Prevalence of the metabolic syndrome and associated factors among inpatients with severe mental illness in Botswana: a cross-sectional study.

INTRODUCTION: The metabolic syndrome, a cluster of inter-related risk factors for cardiovascular diseases is highly prevalent among individuals with obesity and sedentary lifestyle. Chronic psychiatric disorders such as severe mental illness are associated with increased risk for cardiovascular diseases. We aimed to assess the prevalence and correlates of metabolic syndrome among inpatients with severe mental illness in a resource limited setting with high HIV prevalence. METHODS: This was a cross-sectional study among adult inpatients at a referral psychiatric hospital in Botswana. We used convenience sampling to enrol participants available at the time of the study. The National Cholesterol Education Program Adult Treatment Panel-III (NCEP-ATP III) criteria was used to define the metabolic syndrome. Data were analysed using descriptive statistics as well as multiple logistic regression modelling. RESULTS: A total of 137 participants were enrolled. Of these, 119 (87%) had complete data for the main analysis. The overall prevalence of metabolic syndrome was 22.6% (95% CI 15.9, 30.6) and did not differ significantly by gender or HIV status. Age was significantly associated with the risk of having the metabolic syndrome while gender, body mass index, HIV status, and days of moderate physical activity were not. CONCLUSION: There was a moderately high prevalence of metabolic syndrome. Thus, the management of individuals with severe mental illness in resource limited settings should include assessment of cardiovascular risk and target modifiable risk factors in this population. Consideration for the patient's age should be made when rationalizing the limited resources available for assessing metabolic syndrome among patients with severe mental illness.

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.

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.

Test-Retest Reliability of a Computerized Neurocognitive Battery in School-Age Children with HIV in Botswana.

Human immunodeficiency virus (HIV) infection is prevalent among children and adolescents in Botswana, but standardized neurocognitive testing is limited. The Penn Computerized Neurocognitive Battery (PennCNB) attempts to streamline evaluation of neurocognitive functioning and has been culturally adapted for use among youth in this high-burden, low-resource setting. However, its reliability across measurements (i.e., test-retest reliability) is unknown. This study examined the test-retest reliability of the culturally adapted PennCNB in 65 school-age children (age 7-17) living with HIV in Botswana. Intraclass correlation coefficients (ICCs) for PennCNB summary scores (ICCs > 0.80) and domain scores (ICCs = 0.66-0.88) were higher than those for individual tests, which exhibited more variability (ICCs = 0.50-0.82), with the lowest reliability on memory tests. Practice effects were apparent on some measures, especially within memory and complex cognition domains. Taken together, the adapted PennCNB exhibited adequate test-retest reliability at the domain level but variable reliability for individual tests. Differences in reliability should be considered in implementation of these tests.

Disparities in Oral Cancer Stage at Presentation in a High HIV Prevalence Setting In Sub-Saharan Africa.

PURPOSE: Oral cancer is the sixth most common cancer worldwide and is the seventh most common in Botswana. Lack of improvement in oral cancer survival despite the availability of multiple treatment options may be due to the high prevalence of advanced stage at presentation. We identified risk factors for presenting with oral cancer at an advanced stage to facilitate interventions to reduce mortality from oral cancers. METHODS: A retrospective cohort analysis was conducted among individuals with biopsy-confirmed oral cancer at Princess Marina Hospital in Gaborone, Botswana, between 2010 and 2020. Data collected included age at diagnosis, sex, place of residence, HIV status, oral cancer stage, and oral subsite. Multivariable analyses were controlled for age, sex, district of residence, and oral subsite. RESULTS: Of the 218 records analyzed, 79% were male, 58% were HIV-positive, the median age was 56 years (interquartile range: 47-63), and 67% presented with advanced-stage disease. Cancers from hidden oral sites were more likely to present at an advanced stage with an adjusted odds ratio (OR) of 2.98 (95% CI, 1.29 to 6.89; P = .01). Residence in socioeconomically disadvantaged districts was associated with higher likelihood (OR, 2.36; 95% CI, 1.28 to 4.39; P = .01) of advanced stage presentation compared with other districts. HIV infection was not associated with risk of advanced lesion presentation (OR, 1; 95% CI, 0.61 to 1.61; P = .97). CONCLUSION: Hidden oral cancer sites and residence in districts with limited access to care were risk factors for advanced oral cancer at the time of diagnosis in Botswana. These findings support a need to increase efforts to improve access to care and increase oral cancer awareness to decrease the burden of advanced oral cancer.

The Impact of China's Lockdown Policy on the Incidence of COVID-19: An Interrupted Time Series Analysis.

BACKGROUND: Policy changes are often necessary to contain the detrimental impact of epidemics such as those brought about by coronavirus disease (COVID-19). In the earlier phases of the emergence of COVID-19, China was the first to impose strict restrictions on movement (lockdown) on January 23rd, 2020. A strategy whose effectiveness in curtailing COVID-19 was yet to be determined. We, therefore, sought to study the impact of the lockdown in reducing the incidence of COVID-19. METHODS: Daily cases of COVID-19 that occurred in China which were registered between January 12th and March 30th, 2020, were extracted from the Johns Hopkins CSSE team COVID-19 ArcGIS® dashboards. Daily cases reported were used as data points in the series. Two interrupted series models were run: one with an interruption point of 23 January 2020 (model 1) and the other with a 14-day deferred interruption point of 6th February (model 2). For both models, the magnitude of change (before and after) and linear trend analyses were measured, and ß-coefficients reported with 95% confidence interval (CI) for the precision. RESULTS: Seventy-eight data points were used in the analysis. There was an 11% versus a 163% increase in daily cases in models 1 and 2, respectively, in the preintervention periods (p ≤ 0.001). Comparing the period immediately following the intervention points to the counterfactual, there was a daily increase of 2,746% (p < 0.001) versus a decline of 207% (p = 0.802) in model 2. However, in both scenarios, there was a statistically significant drop in the daily cases predicted for this data and beyond when comparing the preintervention periods and postintervention periods (p < 0.001). CONCLUSION: There was a significant decrease the COVID-19 daily cases reported in China following the institution of a lockdown, and therefore, lockdown may be used to curtail the burden of COVID-19.

Service-learning in response to the coronavirus disease 2019 pandemic: Emerging lessons from the Department of Family Medicine and Public Health at the University of Botswana.

The novel coronavirus disease 2019 (COVID-19) pandemic has disrupted many lives worldwide. Training programmes in academic institutions have also been affected by the pandemic. Teaching and learning family medicine and public health medicine in the COVID-19 era require adjustments to training activities. At the University of Botswana, the pandemic presented an opportunity to steer training programmes in the Department of Family Medicine and Public Health Medicine more towards service-learning. The department collaborated with the Ministry of Health and Wellness as well as the District Health Management teams in the national response to the pandemic as essential service providers. The increased demands for service provision were balanced with educational opportunities for trainees during the COVID-19 public health emergency. Including structured ongoing reflections for trainees involved in the COVID-19 response helps to connect service and the academic curriculum.

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.

Heme oxygenase-1 promoter (GT) n polymorphism associates with HIV neurocognitive impairment.

OBJECTIVE: To determine whether regulatory variations in the heme oxygenase-1 (HO-1) promoter (GT) n dinucleotide repeat length could identify unique population genetic risks for neurocognitive impairment (NCI) in persons living with HIV (PLWH), we genotyped 528 neurocognitively assessed PLWH of European American and African American descent and linked genotypes to cognitive status. METHODS: In this cross-sectional study of PLWH (the CNS HIV Antiretroviral Therapy Effect Research cohort), we determined HO-1 (GT) n repeat lengths in 276 African Americans and 252 European Americans. Using validated criteria for HIV-associated NCI (HIV NCI), we found associations between allele length genotypes and HIV NCI and between genotypes and plasma markers of monocyte activation and inflammation. For comparison of HO-1 (GT) n allele frequencies with another population of African ancestry, we determined HO-1 (GT) n allele lengths in African PLWH from Botswana (n = 428). RESULTS: PLWH with short HO-1 (GT) n alleles had a lower risk for HIV NCI (OR = 0.63, 95% CI: 0.42-0.94). People of African ancestry had a lower prevalence of short alleles and higher prevalence of long alleles compared with European Americans, and in subgroup analyses, the protective effect of the short allele was observed in African Americans and not in European Americans. CONCLUSIONS: Our study identified the short HO-1 (GT) n allele as partially protective against developing HIV NCI. It further suggests that this clinical protective effect is particularly relevant in persons of African ancestry, where the lower prevalence of short HO-1 (GT) n alleles may limit induction of HO-1 expression in response to inflammation and oxidative stress. Therapeutic strategies that enhance HO-1 expression may decrease HIV-associated neuroinflammation and limit HIV NCI.

Feasibility of implementing a novel behavioural smoking cessation intervention amongst human immunodeficiency virus-infected smokers in a resource-limited setting: A single-arm pilot trial.

BACKGROUND: Tobacco use is prevalent amongst individuals infected with human immunodeficiency virus (HIV). In resource-constrained settings, pharmacological smoking cessation interventions are unfeasible because of their high cost. There is a need to develop and evaluate behavioural interventions to address the unique challenges of tobacco use in the HIV-infected populations in these settings. OBJECTIVES: The authors aimed to assess the feasibility and acceptability of the Behavioural Activation/Problem Solving for Smoking Cessation (BAPS-SC) intervention programme to determine whether it should be tested in an adequately powered randomised controlled trial. METHOD: The authors merged behavioural activation therapy (BAT) with the principles of problem-solving therapy to create a novel five-session counselling model to address the unique challenges of tobacco cessation amongst those infected with HIV. Feasibility measures included the rate of enrolment amongst those eligible and the retention rate and descriptive analysis of intervention acceptability. The authors' secondary outcome was 7-day point smoking prevalence abstinence, confirmed with breath carbon monoxide. RESULTS: A total of 128 individuals were screened over 8 weeks with 50 deemed eligible and 40 enrolled (80%). Retention at week 12 was 53% (21/40). The 7-day point prevalence abstinence, co-confirmed, at week 12 was 37.5% (15/40). All respondents indicated that they would recommend BAPS-SC to other smokers who want to quit, and would be willing to participate in the programme again up to the point of exit if they did not stop smoking. CONCLUSION: A full-scale randomised control trial comparing BAPS-SC with usual practice is warranted to evaluate the efficacy of this novel intervention in these settings.

Assessment of cardiopulmonary resuscitation equipment in resuscitation trolleys in district hospitals in Botswana: A cross-sectional study.

INTRODUCTION: Successful cardiopulmonary resuscitation (CPR) relies, in part, on the availability and the correct functioning of resuscitation equipment. These data are often lacking in resource-constrained African settings. AIM: To assess the availability and the functional status of CPR equipment in resuscitation trolleys at district hospitals in Botswana. SETTING: The study was conducted across four district hospitals in Botswana. METHODS: A cross-sectional study was conducted using a checklist adopted following the Emergency Medical Services of South Africa (EMSSA) guidelines, modified and contextualised to Botswana. RESULTS: All the four district hospitals had inadequate number of CPR equipment available in the resuscitation trolleys. The overall availability of drugs and equipment ranged from 19% to 31.1%. Availability of equipment needed for maintaining circulation and fluids ranged from 27% to 49%, while availability of items for airway and breathing ranged from 9.2% to 24.1%. The overall availability of essential drugs for resuscitation was only 20.4%, and in some wards expired drugs were kept in the trolley. Out of 40 wards that participated in the study, only 10 kept CPR algorithms in the resuscitation trolley. The resuscitation trolley was checked on a daily basis only in the critical care units. CONCLUSION: The resuscitation trolleys were not maintained as per standards. Failure to improve the existing situation could negatively impact the outcome of CPR. Evidence-based standard checklists for resuscitation trolleys need to be enforced to improve the quality of CPR provision in district hospitals in Botswana.

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.

Assessment of nurses' cardiopulmonary resuscitation knowledge and skills within three district hospitals in Botswana.

BACKGROUND:  Nurses are usually the first to identify the need for and initiate cardiopulmonary resuscitation (CPR) on patients with cardiopulmonary arrest in the hospital setting. Cardiopulmonary resuscitation has been shown to reduce in-hospital deaths when received from adequately trained health care professionals. AIM:  We aimed to investigate nurses' retention of CPR knowledge and skills at district hospitals in Botswana. METHODS:  A quantitative, quasi-experimental study was conducted at three hospitals in Botswana. A pre-test, intervention, post-test, and a re-test after 6 months were utilised to determine the retention of CPR knowledge and skills. Non-probability, convenience sampling technique was used to select 154 nurses.The sequences of the test were consistent with the American Heart Association's 2010 basic life support (BLS) guidelines for health care providers. Data were analysed to compare performance over time. RESULTS:  This study showed markedly deficient CPR knowledge and skills among registered nurses in the three district hospitals. The pre-test knowledge average score (48%) indicated that the nurses did not know the majority of the BLS steps. Only 85 nurses participated in the re-evaluation test at 6 months. While a 26.4% increase was observed in the immediate post-test score compared with the pre-test, the performance of the available participants dropped by 14.5% in the re-test 6 months after the post-test. CONCLUSION:  Poor CPR knowledge and skills among registered nurses may impede the survival and management of cardiac arrest victims. Employers and nursing professional bodies in Botswana should encourage and monitor regular CPR refresher courses.

Management of post abortion complications in Botswana -The need for a standardized approach.

BACKGROUND: Post abortion complications are the third leading cause of maternal death after hemorrhage and hypertension in Botswana where abortion is not legalized. This study aimed at assessing the management of post abortion complications in Botswana. METHODS: A retrospective study was conducted at four hospitals in Botswana in 2014. Socio-demographic, patient management and outcomes data were extracted from patients' medical records. Descriptive statistics and chi-square test were used to analyze and present the data. RESULT: A total of 619 patients' medical records were reviewed. The duration of hospital stay prior to uterine evacuation ranged from less than an hour to 480 hours. All the patients received either prophylactic or therapeutic antibiotics. Use of parenteral antibiotics was significantly associated with severity of abortion, second trimester abortion, use of blood products and the interval between management's decision and uterine evacuation. Uterine evacuation for retained products of conception was achieved by metallic curettage among 516 (83.4%) patients and by vacuum aspiration in 18 (2.9%). At all the study sites, Misoprostol or Oxytocin were used concurrently with surgical evacuation of the uterus. None use of analgesics or anesthetics in the four hospitals ranged between 12.4% to 28.8%. CONCLUSION: There is evidence of delayed patient care and prolonged hospital stay. Metallic curette was the primary method used for uterine evacuation across all the facilities. Pain management and antibiotics use was not standardized. A protocol has to be developed with the aim of standardizing post abortion care.

Is Tobacco Use Associated with Neurocognitive Dysfunction in Individuals with HIV?

INTRODUCTION: The prevalence of HIV-associated neurocognitive disorders continues to rise despite the widespread use of antiretroviral therapy. We aimed to define the risk of neurocognitive dysfunction among smokers relative to nonsmokers. METHODS: We conducted a retrospective cohort study including HIV-infected adults ages 21 to 65 years. The Mental Alternation Test (MAT) was the primary outcome. The odds of cognitive impairment were compared using random-effects logistic regression to adjust for potential confounders. RESULTS: Of 3033, 1486 (49%) were smokers. The odds ratio for the association between smoking and cognitive impairment was 1.12 (95% confidence interval: 0.85-1.49). Nonsmokers had a higher median MAT score relative to smokers ( P = .01). CONCLUSION: There was no evidence that HIV-infected smokers had greater neurocognitive dysfunction relative to HIV-infected nonsmokers. While tobacco use remains an important health risk issue to address in the HIV population, it may not represent a risk factor for neurocognitive impairment.

High Levels of Post-Abortion Complication in a Setting Where Abortion Service Is Not Legalized.

BACKGROUND: Maternal mortality due to abortion complications stands among the three leading causes of maternal death in Botswana where there is a restrictive abortion law. This study aimed at assessing the patterns and determinants of post-abortion complications. METHODS: A retrospective institution based cross-sectional study was conducted at four hospitals from January to August 2014. Data were extracted from patients' records with regards to their socio-demographic variables, abortion complications and length of hospital stay. Descriptive statistics and bivariate analysis were employed. RESULT: A total of 619 patients' records were reviewed with a mean (SD) age of 27.12 (5.97) years. The majority of abortions (95.5%) were reported to be spontaneous and 3.9% of the abortions were induced by the patient. Two thirds of the patients were admitted as their first visit to the hospitals and one third were referrals from other health facilities. Two thirds of the patients were admitted as a result of incomplete abortion followed by inevitable abortion (16.8%). Offensive vaginal discharge (17.9%), tender uterus (11.3%), septic shock (3.9%) and pelvic peritonitis (2.4%) were among the physical findings recorded on admission. Clinically detectable anaemia evidenced by pallor was found to be the leading major complication in 193 (31.2%) of the cases followed by hypovolemic and septic shock 65 (10.5%). There were a total of 9 abortion related deaths with a case fatality rate of 1.5%. Self-induced abortion and delayed uterine evacuation of more than six hours were found to have significant association with post-abortion complications (p-values of 0.018 and 0.035 respectively). CONCLUSION: Abortion related complications and deaths are high in our setting where abortion is illegal. Mechanisms need to be devised in the health facilities to evacuate the uterus in good time whenever it is indicated and to be equipped to handle the fatal complications. There is an indication for clinical audit on post-abortion care to insure implementation of standard protocol and reduce complications.

Undiagnosed and diagnosed diabetes mellitus among hospitalised acute heart failure patients in Botswana.

OBJECTIVE: The objective of this study was to determine the burden of diagnosed and undiagnosed type 2 diabetes mellitus among patients hospitalised with acute heart failure in Botswana. METHODS: The study enrolled 193 consecutive patients admitted with acute heart failure to the medical wards at Princess Marina Hospital in Gaborone. Patients were classified as previously known diabetics, undiagnosed diabetics (glycated haemoglobin ≥ 6.5%) or as non-diabetics (glycated haemoglobin < 6.5%). Data on other comorbid conditions such as hypertension, atrial fibrillation, ischaemic heart disease, stroke, and renal failure were also collected. RESULTS: The mean (SD) age of the participants was 54.2 (17.1) years and 53.9% were men. The percentage of known and undiagnosed diabetes mellitus was 15.5% and 12.4%, respectively. Diabetic patients were significantly more likely to have hypertension (77.8% vs 46.0%, p < 0.001), ischaemic heart disease (20.4% vs 5.0%, p < 0.001), chronic kidney disease (51.3% vs 23.0%, p < 0.001), and stroke (20.4% vs 5.8%, p < 0.01). In addition, diabetics were older than non-diabetics (61.0 years vs 51.6 years, p < 0.001). CONCLUSION: About 27.9% of patients admitted with acute heart failure in Botswana had diabetes, and almost half of them presented with undiagnosed diabetes. These findings indicate that all hospitalised patients should be screened for diabetes.

Developing the Botswana Primary Care Guideline: an integrated, symptom-based primary care guideline for the adult patient in a resource-limited setting.

BACKGROUND: Botswana's health care system is based on a primary care model. Various national guidelines exist for specific diseases. However, most of the guidelines address management at a tertiary level and often appear nonapplicable for the limited resources in primary care facilities. An integrated symptom-based guideline was developed so as to translate the Botswana national guidelines to those applicable in primary care. The Botswana Primary Care Guideline (BPCG) integrates the care of communicable diseases, including HIV/AIDS and noncommunicable diseases, by frontline primary health care workers. METHODS: The Department of Family Medicine, Faculty of Medicine, University of Botswana, together with guideline developers from the Knowledge Translation Unit (University of Cape Town) collaborated with the Ministry of Health to develop the guideline. Stakeholder groups were set up to review specific content of the guideline to ensure compliance with Botswana government policy and the essential drug list. RESULTS: Participants included clinicians, academics, patient advocacy groups, and policymakers from different disciplines, both private and public. Drug-related issues were identified as necessary for implementing recommendations of the guideline. There was consensus by working groups for updating the essential drug list for primary care and expansion of prescribing rights of trained nurse prescribers in primary care within their scope of practice. An integrated guideline incorporating common symptoms of diseases seen in the Botswana primary care setting was developed. CONCLUSION: The development of the BPCG took a broad consultative approach with buy in from relevant stakeholders. It is anticipated that implementation of the BPCG will translate into better patient outcomes as similar projects elsewhere have done.

Prevalence and determinants of metabolic syndrome: a cross-sectional survey of general medical outpatient clinics using National Cholesterol Education Program-Adult Treatment Panel III criteria in Botswana.

BACKGROUND: Low- and middle-income countries, including Botswana, are facing rising prevalence of obesity and obesity-related cardiometabolic complications. Very little information is known about clustering of cardiovascular risk factors in the outpatient setting during routine visits. We aimed to assess the prevalence and identify the determinants of metabolic syndrome among the general outpatients' attendances in Botswana. METHODS: A cross-sectional study was conducted from August to October 2014 involving outpatients aged ≥20 years without diagnosis of diabetes mellitus. A precoded questionnaire was used to collect data on participants' sociodemographics, risk factors, and anthropometric indices. Fasting blood samples were drawn and analyzed for glucose and lipid profile. Metabolic syndrome was assessed using National Cholesterol Education Program-Adult Treatment Panel III criteria. RESULTS: In total, 291 participants were analyzed, of whom 216 (74.2%) were females. The mean age of the total population was 50.1 (±11) years. The overall prevalence of metabolic syndrome was 27.1% (n=79), with no significant difference between the sexes (female =29.6%, males =20%, P=0.11). A triad of central obesity, low high-density lipoprotein-cholesterol, and elevated blood pressure constituted the largest proportion (38 [13.1%]) of cases of metabolic syndrome, followed by a combination of low high-density lipoprotein, elevated triglycerides, central obesity, and elevated blood pressure, with 17 (5.8%) cases. Independent determinants of metabolic syndrome were antihypertensive use and increased waist circumference. CONCLUSION: Metabolic syndrome is highly prevalent in the general medical outpatients clinics. Proactive approaches are needed to screen and manage cases targeting its most important predictors.

Validity of the Finnish Diabetes Risk Score for Detecting Undiagnosed Type 2 Diabetes among General Medical Outpatients in Botswana.

This was a cross-sectional study designed to assess the validity of the Finnish Diabetes Risk Score for detecting undiagnosed type 2 diabetes among general medical outpatients in Botswana. Participants aged ≥20 years without previously diagnosed diabetes were screened by (1) an 8-item Finnish diabetes risk assessment questionnaire and (2) Haemoglobin A1c test. Data from 291 participants were analyzed (74.2% were females). The mean age of the participants was 50.1 (SD = ±11) years, and the prevalence of undiagnosed diabetes was 42 (14.4%) with no significant differences between the gender (20% versus 12.5%, P = 0.26). The area under curve for detecting undiagnosed diabetes was 0.63 (95% CI 0.55-0.72) for the total population, 0.65 (95% CI: 0.56-0.75) for women, and 0.67 (95% CI: 0.52-0.83) for men. The optimal cut-off point for detecting undiagnosed diabetes was 17 (sensitivity = 48% and specificity = 73%) for the total population, 17 (sensitivity = 56% and specificity = 66%) for females, and 13 (sensitivity = 53% and specificity = 77%) for males. The positive predictive value and negative predictive value were 20% and 89.5%, respectively. The findings indicate that the Finnish questionnaire was only modestly effective in predicting undiagnosed diabetes among outpatients in Botswana.