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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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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., Competing Interests: All authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2020. The Authors.)

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.

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.

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.

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., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

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., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Unprotected sexual intercourse after undergoing voluntary medical male circumcision but prior to complete wound healing can lead to major adverse events including HIV acquisition. To better understand perceptions related to early resumption of sex prior to wound healing, 27 focus group discussions were conducted among 238 adult men, women, and community leaders in Botswana. Median age among all participants was 31 years of whom 60% were male and 51% were either employed and receiving salary or self-employed. Only 12% reported being currently married. Pain, not risk of HIV acquisition, was perceived as the main adverse consequence of early resumption of sex. In fact, no participant mentioned that early resumption of sex could lead to an increase in HIV risk. Demonstrating masculinity and virility, fear of losing female partners, and misperception about post-operative wound healing also played key roles in the decision to resume sex prior to complete wound healing. Findings from this study highlight a potentially widespread lack of awareness of the increased risk of HIV acquisition during the wound healing period. Strengthening post-operative counseling and identifying strategies to discourage the early resumption of sex will be increasingly important as older men and HIV-positive men seek voluntary medical male circumcision services.

Randomized trials have shown that voluntary medical male circumcision (VMMC) significantly reduces the risk of HIV acquisition in men. However, the rate of complications associated with the surgical procedure varies from 0.7% to 37.4% in real-world settings. We assessed the frequency, type and severity of adverse events following VMMC among 427 adult men surgically circumcised in southeastern Botswana; 97% completed ≥1 follow-up visit within seven days post-circumcision. Thirty moderate AEs were observed in 28 men resulting in an overall AE rate of 6.7%. Patient satisfaction was high: >95% were very or somewhat satisfied with the procedure and subsequent follow-up care.

: The Botswana workplace wellness program (WWP) for health care workers (HCWs) was initiated in 2007. WWP implementation was assessed using a sequential, explanatory, mixed methods design including a national implementation assessment (27 health districts) and in-depth interviews (n = 38). Level of implementation varied across districts with health screening, therapeutic recreation, and health promotion implemented more frequently than occupational health activities and psychosocial services. Facilitators to WWP implementation included establishment of a dedicated, diverse WWP committee; provision of administrative support, and integration of activities into organizational culture. Barriers included competing priorities related to delivery of health services to clients, limited technical ability to deliver occupation health activities and psychosocial support, receipt of health services from colleagues, and limited appreciation for personal wellness by some HCWs. Ensuring the well-being of HCWs is critical in reaching international health goals.

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.

In 2007, the World Health Organization (WHO) and the joint United Nations agency program on HIV/AIDS (UNAIDS) recommended voluntary medical male circumcision (VMMC) as an add-on strategy for HIV prevention. Fourteen priority countries were tasked with scaling-up VMMC services to 80% of HIV-negative men aged 15-49 years by 2016, representing a combined target of 20 million circumcisions. By December 2012, approximately 3 million procedures had been conducted. Within the following year, there was marked improvement in the pace of the scale-up. During 2013, the total number of circumcisions performed nearly doubled, with approximately 6 million total circumcisions conducted by the end of the year, reaching 30% of the initial target. The purpose of this review article was to apply a systems thinking approach, using the WHO health systems building blocks as a framework to examine the factors influencing the scale-up of the VMMC programs from 2008-2013. Facilitators that accelerated the VMMC program scale-up included: country ownership; sustained political will; service delivery efficiencies, such as task shifting and task sharing; use of outreach and mobile services; disposable, prepackaged VMMC kits; external funding; and a standardized set of indicators for VMMC. A low demand for the procedure has been a major barrier to achieving circumcision targets, while weak supply chain management systems and the lack of adequate financial resources with a heavy reliance on donor support have also adversely affected scale-up. Health systems strengthening initiatives and innovations have progressively improved VMMC service delivery, but an understanding of the contextual barriers and the facilitators of demand for the procedure is critical in reaching targets. There is a need for countries implementing VMMC programs to share their experiences more frequently to identify and to enhance best practices by other programs.

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.

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.

To address health systems challenges in limited-resource settings, global health initiatives, particularly the President's Emergency Plan for AIDS Relief, have seconded health workers to the public sector. Implementation considerations for secondment as a health workforce development strategy are not well documented. The purpose of this article is to present outcomes, best practices, and lessons learned from a President's Emergency Plan for AIDS Relief-funded secondment program in Botswana. Outcomes are documented across four World Health Organization health systems' building blocks. Best practices include documentation of joint stakeholder expectations, collaborative recruitment, and early identification of counterparts. Lessons learned include inadequate ownership, a two-tier employment system, and ill-defined position duration. These findings can inform program and policy development to maximize the benefit of health workforce secondment. Secondment requires substantial investment, and emphasis should be placed on high-level technical positions responsible for building systems, developing health workers, and strengthening government to translate policy into programs.

Purpose: To address the shortage of laboratory scientists in Botswana, an innovative, one-year academic bridging program was initiated at the University of Botswana, to advance diploma-holding laboratory technicians towards becoming laboratory scientists holding Bachelor's degrees. An evaluation was conducted, which described the outcomes of the program and the lessons learned from this novel approach to meeting human resource needs., Methods: This was a cross-sectional, mixed-methods evaluation. Qualitative interviews were conducted with graduates of the Bachelor of Science (BSc) Medical Laboratory Sciences (MLS) bridging program, along with the graduates' current supervisors, and key informants who were involved in program development or implementation. The quantitative data collected included a written questionnaire, completed by program graduates, with a retrospective pre-test/post-test survey of graduates' confidence, in terms of key laboratory competencies., Results: The BSc MLS bridging program produced thirty-three laboratory scientists over 3 years. There was a significant increase in confidence among graduates, for specified competencies, after the program (P<0.05). Graduates reported acquiring new skills and, often, accepting new responsibilities at their former workplace, particularly in relationship to leadership and management. Five graduates enrolled in advanced degree programs. Most graduates assumed increased responsibility. However, only two graduates were promoted after completing the training program. The lessons learned include: the importance of stakeholder involvement, the need for data to identify local needs, financial sustainability, catering for the needs of adult learners, and ensuring a technically challenging work environment, conducive to the application of skills learned during training., Conclusion: A strong public health and clinical laboratory system is essential for the rapid detection and control of emerging health threats, and for patient care. However, there is a need to adequately prepare laboratory human resources, to ensure efficient and effective laboratory services. Advancement of laboratory technicians towards becoming laboratory scientists, through a bridging program, can provide the necessary skills within a short time.

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.

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.

Background: Evidence supports the implementation of task shifting to address health worker shortages that are common in resource-limited settings. However, there is need to learn from established programs to identify ways to achieve the strongest, most sustainable impact. This study examined the Botswana lay counselor cadre, a task shifting initiative, to explore effectiveness and contribution to the health workforce., Methods: This evaluation used multiple methods, including a desk review, a national lay counselor survey (n = 385; response = 94%), in-depth interviews (n = 79), lay counselors focus group discussions (n = 7), lay counselors observations (n = 25), and client exit interviews (n = 47)., Results: Interview and focus group data indicate that lay counselors contribute to essentially all HIV-related programs in Botswana and they conduct the majority of HIV tests and related counseling at public health facilities throughout the country. Interviews showed that the lay counselor cadre is making the workload of more skilled health workers more manageable and increasing HIV acceptance in communities. The average score on a work-related knowledge test was 74.5%. However for 3 questions, less than half answered correctly. During observations, lay counselors demonstrated average competence for most skills assessed and clients (97.9%) were satisfied with services received. From the survey, lay counselors generally reported being comfortable with their duties; however, some reported clinical duties that extended beyond their training and mandate. Multiple factors affecting the performance of the lay counselors were identified, including insufficient resources, such as private counseling space and HIV test kits; and technical, administrative, and supervisory support., Conclusion: Lay counselors are fulfilling an important role in Botswana's healthcare system, serving as the entry point into HIV care, support, and treatment services., Recommendation: For this and other similar task shifting initiatives, it is important that lay counselors' responsibilities are clear and that training and support are adequate to optimize their effectiveness.

We examined the accuracy of self-reported energy intake (rEI) in low-income, urban minority school-aged children at risk for obesity and associated diabetes utilizing a relatively new, simple previously published prediction equation for identifying inaccurate reports of dietary energy intake. Participants included 614 nine-year-old boys (51%) and girls (49%). Three 24-h dietary recalls were collected. Children's height, weight (used to calculate BMI), and percent body fat (%BF) were measured. Physical fitness, reported family history of diabetes, and ethnicity were also collected. A previously published prediction equation was used to determine the validity of rEIs in these children to identify under-, plausible-, and over-reporters. Additionally, we examined the question of whether there is a difference in reporting by sex, ethnicity, BMI, and %BF. On average, 18% of the children were at risk of being overweight, 43% were already overweight at baseline, yet these children reported consuming fewer calories on average than recommended guidelines. Additionally, reported caloric intake in this cohort was negatively associated with BMI and %BF. Using the previously described methods, 49% of participants were identified as under-reporters, whereas 39 and 12% were identified as plausible- and over-reporters, respectively. On average, children reported caloric intakes that were almost 100% of predicted energy requirement (pER) when the sedentary category was assigned. Inactivity and excessive energy intake are important contributors to obesity. With the rising rates of obesity and diabetes in children, accurate measures of energy intake are needed for better understanding of the relationship between energy intake and health outcomes.

Objectives: The objectives were to determine who establishes restaurant portion sizes and factors that influence these decisions, and to examine chefs' opinions regarding portion size, nutrition information, and weight management., Research Methods and Procedures: A survey was distributed to chefs to obtain information about who is responsible for determining restaurant portion sizes, factors influencing restaurant portion sizes, what food portion sizes are being served in restaurants, and chefs' opinions regarding nutrition information, health, and body weight. The final sample consisted of 300 chefs attending various culinary meetings., Results: Executive chefs were identified as being primarily responsible for establishing portion sizes served in restaurants. Factors reported to have a strong influence on restaurant portion sizes included presentation of foods, food cost, and customer expectations. While 76% of chefs thought that they served "regular" portions, the actual portions of steak and pasta they reported serving were 2 to 4 times larger than serving sizes recommended by the U.S government. Chefs indicated that they believe that the amount of food served influences how much patrons consume and that large portions are a problem for weight control, but their opinions were mixed regarding whether it is the customer's responsibility to eat an appropriate amount when served a large portion of food., Discussion: Portion size is a key determinant of energy intake, and the results from this study suggest that cultural norms and economic value strongly influence the determination of restaurant portion sizes. Strategies are needed to encourage chefs to provide and promote portions that are appropriate for customers' energy requirements.

This study establishes the reliability and validity of the Fat Preference Questionnaire, a self-administered instrument to assess preference for dietary fat. Respondents select the food which tastes better and is eaten more frequently from 19 sets of food. Each set is comprised of related foods differing in fat content. The questionnaire was administered to women in laboratory-based (n=63), cross-sectional (n=150), and weight-loss (n=71) studies. The percentage of food sets in which high-fat foods were reported to "taste better" (TASTE score) and to be "eaten more often" (FREQ score) was determined. A measure of dietary fat restriction (DIFF) was created by subtracting TASTE from FREQ. Food intake was assessed by direct measure, 24-h recall, or food diary. Additionally, participants completed a standard survey assessing dietary restraint. Test-retest correlations were high (r=0.75-0.94). TASTE and FREQ scores were positively correlated with total fat intake (r=0.22-0.63). DIFF scores positively correlated with dietary restraint (r=0.39-0.52). Participants in the weight-loss trial experienced declines in fat consumption, TASTE and FREQ scores, and BMI values, and an increase in DIFF scores. Weight loss correlated with declines in FREQ (r=0.36) scores and increases in DIFF scores (r=-0.35). These data suggest that preference for dietary fat declines when following a reduced-fat diet and an increase in restraint for intake of dietary fat is important for weight loss. The Fat Preference Questionnaire is a stable, easily-administered instrument that can be used in research and clinical settings.

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.

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.

Objective: This study investigated food choices made by individuals consuming diets differing in energy density and explores relationships between energy density and diet quality., Design: Cross-sectional, nationally representative survey., Subjects: 7,500 adults (older than 19 years) in the 1994-1996 Continuing Survey of Food Intakes by Individuals., Statistical Analysis: Energy density values were calculated from reported food intake. Subjects were classified as consuming a low-energy-density diet, medium-energy-density diet, or high-energy-density diet using tertile cutoffs. For each group, the percentage consuming various foods/beverages and the mean amount of foods/beverages they consumed was determined along with mean nutrient intakes., Results: Compared with participants consuming a high-energy-density diet, those with a low-energy-density diet had a lower energy intake but consumed more food, by weight, from most food groups. A low-energy-density diet included a relatively high proportion of foods high in micronutrients and water and low in fat, such as fruits and vegetables. Subjects with a low-energy-density diet consumed fewer (nonwater) beverages such as caloric carbonated beverages. They also consumed less fat and had higher intakes of several important micronutrients, including vitamins A, C, and B-6, folate, iron, calcium, and potassium., Conclusions: These analyses further demonstrate the beneficial effects of a low-energy-density diet, which was associated with lower energy intakes, higher food intakes, and higher diet quality than a high-energy-density diet. To achieve a low-energy-density diet, individuals should be encouraged to eat a variety of fruits and vegetables as well as low-fat/reduced-fat, nutrient-dense, and/or water-rich grains, dairy products, and meats/meat alternatives.

Background: Laboratory-based investigations indicate that the consumption of foods with a low energy density (kcal/g) decreases energy intake. Although low-energy-dense diets are recommended for weight management, relations between energy density, energy intake, and weight status have not been clearly shown in free-living persons., Objectives: A representative US sample was used to determine whether dietary energy density is associated with energy intake, the weight of food consumed, and body weight and to explore the influence of food choices (fruit, vegetable, and fat consumption) on energy density and body weight., Design: A cross-sectional survey of adults (n = 7356) from the 1994-1996 Continuing Survey of Food Intakes by Individuals and two 24-h dietary recalls were used., Results: Men and women with a low-energy-dense diet had lower energy intakes (approximately 425 and 275 kcal/d less, respectively) than did those with a high-energy-dense diet, even though they consumed more food (approximately 400 and 300 g/d more, respectively). Normal-weight persons had diets with a lower energy density than did obese persons. Persons with a high fruit and vegetable intake had the lowest energy density values and the lowest obesity prevalence., Conclusions: Adults consuming a low-energy-dense diet are likely to consume more food (by weight) but to have a lower energy intake than do those consuming a higher-energy-dense diet. The energy density of a variety of dietary patterns, including higher-fat diets, can be lowered by adding fruit and vegetables. Our findings support the hypothesis that a relation exists between the consumption of an energy-dense diet and obesity and provide evidence of the importance of fruit and vegetable consumption for weight management.

The increase in the prevalence of obesity has coincided with an increase in portion sizes of foods both inside and outside the home, suggesting that larger portions may play a role in the obesity epidemic. Although it will be difficult to establish a causal relationship between increasing portion size and obesity, data indicate that portion size does influence energy intake. Several well-controlled, laboratory-based studies have shown that providing older children and adults with larger food portions can lead to significant increases in energy intake. This effect has been demonstrated for snacks and a variety of single meals and shown to persist over a 2-d period. Despite increases in intake, individuals presented with large portions generally do not report or respond to increased levels of fullness, suggesting that hunger and satiety signals are ignored or overridden. One strategy to address the effect of portion size is decreasing the energy density (kilojoules per gram; kilocalories per gram) of foods. Several studies have demonstrated that eating low-energy-dense foods (such as fruits, vegetables, and soups) maintains satiety while reducing energy intake. In a clinical trial, advising individuals to eat portions of low-energy-dense foods was a more successful weight loss strategy than fat reduction coupled with restriction of portion sizes. Eating satisfying portions of low-energy-dense foods can help to enhance satiety and control hunger while restricting energy intake for weight management.

A growing body of laboratory-based, clinical, and epidemiological data suggests that low-energy-dense diets are associated with better diet quality, lower energy intakes, and body weight. Dietary energy density can be lowered by adding water-rich fruits, vegetables, cooked grains, and soups to the diet, and by reducing the diet's fat content. Low-energy-dense diets can be successfully incorporated into clinical dietetics since they help lower energy intake without reducing food volume and thus help individuals avoid feeling hungry and deprived. There are multiple steps that could be taken by nutrition professionals and food manufacturers to encourage the consumption of low-energy-dense diets. The goal is to develop reduced-calorie eating plans that meet personal food preferences and also provide satisfying food portions. Since using energy density to guide food choices leads to food patterns consistent with dietary guidelines, policy level initiatives should be devised to help ensure that low-energy-dense diets are affordable and accessible to all.

The rise in obesity rates over the past 30 y has been paralleled by increases in the portion size of many foods and the prevalence of eating away from home. Foods of particular concern are those that have a high energy density (kJ/g). Many well-controlled, laboratory-based studies have found that large portions of energy-dense foods can lead to excess energy intakes. This influence of large portions on energy intake has been supported by data collected in naturalistic settings. Further research is needed to explore strategies that can be used to moderate the effects of portion size on food consumption. One promising strategy is to reduce the energy density of foods, while maintaining food weight or volume, so that consumers can eat satisfying portions while reducing their energy intakes. There is a need for effective educational messages that not only emphasize limiting the consumption of foods high in energy density, but also encourage the consumption of those with a low energy density, such as fruits and vegetables. The delivery of consistent messages will require more cooperation among the food and restaurant industries, policy makers, and scientists. Effective strategies will also require consumers to understand and accept the importance of eating reasonable portions for better health.

Dietary energy density [kcal/g (kJ/g)] influences energy intake under controlled laboratory conditions. Little is known about the energy density of the diets of free-living persons. Because energy density investigations are a relatively new endeavor, there are neither standard calculation methods nor published nationally representative values. This paper examines the calculation of energy density based on systematic exclusion of beverage categories, presents data on variability, and compares values by sex, age, and race/ethnicity in a representative sample of U.S. adults. Mean daily dietary energy density values for adults (aged >19 y) were calculated using two 24-h recalls from the Continuing Survey of Food Intakes by Individuals 1994-1996 based on food, food and liquid meal replacements, food and alcohol, food and juice, food and milk, food and juice and milk, food and energy-containing beverages, and food and all beverages. Energy density varied by calculation method, ranging from 0.94 to 1.85 kcal/g (3.93-7.74 kJ/g). Intraindividual-to-interindividual CV ratios were highest for the food and energy-containing beverages calculation. Men reported diets with a higher energy density than women for all calculation methods (P < 0.0001). There were differences by race/ethnicity and an inverse linear trend for age. These data indicate that beverage inclusion schemes should be clearly defined when reporting energy density values. In epidemiologic studies, calculations based on food and all beverages and food and energy-containing beverages may diminish associations with outcome variables. These nationally representative data, which provide an important frame of reference for other studies, indicate that dietary energy density differs by sex, age, and race/ethnicity.

Objectives: To characterize dietary patterns of rural older adults and relate patterns to weight and nutritional status., Design: Cross-sectional., Setting: Rural Pennsylvania., Participants: One hundred seventy-nine community-dwelling adults aged 66 to 87 years., Measurements: A home visit was conducted to collect demographic, health behavior, and anthropometric data and a blood sample. Five 24-hour dietary recall were administered. Cluster analysis classified participants into dietary patterns using food subgroup servings. Chi-square, analysis of covariance, and logistic regression were used to assess differences across clusters., Results: A low-nutrient-dense cluster (n=107), with higher intake of breads, sweet breads/desserts, dairy desserts, processed meats, eggs, and fats/oils, and a high-nutrient-dense cluster (n=72) with higher intake of cereals, dark green/yellow vegetables, other vegetables, citrus/melons/berries, fruit juices, other fruits, milks, poultry, fish, and beans, were identified. Those in the high-nutrient-dense cluster had lower energy intake; higher energy-adjusted intake of fiber, iron, zinc, folate, and vitamins B(6), B(12), and D; higher Healthy Eating Index scores; higher plasma vitamin B(12) levels; and a lower waist circumference. Those with a low-nutrient-dense dietary pattern were twice as likely to be obese, twice as likely to have low plasma vitamin B(12) levels, and three to 17 times more likely to have low nutrient intake., Conclusion: This study provides support for recommending a high-nutrient-dense dietary pattern for older adults. Behavioral interventions encouraging diets characterized by high-nutrient-dense foods may improve weight and nutritional status of older adults.

Background: Many older Americans are overweight or obese, but it is unclear whether obesity is associated with other nutritional risk indicators., Objective: This study investigated sex-associated differences in nutritional risk among community-dwelling, rural older adults and determined whether weight status [body mass index (BMI; in kg/m(2)) and waist circumference] was related to other measures of nutritional risk., Design: This cross-sectional study explored relations between weight status and nutritional risk, which was determined on the basis of the Level II Screen, overall diet quality, nutrient intakes, and plasma biomarkers., Results: Of the 179 subjects, 44% were overweight (BMI 25-29.9) and 35% were obese (BMI > 30). There were few differences in nutrient intakes between older men and women after we controlled for energy intake. In women, BMI was directly associated with multiple additional nutritional risk indicators, including the number of Level II items (r = 0.30), intakes of fat (r = 0.26) and saturated fat (r = 0.21), and homocysteine concentration (r = 0.25). Weight status in women was inversely associated with intakes of carbohydrates (r = -0.25), fiber (r = -0.35), folate (r = -0.24), magnesium (r = -0.29), iron (r = -0.22), and zinc (r = -0.23); Healthy Eating Index scores (r = -0.22); and plasma pyridoxal 5' phosphate (r = -0.30). Associations with waist circumference were similar. In men, weight status was associated only with plasma cobalamin (r = -0.33 for BMI) and pyridoxal 5' phosphate (r = -0.24 for waist circumference)., Conclusions: Overweight and obese older women, particularly those living alone, may be at greater nutritional risk than are men with a high BMI. Targeted nutritional intervention emphasizing nutrient-dense food choices to improve dietary patterns may be warranted.