Kweneng East Research Articles

Distribution of antiretroviral therapy through private pharmacies and postal courier services during COVID-19 in Botswana: acceptability and reach of two out-of-facility individual differentiated service delivery models.

IntroductionThe advent of COVID‐19 has put pressure on health systems as they implement measures to reduce the risk of transmission to people living with HIV (PLHIV) and healthcare workers. For two out‐of‐facility individual differentiated service delivery (DSD) models, we assessed acceptability of antiretroviral therapy (ART) distribution through private pharmacies and reach of home delivery of ART through courier services during the COVID‐19 pandemic in Botswana.MethodsFrom 24 July to 24 August 2020, we conducted exit interviews with PLHIV receiving ART from 10 high‐volume public facilities in Gaborone, and mapped and conducted an online survey with private pharmacies to assess willingness and capacity to dispense ART to PLHIV enrolled in the Botswana national ART program. We piloted ART home delivery from September 2020 to January 2021 in Gaborone and Kweneng East districts for PLHIV accessing ART at two Tebelopele Wellness Clinics. We used cascade analysis to measure the enrolment and eventual reach (percentage of those reached amongst those who are eligible) of ART home delivery.ResultsSixty‐one PLHIV and 42 private pharmacies participated. Of the PLHIV interviewed, 37 (61%) indicated willingness to access ART from private pharmacies and pay BWP50 (∼US$4) per refill for a maximum of two refills per year. All private pharmacies surveyed were willing to provide ART, and 26 (62%) would charge a dispensing fee (range = BWP50–100; ∼US$4–8) per refill. All pharmacies operated 12 h/day, 6 days/week and on public holidays. In the home delivery pilot, 650 PLHIV were due for refills, 69.5% (n = 452) of whom were eligible for home delivery. Of these, 361 were successfully offered home delivery and 303 enrolled (enrolment = 83.9%: female = 87.2%, male = 77.8%, p = 0.013). A total of 276 deliveries were made, a reach of 61%.ConclusionsProviding ART through private pharmacies and home delivery was acceptable in Botswana during COVID‐19. Surveyed pharmacies were willing and able to dispense ART to PLHIV attending public sector facilities for free or for a nominal fee. Additionally, using courier services for ART home delivery is a novel and viable model in countries with a reliable courier service like Botswana and should be scaled up, particularly in urban areas.

Recent Molecular Assessment of Plasmodium vivax and Plasmodium falciparum Asymptomatic Infections in Botswana.

.In 2016, we reported the presence of Plasmodium vivax in Botswana through active case detection. A real-time PCR was used during a similar study in 10 districts to assess changes in the P. vivax prevalence. We assessed 1,614 children (2–13 years of age) for hemoglobin (Hb; g/dL) and Plasmodium parasites. The median age of all participants was 5.0 years (25th percentile, 3 years; 75th percentile, 8 years). The median Hb (g/dL) level was 12.1, but 18.3% of the participants had anemia (Hb < 11.0 g/dL); these participants were clustered in the younger than 5 years age group in all districts (P < 0.001). The risk of anemia decreased with age 5 years or older (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.197–0.34; P < 0.001). The prevalence rates of Plasmodium parasites were as follows: P. vivax, 12.7%; P. falciparum, 12.7%; P. malariae, 0.74%; and P. ovale (P. ovale curtisi), 0.68%. Mixed infection rates were as follows: P. falciparum and P. vivax, 2.35%; P. falciparum and P. ovale curtisi, 0.56%; P. vivax and P. malariae, 0.06%; and P. falciparum and P. malariae, 0.68%. The infections were largely asymptomatic (99.6%). Using logistic regression, the risk of infection with P. vivax was highest in Kweneng East (OR, 6.2; 95% CI, 2.9–13.1), followed by South East (OR, 5.6; 95% CI, 2.5–12.3) and Ngami (OR, 5.1; 95% CI, 2.2–12.0). Compared to the risk of infection for children younger than 5 years, the risk of infection decreased for children 5 years or older in regions with high rates of P. vivax and P. falciparum infections. P. vivax and P. falciparum have expanded within the asymptomatic population in Botswana; therefore, careful attention is required for their elimination.

High-risk human papillomavirus prevalence in self-collected cervicovaginal specimens from human immunodeficiency virus (HIV)-negative women and women living with HIV living in Botswana.

The prevalence of high-risk human papillomavirus (hrHPV) is poorly described overall and in women living with HIV (WLWH) and HIV-negative women living in Botswana, a high HIV and cervical cancer-burden country. We conducted a pilot study of self-collection and high-risk HPV testing for cervical screening, from which data on HPV prevalence was available. From five health facilities in the Kweneng East District, 1,022 women aged 30-49 years were enrolled to self-collect their cervicovaginal specimen for hrHPV testing by the Xpert HPV Test (Cepheid, Sunnyvale, CA, USA). Crude and age group-adjusted hrHPV prevalence by HIV status were calculated, and the relationship of hrHPV risk groups HPV16>HPV18/45>other hrHPV types) to the presence and severity of visible lesions. Of the 1,022 women enrolled, 1,019 (99.7%), 570 WLWH and 449 HIV-negative women, had hrHPV testing results. Crude hrHPV prevalences were 25.2% (95%CI = 21.2-29.4%) for HIV-negative women and 40.4% (95%CI = 36.3-44.5%) for WLWH. Age group-adjusted hrHPV prevalences were 23.7% (95%CI = 19.9-27.9%) for HIV-negative women and 41.3% (95%CI = 37.2-45.4%) for WLWH. Age group-adjusted prevalences of HPV16 (p<0.001), HPV18/45 (p<0.001), HPV31/33/35/52/58 (p<0.001), and HPV39/56/66/68 (p = 0.011) were greater among WLWH than HIV-negative women. Riskier hrHPV groups were more likely to have visible abnormalities (ptrend = 0.004) and visible abnormalities not eligible for cryotherapy (ptrend = 0.030). hrHPV infection was common among all women in the study living in Botswana, to a greater extent in WLWH than their HIV-negative counterparts. Strategies to triage hrHPV-positive women will be needed to avoid over-treating many women with benign hrHPV infections.

Medication Errors and Blood Pressure Control Among Patients Managed for Hypertension in Public Ambulatory Care Clinics in Botswana.

BackgroundThe prevalence of hypertension in low‐ and middle‐income countries is rapidly increasing, with most cases undiagnosed and many poorly controlled among those diagnosed. Medication reconciliation studies from high‐income countries have demonstrated a high occurrence of antihypertensive medication errors and a strong association between medication errors and inadequate blood pressure control, but data from low‐ and middle‐income countries are lacking.Methods and ResultsWe conducted a cross‐sectional study from April to October 2018 of adult patients on pharmacologic management for known hypertension at 7 public health facilities in Kweneng East District, Botswana. Our aims included to evaluate the frequency of uncontrolled hypertension, the frequency and type of medication errors causing discrepancies between patient‐reported and prescribed antihypertensive medications, and the association between medication errors and uncontrolled hypertension. Descriptive analyses and multivariable logistic regression were used. The prevalence of uncontrolled hypertension was 55% among 280 enrolled adult patients, and 95 (34%) had ≥1 medication error. The most common errors included patients taking medications incorrectly (11.1%; 31/280), patients omitting medications (7.9%; 22/280), and unfilled prescriptions caused by pharmacy stock outs (7.5%%; 21/280). Uncontrolled hypertension was significantly associated with having ≥1 medication error compared with no errors (adjusted odds ratio, 3.26; 95% CI, 1.75–6.06; P<0.001).ConclusionsMedication errors are strongly associated with poor blood pressure control in this setting. Further research is warranted to assess whether medication reconciliation and other low‐cost interventions addressing root causes of medication errors can improve the control of hypertension and other chronic conditions in low‐ and middle‐income countries.

Perceived influence of value systems on the uptake of voluntary medical male circumcision among men in Kweneng East, Botswana

ABSTRACT Botswana is one of the countries in Eastern and Southern Africa significantly impacted by the Human Immunodeficiency Virus (HIV). To control the spread of HIV, the government in 2009 rolled out the voluntary medical male circumcision (VMMC) programme as an additional HIV prevention strategy with the goal of circumcising 80% of HIV negative men by 2016. However, the country failed to achieve this goal as less than 30% of the targeted men were circumcised by 2016. A study was therefore conducted to explore and describe the factors that are perceived by men in Botswana to influence the uptake of VMMC in order to inform future policymaking and programming on VMMC. An exploratory descriptive, qualitative design was utilised to investigate perceived factors influencing the uptake of VMMC among men. Data were collected from 38 men, aged 18–49 years in Kweneng East, Botswana using semi-structured individual interviews and focus group discussions (FGDs). Tesch's method of qualitative data analysis was used to code and categorise transcribed data into meaningful themes. Upon analysis, three themes emerged as influencing the uptake of VMMC: (a) the influence of value systems associated with stakeholder consultation in the community; (b) the influence of value systems associated with cultural beliefs and (c) the influence of value systems associated with religious beliefs. The influence of value systems associated with stakeholder consultation in the community was found to manifest in the form of the lack of consultation with men at the inception of the VMMC; the lack of involvement of village elders during the service delivery process and the lack of involvement of women in VMMC. In addition, the influence of value systems associated with cultural beliefs was found to manifest in the form of the lack of openness between parents and children on sexual matters and the lack of traditional leadership support in VMMC. Lastly, the influence of value systems associated with religious beliefs was found to manifest in the form of religious views not in support of the VMMC and religious views in support of the VMMC. It is concluded that value systems associated with stakeholder consultation, cultural beliefs and religious beliefs were the factors influencing the uptake of VMMC among men in Kweneng East, Botswana, and these factors to a larger extent deterred men from using VMMC services. Based on these findings, it is therefore concluded that government and other providers of VMMC should consider the influence of value systems on the uptake of VMMC in order to provide culturally congruent VMMC services and boost of the uptake of VMMC among men in Kweneng East, Botswana.

Indigenous Tswana pig production characteristics and management practices in southern districts of Botswana.

Indigenous animal genetic resources are vital in agriculture especially in the era of climate change because they are adapted to the harsh local conditions. Therefore, their conservation through utilisation is necessary. Indigenous Tswana pigs are one of the animal genetic resources that need to be protected from becoming extinct. The aim of this study was to determine the population of Tswana pigs, their production characteristics and management practices in the southern districts of Botswana. A survey was done in 15 villages in Kweneng, Kgatleng and South East districts of southern Botswana. A combination of purposive and convenience sampling methods was used to select villages and households where the survey was conducted. A questionnaire with closed- and opened-ended questions was administered to 71 indigenous pig farmers. The data were analysed using descriptive statistics procedure, frequency procedure and principal component analysis. The study established that indigenous Tswana pigs are mainly kept and managed by middle-aged and elderly women with lower level of education and no formal employment. These farmers keep Tswana pigs alongside other livestock species. The population of indigenous Tswana pigs in the surveyed districts is 620. Farmers keep indigenous pigs for cash and for home consumption. The pigs are kept in the backyard and fed kitchen leftovers and others are left to scavenge for feeds. Farmers do not put much effort in attending the health of the indigenous pigs; hence, their ignorance of the parasites and diseases affecting the pigs.

Confidence and performance of health workers in cardiovascular risk factor management in rural Botswana: a cross-sectional study

Abstract Background Social and demographic changes in Botswana are resulting in an increased prevalence of cardiovascular disease (CVD). Providers, mostly nurses, in this setting have limited training in managing CVD risk and few opportunities for continued medical education. We aimed to evaluate providers' perceived confidence in managing CVD risk factors and describe management of patients with hypertension at public-sector clinics in a rural district of Botswana. Methods In this cross-sectional study, we invited public-sector health-care providers in 11 ambulatory clinics in the Kweneng East district of Botswana to complete an anonymous questionnaire survey. We used descriptive statistics to evaluate providers' confidence in managing CVD risk (a Likert scale from 1 [low confidence] to 5 [high confidence]). We used t tests to compare confidence levels between groups of providers and specific risk factors. Additionally, we interviewed patients and did chart reviews to assess how CVD risk factors were managed in 275 hypertensive patients at seven of the 11 sites surveyed. Uncontrolled hypertension was defined as ≥140/90 mm Hg (or ≥130/80 mm Hg in patients with diabetes) for an average of two blood pressure readings and CVD risk was defined using WHO guidelines. Findings Of 88 health care providers invited to participate, 44 registered nurses (80%), four family nurse practitioners (7%), and seven doctors (13%) completed the survey. Providers reported feeling significantly more comfortable managing hypertension than they did diabetes (3·73 vs 3·15; p Interpretation Public sector health-care providers in rural Botswana have low confidence in managing CVD risk factors. Although reported confidence was higher for management of hypertension than for diabetes, there were significant lapses in management of both diseases. CVD and diabetes account for 22% of all adult deaths in Botswana and it is imperative that training in management of these diseases is improved. To address low provider confidence and gaps in guideline-driven CVD prevention, we plan to implement an integrative training programme for health workers in the Kweneng East district of Botswana. Funding Hospital Medicine, Beth Israel Deaconess Medical Center.

Seismicity Study of Botswana from 1966 to 2012

The history of Botswana’s major seismic events has been initiated by two earthquakes that occurred on the 11th of September and 11th of October 1952 with ML Richter magnitudes of 6.1 and 6.7, respectively, in the Okavango Delta Region (ODR). Not much is known and well documented about the seismicity of a larger coverage of Botswana primarily because over the years, local seismic stations were biased to the north-western part of Botswana, to monitor the more seismogenic ODR. The objective of this study is to use data from the International Seismological Centre (ISC) bulletin for the period 1966-2012 to estimate the relative size distribution of seismic events (b-value), the rate of seismic activity (a-value), and associated stress condition prevailing in Botswana to assist in the quest of hazard mitigation. This study shows that micro-seismic activities of magnitude ranging from 1.3 to 5.7 are distributed not only on the northern part of Botswana, but also in other parts of the country such as the Southern (including Kweneng East and West), Central and Eastern Botswana. Based on 327 events extracted from data compiled by the ISC, the frequency-magnitude distribution (FMD) of earthquakes in Botswana from 1966 to 2012 was estimated with b-value and a-value for the entire catalogue found to be 1.2 and 6.3, respectively, implying a region of low stress dominated by small to moderate events. The minimum completeness magnitude (MC), a value that indicates the lowest magnitude above which all seismic events are reliably recorded was found to be 3.8. From this analysis, annual probabilities of occurrence for M4 and M5 events were found to be 67.2% and 4.3%, respectively, while M6 or larger event has an annual probability of 0.3%.

Molecular evidence of high rates of asymptomatic P. vivax infection and very low P. falciparum malaria in Botswana.

BackgroundBotswana is one of eight SADC countries targeting malaria elimination by 2018. Through spirited upscaling of control activities and passive surveillance, significant reductions in case incidence of Plasmodium falciparum (0.96 – 0.01) was achieved between 2008 and 2012. As part of the elimination campaign, active detection of asymptomatic Plasmodium species by a highly sensitive method was deemed necessary. This study was carried out to determine asymptomatic Plasmodium species carriage by nested PCR in the country, in 2012.MethodA cross-sectional study involving 3924 apparently healthy participants were screened for Plasmodium species in 14 districts (5 endemic: Okavango, Ngami, Tutume, Boteti and Bobirwa; and 9 epidemic: North East, Francistown, Serowe-Palapye, Ghanzi, Kweneng West, Kweneng East, Kgatleng, South East, and Good Hope). Venous blood was taken from each participant for a nested PCR detection of Plasmodium species.ResultsThe parasite rates of asymptomatic Plasmodium species detected were as follows: Plasmodium falciparum, 0.16 %; Plasmodium vivax, 4.66 %; Plasmodium malariae, (Pm) 0.16 %; Plasmodium ovale, 0 %, mixed infections (P. falciparum and P. vivax), 0.055 %; and (P. vivax and P. malariae), 0.027 %, (total: 5.062 %). The high proportion of asymptomatic reservoir of P. vivax was clustered in the East, South Eastern and Central districts of the country. There appeared to be a correlation between the occurrence of P. malariae infection with P. vivax infection, with the former only occurring in districts that had substantial P. vivax circulation. The median age among 2–12 year olds for P. vivax infection was 5 years (Mean 5.13 years, interquartile range 3–7 years). The odds of being infected with P. vivax decreased by 7 % for each year increase in age (OR 0.93, 95 % CI 0.87–1.00, p = 0.056).ConclusionWe have confirmed low parasite rate of asymptomatic Plasmodium species in Botswana, with the exception of P.vivax which was unexpectedly high. This has implication for the elimination campaign so a follow up study is warranted to inform decisions on new strategies that take this evidence into account in the elimination campaign.

Factors influencing health care workers' implementation of tuberculosis contact tracing in Kweneng, Botswana.

IntroductionTB contact tracing rates remain low in high burden settings and reasons for this are not well known. We describe factors that influence health care workers' (HCW) implementation of TB contact tracing (CT) in a high TB burden district of Botswana.MethodsData were collected using questionnaires and in-depth interviews in 31 of the 52 health facilities in Kweneng East Health District. Responses were summarized using summary statistics and comparisons between HCW groups were done using parametric or non-parametric tests as per normality of the data distribution.ResultsOne hundred and four HCWs completed questionnaires. Factors that influenced HCW TB contact tracing were their knowledge, attitudes and practices as well as personal factors including decreased motivation and lack of commitment. Patient factors included living further away from the clinic, unknown residential address and high rates of migration and mobility. Administrative factors included staff shortages, lack of transport, poor reporting of TB cases and poor medical infrastructure e.g. suboptimal laboratory services. A national HCW strike and a restructuring of the health system emerged as additional factors during in-depth interviews of TB coordinators.ConclusionMultiple factors lead to poor TB contact tracing in this district. Interventions to increase TB contact tracing will be informed by these findings.

Healthcare Providers' Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning) of Elderly Women from Selected Sites in Botswana

Much of the sexual and reproductive health services and service delivery including family planning target women of child bearing ages (15 - 49 years) and sometimes men. Hardly are there programmes/interventions that specifically target the needs of the elderly women (50 years and above), yet this group has serious sexual and reproductive health needs as many of them are still sexually active. This cross-sectional study obtained the views of a stratified random sample of 169 healthcare providers (doctors, nurses and pharmacists) from four selected sites, Gaborone, Selibe Phikwe, Barolong and Kweneng East health districts in Botswana on how the healthcare system in the selected sites is meeting the SRH/FP needs of the elderly women. The study found out that while overwhelming majority of the healthcare providers feltthat the healthcare system has no programme that specifically target the SRH/FP needs of this significant others and their SRH/FP needs are not being met ,less than 15% indicated that Pap smear screening as well as screening of cervical cancer were on-going. Although there are SRH/FP services available in the healthcare system, the elderly women are minimally accessing these services. Only condom, combined oral contraceptives, progestogen-only pills, treatment of STIs, screening for HIV/AIDS and screening for cervical cancer are accessed and information is also limited to these services. Reasons given by the healthcare providers for the non-accessibility of these services were cultural diversity (80%), people's sexual behavior and perceptions about sex (79%), lack of knowledge about the desired SRH/FP services (76%), religion (73%) and gender issues (62%). The study, advocates as part of policy options to mitigate the obstacles to accessing SRH/FP services, the expansion of counseling programmes, screening and treatment for breast cancer, public awareness campaigns, production and circulation of appropriate educational materials, effective training of healthcare providers and the establishment of separate clinic days for the elderly women' SRH/FP services.

A comparison of the technical efficiencies of health districts and hospitals in Botswana

An attempt is made here to construct and present relative efficiency indices for the services rendered by health districts and specific hospitals in Botswana, using Stochastic Frontier Regression analysis and Data Envelopment Analysis. The analysis indicated that three districts - Kweneng East, Kgalagadi and Boteti - have efficiency scores below the optimum level. Among the 13 hospitals considered, Tsabong Primary Hospital was found to have an efficiency score of less than one. Since the health services involve a number of factors, these indices ought to serve as indicators for further scrutiny of those units (health districts and hospitals) that fall below the optimum efficiency level. The data used for the analysis are from the published material by the Central Statistics Office, Botswana for the year 1997. Health is considered one of the major concerns of the government of Botswana. As a consequence, the authors feel that this study will be useful to policy makers and health planners in giving them some kind of relative ranking among health districts and hospitals.