Sociocultural factors affecting first-year medical students' adjustment to a PBL program at an African medical school.

BACKGROUND: Besides regulatory learning skills, learning also requires students to relate to their social context and negotiate it as they transition and adjust to medical training. As such, there is a need to consider and explore the role of social and cultural aspects in student learning, particularly in problem-based learning, where the learning paradigm differs from what most students have previously experienced. In this article, we report on the findings of a study exploring first-year medical students' experiences during the first semester of an undergraduate problem-based learning medical program at an African medical school. METHOD: We employed a qualitative case study approach using in-depth interviews with 23 first-year medical students. Participants ranged in age from 18 to 25 years. All students were bi/multilingual (some spoke three to five languages), with English as the learning language. We conducted an inductive thematic analysis to systematically identify and analyze patterns in the data using the Braun and Clarke framework. RESULTS: Before medical school, students worked hard to compete for admission to medical school, were primarily taught using a teacher-centered approach, and preferred working alone. At the beginning of medical school, students found it challenging to understand the problem-based learning process, the role of the case, speaking and working effectively in a group, managing a heavy workload, and taking increased responsibility for their learning. By the end of the first semester, most students were handling the workload better, were more comfortable with their peers and facilitators, and appreciated the value of the problem-based learning approach. CONCLUSIONS: Our study highlights the importance of interrogating contextual sociocultural factors that could cause tension when implementing problem-based learning in non-western medical schools. Adjustment to problem-based learning requires a conceptual and pedagogic shift towards learner-centered practice, particularly concerning self-direction, the role of the case, and collaborative learning. As such, there is a need to develop and implement research-informed learning development programs that enable students to reflect on their sociocultural beliefs and practices, and enhance their regulatory learning competence to optimize meaningful and early engagement with the problem-based learning process.

Improvement studies for equitable and evidence-based innovation: an overview of the 'IM-SEEN' model.

BACKGROUND: Health inequalities are ubiquitous, and as countries seek to expand service coverage, they are at risk of exacerbating existing inequalities unless they adopt equity-focused approaches to service delivery. MAIN TEXT: Our team has developed an equity-focused continuous improvement model that reconciles prioritisation of disadvantaged groups with the expansion of service coverage. Our new approach is based on the foundations of routinely collecting sociodemographic data; identifying left-behind groups; engaging with these service users to elicit barriers and potential solutions; and then rigorously testing these solutions with pragmatic, embedded trials. This paper presents the rationale for the model, a holistic overview of how the different elements fit together, and potential applications. Future work will present findings as the model is operationalised in eye-health programmes in Botswana, India, Kenya, and Nepal. CONCLUSION: There is a real paucity of approaches for operationalising equity. By bringing a series of steps together that force programme managers to focus on groups that are being left behind, we present a model that can be used in any service delivery setting to build equity into routine practice.

Novel Education Modules Addressing the Underrepresentation of Skin of Color in Dermatology Training.

BACKGROUND: Representative images of pathology in patients with skin of color are lacking in most medical education resources. This particularly affects training in dermatology, which relies heavily on the use of images to teach pattern recognition. The presentation of skin pathology can vary greatly among different skin tones, and this lack of representation of dark skin phototypes challenges providers' abilities to provide quality care to patients of color.In Botswana and other countries in sub-Saharan Africa, this challenge is further compounded by limited resources and access to dermatologists. There is a need for improved and accessible educational resources to train medical students and local medical providers in basic skin lesion description and diagnosis. OBJECTIVES: We examined whether online Perceptual and Adaptive Learning Modules (PALMs) composed of representative dark skin images could efficiently train University of Botswana medical students to more accurately describe and diagnose common skin conditions in their community. METHODS: Year 4 and 5 medical students voluntarily completed PALMs that teach skin morphology, configuration, and distribution terminology and diagnosis of the most common dermatologic conditions in their community. Pre-tests, post-tests and delayed-tests assessed knowledge acquisition and retention. RESULTS: PALMs training produced statistically significant (P < .0001) improvements in accuracy and fluency with large effect sizes (1.5, 3.7) and good retention after a 12.5-21-week median delay. Limitations were a self-selected group of students, a single institution, slow internet connections, and high drop-out rates. CONCLUSIONS: Overall, population-specific PALMs are a useful tool for efficient development of pattern recognition in skin disease description and diagnosis.

Integrating noncommunicable disease services into primary health care, Botswana.

Despite the rising burden of noncommunicable diseases, access to quality decentralized noncommunicable disease services remain limited in many low- and middle-income countries. Here we describe the strategies we employed to drive the process from adaptation to national endorsement and implementation of the 2016 Botswana primary healthcare guidelines for adults. The strategies included detailed multilevel assessment with broad stakeholder inputs and in-depth analysis of local data; leveraging academic partnerships; facilitating development of supporting policy instruments; and embedding noncommunicable disease guidelines within broader primary health-care guidelines in keeping with the health ministry strategic direction. At facility level, strategies included developing a multimethod training programme for health-care providers, leveraging on the experience of provision of human immunodeficiency virus care and engaging health-care implementers early in the process. Through the strategies employed, the country's first national primary health-care guidelines were endorsed in 2016 and a phased three-year implementation started in August 2017. In addition, provision of primary health-care delivery of noncommunicable disease services was included in the country's 11th national development plan (2017-2023). During the guideline development process, we learnt that strong interdisciplinary skills in communication, organization, coalition building and systems thinking, and technical grasp of best-practices in low- and middle-income countries were important. Furthermore, misaligned agendas of stakeholders, exaggerated by a siloed approach to guideline development, underestimation of the importance of having policy instruments in place and coordination of the processes initially being led outside the health ministry caused delays. Our experience is relevant to other countries interested in developing and implementing guidelines for evidence-based noncommunicable disease services.

Malgré la charge de morbidité croissante des maladies non transmissibles, l'accès à des services décentralisés de qualité pour lutter contre ces maladies reste limité dans de nombreux pays à revenu faible ou intermédiaire. Dans cet article, nous décrivons les stratégies qui ont été employées pour mener les étapes d'adaptation, de validation et de mise en œuvre à l'échelle nationale des Lignes directrices 2016 du Botswana sur les soins de santé primaires pour l'adulte. Ces stratégies ont inclus: une évaluation multiniveau détaillée avec une large implication des parties prenantes et une analyse approfondie des données locales; le recours à des partenariats universitaires; la promotion de l'élaboration d'instruments politiques propices; l'intégration de lignes directrices portant spécifiquement sur les maladies non transmissibles dans les lignes directrices générales sur les soins primaires, en écho à l'orientation stratégique du ministère de la Santé. Au niveau des établissements de santé, les stratégies ont inclus: la création d'un programme de formation multiméthode à destination des prestataires de soins; l'exploitation de l'expérience acquise dans la prise en charge du virus de l'immunodéficience humaine et l'implication des prestataires de soins très tôt dans le processus. Grâce aux stratégies employées, les premières lignes directrices nationales sur les soins de santé primaires ont été validées en 2016, et une étape de mise en œuvre graduelle, sur trois ans, a commencé en août 2017. De plus, la prestation de soins de santé primaires contre les maladies non transmissibles a été incluse dans le 11e plan national de développement du pays (2017-2023). Pendant la phase d'élaboration des lignes directrices, nous avons constaté toute l'importance, dans les pays à revenu faible et intermédiaire, de pouvoir compter sur de solides compétences interdisciplinaires en matière de communication, d'organisation, de création de coalitions et de réflexion systémique et d'obtenir une bonne compréhension technique des meilleures pratiques. Nous avons par ailleurs observé des retards provoqués par des problèmes d'incompatibilité d'agendas entre les différentes parties prenantes, exagérés par des approches cloisonnées lors de la phase d'élaboration des lignes directrices, par la sous-estimation de l'importance d'avoir des outils politiques déjà en place et par des difficultés de coordination des processus initialement pilotés hors du ministère de la Santé. Notre expérience peut être utile pour d'autres pays qui souhaiteraient élaborer et mettre en œuvre des lignes directrices pour des services de soins contre les maladies non transmissibles fondés sur des données probantes.

A pesar de la creciente carga de las enfermedades no transmisibles, el acceso a servicios de calidad descentralizados para estas enfermedades sigue siendo limitado en muchos países de bajos y medianos ingresos. A continuación, describimos las estrategias que empleamos para impulsar el proceso desde la adaptación a la aprobación nacional y la implementación de las directrices de atención primaria de la salud para adultos de Botswana de 2016. Las estrategias incluían una evaluación detallada a varios niveles con amplias aportaciones de las partes interesadas y un análisis a fondo de los datos locales; el aprovechamiento de las asociaciones académicas; la facilidad para elaborar instrumentos normativos de apoyo; la incorporación de directrices sobre las enfermedades no transmisibles en las directrices más amplias sobre la atención primaria de la salud, de conformidad con la dirección estratégica del Ministerio de Salud. A nivel de los centros de salud, las estrategias incluían la elaboración de un programa de capacitación multimétodo para los proveedores de servicios de salud, el aprovechamiento de la experiencia en la prestación de servicios de atención del virus de la inmunodeficiencia humana y la participación de los encargados de la ejecución de los servicios de salud en las primeras etapas del proceso. Gracias a las estrategias empleadas, en 2016 se aprobaron las primeras directrices nacionales de atención primaria de la salud del país y en agosto de 2017 se inició una aplicación por etapas de tres años. Además, la prestación de servicios de atención primaria de la salud para las enfermedades no transmisibles se incluyó en el 11º plan nacional de desarrollo del país (2017-2023). Durante el proceso de desarrollo de las directrices, aprendimos que eran importantes las buenas habilidades interdisciplinarias en comunicación, organización, formación de coaliciones y pensamiento sistémico, así como la comprensión técnica de las mejores prácticas en los países de ingresos bajos y medios. Por otra parte, las agendas desalineadas de las partes interesadas, exageradas por el enfoque aislado del desarrollo de las directrices, la subestimación de la importancia de contar con instrumentos de política y la coordinación de los procesos que inicialmente se llevaban a cabo fuera del ministerio de salud causaron retrasos. Nuestra experiencia es relevante para otros países interesados en desarrollar e implementar directrices para servicios de enfermedades no transmisibles basados en la evidencia.

Intern preparedness for the CanMEDS roles and the Dunning-Kruger effect: a survey.

BACKGROUND: The purpose of this study was to determine whether the first cohort of graduates from a new undergraduate medical programme in Botswana were adequately prepared for internship. METHODS: The authors surveyed 27 interns and 13 intern supervisors on site, who rated intern preparedness for 44 tasks using a previously validated instrument. Tasks were grouped according to the seven roles of the physician in the CanMEDS framework and Cronbach α values confirmed internal consistency. To determine the direction of differences between intern and supervisor ratings for tasks Likert scale ratings were treated as interval data and mean scores calculated. Rating frequencies for each role were compared using the χ2 statistic. Reasons for differences between intern and supervisor ratings were explored by determining correlations between scores using the Spearman ρ statistic, and analysing qualitative data generated by the questionnaire. RESULTS: Preparedness for all seven roles and the majority of tasks was found to be between 'Fairly well prepared' and 'Well prepared'. The ratings for four roles (Medical expert, Communicator, Collaborator, Professional) differed statistically, but not for the three others (Leader, Health advocate, Scholar). Interns rated their proficiency higher than their supervisors for the tasks in six roles; for the 'Professional' role intern ratings were mostly lower. Correlations between intern and supervisors scores were only significant for three roles (Medical expert, Communicator, Collaborator). Qualitative data provided further insights into the reasons for these associations. CONCLUSIONS: Intern preparedness for tasks and roles varied but was generally satisfactory. Based on the analysis of the data seeming discrepancies in between interns and supervisor ratings were investigated and explanations are offered. For three roles the data indicate that their component tasks are understood in the same way by interns and supervisors, but not for the other roles. The Dunning-Kruger effect offers a plausible explanation for higher intern scores for tasks in six of the roles. For the 'Professional' role differences between interns' internal, individual understanding and supervisors' external, group understanding may explain lower intern scores. The fact that respondents may understand the tasks they rate differently has implications for all research of this nature.

Learning support interventions for Year 1 medical students: a review of the literature.

CONTEXT: The journey through medical school can be challenging, especially for undergraduate medical students who must deal with a demanding curriculum, coupled with the demands of transitioning into adulthood. Despite experiencing learning challenges, most students succeed with appropriate learning support. Many medical schools offer learning support programmes, particularly in the latter years, but it has been suggested that such support could be more beneficial, especially during the initial years. OBJECTIVES: This review explores learning support intervention programmes used to address learning challenges and deficits in the first year of medical school. Additionally, we propose a potential framework for supporting learning during the first year of medical school. METHODS: We searched PubMed, Web of Science, MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ERIC (Educational Resources Information Centre), Academic Search Premier and Google Scholar using the search terms 'learning support', 'learning challenge', 'remediation', 'change', 'medical education' and 'first year'. We developed and used a review matrix to record the main elements of each article. We also coded the matrix to identify emerging themes. RESULTS: The main themes that emerged from the study were 'intervention approaches', 'area of intervention', 'intervention strategies', 'intervention dose' and 'intervention outcomes'. INTERVENTIONS: (i) used proactive-deficit, reactive-deficit and proactive-developmental approaches; (ii) addressed content knowledge, academic success skills, personal and professional skills and programme-related elements; (iii) utilised faculty staff-facilitated, peer-facilitated, support staff-facilitated, experiential placement, self-study and reduced-load strategies; (iv) varied in length from 5 weeks to 2 years, and (v) generally showed positive results. CONCLUSIONS: This review has identified the main components of learning support interventions used for Year 1 medical students. Interventions, however, are generally not grounded on empirical assessment that elucidates the nature of the challenges faced by students. Future research should provide empirical understanding of the learning challenges to be addressed.

Correction to: Strengthening medical training programmes by focusing on professional transitions: a national bridging programme to prepare medical school graduates for their role as medical interns in Botswana.

CORRECTION: Forllowing publication of the original article [1], the first author reported that there was a typographical error in the name of one of his co-authors. The correct spelling is Alemayehu Bedada, not Alemayhu Bedada.

Strengthening medical training programmes by focusing on professional transitions: a national bridging programme to prepare medical school graduates for their role as medical interns in Botswana.

BACKGROUND: The improvement of existing medical training programmes in resource-constrained settings is seen as key to addressing the challenge of retaining medical graduates trained at considerable cost both in-country and abroad. In Botswana, the establishment of the national Medical Internship Training Programme (MIT) in 2014 was a first step in efforts to promote retention through the expansion and standardization of internship training, but MIT faces a major challenge related to variability between incoming trainees due to factors such as their completion of undergraduate medical training in different settings. To address this challenge, in August 2016 we piloted a bridging programme for foreign and locally trained medical graduates that aimed to facilitate their transition into internship training. This study aimed to describe the programme and evaluate its impact on the participants' self-rated perceptions of their knowledge, experience, clinical skills, and familiarity with Botswana's healthcare system. METHODS: We conducted a national, intensive, two-week programme designed to facilitate the transition from medical student to intern and to prepare all incoming interns for their work in Botswana's health system. Participants included all interns entering in August 2016. Formats included lectures, workshops, simulations, discussions, and reflection-oriented activities. The Kellogg Foundation Outcomes Logic Model was used to evaluate the programme, and participants self-rated their knowledge, skills, and attitudes across each of the programme objectives on paired questionnaires before and after participation. RESULTS: 48/54 participants (89%) provided paired data. Participants reported a high degree of satisfaction with the programme (mean 4.2/5). Self-rated preparedness improved after participation (mean 3.2 versus 3.7, p < 0.001), as did confidence across 18/19 knowledge/skill domains, suggesting that participants felt that the programme prepared them for their internship training. Exploratory analysis revealed that 20/25 participants (80%) reporting either no effect or a negative effect following participation had rated themselves "extremely" or "quite" prepared beforehand, suggesting the programme grounded expectations for interns who initially were overconfident. In contrast, no interns who had initially rated themselves "moderately" or "somewhat" prepared reported a decline in their self-rated sense of preparedness. Interns commented on the benefits of learning about roles/responsibilities, interacting with clinicians from Botswana's healthcare sectors, and the sense of community the programme engendered. CONCLUSIONS: This programme was feasible to implement and was well-received by participants. Overall, participants perceived an enhancement of their knowledge, skills, and expectations about their role in Botswana's health system after completion of the programme. Our results are likely to be of interest to educators dedicated to training, professional transitions, and career pathways in similar settings in the region and beyond.

Variation in attrition at subnational level: review of the Botswana National HIV/AIDS Treatment (Masa) programme data (2002-2013).

OBJECTIVE: To evaluate the variation in all-cause attrition [mortality and loss to follow-up (LTFU)] among HIV-infected individuals in Botswana by health district during the rapid and massive scale-up of the National Treatment Program. METHODS: Analysis of routinely collected longitudinal data from 226 030 patients who received ART through the Botswana National HIV/AIDS Treatment Program across all 24 health districts from 2002 to 2013. A time-to-event analysis was used to measure crude mortality and loss to follow-up rates (LTFU). A marginal structural model was used to evaluate mortality and LTFU rates by district over time, adjusted for individual-level risk factors (e.g. age, gender, baseline CD4, year of treatment initiation and antiretroviral regimen). RESULTS: Mortality rates in the districts ranged from the lowest 1.0 (95% CI 0.9-1.1) in Selibe-Phikwe, to the highest 5.0 (95% CI 4.0-6.1), in Mabutsane. There was a wide range of overall LTFU across districts, including rates as low as 4.6 (95% CI 4.4-4.9) losses per 100 person-years in Ngamiland, and 5.9 (95% CI 5.6-6.2) losses per 100 person-years in South East district, to rates as high as 25.4 (95% CI 23.08-27.89) losses per 100 person-years in Mabutsane and 46.3 (95% CI 43.48-49.23) losses per 100 person-years in Okavango. Even when known risk factors for mortality and LTFU were adjusted for, district was a significant predictor of both mortality and LTFU rates. CONCLUSION: We found statistically significant variation in attrition (mortality and LTFU) and data quality among districts. These findings suggest that district-level contextual factors affect retention in treatment. Further research needs to investigate factors that can potentially cause this variation.

Human resources for primary health care in sub-Saharan Africa: progress or stagnation?

BACKGROUND: The World Health Organization defines a "critical shortage" of health workers as being fewer than 2.28 health workers per 1000 population and failing to attain 80% coverage for deliveries by skilled birth attendants. We aimed to quantify the number of health workers in five African countries and the proportion of these currently working in primary health care facilities, to compare this to estimates of numbers needed and to assess how the situation has changed in recent years. METHODS: This study is a review of published and unpublished "grey" literature on human resources for health in five disparate countries: Mali, Sudan, Uganda, Botswana and South Africa. RESULTS: Health worker density has increased steadily since 2000 in South Africa and Botswana which already meet WHO targets but has not significantly increased since 2004 in Sudan, Mali and Uganda which have a critical shortage of health workers. In all five countries, a minority of doctors, nurses and midwives are working in primary health care, and shortages of qualified staff are greatest in rural areas. In Uganda, shortages are greater in primary health care settings than at higher levels. In Mali, few community health centres have a midwife or a doctor. Even South Africa has a shortage of doctors in primary health care in poorer districts. Although most countries recognize village health workers, traditional healers and traditional birth attendants, there are insufficient data on their numbers. CONCLUSION: There is an "inverse primary health care law" in the countries studied: staffing is inversely related to poverty and level of need, and health worker density is not increasing in the lowest income countries. Unless there is money to recruit and retain staff in these areas, training programmes will not improve health worker density because the trained staff will simply leave to work elsewhere. Information systems need to be improved in a way that informs policy on the health workforce. It may be possible to use existing resources more cost-effectively by involving skilled staff to supervise and support lower level health care workers who currently provide the front line of primary health care in most of Africa.

Design of a Learning Development Program to Support First-Year Undergraduate Medical Students in the Transition to a PBL Curriculum.

While the evaluation of learning development interventions needs to be considered carefully and included at the curriculum design stage, there is limited literature on the actual design of interventions, especially on how these designs evolve and improve over time. This paper describes the evolution of a learning development program intended to support first-year medical students adjusting to a problem-based learning curriculum. We used a design-based research approach, articulating our theoretical grounding and incorporating students' voices to develop an "optimal" intervention for the specific challenges in our context. We describe lessons learned around four aspects: students' growth and development, teachers' professional growth and development, program design principles, and the emergent components of a learning development program. Overall, our students describe the Learning Success Program as adding value by enabling the adoption of a repertoire of skills and strategies for learning management. Additionally, the incremental nature of design-based research allowed for the development of a context-specific program that considers students' voices through needs assessment and feedback on the program offerings. It has also provided an opportunity for the professional development of teachers through feedback from classroom practice, reflection, and the literature. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01790-3.

Protocol for an automated, pragmatic, embedded, adaptive randomised controlled trial: behavioural economics-informed mobile phone-based reminder messages to improve clinic attendance in a Botswanan school-based vision screening programme.

BACKGROUND: Clinic non-attendance rates are high across the African continent. Emerging evidence suggests that phone-based reminder messages could make a small but important contribution to reducing non-attendance. We will use behavioural economics principles to develop an SMS and voice reminder message to improve attendance rates in a school-based eye screening programme in Botswana. METHODS: We will test a new theory-informed SMS and voice reminder message in a national school-based eye screening programme in Botswana. The control will be the standard SMS message used to remind parents/guardians to bring their child for ophthalmic assessment. All messages will be sent twice. The primary outcome is attendance for ophthalmic assessment. We will use an automated adaptive approach, starting with a 1:1 allocation ratio. DISCUSSION: As far as we are aware, only one other study has used behavioural economics to inform the development of reminder messages to be deployed in an African healthcare setting. Our study will use an adaptive trial design, embedded in a national screening programme. Our approach can be used to trial other forms of reminder message in the future. TRIAL REGISTRATION: ISRCTN 96528723 . Registered on 5 January 2022.

Sociodemographic characteristics of community eye screening participants: protocol for cross-sectional equity analyses in Botswana, India, Kenya, and Nepal.

Background: Attendance rates for eye clinics are low across low- and middle-income countries (LMICs) and exhibit marked sociodemographic inequalities. We aimed to quantify the association between a range of sociodemographic domains and attendance rates from vision screening in programmes launching in Botswana, India, Kenya and Nepal. Methods: We performed a literature review of international guidance on sociodemographic data collection. Once we had identified 13 core candidate domains (age, gender, place of residence, language, ethnicity/tribe/caste, religion, marital status, parent/guardian status, place of birth, education, occupation, income, wealth) we held workshops with researchers, academics, programme implementers, and programme designers in each country to tailor the domains and response options to the national context, basing our survey development on the USAID Demographic and Health Survey model questionnaire and the RAAB7 eye health survey methodology. The draft surveys were reviewed by health economists and piloted with laypeople before being finalised, translated, and back-translated for use in Botswana, Kenya, India, and Nepal. These surveys will be used to assess the distribution of eye disease among different sociodemographic groups, and to track attendance rates between groups in four major eye screening programmes. We gather data from 3,850 people in each country and use logistic regression to identify the groups that experience the worst access to community-based eye care services in each setting. We will use a secure, password protected android-based app to gather sociodemographic information. These data will be stored using state-of-the art security measures, complying with each country's data management legislation and UK law. Discussion: This low-risk, embedded, pragmatic, observational data collection will enable eye screening programme managers to accurately identify which sociodemographic groups are facing the highest systematic barriers to accessing care at any point in time. This information will be used to inform the development of service improvements to improve equity.

Factors Affecting Quality of Life for People Living with Albinism in Botswana.

People with albinism (PWA) in Africa suffer many challenges, including higher risk of skin cancers and deeply embedded stigma. We conducted interviews with PWA to determine factors influencing their quality of life (QOL) in Botswana. Physical concerns expressed included skin/eye health issues and limited access to health care. Psychosocial concerns included stigma/discrimination and myths/superstitions. Environmental concerns included barriers to personal development of education and employment, safety concerns, financial insecurity, and disability rights issues. Pervasive difficulty in obtaining equal rights to physical, psychosocial, and environmental health affected QOL. Education around albinism and disability rights are needed to improve QOL for PWA.

Sociodemographic features of a cohort of people living with albinism in Botswana.

BACKGROUND: Oculocutaneous albinism is disproportionately prevalent in Africa; however, the medical and psychosocial characteristics of people living with albinism (PWA) in Botswana have not been studied. OBJECTIVE: To characterize the demographics, health-related factors, sun-protective behaviors, and psychosocial challenges of PWA in Botswana. METHODS: Overall, 50 PWA and 99 patients without albinism (non-PWA) were recruited and surveyed. RESULTS: Higher proportions of PWA lived in rural villages compared with non-PWA (odds ratio [OR], 2.59; 95% confidence interval [CI], 1.26-5.34). PWA reported limited access to health care more frequently compared with non-PWA (OR, 2.72; 95% CI, 1.11-6.62). High proportions of PWA adopted sun-protective measures, including sunscreen, clothing, and sunlight avoidance. Despite high rates of feeling accepted by family and peers, PWA had increased odds of feeling unaccepted by their community (OR, 15.16; 95% CI, 5.25-31.81), stigmatized by society (OR, 9.37; 95% CI, 3.43-35.62), and affected by stigma in social interactions (OR, 2.21; 95% CI, 1.08-4.54) compared with non-PWA. Three-quarters of PWA had witnessed mistreatment of PWA. LIMITATIONS: Study limitations include the small sample size, convenience sampling, and a non-validated survey instrument. CONCLUSION: PWA faced increased medical and psychosocial challenges compared with non-PWA in Botswana. Our findings can begin to inform public health strategies aimed at promoting improved health care, education, and social inclusion for this population in Botswana and other regions in Africa.

Incidence of Retinopathy of Prematurity in Botswana: A Prospective Observational Study.

BACKGROUND: Retinopathy of prematurity (ROP) is a widely recognized cause of blindness after preterm birth. The incidence of ROP is rising especially in low- and middle-income countries (LMIC) because of improved neonatal care and increased survival of very premature neonates. To date, there is no data on incidence of ROP in Botswana. OBJECTIVE: The purpose of this study was to provide initial data and determine ROP-associated risk factors from a single neonatal care center on the incidence of ROP in Gaborone, Botswana. METHODS: A prospective observational study was conducted at Princess Marina Hospital (PMH) in Gaborone, Botswana. Premature neonates with birth weights (BW) of <1,801 g or gestational age (GA) of <34 weeks were enrolled in this study. Diagnostic examinations were conducted using an indirect ophthalmoscope with 28D lens. ROP findings were classified according to the most advanced stage of ROP reached using the International Classification of ROP (2005). Data were entered into STATA version 15 statistical software for analysis. RESULTS: There were 264 premature infants enrolled in the study. ROP screening was performed on 200 (75.8%). Of all 264 enrolled patients 133 (50.4%) were female. The mean GA was 30.3±2.6 (range 24-37) weeks and the mean BW was 1302.2±285.9 g (range 725-2035). Out of 200 who were screened, we identified 22 with ROP with a ROP incidence of 11%. The incidence of type 1 ROP (sight-threatening) was found to be 3.5%. This study identified a significant difference in possible ROP risk factors between those infants who develop ROP and those who do not, eg, BW (p<0.001), GA (p=0.024) and blood transfusion (p=0.001). CONCLUSION: This study demonstrates that ROP is a treatable cause of blindness in Botswana. Lack of a proper screening protocol, delay in diagnosis and management are plausible reasons for poor outcome in those who were diagnosed with type 1 ROP.

Disparity in access to cataract surgical services leads to higher prevalence of blindness in women as compared with men: results of a national survey of visual impairment.

AIM: The aim of the survey was to estimate the prevalence and determinants of visual impairment and blindness in Botswana 50 years and older and assess access to cataract surgical services. METHOD: a multistage cluster randomized sampling with probability proportional to size was used to select a cross-sectional nationally representative sample of 2,662 subjects. The distance visual acuity was measured and the lens examined for cataracts in each subject. Where pinholes did not improve vision to 6/18 or better, fundus examination was done after mydriasis. Blindness was defined as vision <3/60 and visual impairment as <6/18 to 3/60 in the better eye with available correction. RESULTS: Two thousand one hundred twenty-seven eligible subjects were examined (79.9%). Age- and sex-adjusted prevalence of blindness and severe visual impairment was 3.69% (95% CI: 2.38%-5.00%) and 1.69% (95% CI: 1.04%-2.33%), respectively. Cataracts were the main cause of blindness (46.9%), and severe (58.9%) and moderate (40.2%) visual impairment. After adjusting for age and sex, the prevalence of bilateral cataract blindness and bilateral severe visual impairment in men is 1.0% (95% CI: 0.001%-2.1%) and 1.5% (95% CI: 1.3%-1.7%) compared with 1.6% (95% CI: 0.6%-2.7%) and 2.1% (95% CI: 1.8%-2.8%) in women. 76.9% of men, bilaterally blind from cataract, had cataract surgery in one or both eyes compared with 59.4% of women. Overall, 65.4% of people bilaterally blind from cataract had surgery in one or both eyes. For vision <6/60, the cataract surgical coverage (CSC) for persons is 73.0%, 55.2%, and 61.5% for men, women, and the sample population, respectively. The CSC for persons at vision <6/18 is 62.3%, 48.3%, and 53.2% for men, women, and the sample population, respectively. CONCLUSION: Inequity in access to cataract surgery between men and women in Botswana has contributed to the higher prevalence of cataract-related blindness in women.

Ageing, frailty and resilience in Botswana: rapid ageing, rapid change. Findings from a national working group meeting and literature review.

BACKGROUND: The demography of Botswana is rapidly changing. Successes in tackling communicable diseases and economic development increased life expectancy from 53.7 years in 2006 to 66.8 years in 2016. The prevalence of diseases associated with older age, especially chronic non-communicable diseases including diabetes, hypertension and cerebrovascular disease are suspected to have increased but accurate data are lacking. The country has high youth unemployment and national retirement is at the age of 60, which limits the opportunity to build pensions for prosperity in older age. Changes across health, social care and economic policy are needed to prepare for a future ageing population. METHODS: This article reports on the national working group meeting outputs on issues that face older people, their families, healthcare providers, and policy makers in Botswana. A collaborative working group meeting was convened in Gaborone, Botswana on 25th September 2018 by the University of Botswana and University of Birmingham, UK, to identify key challenges and opportunities for an ageing Batswana population. RESULTS: There was agreement across diverse stakeholders of a need for effective and rapid policy formation to prepare and protect the future health and economy of an ageing Batswana population with a high burden of NCDs. The main priorities for policy-makers must be social care, poverty reduction and healthcare provision, conducted in an evidence-based manner, as far as practicable. To effectively achieve this, research and high-quality data collection mechanisms are required. CONCLUSIONS: Future policy in Botswana must focus on the challenges that an ageing population brings, and development of health and care system resilience for the demographic change could be a model for healthcare policy across Southern Africa.

Building research capacity through programme development and research implementation in resource-limited settings - the Ipabalele study protocol: observational cohort studies determining the effect of HIV on the natural history of cervical cancer in Botswana.

INTRODUCTION: The global burden of cancer continues to increase in low- and middle-income countries, particularly in sub-Saharan Africa (SSA). Botswana, a middle-income country in SSA, has the second highest prevalence of HIV worldwide and has seen an increase in human papillomavirus (HPV)-associated cervical cancer over the last decade in the setting of improved survival of HIV-infected women. There is an urgent need to understand more clearly the causes and consequences of HPV-associated cervical cancer in the setting of HIV infection. We initiated the Ipabalele ('take care of yourself' in Setswana) programme to address this need for new knowledge and to initiate long-term research programme capacity building in the region. In this manuscript, we describe the components of the programme, including three main research projects as well as a number of essential cores to support the activities of the programme. METHODS AND PROCEDURES: Our multidisciplinary approach aims to further current understanding of the problem by implementing three complementary studies aimed at identifying its molecular, behavioural and clinical determinants. Three participant cohorts were designed to represent the early, intermediate and late stages of the natural history of cervical cancer.The functional structure of the programme is coordinated through programmatic cores. These allow for integration of each of the studies within the cohorts while providing support for pilot studies led by local junior investigators. Each project of the Ipabalele programme includes a built-in capacity building component, promoting the establishment of long-lasting infrastructure for future research activities. ETHICS AND DISSEMINATION: Institutional review board approvals were granted by the University of Pennsylvania, University of Botswana and Ministry of Health and wellness of Botswana. Results will be disseminated via the participating institutions and with the help of the Community Advisory Committee, the project's Botswana advisory group.

Ocular complications of HIV infection in sub-Sahara Africa.

This article reviews the magnitude and spectrum of ocular complications of HIV infection in sub-Sahara Africa. A literature search was done using PubMed, Google, and UpToDate and by talking to ophthalmologists and HIV experts working in the region. Ocular complications of HIV infection, mostly retinal, are seen in 29% to 71% of patients. Cytomegalovirus retinitis affects 0% to 16.5% of HIV-infected patients and is treated successfully with intravitreal ganciclovir in South Africa and Botswana. Ocular surface squamous neoplasia is seen in 4% to 7.8% of persons with HIV (a 5%-6% increase in Uganda and Tanzania), and recurrence after surgery occurs in 3.2% to 31.2%. In Zimbabwe, 45% of meningitis in adults is cryptococcal, and cryptococcal meningitis is the third leading cause of death in HIV patients in rural Uganda. In Rwanda, 9% of patients with cryptococcal meningitis developed visual loss and sixth nerve palsy. Thus, HIV infection leads to significant ocular morbidity in sub-Sahara Africa.