PO43--P, and COD under the optimized conditions (T = 30 °C, HRT = 24 h, DO = 0.45 mg/L) were 89.15 ±â€¯2.19%, 92.93 ±â€¯0.60%, and 99.17 ±â€¯1.58%, respectively. Distinctive microbial community distribution was harvested, where anammox bacteria (AnAOB, Candidatus_Kuenenia and Candidatus_Brocadia) were mainly located in biofilm, whereas denitrifying polyphosphate-accumulating organisms (DPAOs, Dechloromonas and Pseudomonas) and ammonium oxidizing bacteria (AOB, Nitrosomonas) basically lived in suspended floc. The SRT separation between biofilm and floc was reached by conserving AnAOB-rich biofilm and termly discharging phosphorus-rich floc.

A Survey of School Nurses' Perceptions of Complementary, Alternative, and Integrative Therapies.

Complementary, alternative, and integrative therapies (CAIs) involve the use of practices outside of mainstream, conventional medicine. Few studies have been conducted on nurses' perception and knowledge of CAI therapies. There is limited information on the protocols school nurses must follow in their practice on CAI use. The purpose of this study is to assess school nurses' perception and knowledge of CAI therapies. A cross-sectional, nonexperimental survey study design was used, and participants were sampled with a cross-sectional convenience method. Members of four state School Nurses Associations were invited to participate in the study. Of the 290 participants, 100% of certified school nurses and 63% of non-certified school nurses believed CAI therapies have a place in their current practice (χ2 = 1.83, df = 1, p < .05). The study found that school nurses believe CAI therapies have a role in the school setting; however, the participants were not comfortable with assessing and administering these therapies.

Using Two-Eyed Seeing to Explore Interagency Collaboration.

Background Health-care environments influence service delivery; approaches need to be more wholistic and culturally competent requiring effective interagency collaboration to bridge traditional Indigenous and mainstream health services. Despite considerable research on collaboration, the concept remains misunderstood, at worst, and formative, at best. Within the nexus of these two diverse health services, there is limited information on how collaborations could be created and sustained effectively. Purpose To explore the perspectives/experiences of collaboration of select Saskatchewan health professionals practicing across these diverse services to understand the concept from their perspectives. Methods This qualitative study explored collaboration through observation and interviews to elicit perspectives (two-eyed seeing) of health professionals working within the context of a traditional-mainstream health services partnership. Results Individual- and system-level factors and accountabilities are needed for successful cross-cultural collaboration and can be enabled by embedding the virtues of Indigenous and values of mainstream health services along with building and maintaining relationships, valuing difference, creating supportive environments and wholistic approaches, having the right people at the table, and making a change for impactful outcomes. Conclusion Findings support the need for implementing contextually relevant collaborative practice models for productive, wholistic health services. Two-eyed seeing provides the ability to capture and catalyze the tremendous value and strengths of both worlds, potentiating complementary aspects to meet the needs of clients and communities.

Integrating herbal medicine into mainstream healthcare in Ghana: clients' acceptability, perceptions and disclosure of use.

BACKGROUND: Although there are current efforts to integrate herbal medicine (HM) into mainstream healthcare in Ghana, there is paucity of empirical evidence on the acceptability and concurrent use of HM, in the formal health facilities in Ghana. This study sought to determine client perception, disclosure and acceptability of integrating herbal medicine in mainstream healthcare in Kumasi, Ghana. METHODS: A cross-sectional study was conducted from May to August, 2015. Five hundred patients presenting at the outpatient departments of Kumasi South, Suntreso and Tafo Government Hospitals in Kumasi were randomly selected. Interviews were conducted with the use of structured questionnaires. A logistic regression analysis, using backward selection, was conducted to determine the influence of socio-demographic and facility related factors on the odds of using HM at the facility. All statistical tests were two-sided and considered significant at a p-value of <0.05. RESULTS: Majority of the study respondents were females (64.8%) and the median age was 36 years. Less than half, 42.2%, of the respondents utilized HM services when they visited the health facility. Reasons for using HM at the facility level included 'being effective' (24.4%), 'easy to access' (25.3%) and 'being comparatively cheaper' (16%). About 86% never disclosed previous use of HM to their health care providers. Socio-economic status and perception of service provision influenced use of herbal medicines. Respondents who rated themselves wealthy had increased odds of using herbal medicines at the health facility as compared to those who rated themselves poor (OR = 4.9; 95%CI = 1.6-15.3). CONCLUSION: This study shows that integration of herbal medicine is feasible and herbal medicines may be generally accepted as a formal source of healthcare in Ghana. The results of this study might serve as a basis for improvement and upscale of the herbal medicine integration programme in Ghana.

A novel A-B process for enhanced biological nutrient removal in municipal wastewater reclamation.

This study developed an innovative A-B process for enhanced nutrients removal in municipal wastewater reclamation, in which a micro-aerated moving bed biofilm reactor served as A-stage and a step-feed sequencing batch reactor (SBR) as B-stage. In the A-stage, 55% of COD and 15% of ammonia nitrogen was removed, while more than 88% of the total nitrogen was removed via nitritation and denitritation, together with 93% of phosphorous removal at the B-stage where ammonia oxidizing bacteria activity was significantly higher than nitrite oxidizing bacteria activity. Meanwhile substantial phenotype of polyphosphate accumulating organisms (PAOs) was also observed in the B-stage SBR. Fluorescence in situ hybridization revealed that Accumulibacter was the dominant PAOs with undetectable Competibacter. Compared to the conventional activated sludge process, the proposed A-B process could offer a more cost-effective alternative for enhanced biological nutrients removal from municipal wastewater with less energy consumption.