The association between smoking and cervical human papillomavirus infection among women from indigenous communities in western Botswana.

INTRODUCTION: Cervical cancer, a malignancy caused by infection with oncogenic human papillomavirus, disproportionally affects women from low resource settings. Persistence of human papillomavirus infection may mediate an association between tobacco use and cervical cancer. In limited resource settings, women from indigenous communities are often marginalized and do not benefit from evidence-based interventions to prevent tobacco use or cervical cancer due to the limited reach of mainstream healthcare services to these communities. This study determined the association between smoking and high-risk human papillomavirus infection among women from indigenous communities in western Botswana. METHODS: A cross-sectional study of women in indigenous communities was conducted between June and October 2022. Demographic, clinical and self-reported smoking data were collected. Cervical cytology and HPV DNA testing for high-risk human papillomavirus genotypes were performed. Multilevel multivariable logistic regression models were fit to evaluate the association between smoking and high-risk human papillomavirus infection while adjusting for potential confounders. RESULTS: A total of 171 participants with a median (interquartile range) age of 40 (31-50) years from three settlements and two villages were recruited for the study. Of these, 17% were current smokers, 32.8% were living with HIV and high-risk human papillomavirus DNA was detected in 32.8% of the cervical specimens. Women who were current smokers, were nearly twice as likely to have cervical high-risk human papillomavirus infection compared to non-smokers (Adjusted Odds Ratio (95% CI); 1.74(1.09, 2.79)) after controlling for confounders. CONCLUSION: These data underscore the need for effective tobacco control to help mitigate cervical cancer risk in this setting. These findings can help inform decisions about targeted cervical cancer prevention and tobacco cessation interventions for women from indigenous communities.

Self-reported cardiovascular disease risk factor screening among people living with HIV vs. members of the general population in Botswana: a community-based study.

BACKGROUND: Morbidity and mortality due to cardiovascular diseases (CVDs) are high and increasing in low- and middle-income countries. People living with HIV (PLWH) are more likely to experience CVD than members of the general population. Therefore, we aimed to assess whether PLWH were more likely to have previously been screened for cardiovascular disease risk factors (CVDRFs) than people without HIV. METHODS: A population-based, cross-sectional study was conducted among individuals aged 16 to 68 years across 22 communities in Botswana from February to August 2017 as part of a larger community-based cluster randomized HIV treatment-as-prevention trial. Participants were asked if they had been screened for and counselled on cardiovascular disease risk factors (history of hypertension or blood pressure check, blood glucose and cholesterol measurements, weight check and weight control, tobacco smoking and cessation, alcohol use and physical activity) in the preceding 3 years. HIV testing was offered to those with an unknown HIV status. Multiple logistic regression analysis controlling for age and sex was used to assess the relationship between CVDRF screening and HIV status. RESULTS: Of the 3981 participants enrolled, 2547 (64%) were female, and 1196 (30%) were PLWH (93% already on antiretroviral therapy [ART]). PLWH were more likely to report previous screening for diabetes (25% vs. 19%, p < 0.001), elevated cholesterol (17% vs. 12%, p < 0.001) and to have had their weight checked (76% vs. 55%, p < 0.001) than HIV-uninfected participants. PLWH were also more likely to have received counselling on salt intake (42% vs. 33%, p < 0.001), smoking cessation (66% vs. 46%, p < 0.001), weight control (38% vs. 29%, p < 0.001), physical activity (46% vs. 34%, p < 0.001) and alcohol consumption (35% vs. 23%, p < 0.001) than their HIV-uninfected counterparts. Overall, PLWH were more likely to have received screening for and/or counselling on CVDRFs (adjusted odds ratio 1.84, 95% CI: 1.46-2.32, p < 0.001). CONCLUSION: PLWH were almost two times more likely to have been previously screened for CVDRFs than those without HIV, indicating a need for universal scale-up of integrated management and prevention of CVDs in the HIV-uninfected population.

Evaluating the impact of a multicountry interprofessional training programme to improve HIV knowledge and clinical confidence among healthcare workers in sub-Saharan Africa: a cohort study.

OBJECTIVE: To assess the impact of an interprofessional case-based training programme to enhance clinical knowledge and confidence among clinicians working in high HIV-burden settings in sub-Saharan Africa (SSA). SETTING: Health professions training institutions and their affiliated clinical training sites in 12 high HIV-burden countries in SSA. PARTICIPANTS: Cohort comprising preservice and in-service learners, from diverse health professions, engaged in HIV service delivery. INTERVENTION: A standardised, interprofessional, case-based curriculum designed to enhance HIV clinical competency, implemented between October 2019 and April 2020. MAIN OUTCOME MEASURES: The primary outcomes measured were knowledge and clinical confidence related to topics addressed in the curriculum. These outcomes were assessed using a standardised online assessment, completed before and after course completion. A secondary outcome was knowledge retention at least 6 months postintervention, measured using the same standardised assessment, 6 months after training completion. We also sought to determine what lessons could be learnt from this training programme to inform interprofessional training in other contexts. RESULTS: Data from 3027 learners were collected: together nurses (n=1145, 37.9%) and physicians (n=902, 29.8%) constituted the majority of participants; 58.1% were preservice learners (n=1755) and 24.1% (n=727) had graduated from training within the prior year. Knowledge scores were significantly higher, postparticipation compared with preparticipation, across all content domains, regardless of training level and cadre (all p<0.05). Among 188 learners (6.2%) who retook the test at >6 months, knowledge and self-reported confidence scores were greater compared with precourse scores (all p<0.05). CONCLUSION: To our knowledge, this is the largest interprofessional, multicountry training programme established to improve HIV knowledge and clinical confidence among healthcare professional workers in SSA. The findings are notable given the size and geographical reach and demonstration of sustained confidence and knowledge retention post course completion. The findings highlight the utility of interprofessional approaches to enhance clinical training in SSA.

Prevalence of depressive symptoms in urban primary care settings: Botswana.

BACKGROUND: The prevalence of depression is estimated to be high in primary care settings, especially amongst people with chronic diseases. Early identification and management of depression can improve chronic disease outcomes and quality of life, however, there are many missed opportunities in primary care. AIM: This study aimed to determine the prevalence and correlates of depression and depressive symptoms in two urban primary care settings. SETTING: The study was conducted at two primary care facilities in the capital city of Botswana. METHODS: We administered a demographic questionnaire and the Patient Health Questionnaire-9 (PHQ-9) to adults attending two primary care facilities. The association between depressive symptoms and demographic variables was determined using Chi-square; level of significance was set at 0.05. We carried out a multivariate analysis using Kruskal-Wallis test to determine the association between demographic characteristics and depression. RESULTS: A sample of 259 participants were recruited (66.8% women, median age 32). The mean PHQ-9 score was 8.71. A total of 39.8% of participants screened positive for depression at a cut-off of 9.0% and 35.1% at a cut-off of 10. Depressive symptoms were significantly associated with employment status and income using the Kruskal-Wallis test, χ2 (1) = 5.649, p = 0.017. CONCLUSION: The high rates of depressive symptoms amongst the study population highlight the need for depression screening in primary care settings. The association between unemployment and income underscore the impact of socio-economic status on mental health in this setting.

Effect of Haemophilus influenzae Type b and 13-Valent Pneumococcal Conjugate Vaccines on Childhood Pneumonia Hospitalizations and Deaths in Botswana.

BACKGROUND: Globally, pneumonia is the leading cause of death among children. Few data exist regarding the effect of Haemophilus influenzae type b (Hib) vaccine and 13-valent pneumococcal conjugate vaccine (PCV-13) on the burden of childhood pneumonia in African settings. METHODS: We collected data on children aged 1 to 59 months at 3 hospitals in Botswana. Hib vaccine and PCV-13 were introduced in Botswana in November 2010 and July 2012, respectively. We compared pneumonia hospitalizations and deaths prevaccine (January 2009 to October 2010) with postvaccine (January 2013 to December 2017) using seasonally adjusted, interrupted time-series analyses. RESULTS: We identified 6943 pneumonia hospitalizations and 201 pneumonia deaths. In the prevaccine period, pneumonia hospitalizations and deaths increased by 24% (rate, 1.24; 95% CI, .94-1.64) and 59% (rate, 1.59; 95% CI, .87-2.90) per year, respectively. Vaccine introduction was associated with a 48% (95% CI, 29-62%) decrease in the number of pneumonia hospitalizations and a 50% (95% CI, 1-75%) decrease in the number of pneumonia deaths between the end of the prevaccine period (October 2010) and the beginning of the postvaccine period (January 2013). During the postvaccine period, pneumonia hospitalizations and deaths declined by 6% (rate, .94; 95% CI, .89-.99) and 22% (rate, .78; 95% CI, .67-.92) per year, respectively. CONCLUSIONS: Pneumonia hospitalizations and deaths among children declined sharply following introduction of Hib vaccine and PCV-13 in Botswana. This effect was sustained for more than 5 years after vaccine introduction, supporting the long-term effectiveness of these vaccines in preventing childhood pneumonia in Botswana.

May Measurement Month 2018: an analysis of blood pressure screening results from Botswana.

During the May Measurement Month 2018 (MMM18) campaign, we aimed to raise hypertension awareness and measure blood pressure (BP) across different communities in Botswana. Study sites included four large villages and Gaborone (capital city). Screening sites were shopping malls, train stations, churches, and workplaces. Individuals aged ≥18 years were recruited through fliers, word of mouth, and as volunteer walk-ins at the sites. Demographic and risk factor data were collected through a questionnaire prior to measuring three BP readings per participant. Weight was measured while height was usually estimated. Hypertension was defined as: systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg or taking antihypertensive medication. The mean of readings 2 and 3 was used and was estimated using multiple imputation where missing. Amongst 4599 participants whose BPs were measured, 54.5% were female, while mean age was 35.9 years. A total of 1510 (32.8%) participants were hypertensive and of those, 712 (47.1%) were aware of the hypertension. Only 35.2% of hypertensives were on antihypertensive treatment with 54.4% had controlled BP. Amongst all hypertensives, only 19.1% had controlled BP. Risk factors associated with higher BP included obesity, more than 1 unit of alcohol/week and BP measured on Sunday. Less than half (47.1%) of those identified as having hypertension during MMM18 were aware of their condition, despite the escalating prevalence of hypertension in the country. Regular BP awareness and opportunistic BP measurement campaigns like MMM are recommended to improve detection and control of hypertension and other cardiovascular risk factors.

Coronavirus disease 2019 in Botswana: Contributions from family physicians.

Coronavirus disease 2019 (COVID-19), the respiratory disease caused by the virus now called as SARS-CoV-2 and first identified in Wuhan, China, has spread to all regions of the world. At the time of this write-up, over 5.1 million people had been infected by the virus globally. The World Health Organization estimates that in Africa over 5 million people would need hospital admission during the course of the pandemic. Interventions to prevent the disease include social distancing and nationwide lockdowns, which, whilst necessary, have had negative effects not only on the economic status of many but also on primary care and especially the management of chronic illnesses. There are opportunities for primary care physicians to continue learning, lend humanitarian aid and provide the needed care in this context. Social media has promising applications in this rapidly changing context.

The validity and reliability of the Patient Health Questionnaire-9 for screening depression in primary health care patients in Botswana.

BACKGROUND: The lack of locally validated screening instruments contributes to poor detection of depression in primary care. The Patient Health Questionnaire-9 (PHQ-9) is a brief and freely available screening tool which was developed for primary care settings; however, its accuracy may be affected by the population in which it is administered. This study aimed to determine the validity and reliability of PHQ-9 for screening depression in a primary care population in Botswana. METHODS: Data was collected from a conveniently selected sample of 257 adult primary care attendants. The Mini International Neuropsychiatric Interview (MINI) depression module was used as a gold standard to assess criterion validity. RESULTS: Sensitivity and specificity of the PHQ-9 for screening for major depression were 72.4 and 76.3 respectively at a cut off score of nine or more. The area under the ROC curve was 0.808. The PHQ-9 demonstrated good internal consistency with a Cronbach alpha of 0.799. Criterion validity was demonstrated by significant correlation (r = 0.528, p < 0.001) between PHQ-9 and the MINI. Significant negative correlation between PHQ-9 scores and all four domains of the WHO quality of life questionnaire- brief version scores demonstrated good convergent validity. CONCLUSIONS: The PHQ-9 is a reliable and valid instrument to screen for depression in primary care facilities in Botswana. Primary care clinicians in Botswana may use the PHQ-9 to screen for depression with a cut -off score of nine. Further studies should focus on integrating routine depression screening in primary care.

Exploring gaps, strategies and solutions for primary care research mentorship in the African context: A workshop report.

BACKGROUND: Primary care needs research to generate evidence relevant to community needs; however, there is a lack of research engagement among primary care physicians, especially in sub-Saharan Africa. Improved research mentorship for family physicians (FPs) can help address prevailing knowledge and practice gaps in primary care research.Workshop process: During the 6th annual Africa Regional Conference of the World Organization of Family Doctors (WONCA), we conducted three workshops on research mentorship for African FPs. Two workshops (one online and one onsite at the pre-conference) were geared towards the young doctors' movement of WONCA Africa. The third was onsite during the main conference. Following a brief presentation on the concept of research mentorship and known gaps, participants broke into small groups and discussed additional gaps, solutions and anticipated readiness for implementing these solutions. We used a content analysis to summarise key concepts and had participants to review the findings.Workshop findings: Identified gaps related to mentees' difficulty initiating and maintaining mentorship relationships and an overall shortage of capable and willing mentors. Organisational solutions focused on capacity building and creating a culture of mentorship. Interpersonal solutions focused on reducing the power distance and increasing reflectivity and feedback. Increasing the use of research networks and both peer and online mentorship were advocated. Barriers to readiness included resource constraints and competing priorities. CONCLUSION: A multi-level approach is needed to address the gaps in research mentorship for African FPs. Identified solutions hold potential for supporting the research engagement needed to improve the population health across Africa.

Home is home-Botswana's return migrant health workers.

The shortage of skilled healthcare workers in Sub-Saharan Africa is aggravated by their emigration to high resource countries. There is evidence that a small number of healthcare workers return to their home countries. It is important to understand the factors that influence decisions to return in order to develop appropriate strategies to attract more back. This study sought to investigate the perspectives of healthcare workers who returned to Botswana after working in the diaspora. We conducted semi-structured interviews of 8 healthcare workers. Using the thematic analysis method we developed a thematic index to code the data. The main reasons for returning were family ties and missing home whilst the key reasons for emigration were concerns about the quality of health care, lack of professional progression opportunities and feeling under-valued. Difficulties reintegrating into the Botswana health care system are a potential push factors for those who return. Policies that aim to attract back healthcare workers should address professional progression, reintegration and improvement of the healthcare system.

Association between depression in carers and malnutrition in children aged 6 months to 5 years.

BACKGROUND:  Childhood malnutrition is an important risk factor for child mortality and underlies close to 50% of child deaths worldwide. Previous studies have found an association between maternal depression and child malnutrition, but it is not known whether this association exists in Botswana. In addition, previous studies excluded non-maternal primary caregivers (PCGs). It is unclear whether the association between primary caregiver depression and child malnutrition remains when non-maternal PCGs are included. AIM: The aim of this study was to determine if there is an association between PCG depression and malnutrition in children aged between 6 months and 5 years in Mahalapye, Botswana. SETTING: The study was conducted in the child welfare clinics of Xhosa and Airstrip clinics, two primary health care facilities in Mahalapye, Botswana. METHODS: This was a case control study. Cases were malnourished children aged between 6 months and 5 years, and controls were non-malnourished children matched for age and gender. The outcome of interest was depression in the PCGs of the cases and controls, which was assessed using the Patient Health Questionnaire 9 (PHQ 9), a depression screening tool. RESULTS: From a sample of 171 children, 84 of whom were malnourished, we found that the malnourished children were significantly more likely to have depressed PCGs (odds ratio = 4.33; 95% CI: 1.89, 9.89) than non-malnourished children in the 6-month to 5-year age group; the PCGs of malnourished children also had lower educational status. CONCLUSION: This study found a significant association between PCG depression and child malnutrition.