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.

Theory-Driven, Multi-Stage Process to Develop a Culturally-Informed Anti-Stigma Intervention for Pregnant Women Living with HIV in Botswana.

Background and Objectives: Despite a well-established universal HIV diagnosis and treatment program, Botswana continues to face a high HIV prevalence, in large part due to persistent stigma, which particularly affects pregnant women and interferes with healthcare engagement. Tackling stigma as a fundamental cause of HIV disparities is an important but understudied aspect of current HIV interventions. Our multinational and multicultural team used a theory-driven, multi-stage iterative process to develop measures and interventions to first identify and then target the most culturally-salient aspects of stigma for mothers living with HIV in Botswana. This methodology report examines the stage-by-stage application of the "What Matters Most" (WMM) theory and lessons learned, sharing a replicable template for developing culturally-shaped anti-stigma interventions. Methods: First, we conducted initial qualitative work based on the WMM theory to identify key structural and cultural factors shaping stigma for women living with HIV in Botswana. Second, we developed a psychometrically validated scale measuring how "what matters most" contributes to and protects against stigma for this population. Third, we designed an anti-stigma intervention, "Mothers Moving towards Empowerment" (MME), centered on the local values identified using WMM theory that underly empowerment and motherhood by adapting a cognitive behavioral therapy (CBT)-informed, group-based, and peer-co-led anti-stigma intervention specifically for pregnant women living with HIV. Fourth, we conducted a pilot study of MME in which participants were allocated to two trial arms: intervention or treatment-as-usual control. Results: Our qualitative research identified that bearing and caring for children are capabilities essential to the concept of respected womanhood, which can be threatened by a real or perceived HIV diagnosis. These values informed the development and validation of a scale to measure these culturally-salient aspects of stigma for women living with HIV in Botswana. These findings further informed our intervention adaptation and pilot evaluation, in which the intervention group showed significant decreases in HIV stigma and depressive symptoms compared to the control group. Participants reported overcoming reluctance to disclose their HIV status to family, leading to improved social support. Conclusion and Global Health Implications: Previous studies have not utilized culturally-based approaches to assess, resist, and intervene with HIV-related stigma. By applying WMM in each stage, we identified cultural and gendered differences that enabled participants to resist HIV stigma. Focusing on these capabilities that enable full personhood, we developed an effective culturally-tailored anti-stigma intervention for pregnant women living with HIV in Botswana. This theory-driven, multi-stage approach can be replicated to achieve stigma reduction for other outcomes, populations, and contexts.

A pilot pragmatic trial of a "what matters most"-based intervention targeting intersectional stigma related to being pregnant and living with HIV in Botswana.

We conducted a pilot trial of an intervention targeting intersectional stigma related to being pregnant and living with HIV while promoting capabilities for achieving 'respected motherhood' ('what matters most') in Botswana. A pragmatic design allocated participants to the intervention (N = 44) group and the treatment-as-usual (N = 15) group. An intent-to-treat, difference-in-difference analysis found the intervention group had significant decreases in HIV stigma (d = - 1.20; 95% CI - 1.99, - 0.39) and depressive symptoms (d = - 1.96; 95% CI - 2.89, - 1.02) from baseline to 4-months postpartum. Some, albeit less pronounced, changes in intersectional stigma were observed, suggesting the importance of structural-level intervention components to reduce intersectional stigma.

Psychosocial predictors of anxiety and depression in a sample of healthcare workers in Botswana during the COVID-19 pandemic: A multicenter cross-sectional study.

Objectives: This study aimed to investigate the psychological impact of the COVID-19 outbreak on healthcare workers across multiple hospitals in different districts in Botswana. Methods: We conducted a cross-sectional study in five public-funded hospitals from three districts in Botswana from 1 June 2020 to 30 October 2020. We used the neuroticism subscale of the 44-item Big Five Inventory, Patient Health Questionnaire, the Oslo 3-item Social Support Scale, the Anxiety Rating Scale, and the 14-item Resilience Scale to obtain data from 355 healthcare workers. Results: The participants' mean age (standard deviation) was 33.77 (6.84) years. More females (207, 59%) responded than males (144, 41%). Anxiety and depression were experienced by 14% and 23% of the participants, respectively. After multiple regression analyses, neuroticism predicted depression (B = 0.22; p < 0.01) and anxiety disorder (B = 0.31; p < 0.01). Lower educational status (B = -0.13; p = 0.007) predicted anxiety and younger age (B = -0.10; p = 0.038) predicted depression, while resilience negatively correlated with both disorders. Conclusion: There is a need to develop and implement interventions targeted at these identified risk and protective factors that can be easily delivered to healthcare workers during this pandemic.

Stigma, Structural Vulnerability, and "What Matters Most" Among Women Living With HIV in Botswana, 2017.

Objectives. To explore whether beneficial health care policies, when implemented in the context of gender inequality, yield unintended structural consequences that stigmatize and ostracize women with HIV from "what matters most" in local culture. Methods. We conducted 46 in-depth interviews and 5 focus groups (38 individuals) with men and women living with and without HIV in Gaborone, Botswana, in 2017. Results. Cultural imperatives to bear children bring pregnant women into contact with free antenatal services including routine HIV testing, where their HIV status is discovered before their male partners'. National HIV policies have therefore unintentionally reinforced disadvantage among women with HIV, whereby men delay or avoid testing by using their partner's status as a proxy for their own, thus facilitating blame toward women diagnosed with HIV. Gossip then defines these women as "promiscuous" and as violating the essence of womanhood. We identified cultural and structural ways to resist stigma for these women. Conclusions. Necessary HIV testing during antenatal care has inadvertently perpetuated a structural vulnerability that propagates stigma toward women. Individual- and structural-level interventions can address stigma unintentionally reinforced by health care policies.

Mental health research in Botswana: a semi-systematic scoping review.

Mental and substance use disorders are a leading cause of disability worldwide. Despite this, there is a paucity of mental health research in low- and middle-income countries, especially in sub-Saharan Africa. We carried out a semi-systematic scoping review to determine the extent of mental health research in Botswana. Using a predetermined search strategy, we searched the databases Web of Science, PubMed, and EBSCOhost (Academic Search Complete, CINAHL with Full Text, MEDLINE, MEDLINE with Full Text, MLA International Bibliography, Open Dissertations) for articles written in English from inception to June 2020. We identified 58 studies for inclusion. The most researched subject was mental health aspects of HIV/AIDS, followed by research on neurotic and stress-related disorders. Most studies were cross-sectional and the earliest published study was from 1983. The majority of the studies were carried out by researchers affiliated to the University of Botswana, followed by academic institutions in the USA. There seems to be limited mental health research in Botswana, and there is a need to increase research capacity.

'Mothers moving towards empowerment' intervention to reduce stigma and improve treatment adherence in pregnant women living with HIV in Botswana: study protocol for a pragmatic clinical trial.

BACKGROUND: With high rates of HIV and multiple vulnerable subgroups across diverse settings, there is a need for culturally based, HIV stigma reduction interventions. Pregnant women who are living with HIV are especially in need of services to protect not only their own but also their children's lives. Uptake of HIV services worldwide is hindered by stigma towards persons living with HIV/AIDS. While cultural context plays a key role in shaping HIV stigma, these insights have not yet been fully integrated into stigma reduction strategies. By utilizing the "What Matters Most" stigma framework, we propose that an intervention to counter culturally salient aspects of HIV stigma will improve treatment adherence and other relevant outcomes. A pragmatic clinical trial in Botswana will evaluate the "Mothers Moving towards Empowerment" (MME) intervention, which seeks to address HIV stigma in Botswana and to specifically engage pregnant mothers so as to promote antiretroviral therapy (ART) adherence in the postpartum period. METHODS: This study will test MME against treatment as usual (TAU) among pregnant mothers diagnosed with HIV and their infants. Outcomes will be assessed during pregnancy and 16 weeks postpartum. Women who meet eligibility criteria are assigned to MME or TAU. Women assigned to MME are grouped with others with similar estimated delivery dates, completing up to eight intervention group sessions scheduled before week 36 of their pregnancies. Primary outcomes among mothers include (i) reducing self-stigma, which is hypothesized to mediate improvements in (ii) psychological outcomes (quality of life, depression and social functioning), and (iii) adherence to antenatal care and ART. We will also examine a set of follow-up infant birth outcomes (APGAR score, preterm delivery, mortality (at < 16 weeks), birth weight, vaccination record, and HIV status). DISCUSSION: Our trial will evaluate MME, a culturally based HIV stigma reduction intervention using the "What Matters Most" framework, to reduce stigma and improve treatment adherence among pregnant women and their infants. This study will help inform further refinement of MME and preparation for a future large-scale, multisite, randomized controlled trial (RCT) in Botswana. TRIAL REGISTRATION: ClinicalTrials.gov NCT03698981 . Registered on October 8, 2018.

Cannabis Use Disorder Among First-Year Undergraduate Students in Gaborone, Botswana.

Cannabis use disorder (CUD) poses major clinical and public health concerns globally. It is a growing problem among the youth in Botswana, yet little research has been done on this subject. The present study hoped to address this gap in knowledge by determining the prevalence and associated factors of CUD among first-year university students in Botswana. A cross-sectional study was conducted among 410 first-year university undergraduates, using a modified version of the 37-item World Health Organization (WHO) drug questionnaire and DSM-5 criteria for CUD. The mean age of the respondents was 20.8 (SD = 1.5) years, and the male to female ratio was 1:1.1. Of the 401 students whose responses were analyzed, 37(9,2%) had used cannabis at least once in the last 12 months, but only 19 (4.7%) met the DSM-5 criteria for CUD. After binary regression analysis, difficulty in coping with the new environment/academic activities, receiving more than 150 USD monthly were positively associated with CUD, while regular participation in religious activities was negatively associated. CUD was found among the first-year undergraduates studied. Promoting protective activities such as religious activities and strengthening programs that teach students how to cope with academic stress and a new environment would be helpful.

Pharmacotherapeutic interventions for bipolar disorder type II: addressing multiple symptoms and approaches with a particular emphasis on strategies in lower and middle-income countries.

Introduction: Appropriately managing mental disorders is a growing priority across countries in view of the impact on morbidity and mortality. This includes patients with bipolar disorders (BD). Management of BD is a concern as this is a complex disease with often misdiagnosis, which is a major issue in lower and middle-income countries (LMICs) with typically a limited number of trained personnel and resources. This needs to be addressed.Areas covered: Medicines are the cornerstone of managing patients with Bipolar II across countries including LMICs. The choice of medicines, especially antipsychotics, is important in LMICs with high rates of diabetes and HIV. However, care is currently compromised in LMICs by issues such as the stigma, cultural beliefs, a limited number of trained professionals and high patient co-payments.Expert opinion: Encouragingly, some LMICs have introduced guidelines for patients with BD; however, this is very variable. Strategies for the future include addressing the lack of national guidelines for patients with BD, improving resources for mental disorders including personnel, improving medicine availability and patients' rights, and monitoring prescribing against agreed guidelines. A number of strategies have been identified to improve the treatment of patients with Bipolar II in LMICs, and will be followed up.

"It's When the Trees Blossom": Explanatory Beliefs, Stigma, and Mental Illness in the Context of HIV in Botswana.

Mental illness is a common comorbidity of HIV and complicates treatment. In Botswana, stigma impedes treatment of mental illness. We examined explanatory beliefs about mental illness, stigma, and interactions between HIV and mental illness among 42 adults, from HIV clinic and community settings, via thematic analysis of interviews. Respondents endorse witchcraft as a predominant causal belief, in addition to drug abuse and effects of HIV. Respondents describe mental illness as occurring "when the trees blossom," underscoring a conceptualization of it as seasonal, chronic, and often incurable and as worse than HIV. Consequently, people experiencing mental illness (PEMI) are stereotyped as dangerous, untrustworthy, and cognitively impaired and discriminated against in the workplace, relationships, and sexually, increasing vulnerability to HIV. Clinical services that address local beliefs and unique vulnerabilities of PEMI to HIV, integration with peer support and traditional healers, and rehabilitation may best address the syndemic by facilitating culturally consistent recovery-oriented care.

Psychoactive substance use among first-year students in a Botswana University: pattern and demographic correlates.

BACKGROUND: Substance use amongst university students is a recognized problem worldwide. Few studies have been carried out in this group in Botswana. These studies have been mostly limited to the use of alcohol and tobacco. Therefore, this study was designed to investigate the pattern of general substance use, its association with psychological distress and common socio-demographic factors among first-year undergraduates in a Botswana University. METHODS: A total of 401 students were interviewed using a modified W.H.O. student drug use questionnaire and the 12 item General Health Questionnaire (GHQ12) to assess the pattern of psychoactive substance use and its relationship with psychological distress amongst university students in Botswana. RESULTS: Alcohol was the most (31.9%) commonly used psychoactive substance. Age of debut for most psychoactive substances was between the ages of 15-18 years. Current use of alcohol (p = 0.045), amphetamine-type stimulants (p = 0.004) and benzodiazepines (p = 0.021) were associated with significant psychological distress. A positive relationship was observed between low participation in religious activities and substance use (OR = 4.63, 95%CI: 2.03-10.51), while a negative association was observed between not having a friend who uses drugs and substance use (OR = 0.44, 95%CI: 0.19-0.99). CONCLUSIONS: There is a significant substance abuse problem in the undergraduate population in Botswana. Our findings followed the global trend, with alcohol being the most commonly used substance. Religious participation demonstrates potential to be one of the solutions to this problem, but how to harness its seemingly protective influences is a field for further study.

HIV Prevalence Among Hospitalized Patients at the Main Psychiatric Referral Hospital in Botswana.

We examined HIV prevalence among patients 18-49 year olds admitted to a psychiatric hospital in Botswana in 2011 and 2012. The retrospective study analyzed females (F) and males (M) separately, comparing proportions with Chi square test and continuous variables with Wilcoxon rank-sum test, assessing significance at the 5% level. HIV seroprevalence among hospitalized psychiatric patients was much more common among females (53%) compared with males (19%) (p < 0.001). These women also appeared more vulnerable to infection compared with females in the general population (29%) (p < 0.017). Among both women and men, HIV-infection appeared most common among patients with organic mental disorders (F:68%, M:41%) and neurotic, stress related and somatoform disorders (F:68%, M:42%). The largest proportion of HIV infections co-occurred among patients diagnosed with schizophrenia, schizotypal and other psychotic disorders (F:48%; M:55%), mood (affective) disorders (F:21%; M:16%) and neurotic, stress-related and somatoform disorders (F:16%; M:20%). Interventions addressing both mental health and HIV among women and men require development.

Prescribing pattern of psychotropic medications in child psychiatric practice in a mental referral hospital in Botswana.

INTRODUCTION: There is a growing preference for psycho-pharmacological therapy over non-pharmacological care. The prescription pattern and the choice of psychotropic medications vary in different settings. Whilst newer agents and rational prescribing are favored in the more specialized settings, the pattern remains unclear in less specialized units, largely due to lack of data. The aims were to conduct a treatment audit in the only mental referral hospital in Botswana, which is a non-specialized child and adolescent care setting and see how it conforms to best practice. METHODS: A retrospective audit which involved the extraction of socio-demographic and clinical information from the records of patients who were ≤ 17 years and seen from January 1, 2012-July 31, 2016. RESULTS: A total of 238 files were used for this report. Mean age (SD) was 12.41 (4.1) years. Of the 120 (50.4%) patients who had pharmacological intervention, only 85(70.8%) had monotherapy. The most commonly prescribed psychotropic agents were antipsychotics (40%). Off-label use of antipsychotics and polypharmacy were 31.2% and 29.2% respectively. CONCLUSION: The level of conformity to standard practice in terms of psychotropic prescribing in our setting is consistent with the reports from developed countries where more specialized care ostensibly exists. Further studies will be necessary to determine the scope of psychotropic use.

Dyskinesia in an unmedicated adolescent with a 5-year history of tobacco use: a case report.

BACKGROUND: Tobacco use among mentally ill patients is approximately two to three times higher than that in the general population. Withdrawal from tobacco is a common occurrence and many authors have described various symptoms of nicotine withdrawal. Dyskinesia, however, has not been reported as one of the symptoms of nicotine withdrawal in adolescents without any psychopathology or medical illness. CASE PRESENTATION: We report a case of a 17-year-old Motswana boy of the Tswana ethnic group with primary school education and a 5-year history of tobacco use who developed dyskinesia approximately 48 hours after cessation of tobacco and had some relief with nicotine gum. CONCLUSION: In addition to the documented symptoms of nicotine withdrawal, clinicians should look out for dyskinesia, which may be one of the rare symptoms of withdrawal in chronic tobacco users.

Mental health in Botswana.

Botswana is a landlocked country located in southern Africa. More than two-thirds of it (70%) is covered by the Kalahari Desert, known locally as the Kgalagadi. The majority (82%) of the nearly 2 million population live in the eastern part, along the railway line from Lobatse in the south-east to Francistown in the north-east, and the rest in the central part, including the Okavango River delta.