Development and psychometric testing of a scale to measure effective rural emergency transfer (RET).

BACKGROUND: The process of transferring patients from small rural primary care facilities to referral facilities impacts the quality of care and effectiveness of the referral healthcare system. The study aimed to develop and evaluate the psychometric properties of a scale measuring requirements for effective rural emergency transfer. METHODS: An exploratory sequential design was utilized to develop a scale designed to measure requirements for effective emergency transport. Phase one included a qualitative, interview study with 26 nursing transport providers. These transcripts were coded, and items developed for the proposed scale. Phase two included a content validity review by these 16 transport providers of the domains and items developed. Phase three included development and evaluation of psychometric properties of a scale designed to measure requirements for effective emergency transport. This scale was then tested initially with 84 items and later reduced to a final set of 58 items after completion by 302 transport nurses. The final scale demonstrated three factors (technology & tools; knowledge & skills; and organization). Each factor and the total score reported excellent scale reliability. RESULTS: The initial item pool consisted of 84 items, generated, and synthesized from an extensive literature review and the qualitative descriptive study exploring nurses' experiences in rural emergency patient transportation. A two-round modified Delphi method with experts generated a scale consisting of 58 items. A cross-sectional study design was used with 302 nurses in rural clinics and health in four rural health districts. A categorical principal components analysis identified three components explaining 63.35% of the total variance. The three factors, technology, tools, personal knowledge and skills, and organization, accounted for 27.32%, 18.15 and 17.88% of the total variance, respectively. The reliability of the three factors, as determined by the Categorical Principal Component Analysis (CATPCA)'s default calculation of the Cronbach Alpha, was 0.960, 0.946, and 0.956, respectively. The RET Cronbach alpha was 0.980. CONCLUSIONS: The study offers a three-factor scale to measure the effectiveness of emergency patient transport in rural facilities to better understand and improve care during emergency patient transport.

Experiences of rural nurses with emergency patient transport in a resource limited setting.

BACKGROUND: Registered nurses are primary care providers during most patient transfers from rural areas. Various local conditions and circumstances impact the provision of nursing care prior to and during transportation. These include clinic staffing, uneven access to functioning equipment and other necessary infrastructure across settings, the wide-ranging clinical need for specialty care, and complex social and interpersonal circumstances that play a role in care-seeking and transport decision-making. This study explored the experiences of nurses with emergency patient transport in rural health facilities in Botswana. METHOD: A qualitative descriptive approach was used using a semi structured interview. Twenty-six registered nurses from four remote, isolated rural health districts in Botswana participated in this study. Purposive convenience sampling technique was employed. RESULTS: The ten main themes under transporter were infringement of scope of practice, inadequate knowledge and skills, distressful practice, restriction from making decisions, challenges with staffing, Ineffective facilities clustering, lack of support from the managers, shortage of technology and tools, non-enabling infrastructure, and transport related tasks. DISCUSSION AND CONCLUSION: The perceived ineffective emergency transfer of patients was associated with work system shortfalls. The work system needs to be balanced and consider the requirements of the various stakeholders involved in the processes for optimal performance of patient transport.

Batswana Adolescents' Attitudes Toward Sex With Older Adults: Psychometric Properties of the Attitudes Toward Transactional Sex Scale.

A programmatic series of studies developed and evaluated the Attitudes toward Transactional Sex Scale (ATTS) to measure adolescents' attitudes toward engaging in a sexual encounter initiated by an older adult offering desired objects such as cell phone, clothes, cash, or car rides in exchange for sex. Qualitative interviews informed the initial item generation followed by a series of studies assessing the psychometric properties of the measure. Study 1 evaluated the ATTS in a sample of 186 Batswana adolescents and assessed the factor structure, item-to-whole correlations, internal consistency, and convergent validity. In Study 2, the ATTS was administered to a cross-validation sample (N = 387). Confirmatory factor analysis, convergent validity, and internal consistency were consistent with the findings from the original sample. Discriminant validity was also assessed in Study 2. A subset of the sample (N = 119) completed the measure on two occasions and yielded satisfactory test-retest reliability. The resulting instrument appears to have sound psychometric properties and can be used to measure adolescents' attitudes toward accepting such adult sexual initiation that are implicated in the disproportionate burden of HIV among adolescents and young adults in sub-Saharan Africa. No existing measure with known psychometric properties has previously been available.

A coordinated health policy in response to COVID-19: A case of Botswana.

INTRODUCTION: This paper documents policy decisions and transformations in response to the COVID-19 pandemic in Botswana and utilizes the multi-sectoral approach (MSA) in providing this analysis. METHOD: A desk review of the different government gazette documents was conducted to trace health policy evolutionary developments and their impact on the general lives of the people of Botswana. FINDINGS: Revealed the actors, roles in this policy transformation and the conditions that enhanced the smooth implementation of the policies are discussed. CONCLUSION: The paper concludes by making some recommendations for the country's preparedness and anticipatory guidance for any other pandemic or disaster that may arise. CLINICAL RELEVANCE: This paper highlights the importance of the multisectoral approach in addressing crises such as pandemics. It also demonstrates the need for countries to have well-defined guidelines to allow decision making in the delivery of efficient health services to the general population during pandemics.

Nurses and COVID-19 response in Botswana.

INTRODUCTION: The advent of the COVID-19 pandemic necessitated the Botswana Presidential Task Force, in collaboration with the Ministry of Health and Wellness (MoHW), to devise strategies to utilize the already overburdened health personnel to combat the spread of the coronavirus. This descriptive case study aimed to describe nurses' role during COVID-19 in Botswana. DESIGN AND METHODS: A case study analysis was used to describe nurses' roles during COVID-19. Data were collected through observing events in various health facilities and various media platforms that described how nurses had to position themselves to combat the pandemic. Content analysis was done by coding and developing categories that put like content together and generate thematic areas. RESULTS: Nurses from different sectors were redeployed to assist in setting up different units at the COVID-19 makeshift hospital, taking away from the already understaffed section of health care workers resulting in the overburden and work overload. Furthermore, nurses continued with their regular day-to-day nursing care duties in various healthcare settings, albeit under a severe shortage due to the national response to COVID-19. CONCLUSION: Adaptations and experiential strategies enabled the distribution of the nursing workforce to cover all locations to curb the spread of COVID-19 despite the challenges encountered. Recommendations and lessons learned on how to prepare for future pandemics are also discussed. CLINICAL RELEVANCE: Due to their large numbers, nurses formed the backbone of the Botswana COVID-19 response strategy. Therefore, policy-makers should be responsive to the nurses' perspectives when developing strategic policies on how to deal with pandemics based on their experiences.

Comparison on treatment outcomes of patients enrolled on anti-retroviral therapy at different levels of the health-care system in a high HIV/AIDS setting.

HIV/AIDS prevalence in Botswana is amongst the highest in the world and remains a significant public health problem. however, the introduction of anti-retroviral therapy (ART) lead to a significant reduction in morbidity and mortality. Decentralization of anti-retroviral therapy has improved access to treatment for people living with HIV. Treatment outcomes for patient initiated on treatment at different levels of care is unknown and this study seeks to compare treatment outcomes of patients enrolled on ART at different levels of the health care. This is a retrospective cross-sectional study that included review of data from January 2017 to December 2018. The study was conducted in 2 health districts in the country. Nine hundred and sixty (960) patient's record were included in analysis. More than half (63%) of patients were enrolled at primary care level while 37% were at tertiary level. Sixty one percent (n = 587) were female while 39% (n = 373) were males. There were no statistically significant differences in viral load suppression after 12 months of treatment between patients enrolled at tertiary level and primary care level, x2 = 0.75, p value = 0.56. Time to initiation was longer at tertiary (median = 126) compared to primary are level (median = 18), p < 0.001. We reccommend further decentralization of ART services to lower levels of the health care system to initiate PLWHIV early on treatment and improve their health outcomes and reduce transmission through treatment by prevention.

Substantial Increase in Transactional Sex and HIV Risk Among Adolescents During the COVID-19 Pandemic: Results From a Repeated Cross-Sectional Study in Botswana.

The COVID-19 pandemic and resulting public health response has disrupted the lives of adolescents and their families worldwide. We evaluated the impact of the pandemic on attitudes, beliefs, and sexual risk behavior among adolescents in Botswana. Participants were recruited using household-based sampling across residential districts (blocks) in and around Gaborone, Botswana, and completed surveys on laptop computers at a private, central location. We compared baseline survey data from 380 adolescents who completed the survey pre-pandemic (n = 139) to those who completed the survey intra-pandemic (n = 241). Participants had a mean age of 15.2 years; 58.6% were girls and 41.4% were boys. Intra-pandemic, participants reported greater engagement in transactional sex (38.1% compared to 13.6% pre-pandemic, p <. 05), more favorable attitudes toward transactional sex with sugar daddies and sugar mommies (p <. 05), greater intentions to remain sexually active in the future (29.2% vs.13.6%, respectively, p <.05), and lower self-efficacy in handling risky sexual situations (p < .01). Public health interventions that lessen these concerning shifts in attitudes and behaviors will be key to protecting the sexual health of adolescents and to supporting their safe transition to adulthood.

The utility of a modified WHO TB screening tool among children at a Botswana child welfare clinic.

BACKGROUND: In high TB/HIV settings, the increased risk for TB amongst children exposed to HIV has been established through biomedical tests. Screening HIV exposed children for TB can improve early childhood TB detection and treatment. OBJECTIVE: This study assessed the utility of a modified World Health Organization (WHO) tool by including HIV variables, to determine TB exposure amongst HIV exposed children presenting to a "Well Child" Clinic (CWC). METHODS: Clinical data were obtained from medical records and/or from the caregivers of children presenting to CWC. Data was analyzed to explore factors associated with positive screening for TB, including being exposed to HIV and current HIV status. RESULTS: Five percent (55/1100) screened reported a close TB contact and 21% (n=231) had positive TB symptom screen. History of close TB contact was a risk factor for positive screening for TB symptoms (OR 1.89 CI 1.05-3.4) while being HIV negative was protective (OR 0.3, Cl 0.19-0.62). HIV exposure was associated with increased risk of TB exposure (OR 2.9 CI 1.61-5.19). CONCLUSION: Integrating HIV variables in the existing WHO screening tool for childhood TB can be useful in early detection and treatment of TB in HIV exposed children in resource limited settings.

Gaps, Challenges, and Opportunities for Global Health Leadership Training.

Background: Global Health Leadership (GHL) programs are essential for training emerging health care professionals to be effective leaders. Synthesizing knowledge acquired through experience implementing GHL programs can inform future recommendations for GHL. Objective: To describe the lessons learned, highlighting gaps, challenges and opportunities, during implementation of two GHL capacity building programs, namely the Afya Bora Consortium Fellowship in Global Health Leadership and the Sustaining Technical and Analytic Resources (STAR) fellowship and internship program for global health professionals. Methods: A mixed methods case-comparison study was conducted, using qualitative data (expert opinion) collected from the Program Directors in order to understand the experiences of the two GHL programs. A structured response guide was used to assess the overall experience in GHL program implementation, operational challenges and reported gaps. Afya Bora and STAR have been implemented for 8 and 2.5 years respectively. Thus, the analysis reflects a snapshot of the two programs at different stages. Findings: The results reflect knowledge gained through extensive experience in implementing the two GHL programs. Afya Bora has trained 188 multi-disciplinary fellows, and 100% of the African fellows are engaged in leadership positions in government departments and non-governmental organizations (NGOs) in their countries. STAR has placed 147 participants (89 fellows and 58 interns) in more than 25 countries globally. Both programs were successful in strengthening south-south and north-south collaborations for a common goal of improving global health. Implementation of both fellowships identified room for improvement in operational procedures and financing of the programs, and highlighted knowledge and skills gaps, as well as challenges in sustainability of the training programs. Conclusions: Afya Bora and STAR have had significant impact and have contributed to changing the leadership landscape in global health. Future GHL programs should address sustainability in terms of financing, delivery modalities and domestic integration of knowledge.

Association of Adolescent- and Parent-Reported Relationship Functioning with HIV Sexual Risk Among Adolescents in Botswana.

Globally, adolescents in sub-Saharan Africa are the youth most affected by HIV. Parent-adolescent relationships can be protective in child and adolescent development and may be implicated in lowered adolescent HIV sexual risk. However, the importance of parental and adolescent perceptions of their relationship and assessing the implications of family functioning in adolescents' risk for HIV or other sexually transmitted infections are not well established in the research literature. This dyadic study simultaneously assessed both parents' and adolescents' perceptions of family functioning and their relationships with adolescent sexual behaviors in Botswana. Seventy-two parent-adolescent dyads completed audio computer-assisted self-interview surveys. Surveys, independently completed by parents and their adolescent, assessed multiple indicators of their relationship and is the first such study in Botswana to collect the perspectives of both the parents and their adolescents. The results highlight significantly discrepant views of their relationships and revealed that the magnitude of those discrepancies was associated with greater adolescent HIV sexual risk behavior across multiple measures of family relationships. Parents' inaccurate perceptions of their adolescents' sexual activity were also associated with greater adolescent sexual risk. These findings elucidate the importance of improving parent-adolescent communications and relationships, which may subsequently assist in lowering adolescents' sexual risk for HIV and other negative sexual health outcomes.

Integrated management of HIV/NCDs: knowledge, attitudes, and practices of health care workers in Gaborone, Botswana.

BACKGROUND: The epidemiologic transition and double disease burden from chronic infections and Non-communicable diseases (NCDs) worldwide requires re-engineering of healthcare delivery systems. Healthcare workers (HCWs) need to adapt to new integrated disease management approaches and change from current disease-specific management. OBJECTIVES: The study aimed to determine HCWs knowledge, capacity and skills for management of NCDs among HIV patients and their attitudes towards integrated HIV/NCDs disease management approaches for future clinical practice. METHODS: Descriptive cross-sectional survey among HCWs attending to HIV patients at selected government facilities. RESULTS: One hundred out of 105 responses were analysed. Only 6% could fully define NCDs. Awareness levels of NCDs were high: Diabetes and hypertension 98%; cancer 96%; cardiovascular diseases 86%. However, 11.8% and 58% classified HIV and malaria respectively as NCDs. Most respondents (88%) believe that integrating HIV/NCDs care would be good use of resources while 62% disagreed with current separate facility management of HIV patients with NCDs. Over 60% routinely screened HIV patients for NCDs risk factors: Smoking (87.2%), alcohol (90.8%), diet (84.9%) and physical activity (73.5%). CONCLUSION: There were gaps in detailed knowledge on NCDs, but positive attitude towards routine primary care integrated HIV/NCDs management, showing likely support for implementation of such policy.

Gender Differences in Sexual and Reproductive Health Protective and Risk Factors of Batswana Adolescents: Implications for Parent and Adolescent Interventions.

Adolescents in sub-Saharan Africa and in Botswana in particular continue to bear the brunt of the HIV epidemic. This analysis assessed gender differences among theory-based sexual and reproductive health protective and risk factors in a cross-sectional sample of 228 Batswana adolescents. Incongruence between preferred and actual sources of sexual information and several important gender differences in parent-adolescent relationships, psychosocial influences, and adolescent sexual behaviors were identified. Parents were the fourth most common source of information about sex; yet, over three-quarters of adolescents preferred to have parents teach them about sex. Boys reported more positive relationships with their parents and girls reported more positive attitudes toward transactional sex. Both boys and girls reported similarly low levels of parental monitoring, parental communication, and parental responsiveness, all of which are important protective factors. These findings suggest interventions should address these gender differences and consider offering parallel interventions for adolescents and their parents in Botswana.

Perceptions of key participants about Botswana adolescents' risks of unplanned pregnancy, sexually transmitted diseases, and HIV: Qualitative findings.

AIM: The qualitative research findings are reported on the perceptions of key participants in Botswana about adolescent sexuality problems and the feasibility (with suggestions) of an adolescent prevention intervention. METHODS: Twenty adult key participants who were selected through purposive sampling from schools and youth centers responded to open-ended questions during face-to-face individual in-depth interviews that were conducted between December, 2011 and January, 2012 in Gaborone, Botswana. RESULTS: The data were analyzed by using an inductive content analysis. Five major themes and 12 subthemes emerged from the interviews. The key participants discussed situations that exposed adolescents to HIV, sexually transmitted infections, and pregnancy. They also discussed unsafe sexual practices, the consequences of unprotected sex, poor parent-adolescent communication on sexuality, and the need for a sexuality education program. CONCLUSION: Policy changes are needed to improve collaboration between adolescents, parents, teachers, and youth officers in order to address adolescent sexuality problems. Further research is needed to explore the ways in which to improve sexuality communication between these groups. The results of the study provide valuable information on the sexuality risks that expose adolescents to HIV, pregnancy, and sexually transmitted infections and the strategies for the prevention of these risks, thus informing targeted interventions for risk reduction for adolescents.

Training tomorrow's leaders in global health: impact of the Afya Bora Consortium Fellowship on the careers of its alumni.

BACKGROUND: Effective leadership is a cornerstone of successful healthcare delivery in resource limited settings throughout the world. However, few programs in Africa prepare healthcare professionals with the leadership skills vital to the success of the healthcare systems in which they work. One such program, the Afya Bora Consortium Fellowship in Global Health Leadership, has been training health professionals since 2011. The purpose of this study was to assess what career changes, if any, the Afya Bora Fellowship's alumni have experienced since completing the fellowship, and to describe those changes. METHODS: The Afya Bora Fellowship is a multidisciplinary, one-year training program that teaches health professionals leadership skills through didactic and experiential learning in four African countries. Between January 2011 and June 2013 the consortium trained 42 nurses and doctors. In November 2013, an electronic survey was sent to all alumni to assess their performance in the workplace post-fellowship. RESULTS: Thirty-one (74 %) of 42 alumni completed surveys. Twenty-one (68 %) reported changes to their position at work; of those, sixteen (76 %) believed the change was due to participation in the fellowship. All alumni reported improved performance at work, and cited the application of a wide range of fellowship skills, including leadership, research, communication, and mentoring. Twenty-six (84 %) alumni spearheaded improvements in their workplaces and almost all (97 %) remained in contact with colleagues from the fellowship. Among the respondents there were five publications, nine manuscripts in preparation, and three international conference presentations. CONCLUSIONS: Afya Bora alumni overwhelmingly reported that the one year fellowship positively influenced both their work and career trajectory. Training health professionals in leadership skills through didactic modules with the opportunity to apply learned skills at attachment sites in the Afya Bora Fellowship has an impact on performance in the workplace and the potential to improve long-term institutional capacity.

Interprofessional Fellowship Training for Emerging Global Health Leaders in Africa to Improve HIV Prevention and Care: The Afya Bora Consortium.

HIV continues to challenge health systems, especially in low- and middle-income countries in Sub-Saharan Africa. A qualified workforce of transformational leaders is required to strengthen health systems and introduce policy reforms to address the barriers to HIV testing, treatment, and other HIV services. The 1-year Afya Bora Consortium Fellowship in Global Health capitalizes on academic partnerships between African and U.S. universities to provide interprofessional leadership training through classroom, online, and service-oriented learning in 5 countries in Africa. This fellowship program prepares health professionals to design, implement, scale-up, evaluate, and lead health programs that are population-based and focused on prevention and control of HIV and other public health issues of greatest importance to African communities and health service settings. Afya Bora nurse fellows acquire leadership attributes and competencies that are continuously and systematically tested during the entire program. This multinational training platform promotes interprofessional networks and career opportunities for nurses.

Cross-cultural adaptation of an adolescent HIV prevention program: social validation of social contexts and behavior among Botswana adolescents.

An evidence-based HIV prevention intervention was adapted for Botswana youth with qualitative interviews, input from an adolescent panel, and social validation. Qualitative interviews were conducted with 40 boys and girls ages 13-19. An adolescent panel then drafted scenarios reflecting social situations described in the interviews that posed risk for HIV. A social validation sample (N = 65) then indicated the prevalence and difficulty of each situation. Youth described informational needs, pressures to use alcohol and drugs, peer pressure for unprotected sex, and intergenerational sex initiations as risk-priming situations. From 17% to 57% of the social validation sample had personally experienced the situations drafted by the adolescent panel. There were no differences in the ratings of boys versus girls, but youth over age 16 more often reported that they had experienced these risky situations. The results were embedded into the intervention. Major changes to the intervention resulted from this three-phase process.

Depression in HIV-positive women in Gaborone, Botswana.

This cross-sectional study measured prevalence of depression and suicide ideation in 62 randomly selected HIV-positive (HIV+) women in Botswana, a resource-limited country at the center of the HIV/AIDS epidemic. They were administered two screening measures of depression, an inventory of activities of daily living (ADL), and subjective questionnaire of cognitive functioning. Results show that the two screening measures are useful for detecting depression in women infected with HIV in resource-limited countries. Diagnosis of depression is of great importance, not only clinically, but also to ensure judicious allocation of scarce medical resources in the regions worst affected by the HIV epidemic.

Rapid psychosocial function screening test identified treatment failure in HIV+ African youth.

Psychosocial dysfunction in older children and adolescents is common and may lead to nonadherence to HIV treatments. Poor adherence leads to HIV treatment failure and the development of resistant virus. In resource-limited settings where treatment options are typically limited to only one or two available lines of therapy, identification of individuals at highest risk of failure before failure occurs is of critical importance. Rapid screening tools for psychosocial dysfunction may allow for identification of those children and adolescents who are most likely to benefit from limited psychosocial support services targeted at preventing HIV treatment failure. The Pediatric Symptom Checklist (PSC) is used in high resource settings for rapid identification of at-risk youth. In 692 HIV-infected treated children (ages of 8-< 17 years) in Botswana, having a high score on the PSC was associated with having virologic failure (OR 1.7, 95% CI: 1.1-2.6). The PSC may be a useful screening tool in pediatric HIV.

HIV-Related knowledge, attitudes, and practice among educated young adults in Botswana.

Students at the University of Botswana, an at-risk group, have previously been shown to have high levels of risky sexual behavior despite widespread knowledge that these behaviors might lead to HIV-1 infection. As there have recently been considerable efforts focused on HIV-1 prevention in Botswana through nationwide media education campaigns and the opening of voluntary counselling and testing centers, re-evaluation of HIV-related knowledge, attitudes, and practices among students is needed. A cross-sectional survey was administered to 393 students chosen via a random cluster method. Respondents were 50% junior and 50% senior students with 42% males. Half (52%) were "single", 44% were "in a relationship", and 4% were "married". The mean percentage of knowledge questions answered correctly was 96%. 98% agreed that all sexually active adults should know their status and that condom use is important, but only 56% believed getting tested was common and 66% believed that it was common for students to always use a condom. As with the previous survey, we again found that students had excellent knowledge yet perceived use of testing services and condoms remain lower than might be predicted based on knowledge scores.