Community Knowledge, Perceptions and Experiences on Healthcare Services for Malaria Prevention and Treatment in the Okavango Delta, Botswana.

This paper analyses community knowledge, perceptions, and experiences of effectiveness of healthcare service provision on malaria prevention/treatment in two disease-endemic villages of the Okavango Delta panhandle in northern Botswana. A stratified random sampling of 355 households was conducted in October-November 2015. Follow-up retrospective cohort interviews were undertaken in August 2016 from 79 households that reported malaria incidences during the household survey. Data were also collected from 16 key informant interviews and 2 focus group discussions participants. Descriptive statistics and content analyses were used to summarise quantitative and qualitative data, respectively. Results indicate that communities in the study sites had positive perceptions about efficiency of health services based on availability, accessibility and utilization, adequacy of prevention and treatment interventions. Local health clinics were crucial information channels used by respondents. Additionally, factors related to acceptability, availability and accessibility are likely to contribute to perceived effectiveness of the interventions provided by healthcare service providers. Affirmation of efficiency health service provision against malaria has public health implications for adherence to treatment/prevention and participation in community health education campaigns and program implementation in the Okavango Delta region.

Orphans' perspectives on grief and loss in Botswana.

This paper seeks to examine orphaned children's experiences on grief and loss in Botswana, and its impact on their well-being and make policy recommendations. A cross sectional design which utilized survey questionnaires was employed. Data were collected from 11 districts (3 urban and 8 rural) among orphan children aged 10-18 years. Chi-squared test was used to identify variables believed to be associated with loss and grief. Unadjusted (simple) and adjusted multiple logistic regression was used to investigate factors associated with loss. Of the 732 participants (53.1%) were females and mean age was 13.5 years (SD = 2.7); and 44.6% of these children had experienced death of a close family member in the past year which had been communicated. Children had access to education, lower primary (19.5%), upper primary (39.1%), junior secondary (32.5%), senior secondary school (6.6%), and (0.3%) in tertiary institutions. Most children (88.6%) had not experienced stigma and discrimination at school; 55.2% lived with grandparents, aunts (23.4%), siblings (11.8%), uncles (4.0%), other relatives (3.5%) and non-relatives (0.1%). Unadjusted logistic regression indicated that loss was significantly associated with having someone to talk to (OR = 0.72, 95% CI, 0.53-0.98, p = 0.03), change of residence (OR = 3.08, 95% CI, 1.94-4.90, p < 0.01), having siblings (OR = 2.06, 95% CI, 1.38-3.07, p < 0.01) and being from urban areas (OR = 0.56, 95% CI, 0.41-0.78, p < 0.01). In the adjusted model, loss was significantly associated with change of residence (OR = 2.72, 95% CI, 1.69-4.35, p < 0.01), having siblings (OR = 1.98, 95% CI, 1.30-3.01, p < 0.01) and being from urban areas (OR = 0.65, 95% CI, 0.46-0.93, p = 0.02). Age-specific interventions aimed at addressing the emotional, psychosocial and economic impacts of grief and loss are critical in preventing negative coping behaviors and improving the quality of life of orphans.

The prevalence of urogenital and intestinal schistosomiasis among school age children (6-13 years) in the Okavango Delta in Botswana.

This study sought to investigate prevalence of urogenital and intestinal schistosomiasis among school age children 6-13 years in selected communities in the Okavango Delta. The termination of the Botswana national schistosomiasis control program in 1993 contributed to its neglect. An outbreak of schistosomiasis in 2017 at one of the primary schools in the northeastern part of the country resulted in 42 positive cases, indicating that the disease exists. A total of 1,611 school age children 6-13 years were randomly selected from school registers in 10 primary schools; from which 1603 urine and 1404 stool samples were collected. Macroscopic examination of urine and stool for color, odor, blood; viscosity, consistency, and the presence of worms. Urine filtration and centrifugation methods were used to increase sensitivity of detecting parasite ova. Kato-Katz and Formalin-Ether were used for the examination of stool samples. Data were analyzed using SPSS version 25. Results were expressed as odds ratio (OR) with their 95% CI and statistical significance set at p < 0.05. A total of (n = 1611) school age children 6-13 years participated in the study, mean age 9.7years (SD 2.06), females (54%) and males (46%). Results indicated an overall prevalence of SS. hematobium and S.mansoni at 8.7% and 0.64% respectively. Intensity of SS. hematobium was generally light (97.6%) and heavy intensity (2.4%). Results also revealed a knowledge deficit, about 58% of children had never heard of bilharzia even though they lived in communities where the disease was previously endemic. Learners who had a family member who previously suffered from schistosomiasis had higher knowledge than those who did not. Interestingly, these learners were likely to engage in risky behaviors compared to those with lower knowledge of the disease. An integrated approach that emphasizes health education, mass drug administration, water, sanitation, and hygiene infrastructure should be prioritized for prevention and control of schistosomiasis.

LOCAL KNOWLEDGE OF ADAPTIVE STRATEGIES AGAINST MALARIA ENDEMICITY IN THE OKAVANGO DELTA, BOTSWANA.

Background: An increasing recognition of the need to eliminate malaria infection globally and particularly in Africa where more than 90% of the cases originate, should enhance community awareness and participation in the same. The perennial freshwater of Okavango Delta located in northern Botswana, which is a source of rural livelihoods and a suitable habitat for the malaria-causing mosquito, and where malaria is endemic provides a suitable environment for the study. Therefore, local households' adaptive strategies against malaria transmission in the Okavango Delta were investigated. Materials and Methods: The data used in this paper is a subset or retrospective cohort of 79 households that reported malaria cases/incidences during the first community level household survey conducted from October-November 2015 on 355 households in Shakawe and Ngarange. The households were selected through stratified random sampling in the two study villages. The retrospective cohort household survey was conducted from 7-19 August 2016, in the two study sites. Data were collected through socio-economic survey, key informants' interviews and focus group discussions. Results: The results obtained indicate that most cohort households embraced several adaptive strategies against malaria transmission. These included, inter alia, knowledge capacity building through attendance of health information and education workshops (69%), modifications of houses structures (49.4%), timing of activities and restricting movement at certain times of the day (43%). Discussion: Although most of the stated adaptive strategies such as house screening were not exclusively aimed towards malaria prevention and adaptation, they nonetheless had postive spill over effect that could be a catalyst for eliminating malaria in the study area.

Threats to maternal and child well-being in rural communities in Ngamiland, Botswana.

The authors' main objective of the study was to explore threats to maternal and child well-being in two nonriparian and two riparian communities in the east and west of the Okavango River Basin in Ngamiland District, Botswana. Primary data were collected from a simple random sample of 60 households. Data on women's access to human, financial, physical and institutional capital, productive assets and livelihood activities, household food resources, and social services (education, health, water, sanitation) were collected. Children's nutritional status was also evaluated. Our observations reveal that caregiving is gender biased toward women whose well-being is undermined by their limited access to resources. Further, women's poor access to basic household resources undermines gains made through clinic-based maternal and child welfare nutrition programs. In addition, a significant proportion of children's caregivers have access to low-tier primary health care provision in the study area, but inadequate physical infrastructural development limits their access to specialized care, particularly emergency obstetric services. Childhood malnutrition is also a concern in the study area, and it mostly affects children whose caregivers have limited access to resources. The authors conclude that improving maternal and child access to education and health services remains a challenge in the district. The authors recommend interventions that prioritize sensitive aspects of child well-being, early childhood education, and development.

People living with HIV and AIDS on the brink: stigma--a complex sociocultural impediment in the fight against HIV and AIDS in Botswana.

HIV-related stigma is a life-altering phenomenon. The consequence of the stigmatization process sets apart stigmatized person(s) as a distinct category, leading to various forms of disapproval, rejection, exclusion, labeling, stereotyping, and discrimination. Stigma of HIV-positive people in Botswana is a complex social phenomenon associated with the disease itself and the behaviors that lead to infection. This is a synthesis paper based on the literature review on HIV- and AIDS-related stigmatization of HIV-positive people in Botswana and in-depth interviews with people living with HIV and AIDS (PLWHAs). I examine the literature on HIV- and AIDS-related stigmatization and subsequent discrimination and the implications for intervention programs for people living with HIV and AIDS. The findings from the literature and in-depth interviews show that HIV-AIDS-related stigma is deeply embedded in societal structures and culture which promote nonacceptance of those branded HIV positive. This often is reinforced at a practical level by pervasive negative attitudes toward PLWHAs. Recommendations argue for the adoption of Healthy Relationship. This intervention seeks to promote and strengthen decision-making skills among PLWHAs and programs that promote destigmatization of, and tolerant attitudes toward, PLWHAs.

The Croton megalobotrys Müll Arg. traditional medicine in HIV/AIDS management: Documentation of patient use, in vitro activation of latent HIV-1 provirus, and isolation of active phorbol esters.

ETHNOPHARMACOLOGICAL RELEVANCE: Current HIV therapies do not act on latent cellular HIV reservoirs; hence they are not curative. While experimental latency reversal agents (LRAs) can promote HIV expression in these cells, thereby exposing them to immune recognition, existing LRAs exhibit limited clinical efficacy and high toxicity. We previously described a traditional 3-step medicinal plant regimen used for HIV/AIDS management in Northern Botswana that inhibits HIV replication in vitro. Here we describe use of one component of the regimen that additionally contains novel phorbol esters possessing HIV latency-reversal properties. AIM OF THE STUDY: We sought to document experiences of traditional medicine users, assess the ability of traditional medicine components to reverse HIV latency in vitro, and identify pure compounds that conferred these activities. MATERIALS AND METHODS: Experiences of two HIV-positive traditional medicine users (patients) were documented using qualitative interview techniques. Latency reversal activity was assessed using a cell-based model (J-Lat, clone 9.2). Crude plant extracts were fractionated by open column chromatography and reverse-phase HPLC. Compound structures were elucidated using NMR spectroscopy and mass spectrometry. RESULTS: Patients using the 3-step regimen reported improved health over several years despite no reported use of standard HIV therapies. Crude extracts from Croton megalobotrys Müll Arg. ("Mukungulu"), the third component of the 3-step regimen, induced HIV expression in J-lat cells to levels comparable to the known LRA prostratin. Co-incubation with known LRAs and pharmacological inhibitors indicated that the active agent(s) in C. megalobotrys were likely to be protein kinase C (PKC) activator(s). Consistent with these results, two novel phorbol esters (Namushen 1 and 2) were isolated as abundant components of C. megalobotrys and were sufficient to confer HIV latency reversal in vitro. CONCLUSION: We have identified novel LRAs of the phorbol ester class from a medicinal plant used in HIV/AIDS management. These data, combined with self-reported health effects and previously-described in vitro anti-HIV activities of this traditional 3-step regimen, support the utility of longitudinal observational studies of patients undergoing this regimen to quantify its effects on plasma viral loads and HIV reservoir size in vivo.

Clinical Malaria Transmission Trends and Its Association with Climatic Variables in Tubu Village, Botswana: A Retrospective Analysis.

Good knowledge on the interactions between climatic variables and malaria can be very useful for predicting outbreaks and preparedness interventions. We investigated clinical malaria transmission patterns and its temporal relationship with climatic variables in Tubu village, Botswana. A 5-year retrospective time series data analysis was conducted to determine the transmission patterns of clinical malaria cases at Tubu Health Post and its relationship with rainfall, flood discharge, flood extent, mean minimum, maximum and average temperatures. Data was obtained from clinical records and respective institutions for the period July 2005 to June 2010, presented graphically and analysed using the Univariate ANOVA and Pearson cross-correlation coefficient tests. Peak malaria season occurred between October and May with the highest cumulative incidence of clinical malaria cases being recorded in February. Most of the cases were individuals aged >5 years. Associations between the incidence of clinical malaria cases and several factors were strong at lag periods of 1 month; rainfall (r = 0.417), mean minimum temperature (r = 0.537), mean average temperature (r = 0.493); and at lag period of 6 months for flood extent (r = 0.467) and zero month for flood discharge (r = 0.497). The effect of mean maximum temperature was strongest at 2-month lag period (r = 0.328). Although malaria transmission patterns varied from year to year the trends were similar to those observed in sub-Saharan Africa. Age group >5 years experienced the greatest burden of clinical malaria probably due to the effects of the national malaria elimination programme. Rainfall, flood discharge and extent, mean minimum and mean average temperatures showed some correlation with the incidence of clinical malaria cases.

Croton megalobotrys Müll Arg. and Vitex doniana (Sweet): Traditional medicinal plants in a three-step treatment regimen that inhibit in vitro replication of HIV-1.

ETHNOPHARMACOLOGICAL RELEVANCE: Human Immunodeficiency Virus (HIV) strains resistant to licensed anti-retroviral drugs (ARVs) continue to emerge. On the African continent, uneven access to ARVs combined with occurrence of side-effects after prolonged ARV therapy have led to searches for traditional medicines as alternative or complementary remedies to conventional HIV/AIDS management. AIM OF THE STUDY: Here we characterize a specific three-step traditional HIV/AIDS treatment regimen consisting of Cassia sieberiana root, Vitex doniana root, and Croton megalobotrys bark by combining qualitative interviews of traditional medical knowledge users in Botswana with in vitro HIV replication studies. MATERIALS AND METHODS: Crude extracts from a total of seven medicinal plants were tested for in vitro cytotoxicity and inhibition of wild-type (NL4.3) and ARV-resistant HIV-1 replication in an immortalized GFP-reporter CD4+ T-cell line. RESULTS: C. sieberiana root, V. doniana root, and C. megalobotrys bark extracts inhibited HIV-1NL4.3 replication with dose-dependence and without concomitant cytotoxicity. C. sieberiana and V. doniana extracts inhibited HIV-1 replication by 50% at 84.8µg/mL and at 25µg/mL, respectively, while C. megalobotrys extracts inhibited HIV-1 replication by a maximum of 45% at concentrations as low as 0.05µg/mL. Extracts did not interfere with antiviral activities of licensed ARVs when applied in combination and exhibited comparable efficacies against viruses harboring major resistance mutations to licensed protease, reverse-transcriptase, or integrase inhibitors. CONCLUSIONS: We report for the first time a three-step traditional HIV/AIDS regimen, used alone or in combination with standard ARV regimens, where each step exhibited more potent ability to inhibit HIV replication in vitro. Our observations support the "reverse pharmacology" model where documented clinical experiences are used to identify natural products of therapeutic value.

Assessment of risk factors associated with malaria transmission in tubu village, northern botswana.

This study investigated potential risk factors associated with malaria transmission in Tubu village, Okavango subdistrict, a malaria endemic area in northern Botswana. Data was derived from a census questionnaire survey, participatory rural appraisal workshop, field observations, and mosquito surveys. History of malaria episodes was associated with several factors: household income (P < 0.05), late outdoor activities (OR = 7.016; CI = 1.786-27.559), time spent outdoors (P = 0.051), travel outside study area (OR = 2.70; CI = 1.004-7.260), nonpossession of insecticide treated nets (OR = 0.892; CI = 0.797-0.998), hut/house structure (OR = 11.781; CI = 3.868-35.885), and homestead location from water bodies (P < 0.05). No associations were established between history of malaria episodes and the following factors: being a farmer (P > 0.05) and number of nets possessed (P > 0.05). Eave size was not associated with mosquito bites (P > 0.05), frequency of mosquito bites (P > 0.05), and time of mosquito bites (P > 0.05). Possession of nets was very high (94.7%). Close proximity of a health facility and low vegetation cover were added advantages. Some of the identified risk factors are important for developing effective control and elimination strategies involving the community, with limited resources.

Ethno-veterinary practices amongst livestock farmers in Ngamiland District, Botswana.

We carried out a study to determine ethno-veterinary knowledge used to treat and prevent livestock diseases in Toteng Village in Ngamiland District, northwestern Botswana. Primary data were collected through simple random sampling of 45 households in Toteng. Respondents were either livestock owners or cattle herders. Respondents were interviewed using a structured questionnaire which had both open and closed-ended questions. Cattle ownership or herdership in Toteng is an inter-generational occupation with people ranging from 15 to 94 years old. Cattle were acquired either through inheritance, buying, mafisa (reciprocal exchange) system or government scheme. Women in the study area were more involved in livestock farming activities. Eleven livestock diseases were reported to be prevalent in the study area. The top six diseases were tlhako le molomo -foot and mouth disease (FMD), matlho -eye infections, letshololo-diarrhea, madi -pasteurollosis, mokokomalo -aphosphorisis and pholoso-contagious abortion. At least nine medicinal plant species having ethno-veterinary applications were recorded in the study area. Single plants are mostly used rather than a combination of plants. A number of social strategies were mentioned such as 'go fetola mafudiso' - to change grazing areas, and 'go thaa lesaka' - to ritualistically 'protect a kraal' or livestock against evil spells and predators (lions). Although the intervention of conventional veterinary medicine is pervasive in Toteng, and many livestock owners are resorting to it, there is evidence, however, of generalized ethno-veterinary knowledge used to treat and prevent livestock diseases. Local farmers and their herders in Ngamiland are not only knowledgeable and experienced in treating a range of livestock diseases, but also in performing other veterinary tasks such as assisting in births, treating fractures and range management strategies to mitigate particular threats from their local environment. The efficacy of ethno-veterinary knowledge for preventing and treating livestock diseases and range management strategies identified in this study need to be fully investigated and integrated in veterinary extension services.

Knowledge and practices on malaria in Tubu village, in a malaria-endemic area in northern Botswana: implications for interventions.

Background: Health education based on understanding community and individual knowledge, attitudes and practices on malaria is gaining momentum as one of the methods for malaria control. The purpose of the survey was to assess peoples' knowledge and perceptions on malaria in order to generate information to contribute to the malaria elimination programme being implemented by the Ministry of Health of Botswana. Materials and Methods: A cross-sectional structured questionnaire-based survey and participatory rural appraisals were conducted to assess the knowledge and practices regarding malaria among all the 71 households of Tubu village, located on the fringes of the Okavango Delta. Relative frequencies were calculated using the SPSS version 20.0 package. Results: Information dissemination by the Government through different structures, by the media as well as individuals in the community, played a vital role in making the community aware of malaria. Respondents showed some basic knowledge on malaria transmission (95.8%), signs and symptoms (88.7%) and prevention measures (98.6%). They associated malaria with rainfall, floods and harvesting. Respondents indicated that mosquitoes were abundant in grassy areas (60.6%) and stagnant waters (59.2%). 98.6% of the respondents said insecticide-treated bednets were the main method for malaria prevention. As the first option, all respondents who had a history of a malaria episode visited the clinic and not traditional medical practitioners. However, there were few respondents (14.1%) with misconceptions on malaria aspects like where mosquitoes breed. Conclusions: Generally, the high level of awareness and good practices shown by the community were ideal for sustainable implementation of community-based malaria intervention programmes. Misconceptions on malaria need to be corrected as these may have some detrimental effects on the Ministry of Health's goal of malaria elimination in Botswana by 2016.

Determination of potentially toxic heavy metals in traditionally used medicinal plants for HIV/AIDS opportunistic infections in Ngamiland District in Northern Botswana.

The determination of four potentially toxic heavy metals, arsenic, chromium, lead and nickel in twelve plant species used for the treatment of perceived HIV and AIDS-associated opportunistic infections by traditional healers in Ngamiland District in Northern Botswana, a metal mining area, was carried out using atomic absorption spectrometry. The medicinal plants; Dichrostachys cinerea, Maerua angolensis, Mimusops zeyheri, Albizia anthelmintica, Plumbago zeylanica, Combretum imberbe, Indigofera flavicans, Clerodendrum ternatum, Solanum panduriforme, Capparis tomentosa, Terminalia sericea and Maytenus senegalensis contained heavy metals in varying quantities: arsenic 0.19-0.54 µg g(-1), chromium 0.15-1.27 µg g(-1), lead 0.12-0.23 µg g(-1) and nickel 0.09-0.21 µg g(-1) of dry weight. Chromium was found to be the most abundant followed by arsenic and lead. Nickel was undetectable in nine plant species. M. senegalensis contained the largest amounts of arsenic, chromium and lead. All metals determined were below the WHO permissive maximum levels. The possible maximum weekly intakes of the heavy metals following treatment regimes were insignificant compared to the provisional tolerable weekly intake levels recommended by WHO and the Joint FAO/WHO Expert Committee on Food Additives. This suggests that heavy metal exposure to patients originating from consumption of traditional medicinal plant preparations is within non health-compromising limits.

Old plants newly discovered: Cassia sieberiana D.C. and Cassia abbreviata Oliv. Oliv. root extracts inhibit in vitro HIV-1c replication in peripheral blood mononuclear cells (PBMCs) by different modes of action.

ETHNOPHARMACOLOGICAL RELEVANCE: Despite advances in anti-retroviral therapy which has transformed HIV/AIDS from a fatal to a manageable chronic disease, increasing viral drug resistance, side effects and uneven access to anti-retroviral drugs remain considerable therapeutic challenges. Partly as a consequence of these shortcomings and partly based on the fact that HIV/AIDS gives rise to opportunistic infections whose symptoms have been managed in Africa in an HIV/AIDS-independent context by traditional healers for centuries, many HIV/AIDS patients use herbal medicines. The aim of this study was to screen selected medicinal plants from Botswana, used by traditional healers to treat/manage HIV/AIDS, for inhibitory activities on HIV replication. MATERIALS AND METHODS: Based on an ethnomedical survey, ethanolic tannin-containing and tannin-free extracts from 10 medicinal plants were tested for inhibitory properties against a clone of HIV-1c (MJ(4)) measuring cytopathic effect protection and levels of viral p24 antigen in infected PBMCs. RESULTS: Cassia sieberiana D.C., Cassia abbreviata Oliv. Oliv. and Plumbago zeylanica L. extracts showed significant inhibition of HIV-1c (MJ(4)) replication. The inhibitory activity of the Plumbago zeylanica extract could be attributed to its tannin content. Anti-HIV activity of Cassia sieberiana root and bark extracts, and Cassia abbreviata root extracts occurred in a concentration-dependent manner with an effective concentration (EC(50)) of 65.1µg/ml, 85.3µg/ml and 102.8µg/ml, respectively. Experiments to elucidate possible mechanism(s) of action revealed that Cassia sieberiana root and bark extracts blocked HIV replication at its binding- (EC(50)=70.2µg/ml and 90.8µg/ml, respectively) and entry stage (EC(50)=88.9µg/ml and 100.5µg/ml, respectively) while Cassia abbreviata extracts did not. CONCLUSIONS: We report here for the first time a direct inhibitory effect on HIV-1c replication of extracts from two extremely popular medicinal plants, Cassia sieberiana and Cassia abbreviata. Considering the traditional uses of both Cassia species, our findings strongly suggest pilot clinical observational studies involving traditional healers to further evaluate the therapeutic potential of the Cassia extracts.