Using routine programmatic data to measure HIV incidence among pregnant women in Botswana.

INTRODUCTION: Pregnant women in sub-Saharan Africa have high risk of HIV acquisition, yet approaches for measuring maternal HIV incidence using routine surveillance systems are undefined. We used programmatic data from routine antenatal care (ANC) HIV testing in Botswana to measure real-world HIV incidence during pregnancy. METHODS: From January 2018 to September 2019, the Botswana Ministry of Health and Wellness implemented an HIV testing program at 139 ANC clinics. The program captured information on testers' age, testing date and result, and antiretroviral treatment (ART) initiation. In our analysis, we excluded individuals who previously tested HIV-positive prior to their first ANC visit. We defined incident HIV infection as testing HIV-positive at an ANC visit after a prior HIV-negative result within ANC. RESULTS: Overall, 29,570 pregnant women (median age 26 years, IQR 22-31) tested for HIV at ANC clinics: 3% (836) tested HIV-positive at their first recorded ANC visit and 97% tested HIV-negative (28,734). Of those who tested HIV-negative, 28% (7940/28,734) had a repeat HIV test recorded at ANC. The median time to HIV re-testing was 92 days (IQR 70-112). In total, 17 previously undiagnosed HIV infections were detected (HIV incidence 8 per 1000 person-years, 95% CI 0.5-1.3). ART initiation among women newly diagnosed with HIV at ANC (853) was 88% (671/762). CONCLUSIONS: In Botswana, real-world HIV incidence among pregnant women at ANC remains above levels of HIV epidemic control (≤ 1 per 1000 person-years). This study shows how HIV programmatic data can answer timely population-level epidemiological questions and inform ongoing implementation of HIV prevention and treatment programs.

Frequent Detection of Undiagnosed HIV Within Emergency Departments in Botswana.

ABSTRACT: Among 130,161 HIV testing records from unique individuals at 149 programmatic sites in Botswana, frequency of detecting undiagnosed HIV infection within emergency departments (EDs) was 4.7% (455/9695), 2-fold higher than other clinic-based HIV counseling and testing. Men and noncitizens less frequently initiated same-day antiretroviral therapy after testing HIV positive within emergency departments.

Comparing COVID-19 physical distancing policies: results from a physical distancing intensity coding framework for Botswana, India, Jamaica, Mozambique, Namibia, Ukraine, and the United States.

BACKGROUND: Understanding the differences in timing and composition of physical distancing policies is important to evaluate the early global response to COVID-19. A physical distancing intensity monitoring framework comprising 16 domains was recently published to compare physical distancing approaches across 12 U.S. States. We applied this framework to a diverse set of low and middle-income countries (LMICs) (Botswana, India, Jamaica, Mozambique, Namibia, and Ukraine) to test the appropriateness of this framework in the global context and to compare the policy responses in these LMICs with a sample of U.S. States during the first 100-days of the pandemic. RESULTS: The LMICs in our sample adopted wide ranging physical distancing policies. The highest peak daily physical distancing intensity during this period was: Botswana (4.60); India (4.40); Ukraine (4.40); Namibia (4.20); Mozambique (3.87), and Jamaica (3.80). The number of days each country stayed at peak policy intensity ranged from 12-days (Jamaica) to more than 67-days (Mozambique). We found some key similarities and differences, including substantial differences in whether and how countries expressly required certain groups to stay at home. Despite the much higher number of cases in the US, the physical distancing responses in our LMIC sample were generally more intense than in the U.S. States, but results vary depending on the U.S. State. The peak policy intensity for the U.S. 12-state average was 3.84, which would place it lower than every LMIC in this sample except Jamaica. The LMIC sample countries also reached peak physical distancing intensity earlier in outbreak progression compared to the U.S. states sample. The easing of physical distancing policies in the LMIC sample did not discernably correlate with change in COVID-19 incidence. CONCLUSIONS: This physical distancing intensity framework was appropriate for the LMIC context with only minor adaptations. This framework may be useful for ongoing monitoring of physical distancing policy approaches and for use in effectiveness analyses. This analysis helps to highlight the differing paths taken by the countries in this sample and may provide lessons to other countries regarding options for structuring physical distancing policies in response to COVID-19 and future outbreaks.

Voluntary Medical Male Circumcision and Perceived Sexual Functioning, Satisfaction, and Risk Behavior: A Qualitative Study in Botswana.

This article examines perceptions of sexual functioning, satisfaction, and risk-taking related to voluntary medical male circumcision (VMMC) in Botswana. Twenty-seven focus group discussions were conducted in four purposively selected communities with community leaders, men, and women. Discussions were analyzed using an inductive content analytic approach. Perceptions of VMMC's impact on sexual functioning and satisfaction varied. Increased satisfaction was attributed to improved penile health and increased ejaculatory latency time, whereas decreased satisfaction was attributed to erectile dysfunction and increased vaginal irritation during sex. Most participants thought sexual disinhibition occurred after circumcision; nevertheless, some women said they used male circumcision status as a marker of HIV status, thereby influencing sexual decision-making and partner selection. Messaging should emphasize that VMMC does not afford complete HIV protection. Optimizing VMMC's impact requires increasing uptake while minimizing behavioral disinhibition, with a balance between potential messaging of improved sexual functioning and satisfaction and the potential impact on sexual disinhibition.

Triggering the decision to undergo medical male circumcision: a qualitative study of adult men in Botswana.

In 2007, the World Health Organization endorsed voluntary medical male circumcision (VMMC) as part of comprehensive HIV-prevention strategies. A major challenge facing VMMC programs in sub-Saharan Africa remains demand creation; there is urgent need for data on key elements needed to trigger the decision among eligible men to seek VMMC. Using qualitative methods, we sought to better understand the circumcision decision-making process in Botswana related to VMMC. From July to November 2013, we conducted 27 focus group discussions in four purposively selected communities in Botswana with men (stratified by circumcision status and age), women (stratified by age) and community leaders. All discussions were facilitated by a trained same-sex interviewer, audio recorded, transcribed and translated to English, and analyzed for key themes using an inductive content analytic approach. Improved hygiene was frequently cited as a major benefit of circumcision and many participants believed that cleanliness was directly responsible for the protective effect of VMMC on HIV infection. While protection against HIV was frequently noted as a benefit of VMMC, the data indicate that increased sexual pleasure and perceived attractiveness, not fear of HIV infection, was an underlying reason why men sought VMMC. Data from this qualitative study suggest that more immediate benefits of VMMC, such as improved hygiene and sexual pleasure, play a larger role in the circumcision decision compared with protection from potential HIV infection. These findings have immediate implications for targeted demand creation and mobilization activities for increasing uptake of VMMC among adult men in Botswana.

Continuing professional development training needs of medical laboratory personnel in Botswana.

BACKGROUND: Laboratory professionals are expected to maintain their knowledge on the most recent advances in laboratory testing and continuing professional development (CPD) programs can address this expectation. In developing countries, accessing CPD programs is a major challenge for laboratory personnel, partly due to their limited availability. An assessment was conducted among clinical laboratory workforce in Botswana to identify and prioritize CPD training needs as well as preferred modes of CPD delivery. METHODS: A self-administered questionnaire was disseminated to medical laboratory scientists and technicians registered with the Botswana Health Professions Council. Questions were organized into domains of competency related to (i) quality management systems, (ii) technical competence, (iii) laboratory management, leadership, and coaching, and (iv) pathophysiology, data interpretation, and research. Participants were asked to rank their self-perceived training needs using a 3-point scale in order of importance (most, moderate, and least). Furthermore, participants were asked to select any three preferences for delivery formats for the CPD. RESULTS: Out of 350 questionnaires that were distributed, 275 were completed and returned giving an overall response rate of 79%. The most frequently selected topics for training in rank order according to key themes were (mean, range) (i) quality management systems, most important (79%, 74-84%); (ii) pathophysiology, data interpretation, and research (68%, 52-78%); (iii) technical competence (65%, 44-73%); and (iv) laboratory management, leadership, and coaching (60%, 37-77%). The top three topics selected by the participants were (i) quality systems essentials for medical laboratory, (ii) implementing a quality management system, and (iii) techniques to identify and control sources of error in laboratory procedures. The top three preferred CPD delivery modes, in rank order, were training workshops, hands-on workshops, and internet-based learning. Journal clubs at the workplace was the least preferred method of delivery of CPD credits. CONCLUSIONS: CPD programs to be developed should focus on topics that address quality management systems, case studies, competence assessment, and customer care. The findings from this survey can also inform medical laboratory pre-service education curriculum.

Strengthening monitoring and evaluation (M&E) and building sustainable health information systems in resource limited countries: lessons learned from an M&E task-shifting initiative in Botswana.

BACKGROUND: The demand for quality data and the interest in health information systems has increased due to the need for country-level progress reporting towards attainment of the United Nations Millennium Development Goals and global health initiatives. To improve monitoring and evaluation (M&E) of health programs in Botswana, 51 recent university graduates with no experience in M&E were recruited and provided with on-the-job training and mentoring to develop a new cadre of health worker: the district M&E officer. Three years after establishment of the cadre, an assessment was conducted to document achievements and lessons learnt. METHODS: This qualitative assessment included in-depth interviews at the national level (n = 12) with officers from government institutions, donor agencies, and technical organizations; and six focus group discussions separately with district M&E officers, district managers, and program officers coordinating different district health programs. RESULTS: Reported achievements of the cadre included improved health worker capacity to monitor and evaluate programs within the districts; improved data quality, management, and reporting; increased use of health data for disease surveillance, operational research, and planning purposes; and increased availability of time for nurses and other health workers to concentrate on core clinical duties. Lessons learnt from the assessment included: the importance of clarifying roles for newly established cadres, aligning resources and equipment to expectations, importance of stakeholder collaboration in implementation of sustainable programs, and ensuring retention of new cadres. CONCLUSION: The development of a dedicated M&E cadre at the district level contributed positively to health information systems in Botswana by helping build M&E capacity and improving data quality, management, and data use. This assessment has shown that such cadres can be developed sustainably if the initiative is country-led, focusing on recruitment and capacity-development of local counterparts, with a clear government retention plan.

Improving the quality of health information: a qualitative assessment of data management and reporting systems in Botswana.

BACKGROUND: Ensuring that data collected through national health information systems are of sufficient quality for meaningful interpretation is a challenge in many resource-limited countries. An assessment was conducted to identify strengths and weaknesses of the health data management and reporting systems that capture and transfer routine monitoring and evaluation (M&E) data in Botswana. METHODS: This was a descriptive, qualitative assessment. In-depth interviews were conducted at the national (n = 27), district (n = 31), and facility/community (n = 71) levels to assess i) M&E structures, functions, and capabilities; ii) indicator definitions and reporting guidelines; iii) data collection forms and tools; iv) data management processes; and v) links with the national reporting system. A framework analysis was conducted using ATLAS.ti v6.1. RESULTS: Health programs generally had standardized data collection and reporting tools and defined personnel for M&E responsibilities at the national and district levels. Best practices unique to individual health programs were identified and included a variety of relatively low-resource initiatives such as attention to staffing patterns, making health data more accessible for evidence-based decision-making, developing a single source of information related to indicator definitions, data collection tools, and management processes, and utilization of supportive supervision visits to districts and facilities. Weakness included limited ownership of M&E-related duties within facilities, a lack of tertiary training programs to build M&E skills, few standard practices related to confidentiality and document storage, limited dissemination of indicator definitions, and limited functionality of electronic data management systems. CONCLUSIONS: Addressing fundamental M&E system issues, further standardization of M&E practices, and increasing health services management responsiveness to time-sensitive information are critical to sustain progress related to health service delivery in Botswana. In addition to high-resource initiatives, such as investments in electronic medical record systems and tertiary training programs, there are a variety of low-resource initiatives, such as regular data quality checks, that can strengthen national health information systems. Applying best practices that are effective within one health program to data management and reporting systems of other programs is a practical approach for strengthening health informatics and improving data quality.

Looking back to see forward: multidirectional learning between the US Ryan White HIV/AIDS Program and the US President's Emergency Plan for AIDS Relief.

To end the HIV epidemic as a public health threat, there is urgent need to increase the frequency, depth and intentionality of bidirectional and mutually beneficial collaboration and coordination between the USA and global HIV/AIDS response. The US Health Resources and Services Administration (HRSA) is uniquely positioned to showcase bidirectional learning between high-income and low-income and middle-income countries (LMICs) in the fight against HIV. For 30 years, HRSA has successfully administered the Ryan White HIV/AIDS Program (RWHAP), the largest federal programme designed specifically for people with HIV in the USA. Further, HRSA has developed and delivered innovative, cost-effective, impactful HIV programmes in over 30 countries as an implementing agency for the US President's Emergency Plan for AIDS Relief (PEPFAR). When PEPFAR was authorised in 2003, HRSA rapidly developed systems and infrastructures to deliver life-saving treatment, initiated workforce development programmes to mitigate health worker shortages, and laid the path for transitioning PEPFAR activities from US-based organisations to sustainable, country-led entities. As global programmes matured, lessons learnt within LMICs gradually began strengthening health services in the USA. To fully optimise synergies between RWHAP and PEPFAR, there is a critical need to build on successful initiatives, harness innovation and technology, and inculcate the spirt of multidirectional learning into global health. HRSA is promoting bidirectional learning between domestic and international HIV programming through documenting, sharing and implementing strategies, lessons learnt, best practices and effective models of care to accelerate achievement of HIV epidemic control and support country-led, sustained responses to public health threats.

Establishing a health information workforce: innovation for low- and middle-income countries.

BACKGROUND: To address the shortage of health information personnel within Botswana, an innovative human resources approach was taken. University graduates without training or experience in health information or health sciences were hired and provided with on-the-job training and mentoring to create a new cadre of health worker: the district Monitoring and Evaluation (M&E) Officer. This article describes the early outcomes, achievements, and challenges from this initiative. METHODS: Data were collected from the district M&E Officers over a 2-year period and included a skills assessment at baseline and 12 months, pre- and post-training tests, interviews during stakeholder site visits, a survey of achievements, focus group discussions, and an attrition assessment. RESULTS: An average of 2.7 mentoring visits were conducted for M&E Officers in each district. There were five training sessions over 18 months. Knowledge scores significantly increased (p < 0.05) during the three trainings in which pre/post tests were administered. Over 1 year, there were significant improvements (p < 0.05) in self-rated skills related to computer literacy, checking data validity, implementing data quality procedures, using data to support program planning, proposing indicators, and writing M&E reports. Out of the 34 district M&E Officers interviewed during site visits, most were conducting facility visits to review data (27/34; 79%), comparing data sets over time (31/34; 91%), backing up data (32/34; 94%), and analyzing data (32/34; 94%). Common challenges included late facility reports (28/34; 82%), lack of transportation (22/34; 65%), inaccurate facility reports (10/34; 29%), and colleagues' misunderstanding of M&E (10/34; 29%). Six posts were vacated in the first year (6/51; 12%). A total of 49 Officers completed the achievements survey; of these, common accomplishments related to improvements in data management (35/49; 71%), data quality (31/49; 63%), data use (29/49; 59%), and capacity development (26/49; 53%). CONCLUSIONS: The development of a cadre of district M&E Officers has contributed positively to the health information system in Botswana. In the absence of tertiary training related to health information, on-the-job training and mentoring of university graduates can be an effective approach for developing a new professional cadre of M&E expertise and for strengthening capacity within a national health system.

Intensified Assisted Partner Notification Implementation in Botswana Increased Partner Identification but Not HIV Case-Finding: Findings Highlight the Need for Improved Data Monitoring.

BACKGROUND: How to implement and monitor assisted partner services (APS) programs for HIV infection as they go to scale-up is uncertain. SETTING: Forty Botswana Ministry of Health clinics, 2018-2020. METHODS: We compared 2 APS implementation phases. During phase 1, training, supervision, and data collection were minimal; only newly diagnosed HIV-positive persons received APS, and APS recipients notified partners themselves or jointly with counselors. Phase 2 included the following: intensified training and supervision; APS provision to previously diagnosed, untreated persons; structured interview records; and counselors offering to notify partners directly. RESULTS: Five thousand one hundred seventy-five and 1265 newly diagnosed HIV-positive persons received APS in phases 1 and 2, respectively. Comparing the phases, program reach (percentage of newly diagnosed cases receiving APS) increased from 86% to 93%, the contact index (sex partners named per case) increased from 0.85 to 1.32, and the percentage of cases with an identified HIV-positive partner increased from 12.6% to 60% (P < 0.001, all outcomes). The testing index (partners tested per case) was higher in phase 1 (0.56 vs. 0.45, P = 0.05), whereas the case-finding index (partners testing HIV-positive per case) did not change (0.13 vs. 0.14, P = 0.50). Five hundred seventy-eight (76%) of 756 HIV-positive partners in phase 2 were previously diagnosed; cases identified only 15% of these partners as HIV-positive at their initial interview. CONCLUSIONS: APS scale-up increased reach, the contact index, and the identification of previously diagnosed sex partners but not HIV case-finding. Improved, more comprehensive data likely explain the absence of increased case-finding, highlighting the need for more comprehensive data collection.

HIV testing criteria to reduce testing volume and increase positivity in Botswana.

OBJECTIVE: We used data from a routine HIV testing program to develop risk scores to identify patients with undiagnosed HIV infection while reducing the number of total tests performed. DESIGN: Multivariate logistic regression. METHODS: We included demographic factors from HIV testing data collected in 134 Botswana Ministry of Health & Wellness facilities during two periods (1 October 2018- 19 August 2019 and 1 December 2019 to 30 March 2020). In period 2, the program collected additional demographic and risk factors. We randomly split each period into prediction/validation datasets and used multivariate logistic regression to identify factors associated with positivity; factors with adjusted odds ratios at least 1.5 were included in the risk score with weights equal to their coefficient. We applied a range of risk score cutoffs to validation datasets to determine tests averted, test positivity, positives missed, and costs averted. RESULTS: In period 1, three factors were significantly associated with HIV positivity (coefficients range 0.44-0.87). In period 2, 12 such factors were identified (coefficients range 0.44-1.37). In period 1, application of risk score cutoff at least 1.0 would result in 50% fewer tests performed and capture 61% of positives. In period 2, a cutoff at least 1.0 would result in 13% fewer tests and capture 96% of positives; a cutoff at least 2.0 would result in 40% fewer tests and capture 83% of positives. Costs averted ranged from 12.1 to 52.3%. CONCLUSION: Botswana's testing program could decrease testing volume but may delay diagnosis of some positive patients. Whether this trade-off is worthwhile depends on operational considerations, impact of testing volume on program costs, and implications of delayed diagnoses.

Sexual risk compensation following voluntary medical male circumcision: Results from a prospective cohort study amongst human immunodeficiency virus-negative adult men in Botswana.

BACKGROUND: Circumcised men may increase sexual risk-taking following voluntary medical male circumcision (VMMC) because of decreased perceptions of risk, which may negate the beneficial impact of VMMC in preventing new human immunodeficiency virus (HIV) infections. OBJECTIVES: We evaluated changes in sexual behaviour following VMMC. METHOD: We conducted a prospective cohort study amongst sexually active, HIV-negative adult men undergoing VMMC in Gaborone, Botswana, during 2013-2015. Risky sexual behaviour, defined as the number of sexual partners in the previous month and ≥ 1 concurrent sexual partnerships during the previous 3 months, was assessed at baseline (prior to VMMC) and 3 months post-VMMC. Change over time was assessed by using inverse probability weighted linear and conditional logistic regression models. RESULTS: We enrolled 523 men; 509 (97%) provided sexual behaviour information at baseline. At 3 months post-VMMC, 368 (72%) completed the follow-up questionnaire. At baseline, the mean (95% confidence interval) number of sexual partners was 1.60 (1.48, 1.65), and 111 (31% of 353 with data) men reported engaging in concurrent partnerships. At 3 months post-VMMC, 70 (23% of 311 with data) reported fewer partners and 19% had more partners. Amongst 111 men with a concurrent partnership at baseline, 52% reported none post-VMMC. Amongst the 242 (69%) without a concurrent partnership at baseline, 19% reported initiating one post-VMMC. After adjustment for loss to follow-up, risky sexual behaviour post-VMMC (measured as mean changes in a number of partners and proportion engaging in concurrency) was similar to baseline levels. CONCLUSION: We found no evidence of sexual risk compensation in the 3 months following VMMC.

Sexual function after voluntary medical male circumcision for human immunodeficiency virus prevention: Results from a programmatic delivery setting in Botswana.

BACKGROUND: Uptake of voluntary medical male circumcision (VMMC) remains modest in Botswana in spite of the government's commitment and service provision availability. Data on sexual function post-VMMC in programmatic settings could help guide messaging tailored to Botswana. OBJECTIVES: At 3-month post-VMMC, we evaluated changes in sexual function and satisfaction with the VMMC procedure amongst a cohort of HIV-negative, sexually active men aged 18-49 years who underwent VMMC in a public-sector clinic in Botswana. METHODS: We assessed whether each of the following domains of sexual function had improved, stayed the same or worsened since VMMC: sexual desire, ability to use condoms, ease of vaginal penetration, ease of ejaculation, ability to achieve and maintain an erection and hygiene or cleanliness. RESULTS: Data on sexual function were available for 378 men at 3-month post-VMMC. Median age was 27 years - 54% had a higher than secondary education, 72% were employed and 27% were married. Nearly all (96%) the men reported improvement in at least one domain of sexual function, while 19% reported improvement in all six domains. One-fourth (91/378, 24%) of the men reported that at least one domain of sexual function worsened post-VMMC. The most frequently reported domain that worsened was sexual desire (11%); in all other domains, < 10% of the men reported worsening. Men who reported any worsening sexual function were 2.3-fold as likely to be less than 'very satisfied' with the VMMC procedure (risk ratio 2.36, 95% confidence interval [CI] 1.66-3.34, p < 0.001). CONCLUSION: Emphasising improved sexual function experienced after VMMC in demand-creation efforts could potentially increase VMMC uptake in Botswana.

Immediate Motivators to Seeking Voluntary Medical Male Circumcision Among HIV-Negative Adult Men in an Urban Setting in Botswana.

Randomized trials have shown that voluntary medical male circumcision (VMMC) significantly reduces HIV acquisition risk in men. We sought to identify subpopulations of Botswanan men with high levels of VMMC uptake by comparing an observational cohort of men presenting for circumcision services at two high-volume clinics in Botswana's capital city, Gabo-rone, with a matched, population-based random sample of uncircumcised men. Among these high uptake VMMC subpopulations, we then examined the immediate factors that play a role in men's decision to seek VMMC services. As compared to their population-based controls, men choosing to undergo circumcision were more likely to be ages 24-34, more highly educated, to have a religious affiliation, and in a serious relationship. Our results suggest that married men and highly educated men were more likely to pursue circumcision for personal hygiene reasons. These findings have direct implications for targeted demand creation and mobilization activities to increase VMMC uptake in Botswana.

Clinical outcomes of a cohort of migrants and citizens living with human immunodeficiency virus in Botswana: implications for Joint United Nation Program on HIV and AIDS 90-90-90 targets.

The aim of the study was to evaluate the human immunodeficiency virus (HIV) treatment cascade and mortality in migrants and citizens living with HIV in Botswana.Retrospective 2002 to 2016 cohort study using electronic medical records from a single center managing a high migrant case load.Records for 768 migrants and 3274 citizens living with HIV were included. Maipelo Trust, a nongovernmental organization, funded care for most migrants (70%); most citizens (85%) had personal health insurance. Seventy percent of migrants and 93% of citizens had received antiretroviral therapy (ART). At study end, 44% and 27% of migrants and citizens, respectively were retained in care at the clinic (P < .001). Among the 35% and 60% of migrants and citizens on ART respectively with viral load (VL) results in 2016, viral suppression was lower among migrants (82%) than citizens (95%) (P < .001). Citizens on ART had a median 157-unit [95% confidence interval (CI) 122-192] greater increase in CD4+ T-cell count (last minus first recorded count) than migrants after adjusting for baseline count (P < .001). Five-year survival was 92% (95% CI = 87.6-94.8) for migrants and 96% (95% CI = 95.4-97.2) for citizens. Migrants had higher mortality than citizens after entry into care (hazard ratio = 2.3, 95% CI = 1.34-3.89, P = .002) and ART initiation (hazard ratio = 2.2, 95% CI = 1.24-3.78, P = .01).Fewer migrants than citizens living with HIV in Botswana were on ART, accessed VL monitoring, achieved viral suppression, and survived. The HIV treatment cascade appears suboptimal for migrants, undermining local 90-90-90 targets. These results highlight the need to include migrants in mainstream-funded HIV treatment programs, as microepidemics can slow HIV epidemic control.

Associations between healthcare worker participation in workplace wellness activities and job satisfaction, occupational stress and burnout: a cross-sectional study in Botswana.

OBJECTIVES: Healthcare workers (HWs) are prone to high levels of stress and burnout, particularly when caring for people with HIV/AIDS. This study assessed whether participation in Botswana's Workplace Wellness Programme (WWP) for HWs was associated with job satisfaction, occupational stress, well-being and burnout. METHODS: Using multistage sampling, a paper-based questionnaire was distributed to 1856 randomly selected HWs at 135 public facilities across Botswana. Well-validated scales assessed key outcomes. Analysis of covariance models were built for psychosocial factors associated with WWP participation, controlling for associated demographics. RESULTS: Response rate was 73% (n=1348). The majority of respondents were female (62%), not married (65%) and had children (84%). Mean age was 40.0 years (SD±9.9). Respondents were roughly split between participation in no WWP activities (29.4%), 1-6 WWP activities (38.9%) and seven or more WWP activities (31.7%) in the past year. High participation was associated with older age, being a doctor or other professional, working at hospitals or District Health Management Teams, working longer in health services or working longer at a facility. In unadjusted analyses, high participation was significantly associated (P<0.05) with higher satisfaction with overall job, work, supervision, promotion, pay and professional efficacy and lower stress, exhaustion and cynicism. All associations remained significant in controlled analyses except cynicism. CONCLUSIONS: Results from this study suggest that participation in workplace wellness activities is associated with higher satisfaction with multiple job facets and lower stress, exhaustion and cynicism. Introduction of these activities may help ameliorate high occupational stress levels among HWs.

Modifying the health system to maximize voluntary medical male circumcision uptake: a qualitative study in Botswana.

BACKGROUND: In 2007, the World Health Organization and the Joint United Nations Programme on HIV/AIDS endorsed voluntary medical male circumcision (VMMC) as an add-on HIV-prevention strategy. Similar to many other sub-Saharan countries, VMMC uptake in Botswana has been low; as of February 2016, only 42.7% of the program target had been achieved. Previous work has examined how individual-level factors, such as knowledge and attitudes, influence the update of VMMC. This paper examines how factors related to the health system can be leveraged to maximize uptake of circumcision services, with a focus on demand creation, access to services, and service delivery. METHODS: Twenty-seven focus group discussions with 238 participants were conducted in four communities in Botswana among men (stratified by circumcision status and age), women (stratified by age), and community leaders. A semi-structured guide was used by a trained same-gender interviewer to facilitate discussions, which were audio recorded, transcribed, translated to English, and analyzed using an inductive analytic approach. RESULTS: Participants felt demand creation activities utilizing age- and gender-appropriate mobilizers and community leaders were more effective than mass media campaigns. Participants felt improved access to VMMC clinics would facilitate service uptake, as would designated men's clinics with male-friendly providers for VMMC service delivery. Additionally, providing comprehensive pre-procedure counseling and education, outlining the benefits and disadvantages of the surgical procedure, and explaining the differences between the surgical and non-surgical procedures, were suggested by participants to increase understanding and uptake of VMMC. CONCLUSION: Cultural acceptability of circumcision services can be improved by engaging age- and gender-appropriate community mobilizers. Involving influential community leaders, providing a forum for men to discuss health issues, and bringing services closer to people can increase VMMC utilization. Service delivery can be improved by communicating the pros and cons of the procedure to the clients for informed decision-making.

Dietary energy density in the treatment of obesity: a year-long trial comparing 2 weight-loss diets.

BACKGROUND: Consuming foods low in energy density (kcal/g) decreases energy intake over several days, but the effectiveness of this strategy for weight loss has not been tested. OBJECTIVE: The effects on weight loss of 2 strategies for reducing the energy density of the diet were compared over 1 y. DESIGN: Obese women (n = 97) were randomly assigned to groups counseled either to reduce their fat intake (RF group) or to reduce their fat intake and increase their intake of water-rich foods, particularly fruit and vegetables (RF+FV group). No goals for energy or fat intake were assigned; the subjects were instructed to eat ad libitum amounts of food while following the principles of their diet. RESULTS: After 1 y, study completers (n = 71) in both groups had significant decreases in body weight (P < 0.0001). Subjects in the RF+FV group, however, had a significantly different pattern of weight loss (P = 0.002) than did subjects in the RF group. After 1 y, the RF+FV group lost 7.9 +/- 0.9 kg and the RF group lost 6.4 +/- 0.9 kg. Analysis of all randomly assigned subjects also showed a different pattern of weight loss between groups (P = 0.021). Diet records indicated that both groups had similar reductions in fat intake. The RF+FV group, however, had a lower dietary energy density than did the RF group (P = 0.019) as the result of consuming a greater weight of food (P = 0.025), especially fruit and vegetables (P = 0.037). The RF+FV group also reported less hunger (P = 0.003). CONCLUSION: Reducing dietary energy density, particularly by combining increased fruit and vegetable intakes with decreased fat intake, is an effective strategy for managing body weight while controlling hunger.

Reductions in dietary energy density are associated with weight loss in overweight and obese participants in the PREMIER trial.

BACKGROUND: Dietary energy density (ED) reductions are associated with energy intake (EI) reductions. Little is known about influences on body weight (BW). OBJECTIVES: We examined the effects of behavioral interventions on ED values and explored how 6-mo ED changes relate to BW. DESIGN: Prehypertensive and hypertensive persons were randomly assigned to 1 of 3 groups: the established group received an 18-session intervention implementing well-established hypertension recommendations (eg, weight loss, sodium reduction, and physical activity), the established+Dietary Approaches to Stop Hypertension (DASH) group received an 18-session intervention also implementing the DASH diet, and the advice group received 1 session on these topics. Two 24-h dietary recalls were collected (n=658). RESULTS: Each group had significant declines in EI, ED, and BW. The established and established+DASH groups had the greatest EI and BW reductions. The established+DASH group had the greatest ED reduction and the greatest increase in the weight of food consumed. When groups were combined and analyzed by ED change tertiles, participants in the highest tertile (ie, largest ED reduction) lost more weight (5.9 kg) than did those in the middle (4.0 kg) or lowest (2.4 kg) tertile. Participants in the highest and middle tertiles increased the weight of food they consumed (300 and 80 g/d, respectively) but decreased their EI (500 and 250 kcal/d). Conversely, those in the lowest tertile decreased the weight of food consumed (100 g/d), with little change in EI. The highest and middle tertiles had favorable changes in fruit, vegetable, vitamin, and mineral intakes. CONCLUSION: Both large and modest ED reductions were associated with weight loss and improved diet quality.