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Background: Botswana has made significant investments in its health care information infrastructure, including vertical programs for child health and nutrition, HIV care, and tuberculosis. However, effectively integrating the more than 18 systems in place for data collection and reporting has proved to be challenging. The Botswana Health Data Collaborative Roadmap Strategy (2020-24) states that "there exists parallel reporting systems and data is not integrated into the mainstream reports at the national level," seconded by the Botswana National eLearning strategy (2020), which states that "there is inadequate information flow at all levels, proliferation of systems, reporting tools are not synthesized; hence too many systems are not communicating.", Objective: The objectives of this study are to (1) create a visual representation of how data are processed and the inputs and outputs through each health care system level; (2) understand how frontline workers perceive health care data sharing across existing platforms and the impact of data on health care service delivery., Methods: The setting included a varied range of 30 health care facilities across Botswana, aiming to capture insights from multiple perspectives into data flow and system integration challenges. The study design combined qualitative and quantitative methodologies, informed by the rapid assessment process and the technology assessment model for resource limited settings. The study used a participatory research approach to ensure comprehensive stakeholder engagement from its inception. Survey instruments were designed to capture the intricacies of data processing, sharing, and integration among health care workers. A purposive sampling strategy was used to ensure a wide representation of participants across different health care roles and settings. Data collection used both digital surveys and in-depth interviews. Preliminary themes for analysis include perceptions of the value of health care data and experiences in data collection and sharing. Ethical approvals were comprehensively obtained, reflecting the commitment to uphold research integrity and participant welfare throughout the study., Results: The study recruited almost 44 health care facilities, spanning a variety of health care facilities. Of the 44 recruited facilities, 27 responded to the surveys and participated in the interviews. A total of 75% (112/150) of health care professionals participating came from clinics, 20% (30/150) from hospitals, and 5% (8/150) from health posts and mobile clinics. As of October 10, 2023, the study had collected over 200 quantitative surveys and conducted 90 semistructured interviews., Conclusions: This study has so far shown enthusiastic engagement from the health care community, underscoring the relevance and necessity of this study's objectives. We believe the methodology, centered around extensive community engagement, is pivotal in capturing a nuanced understanding of the health care data ecosystem. The focus will now shift to the analysis phase of the study, with the aim of developing comprehensive recommendations for improving data flow within Botswana's health care system., International Registered Report Identifier (irrid): DERR1-10.2196/52411., (©Grey Faulkenberry, Audrey Masizana, Badisa Mosesane, Kagiso Ndlovu. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 09.10.2024.)

Goat milk could be used to reduce malnutrition since it is highly nutritious, and many people in rural communities in South Africa rear small ruminants for survival. However, the risk of food contamination by antibiotic residues is one of the significant problems facing public health, and is a result of the irresponsible use of veterinary drugs. One hundred goat farmers were interviewed using a questionnaire, and raw milk samples from 266 goats were collected and analysed for the presence of antibiotic residues. Screening for amoxicillin, tetracycline, sulfamethazine, erythromycin, and streptomycin residues was done using the enzymelinked immunosorbent assay (ELISA) while high-performance liquid chromatography (HPLC) was carried out for confirmation. The questionnaire shows that all (100%) of the participants acknowledged the use of antibiotics on their goats and 99% of them were aware of the possibility of antibiotic residues in milk. ELISA results for residues of erythromycin, sulfamethazine and amoxicillin exceeded the Codex Alimentarius maximum residue levels (MRLs) in 94.7%, 82.3%, and 35.3% of analysed samples, respectively. Tetracycline was present in all (100%) analysed milk samples, and streptomycin was detected in 18.7% of samples; however, these results were below the recommended MRLs. The HPLC method confirmed the presence of streptomycin and tetracycline residues in 90% and 40% of the samples analysed. However, the concentrations were below the accepted MRL standards. Approximately 76.6% of samples exceeded the established MRL for sulfamethazine and 10% for erythromycin. Amoxicillin was not detected by the HPLC method. The results obtained in this study indicate a high level of contamination of goat milk with antibiotic residues, which may harm the health of the consumers.

Background: The COVID-19 pandemic brought challenges requiring timely health data sharing to inform accurate decision-making at national levels. In Botswana, we adapted and integrated the Research Electronic Data Capture (REDCap) and the District Health Information System version 2 (DHIS2) platforms to support timely collection and reporting of COVID-19 cases. We focused on establishing an effective COVID-19 data flow at the national public health laboratory, being guided by the needs of health care professionals at the National Health Laboratory (NHL). This integration contributed to automated centralized reporting of COVID-19 results at the Ministry of Health (MOH)., Objective: This paper reports the experiences, challenges, and lessons learned while designing, adapting, and implementing the REDCap and DHIS2 platforms to support COVID-19 data management at the NHL in Botswana., Methods: A participatory design approach was adopted to guide the design, customization, and implementation of the REDCap platform in support of COVID-19 data management at the NHL. Study participants included 29 NHL and 4 MOH personnel, and the study was conducted from March 2, 2020, to June 30, 2020. Participants' requirements for an ideal COVID-19 data management system were established. NVivo 11 software supported thematic analysis of the challenges and resolutions identified during this study. These were categorized according to the 4 themes of infrastructure, capacity development, platform constraints, and interoperability., Results: Overall, REDCap supported the majority of perceived technical and nontechnical requirements for an ideal COVID-19 data management system at the NHL. Although some implementation challenges were identified, each had mitigation strategies such as procurement of mobile Internet routers, engagement of senior management to resolve conflicting policies, continuous REDCap training, and the development of a third-party web application to enhance REDCap's capabilities. Lessons learned informed next steps and further refinement of the REDCap platform., Conclusions: Implementation of REDCap at the NHL to streamline COVID-19 data collection and integration with the DHIS2 platform was feasible despite the urgency of implementation during the pandemic. By implementing the REDCap platform at the NHL, we demonstrated the possibility of achieving a centralized reporting system of COVID-19 cases, hence enabling timely and informed decision-making at a national level. Challenges faced presented lessons learned to inform sustainable implementation of digital health innovations in Botswana and similar resource-limited countries., (©Kagiso Ndlovu, Kabelo Leonard Mauco, Onalenna Makhura, Robin Hu, Nkwebi Peace Motlogelwa, Audrey Masizana, Emily Lo, Thongbotho Mphoyakgosi, Sikhulile Moyo. Originally published in JMIR Formative Research (https://formative.jmir.org), 16.04.2024.)

Vitamin K antagonists (VKA) is the primary anticoagulant in most settings of Sub-Saharan Africa. Understanding the quality of anticoagulation services in the continent is vital in optimising the intended benefits. This study assessed the quality of anticoagulation and associated factors among VKA-treated patients in nine SSA countries. We conducted a retrospective cohort study of randomly selected patients on anticoagulation from 20 clinics in Botswana, the Democratic Republic of Congo, Ethiopia, Gambia, Ghana, Mozambique, Nigeria, Tanzania, and South Africa. Eligible participants were those on VKAs for at least three months and with at least four international normalised ratios (INR) results in 2019-2021. We report the proportion of INR values in the therapeutic range, time-in-therapeutic range (TTR) using the Rosendaal method, and the proportion of patients with TTR ≥ 65% (optimal anticoagulation). The mean age was 51.1(16.1) years, and 64.2% were women. The most common indications for VKA included venous thromboembolism (29.6%), prosthetic valves (26.7%) and atrial fibrillation/flutter (30.1%). We analysed 6743 INR tests from 1011 participants, and of these, 48.5% were sub-therapeutic, 34.1% therapeutic, and 17.4% were supratherapeutic relative to disease-specific reference ranges. TTR was calculated for 660 patients using 4927 INR measurements. The median (interquartile range [IQR]) TTR was 35.8(15.9,57.2) %. Optimal anticoagulation control was evident in 19.2% of participants, varying from 2.7% in Tanzania to 23.1% in Ethiopia. The proportion of patients with TTR ≥ 65% was 15,4% for prosthetic heart valves, 21.1% for venous thromboembolism and 23.7% for atrial fibrillation or flutter. Countries with universal health coverage had higher odds of optimal anticoagulation control (adjusted odds ratio (aOR) 1.79, 95% confidence interval [CI], 1.15- 2.81, p = 0.01). Patients on VKAs for different therapeutic indications in SSA had suboptimal TTR. Universal health coverage increased the odds of achieving TTR by 79%. The evidence calls for more intensive warfarin management strategies in SSA, including providing VKA services without out-of-pocket payments., (© 2024. The Author(s).)

Background: In resource-limited countries, access to specialized health care services such as dermatology is limited. Clinical decision support systems (CDSSs) offer innovative solutions to address this challenge. However, the implementation of CDSSs is commonly associated with unique challenges. VisualDx-an exemplar CDSS-was recently implemented in Botswana to provide reference materials in support of the diagnosis and management of dermatological conditions. To inform the sustainable implementation of VisualDx in Botswana, it is important to evaluate the intended users' perceptions about the technology., Objective: This study aims to determine health care workers' acceptance of VisualDx to gauge the feasibility of future adoption in Botswana and other similar health care systems., Methods: The study's design was informed by constructs of the Technology Acceptance Model. An explanatory, sequential, mixed methods study involving surveys and semistructured interviews was conducted. The REDCap (Research Electronic Data Capture; Vanderbilt University) platform supported web-based data capture from March 2021 through August 2021. In total, 28 health care workers participated in the study. Descriptive statistics were generated and analyzed using Excel (Microsoft Corp), and thematic analysis of interview transcripts was performed using Delve software., Results: All survey respondents (N=28) expressed interest in using mobile health technology to support their work. Before VisualDx, participants referenced textbooks, journal articles, and Google search engines. Overall, participants' survey responses showed their confidence in VisualDx (18/19, 95%); however, some barriers were noted. Frequently used VisualDx features included generating a differential diagnosis through manual entry of patient symptoms (330/681, 48.5% of total uses) or using the artificial intelligence feature to analyze skin conditions (150/681, 22% of total uses). Overall, 61% (17/28) of the survey respondents were also interviewed, and 4 thematic areas were derived., Conclusions: Participants' responses indicated their willingness to accept VisualDx. The ability to access information quickly without internet connection is crucial in resource-constrained environments. Selected enhancements to VisualDx may further increase its feasibility in Botswana. Study findings can serve as the basis for improving future CDSS studies and innovations in Botswana and similar resource-limited countries., (©Kagiso Ndlovu, Nate Stein, Ruth Gaopelo, Michael Annechino, Mmoloki C Molwantwa, Mosadikhumo Monkge, Amy Forrestel, Victoria L Williams. Originally published in JMIR Formative Research (https://formative.jmir.org), 10.10.2023.)

This study sought to determine the association between social media and self-rated health. This study used the 2022 Health Information National Trends Survey for American adults. A statistical analysis was conducted using Chi-square and multivariable logistic regression. Of the 6018 study participants, the majority reported that they were in excellent/very good and good health (82.9%, n = 4930). More than half (58.2%, n = 3268) of the respondents reported that they visited a social media site almost every day in the past 12 months, while 76.8% ( n = 4843) reported that they never interacted with people who had similar health or medical issues on social media. There was no association between everyday visits to a social media site, interaction with people with similar health/medical issues on social media, or watching a health-related video on social media and self-rated health. Those who had full-time employment were more likely to rate their health as excellent/very good/good (AOR: 2.394, 95% Conf. Int: 1.820-3.149) compared to those with no full-time employment. Marital status, confidence in taking care of oneself, education, and current smoking were associated with self-rated health. This study showed that the use of social media which included the watching of health-related videos was not associated with self-rated health.

Background: Human resources for health (HRH) shortages are a major limitation to equitable access to healthcare. African countries have the most severe shortage of HRH in the world despite rising communicable and non-communicable disease (NCD) burden. Task shifting provides an opportunity to fill the gaps in HRH shortage in Africa. The aim of this scoping review is to evaluate task shifting roles, interventions and outcomes for addressing kidney and cardiovascular (CV) health problems in African populations., Methods: We conducted this scoping review to answer the question: "what are the roles, interventions and outcomes of task shifting strategies for CV and kidney health in Africa?" Eligible studies were selected after searching MEDLINE (Ovid), Embase (Ovid), CINAHL, ISI Web of Science, and Africa journal online (AJOL). We analyzed the data descriptively., Results: Thirty-three studies, conducted in 10 African countries (South Africa, Nigeria, Ghana, Kenya, Cameroon, Democratic Republic of Congo, Ethiopia, Malawi, Rwanda, and Uganda) were eligible for inclusion. There were few randomized controlled trials (n = 6; 18.2%), and tasks were mostly shifted for hypertension (n = 27; 81.8%) than for diabetes (n = 16; 48.5%). More tasks were shifted to nurses (n = 19; 57.6%) than pharmacists (n = 6; 18.2%) or community health workers (n = 5; 15.2%). Across all studies, the most common role played by HRH in task shifting was for treatment and adherence (n = 28; 84.9%) followed by screening and detection (n = 24; 72.7%), education and counselling (n = 24; 72.7%), and triage (n = 13; 39.4%). Improved blood pressure levels were reported in 78.6%, 66.7%, and 80.0% for hypertension-related task shifting roles to nurses, pharmacists, and CHWs, respectively. Improved glycaemic indices were reported as 66.7%, 50.0%, and 66.7% for diabetes-related task shifting roles to nurses, pharmacists, and CHWs, respectively., Conclusion: Despite the numerus HRH challenges that are present in Africa for CV and kidney health, this study suggests that task shifting initiatives can improve process of care measures (access and efficiency) as well as identification, awareness and treatment of CV and kidney disease in the region. The impact of task shifting on long-term outcomes of kidney and CV diseases and the sustainability of NCD programs based on task shifting remains to be determined., (© 2023. The Author(s).)

Background: Electronic record (eRecord) systems and mobile health (mHealth) apps have documented potential to improve health service delivery, resulting in increased global uptake. However, their interoperability remains a global challenge hindering diagnosis, monitoring of health conditions, and data access irrespective of geographic location. Given the widespread use of mobile devices by patients and health care providers, linking mHealth apps and eRecord systems could result in a comprehensive and seamless data exchange within a health care community. The Botswana National eHealth Strategy recognizes interoperability as an issue and mHealth as a potential solution for some health care needs but is silent on how to make mHealth apps interoperable with existing eRecord systems. A literature review and analysis of existing mHealth interoperability frameworks found none suitable for Botswana. As such, it was critical to conceptualize, design, and develop an mHealth-eRecord Interoperability Framework (mHeRIF) to enhance the interoperability pillar of the Botswana National eHealth Strategy and leverage the full benefits of linking mHealth apps with other health information systems., Objective: This study aimed to validate the developed mHeRIF and determine whether it requires further refinement before consideration towards enhancing the National eHealth Strategy., Methods: Published framework validation approaches guided the development of a survey administered to 12 purposively selected local and international eHealth experts. In total, 25% (3/12) of the experts were drawn from Botswana, 25% (3/12) were drawn from low- and middle-income countries in sub-Saharan Africa, 25% (3/12) were drawn from low- and middle-income countries outside Africa, and 25% (3/12) were drawn from high-income countries. Quantitative responses were collated in a Microsoft Excel (Microsoft Corp) spreadsheet for descriptive analysis, and the NVivo software (version 11; QSR International) was used to aid the thematic analysis of the qualitative open-ended questions., Results: The analysis of responses showed overall support for the content and format of the proposed mHeRIF. However, some experts' suggestions led to 4 modest revisions of the mHeRIF., Conclusions: Overall, the experts' reviews showed that the mHeRIF could contribute to the National eHealth Strategy by guiding the linking of mHealth apps to existing eRecord systems in Botswana. Similarly, the experts validated an architectural model derived from the mHeRIF in support of the first mobile telemedicine initiative considered for national rollout in Botswana. The mHeRIF helps identify key components to consider before and after linking mHealth apps to eRecord systems and is being considered for use as the foundation of such interoperability in Botswana., (©Kagiso Ndlovu, Maurice Mars, Richard E Scott. Originally published in JMIR Formative Research (https://formative.jmir.org), 02.05.2023.)

Leishmaniasis is a neglected tropical disease that is caused by the Leishmania parasite. It is estimated that there are more than 350 million people at risk of infection annually. Current treatments that are in clinical use are expensive, have toxic side effects, and are facing parasitic resistance. Therefore, new drugs are urgently required. In the quest for new, safe, and cost-effective drugs, a series of novel ethylene glycol derivatives of nitrofurantoin was synthesised and the in vitro antileishmanial efficacy of the compounds tested against Leishmania donovani and Leishmania major strains. Arylated ethylene glycol derivatives were found to be the most potent, with submicromolar activity up to 294-fold greater than the parent compound nitrofurantoin. Analogues 2j and 2k had the best antipromastigote activities with submicromolar IC 50 values against L. major IR-173 and antimonial-resistant L. donovani 9515 strains., (© 2023 The Authors. Archiv der Pharmazie published by Wiley-VCH GmbH on behalf of Deutsche Pharmazeutische Gesellschaft.)

Background: The use of information and communication technologies for health-eHealth-is described as having potential to improve the quality of health care service delivery. Consequently, there is an increased global trend toward adoption of eHealth interventions by health care systems worldwide. Despite the proliferation of eHealth solutions, many health care institutions especially in transitioning countries are struggling to attain effective data governance approaches. The Ministry of Health in Botswana is an exemplar institution continually seeking better approaches to strengthen health data governance (HDG) approaches following the adoption of eHealth solutions. Recognizing the need for a global HDG framework, the Transform Health coalition conceptualized HDG principles that are structured around 3 interconnected objectives: protecting people, promoting the value of health, and prioritizing equity., Objective: The aim of the study is to solicit and evaluate perceptions and attitudes of health sector workers in Botswana toward the HDG principles by Transform Health and derive any future guidance., Methods: Purposive sampling was used to select participants. A total of 23 participants from various health care organizations in Botswana completed a web-based survey and 10 participated in a follow-up remote round-table discussion. The aim of the round-table discussion was to gain further insight into participants' responses from the web-based survey. Participants were from the following health care cadres: nurses, doctors, information technology professionals, and health informaticians. Both validity and reliability testing were performed for the survey tool before sharing it with study participants. An analysis of participants' close-ended responses from the survey was performed using descriptive statistics. Thematic analysis of open-ended responses from the questionnaire and the round-table discussion was achieved using the Delve software and the widely accepted principles of thematic analysis., Results: Although some participants highlighted having measures in place similar to the HDG principles, there were some who either did not know or disagreed that their organizations already had in place mechanisms similar to the proposed HDG principles. Participants further expressed relevance and importance of the HDG principles in the context of Botswana. However, some modifications to the principles were also suggested., Conclusions: This study highlights the necessity of data governance in health care particularly toward meeting the requirements for Universal Health Coverage. The existence of other health data governance frameworks calls for a critical analysis to assess the most appropriate and applicable framework in the context of Botswana and similar transitioning countries. An organization-centered approach may be most appropriate, as well as strengthening of existing organizations' HDG practices with the Transform Health principles., (©Kagiso Ndlovu, Kabelo Leonard Mauco, Star Chibemba, Steven Wanyee, Tom Oluoch. Originally published in JMIR Formative Research (https://formative.jmir.org), 13.03.2023.)

Background: Tobacco use is one of the notable risk factors for non-communicable diseases globally. The objective of this study was to assess the prevalence of tobacco use and identify its correlates in the general population of Botswana aged 15 to 69 years., Methods: This study used a nationally representative WHO STEPwise Approach to Non-Communicable Disease Risk Factor Surveillance (STEPS) risk factors conducted in 2014 to explore the prevalence of tobacco use and its correlates in Botswana. Using IBM SPSS version 27, data on 4062 people aged 15 to 69 years who had been selected using multistage cluster sampling and had successfully completed the individual questionnaire were analysed. The prevalence of current tobacco smoking and smokeless tobacco use was determined using descriptive statistics while multivariable logistic regression was employed to assess correlates of current tobacco smoking and smokeless tobacco use. All comparisons were statistically significant at 5% significance level., Results: From a total sample of 4062 participants the prevalence of current tobacco smoking was estimated to be 12.9% while smokeless tobacco use was 3.2%. Adjusted results indicate that the odds of current tobacco smoking were eight times (AOR = 8.57, C.I = 6.28-11.7) higher among males compared to their female counterparts; six(AOR = 6.52, C.I 3.64-11.6) and three (AOR = 3.27, C.I. =2.07-5.15) times higher among respondents with no education and primary level education respectively, compared to their counterparts with tertiary or higher education; while for alcohol users the odds of current tobacco smoking were four times (AOR = 4.28, C.I = 2.93-6.24) higher than among non-alcohol users. The odds of smokeless tobacco use were significantly higher among women compared to men (AOR = 7.34, C.I = 4.01-13.4); individuals aged 50-59 (AOR = 1.15, C.I = 1.06-3.37) and 60-69 years (AOR = 1.23, C.I. =1.08-3.63) compared to 15-29 years; individuals with no education (AOR = 2.07, C.I = 1.03-4.02) and primary education (AOR = 1.05, C.I = 1.01-2.23) compared to individuals with tertiary education. However, the odds of smokeless tobacco use were significantly lower among individuals who consume alcohol (AOR = 0.48, C.I. = 0.29-0.80) compared to non-alcohol consumers., Conclusion: Findings of this study indicate the need to strengthen existing national policies to reduce harmful use of tobacco among men, women, older adults, no or primary education level individuals and alcohol users., (© 2023. The Author(s).)

Aims: Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs., Methods: We searched electronic data bases including PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and Web of Science to identify studies that employed the GHOISS risk tool in managing complex limb injuries published from April 2006, when the score was introduced, until April 2021. Primary outcome was the measured sensitivity and specificity of the GHOISS risk tool for predicting amputation at a specified threshold score. Secondary outcomes included length of stay, need for plastic surgery, deep infection rate, time to fracture union, and functional outcome measures. Diagnostic test accuracy meta-analysis was performed using a random effects bivariate binomial model., Results: We identified 1,304 records, of which six prospective cohort studies and two retrospective cohort studies evaluating a total of 788 patients were deemed eligible for inclusion. A diagnostic test meta-analysis conducted on five cohort studies, with 474 participants, showed that GHOISS at a threshold score of 14 has a pooled sensitivity of 93.4% (95% confidence interval (CI) 78.4 to 98.2) and a specificity of 95% (95% CI 88.7 to 97.9) for predicting primary or secondary amputations in people with complex lower limb injuries., Conclusion: GHOISS is highly accurate in predicting success of limb salvage, and can inform management and predict secondary outcomes. However, there is a need for high-quality multicentre trials to confirm these findings and investigate the effectiveness of the score in children, and in predicting secondary amputations.Cite this article: Bone Joint J  2023;105-B(1):21-28.

Background: Few countries are likely to achieve universal sanitation within the next decade as sustaining household sanitation coverage remains a critical challenge. This study aimed to investigate factors that may have supported or hindered sustainability of sanitation coverage 1-2 years after the completion of an integrated, area-wide sanitation program in 4 countries., Methods: We conducted qualitative analyses to identify factors related to the sustainability of sanitation coverage in Bhutan, Kenya, Nepal, and Zambia, 2 years after completion of the Sustainable Sanitation and Hygiene for All program. From November 2019 to March 2020, we conducted focus group discussions and key informant interviews with community members, project implementers, and decision makers. We triangulated the qualitative findings with data from household surveys to characterize subnational sanitation coverage throughout implementation and 1-2 years after., Results: Our data revealed behavioral, contextual, and service delivery factors that were related to the sustainability of sanitation improvements. Service delivery factors included follow-up hygiene promotion, access to construction materials, local government commitment postimplementation, functioning monitoring systems, private sector uptake of supply chain improvements, and capacity for innovation. Contextual and behavioral factors included poverty, soil type, road networks, social cohesion, desire for improved latrines, maintenance and cleaning, and knowledge of sanitation benefits., Conclusion: The presence or absence of sustainability factors identified through this research may have implications on where certain programmatic approaches will work and where adaptations may be required. By comparing sustainability factors with subnational slippage rates, we were able to illustrate how local service delivery systems may respond to barriers and enablers. Understanding the programmatic and contextual factors that either drive or hinder long-term sanitation coverage may allow for greater program impact through adapting implementation based on existing challenges in service delivery and context., (© Sakas et al.)

Compelling evidence from three randomised controlled trials, which showed that voluntary medical male circumcision (VMMC) reduces HIV acquisition from women to men by up to 60%, led to WHO recommending that VMMC be implemented in 14 priority countries. As one of the priority countries, Eswatini aimed to reach 80% VMMC coverage among boys and men aged 10-49 years since programme inception in 2009. By the end of 2019, however, the country had reached a modest 40%. VMMC is intrinsically tied to perceptions of masculinity and male gender identity. Comprehending the role of context-specific masculinity as it relates to VMMC may contribute to our understanding of community attitudes towards VMMC and men's decision-making. Drawing on focus group discussion data, this study aimed to explore the linkage between sexuality, masculinity and health interventions within Eswatini. Using critical discourse analysis, the study identified two discourses: sexuality, masculinity and circumcision, and income, masculinity, and circumcision. In the first discourse, participants constructed discursive linkages between circumcision as an adult and loss of penile sensitivity, decreased libido and sexual performance, and adverse events. The second discourse, income, masculinity, and circumcision located circumcision within the social and material realities faced by Swazi men, gender norms and provision within family structures.

Background: In emerging market countries in sub-Saharan Africa, access to specialty services such as dermatology is limited. Teledermatology is an innovative solution to address this issue; however, many initiatives have been tried without sustained success. Recently, WhatsApp has been used as a store-and-forward telemedicine communication platform for consultation and education in Botswana., Objective: This study aims to describe the utilization of WhatsApp for teledermatology and the satisfaction levels of participating providers., Methods: A 2-part pilot study was conducted. First, a retrospective review was performed of WhatsApp communications received by participating dermatologists in Gaborone, Botswana, from January 2016 to December 2019. Sender information, patient demographics and history, response time, diagnoses made, and follow-up recommendations were collected. Second, a 12-question cross-sectional survey was distributed to health care providers who utilized WhatsApp for teledermatology during this period. Descriptive statistics were then performed., Results: There were 811 communication threads over the study period. The majority (503/811, 62%) of communications were consultations from providers inquiring about a specific patient, followed by multidisciplinary care coordination communications (90/811, 11%). Our in-depth analysis focused on the former. In 323 (64%) provider consultations, dermatologists responded within 1 hour. A diagnosis was made in 274 (55%) consultations. Dermatologists gave treatment recommendations remotely in 281 (56%) consultations and recommended an in-person dermatology visit in 163 (32%). Of the 150 health care providers surveyed, 23 (15%) responded. All respondents (100%) felt that there was a need for teledermatology and improved teledermatology education in Botswana. Moreover, 17 (74%) respondents strongly felt that the guidance received via WhatsApp was high quality, and 22 (96%) were satisfied with WhatsApp as a platform for teledermatology., Conclusions: This retrospective review and survey demonstrated that WhatsApp is a quick, well-received, and sustainable method of communication between dermatologists and providers across Botswana. The app may offer a solution to the challenges providers face in accessing specialty referral systems, point-of-care education, and medical decision-making support for complex dermatologic cases in Botswana. The information gained from this pilot study can serve as the basis for future telemedicine studies to improve the implementation of teledermatology in Botswana and other resource-limited countries., (©Erika Koh, Abena Maranga, Tshepo Yane, Kagiso Ndlovu, Bwanali Jereni, Maitseo Kuno Nwako-Mohamadi, Carrie Kovarik, Amy Forrestel, Victoria L Williams. Originally published in JMIR Dermatology (http://derma.jmir.org), 27.07.2022.)

Background: Similar to many low- and middle-income countries, Botswana has identified eHealth as a means of improving health care service provision and delivery. The National Malaria Programme (NMP) in Botswana has implemented the District Health Information System version 2 (DHIS2) to support timely malaria case reporting across its 27 health districts; however, the implementation of an eHealth system is never without challenges. Barriers to the implementation of eHealth innovations within health care settings may arise at the individual or organizational levels. As such, the evaluation of user perceptions of the technology is an important step that can inform its sustainable implementation. The DHIS2 was implemented without evaluating user perceptions beforehand; therefore, the Botswana Ministry of Health and Wellness was uncertain about the likelihood of acceptance and use of the platform., Objective: We aimed to determine the acceptance of the DHIS2 platform by the NMP in Botswana to gauge whether adoption would be successful., Methods: The study's design was informed by constructs of the technology acceptance model. A survey, with items assessed using a 7-point Likert scale, and focus group discussions were undertaken with DHIS2 core users from 27 health districts and NMP personnel at the Ministry of Health and Wellness. The web-based survey was administered from August 3, 2020 to September 30, 2020., Results: Survey participants were core users (n=27). Focus group participants were NMP personnel (n=5). Overall, participants' survey responses (frequently occurring scores of 7) showed their confidence in the DHIS2 platform for case-based surveillance of malaria; however, participants also noted some organizational issues that could compromise user acceptance of the DHIS2 platform., Conclusions: Participants' responses indicated their acceptance of the DHIS2 platform; however, the consideration of factors related to organizational readiness could further enhance successful acceptance, and consequently, successful adoption of the platform by the malaria program in Botswana., (©Kagiso Ndlovu, Kabelo Leonard Mauco, Mpho Keetile, Khutsafalo Kadimo, Refilwe Yvonne Senyatso, Davies Ntebela, Buthugwashe Valela, Clement Murambi. Originally published in JMIR Formative Research (https://formative.jmir.org), 15.03.2022.)

Background: The proliferation of mHealth solutions and eRecord systems is inevitable in developing countries, and ensuring their bi-directional interoperability is essential. Interoperability has been described as the ability for two or more systems or components to exchange information and use the information that has been exchanged. Given the importance of linking mHealth solutions to eRecord systems in the developing world, a suitable interoperability framework is required to provide an agreed approach to interoperability and specify common elements. Although eHealth interoperability frameworks exist in the literature, none meet all the requirements for linking mHealth solutions to eRecord systems in developing countries. The aim of this paper was to describe the design and development of a conceptual framework for linking mHealth solutions to eRecord systems in Botswana, as an exemplar., Methods: An iterative and reflective process was adopted, supported by existing literature and research including consultations with eHealth experts, and guidance from existing frameworks. These collectively identified key elements, concepts, and standards relevant and essential for framework design and development., Results: The mHealth-eRecord Interoperability Framework (mHeRIF) was developed which highlights the need for: governance and regulation of mHealth and eRecord systems, a national health information exchange, and which interoperability levels to achieve. Each of these are supported by integral themes and concepts. It also addresses the need for regular review, accreditation, and alignment of framework concepts and themes with a National eHealth Strategy Interoperability Development Process. To demonstrate the framework's applicability, a proposed architecture for the Kgonafalo mobile telemedicine programme is presented., Conclusion: Interoperable mHealth solutions and eRecords systems have the potential to strengthen health systems. This paper reports the design and development of an evidence-based mHeRIF to align with, build upon, and expand National eHealth Strategies by guiding the linking of mHealth solutions to eRecord systems in Botswana and other developing countries facing similar circumstances., (© 2021. The Author(s).)

Objectives: To determine the incidence and major drivers of catastrophic costs among TB-affected households in Zimbabwe., Methods: We conducted a nationally representative health facility-based survey with random cluster sampling among consecutively enrolled drug-susceptible (DS-TB) and drug-resistant TB (DR-TB) patients. Costs incurred and income lost due to TB illness were captured using an interviewer-administered standardised questionnaire. We used multivariable logistic regression to determine the risk factors for experiencing catastrophic costs., Results: A total of 841 patients were enrolled and were weighted to 900 during data analysis. There were 500 (56%) males and 46 (6%) DR-TB patients. Thirty-five (72%) DR-TB patients were HIV co-infected. Overall, 80% (95% CI: 77-82) of TB patients and their households experienced catastrophic costs. The major cost driver pre-TB diagnosis was direct medical costs. Nutritional supplements were the major cost driver post-TB diagnosis, with a median cost of US$360 (IQR: 240-600). Post-TB median diagnosis costs were three times higher among DR-TB (US$1,659 [653-2,787]) than drug DS-TB-affected households (US$537 [204-1,134]). Income loss was five times higher among DR-TB than DS-TB patients. In multivariable analysis, household wealth was the only covariate that remained significantly associated with catastrophic costs: The poorest households had 16 times the odds of incurring catastrophic costs versus the wealthiest households (adjusted odds ratio [aOR: 15.7 95% CI: 7.5-33.1])., Conclusion: The majority of TB-affected households, especially those affected by DR-TB, experienced catastrophic costs. Since the major cost drivers fall outside the healthcare system, multi-sectoral approaches to TB control and linking TB patients to social protection may reduce catastrophic costs., (© 2021 John Wiley & Sons Ltd.)

Background: Significant investments have been made towards the implementation of mHealth applications and eRecord systems globally. However, fragmentation of these technologies remains a big challenge, often unresolved in developing countries. In particular, evidence shows little consideration for linking mHealth applications and eRecord systems. Botswana is a typical developing country in sub-Saharan Africa that has explored mHealth applications, but the solutions are not interoperable with existing eRecord systems. This paper describes Botswana's eRecord systems interoperability landscape and provides guidance for linking mHealth applications to eRecord systems, both for Botswana and for developing countries using Botswana as an exemplar., Methods: A survey and interviews of health ICT workers and a review of the Botswana National eHealth Strategy were completed. Perceived interoperability benefits, opportunities and challenges were charted and analysed, and future guidance derived., Results: Survey and interview responses showed the need for interoperable mHealth applications and eRecord systems within the health sector of Botswana and within the context of the National eHealth Strategy. However, the current Strategy does not address linking mHealth applications to eRecord systems. Across Botswana's health sectors, global interoperability standards and Application Programming Interfaces are widely used, with some level of interoperability within, but not between, public and private facilities. Further, a mix of open source and commercial eRecord systems utilising relational database systems and similar data formats are supported. Challenges for linking mHealth applications and eRecord systems in Botswana were identified and categorised into themes which led to development of guidance to enhance the National eHealth Strategy., Conclusion: Interoperability between mHealth applications and eRecord systems is needed and is feasible. Opportunities and challenges for linking mHealth applications to eRecord systems were identified, and future guidance stemming from this insight presented. Findings will aid Botswana, and other developing countries, in resolving the pervasive disconnect between mHealth applications and eRecord systems., (© 2021. The Author(s).)

Background: The most commonly diagnosed cancers among women are breast and cervical cancers, with cervical cancer being a relatively bigger problem in low and middle income countries (LMICs) than breast cancer., Methods: The main aim of this study was to asses factors associated with and socioeconomic inequalities in breast and cervical cancer screening among women aged 15-64 years in Botswana. This study is part of the broad study on Chronic Non-Communicable Diseases in Botswana conducted (NCD survey) in 2016. The NCD survey was conducted across 3 cities and towns, 15 urban villages and 15 rural areas of Botswana. The survey collected information on several NCDs and risk factors including cervical and breast cancer screening. The survey adopted a multistage sampling design and a sample of 1178 participants (males and females) aged 15 years and above was selected in both urban and rural areas of Botswana. For this study, a sub-sample of 813 women aged 15-64 years was selected and included in the analysis. The inequality analysis was conducted using decomposition analysis using ADePT software version 6. Logistic regression models were used to show the association between socioeconomic variables and cervical and breast cancer screening using SPSS version 25. All comparisons were considered statistically significant at 5%., Results: Overall, 6% and 62% of women reported that they were screened for breast and cervical cancer, respectively. Women in the poorest (AOR = 0.16, 95% CI = 0.06-0.45) and poorer (AOR = 0.37, 95% CI = 0.14-0.96) wealth quintiles were less likely to report cervical cancer screening compared to women in the richest wealth quintile. Similarly, for breast cancer, the odds of screening were found to be low among women in the poorest (AOR = 0.39, 95% CI = 0.06-0.68) and the poorer (AOR = 0.45, 95% CI = 0.13-0.81)) wealth quintiles. Concentration indices (CI) showed that cervical (CI = 0.2443) and breast cancer (CI = 0.3975) screening were more concentrated among women with high SES than women with low SES. Wealth status was observed to be the leading contributor to socioeconomic inequality observed for both cervical and breast cancer screening., Conclusions: Findings in this study indicate the need for concerted efforts to address the health care needs of the poor in order to reduce cervical and breast cancer screening inequalities., Competing Interests: The authors have declared that no competing interests exist.

Background: mHealth presents innovative approaches to enhance primary healthcare delivery in developing countries like Botswana. The impact of mHealth solutions can be improved if they are interoperable with eRecord systems such as electronic health records, electronic medical records and patient health records. eHealth interoperability frameworks exist but their availability and utility for linking mHealth solutions to eRecords in developing world settings like Botswana is unknown. The recently adopted eHealth Strategy for Botswana recognises interoperability as an issue and mHealth as a potential solution for some healthcare needs, but does not address linking the two., Aim: This study reviewed published reviews of eHealth interoperability frameworks for linking mHealth solutions with eRecords, and assessed their relevance to informing interoperability efforts with respect to Botswana's eHealth Strategy., Methods: A structured literature review and analysis of published reviews of eHealth interoperability frameworks was performed to determine if any are relevant to linking mHealth with eRecords. The Botswanan eHealth Strategy was reviewed., Results: Four articles presented and reviewed eHealth interoperability frameworks that support linking of mHealth interventions to eRecords and associated implementation strategies. While the frameworks were developed for specific circumstances and therefore were based upon varying assumptions and perspectives, they entailed aspects that are relevant and could be drawn upon when developing an mHealth interoperability framework for Botswana. Common emerging themes of infrastructure, interoperability standards, data security and usability were identified and discussed; all of which are important in the developing world context such as in Botswana. The Botswana eHealth Strategy recognises interoperability, mHealth, and eRecords as distinct issues, but not linking of mHealth solutions with eRecords., Conclusions: Delivery of healthcare is shifting from hospital-based to patient-centered primary healthcare and community-based settings, using mHealth interventions. The impact of mHealth solutions can be improved if data generated from them are converted into digital information ready for transmission and incorporation into eRecord systems. The Botswana eHealth Strategy stresses the need to have interoperable eRecords, but mHealth solutions must not be left out. Literature insight about mHealth interoperability with eRecords can inform implementation strategies for Botswana and elsewhere.

Purpose: Child eye health is a significant public health issue in low- and middle-income countries, such as Botswana, and the need for eye care requires a well-integrated and innovative approach. Traditional vision screening tools are costly, difficult to transport, and reliant on highly trained eye care professionals. Novel smartphone-based vision screening technologies, however, are low cost, portable, and easily operated by trained novice users. Peek Vision is a mobile health (m-Health) organization that creates smartphone applications that screen for visual acuity, generate referrals to eye care professionals, and send phone notifications to those being screened. Methodology: In 2016, the government of Botswana partnered with local and international stakeholders to implement Peek vision screening in a subset of schoolchildren. From June to December of 2016, teachers, health assistants, nurses, and other volunteers in 49 schools in the Goodhope Subdistrict utilized Peek applications to screen schoolchildren, using acuity <6/12 in the better eye as a threshold for visual impairment. Results: Among 12,877 children screened, the application identified 16% (2,065/12,877) as screening positive for visual impairment, and these students were referred for optometric care. Ultimately, 96% (1,985/2,065) attended optometry triage camps, during which 42% (835/1,985) were provided with spectacles, 5% (94/1,985) received ophthalmic medications, and 3% (63/1,985) were referred for ophthalmic care. These findings underscore the need for comprehensive vision screening in schoolchildren in Botswana. Furthermore, the successful implementation of Peek smartphone applications illustrates the potential of m-Health technology for enacting comprehensive vision screening programs at a national level in Botswana and other similar countries.

Occult hepatitis B virus (HBV) infection (OBI) is defined as the presence of HBV DNA in the liver with or without detectable HBV DNA in the serum of individuals testing HBV surface antigen (HBsAg) negative using currently available assays. The prevalence of OBI among patients receiving hemodialysis (HD) treatment remains poorly characterized in South Africa despite the high prevalence of HBV. We sought to determine the prevalence of OBI in HD units in tertiary hospitals of KwaZulu-Natal and to characterize the HBV S gene mutations potentially responsible for OBI. A cross-sectional descriptive study of residual diagnostic plasma samples from 85 HBsAg-negative patients receiving HD treatment was included. The PreS/S gene was amplified with a nested HBV polymerase chain reaction for downstream next-generation sequencing, to determine the viral genotype and identify S gene mutations associated with OBI. Nine of the 85 samples had OBI, based on detectable HBV DNA. The point prevalence of OBI was 10.6% (95% control interval: 5.5%-19.1%). Phylogenetic analysis of the samples with OBI showed that all belonged to genotype A. Three (~33%) samples had mutations in the major hydrophilic region (MHR) within the S gene, three (~33%) had mutations within the S gene but outside the MHR, whilst the remaining three had no mutations observed. The prevalence of OBI in HBsAg-negative patients undergoing HD was 10.6%, suggesting that OBI is a clinically significant problem in patients with HD in this region. The screening methods for HBV infection need to be revised to include nucleic acid testing., (© 2019 Wiley Periodicals, Inc.)

Background: Serious childhood illnesses (SCI), defined as severe pneumonia, severe dehydration, sepsis, and severe malaria, remain major contributors to amenable child mortality worldwide. Inadequate recognition and treatment of SCI are factors that impact child mortality in Botswana. Skills assessments of providers caring for SCI have not been validated in low and middle-income countries., Objective: To establish preliminary inter-rater reliability, validity evidence, and feasibility for an assessment of providers who care for SCI using simulated patients and remote video capture in community clinic settings in Botswana., Methods: This was a pilot study. Four scenarios were developed via a modified Delphi technique and implemented at primary care clinics in Kweneng, Botswana. Sessions were video captured and independently reviewed. Response process and internal structure analysis utilized intra-class correlation (ICC) and Fleiss' Kappa. A structured log was utilized for feasibility of remote video capture., Results: Eleven subjects participated. Scenarios of Lower Airway Obstruction (ICC = 0.925, 95%CI 0.695-0.998) and Hypovolemic Shock from Severe Dehydration (ICC = 0.892, 95%CI 0.596-0.997) produced excellent ICC among raters while Lower Respiratory Tract Infection (LRTI, ICC = 0, 95%CI -0.034-0.97) and LRTI + Distributive Shock from Sepsis (0.365, 95%CI -0.025-0.967) were poor. Oxygen therapy (0.707), arranging transport (0.706), and fluid administration (0.701) demonstrated substantial task reliability., Conclusions: Initial development of an assessment tool demonstrates many, but not all, criteria for validity evidence. Some scenarios and tasks demonstrate excellent reliability among raters, but others may be limited by manikin design and study implementation. Remote simulation assessment of some skills by clinic-based providers in global health settings is reliable and feasible., Competing Interests: The authors have declared that no competing interests exist.

The following correspondence provides an overview of TV White Space (TVWS) technology, regulations, and potential applications to the health care sector. This report also introduces "Project Kgolagano," a Botswana-based initiative representing the first endeavour to utilize TVWS internet connection for practising telemedicine. TV "white space" refers to the previously unused, wasted spectrum within TV radiofrequency channels that can now be leveraged to obtain broadband internet access. TVWS represents a less costly, faster, and farther-reaching internet connection that is a promising option for connecting the previously unconnected populations of remote and underserved areas. The Botswana-University of Pennsylvania Partnership, Microsoft, Botswana Innovation Hub, Vista Life Sciences, and Global Broadband Solutions have partnered together to bring TVWS wireless broadband access to healthcare facilities in poorly connected regions of Botswana (Lobatse, Francistown, Maun, Gaborone) in order to improve healthcare delivery and facilitate telemedicine in dermatology, cervical cancer screening, and family medicine (HIV/AIDS, TB, general adult and pediatric medicine)., (© The Author(s) 2015.)

Effective health care delivery is significantly compromised in an environment where resources, both human and technical, are limited. Botswana's health care system is one of the many in the African continent with few specialized medical doctors, thereby posing a barrier to patients' access to health care services. In addition, the traditional landline and non-robust Information Technology (IT) network infrastructure characterized by slow bandwidth still dominates the health care system in Botswana. Upgrading of the landline IT infrastructure to meet today's health care demands is a tedious, long, and expensive process. Despite these challenges, there still lies hope in health care delivery utilizing wireless telecommunication services. Botswana has recently experienced tremendous growth in the mobile telecommunication industry coupled with an increase in the number of individually owned mobile devices. This growth inspired the Botswana-UPenn Partnership (BUP) to collaborate with local partners to explore using mobile devices as tools to improve access to specialized health care delivery. Pilot studies were conducted across four medical specialties, including radiology, oral medicine, dermatology, and cervical cancer screening. Findings from the studies became vital evidence in support of the first scale-up project of a mobile telemedicine solution in Botswana, also known as "Kgonafalo." Some technical and social challenges were encountered during the initial studies, such as malfunctioning of mobile devices, accidental damage of devices, and cultural misalignment between IT and healthcare providers. These challenges brought about lessons learnt, including a strong need for unwavering senior management support, establishment of solid local public-private partnerships, and efficient project sustainability plans. Sustainability milestones included the development and signing of a Memorandum of Understanding (MOU) between the Botswana government and a private telecommunications partner, the publication and awarding of the government tender to a local IT company, and the development and signing of a Memorandum of Agreement between the Ministry of Health Clinical Services department and the local tender winner. The initial system scale-up is scheduled to occur in 2014 and to ensure the project's sustainability, the system is aligned with the national eHealth strategy and local ownership of the project remains at the forefront (1).