Billy Tsima

Training hospital providers in basic CPR skills in Botswana: Acquisition, retention and impact of novel training techniques

OBJECTIVE Globally, one third of deaths each year are from cardiovascular diseases, yet no strong evidence supports any specific method of CPR instruction in a resource-limited setting. We hypothesized that both existing and novel CPR training programs significantly impact skills of hospital-based healthcare providers (HCP) in Botswana. METHODS HCP were prospectively randomized to 3 training groups: instructor led, limited instructor with manikin feedback, or self-directed learning. Data was collected prior to training, immediately after and at 3 and 6 months. Excellent CPR was prospectively defined as having at least 4 of 5 characteristics: depth, rate, release, no flow fraction, and no excessive ventilation. GEE was performed to account for within subject correlation. RESULTS Of 214 HCP trained, 40% resuscitate ≥ 1/month, 28% had previous formal CPR training, and 65% required additional skills remediation to pass using AHA criteria. Excellent CPR skill acquisition was significant (infant: 32% vs. 71%, p<0.01; adult 28% vs. 48%, p<0.01). Infant CPR skill retention was significant at 3 (39% vs. 70%, p<0.01) and 6 months (38% vs. 67%, p<0.01), and adult CPR skills were retained to 3 months (34% vs. 51%, p=0.02). On multivariable analysis, low cognitive score and need for skill remediation, but not instruction method, impacted CPR skill performance. CONCLUSIONS HCP in resource-limited settings resuscitate frequently, with little CPR training. Using existing training, HCP acquire and retain skills, yet often require remediation. Novel techniques with increased student: instructor ratio and feedback manikins were not different compared to traditional instruction.

Prevalence and determinants of metabolic syndrome: a cross-sectional survey of general medical outpatient clinics using National Cholesterol Education Program-Adult Treatment Panel III criteria in Botswana

Background Low- and middle-income countries, including Botswana, are facing rising prevalence of obesity and obesity-related cardiometabolic complications. Very little information is known about clustering of cardiovascular risk factors in the outpatient setting during routine visits. We aimed to assess the prevalence and identify the determinants of metabolic syndrome among the general outpatients’ attendances in Botswana. Methods A cross-sectional study was conducted from August to October 2014 involving outpatients aged ≥20 years without diagnosis of diabetes mellitus. A precoded questionnaire was used to collect data on participants’ sociodemographics, risk factors, and anthropometric indices. Fasting blood samples were drawn and analyzed for glucose and lipid profile. Metabolic syndrome was assessed using National Cholesterol Education Program-Adult Treatment Panel III criteria. Results In total, 291 participants were analyzed, of whom 216 (74.2%) were females. The mean age of the total population was 50.1 (±11) years. The overall prevalence of metabolic syndrome was 27.1% (n=79), with no significant difference between the sexes (female =29.6%, males =20%, P=0.11). A triad of central obesity, low high-density lipoprotein-cholesterol, and elevated blood pressure constituted the largest proportion (38 [13.1%]) of cases of metabolic syndrome, followed by a combination of low high-density lipoprotein, elevated triglycerides, central obesity, and elevated blood pressure, with 17 (5.8%) cases. Independent determinants of metabolic syndrome were antihypertensive use and increased waist circumference. Conclusion Metabolic syndrome is highly prevalent in the general medical outpatients clinics. Proactive approaches are needed to screen and manage cases targeting its most important predictors.

Addressing the challenge of the emerging NCD epidemic: lessons learned from Botswana’s response to the HIV epidemic

Botswana has the second highest prevalence of human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS) in the world, and yet it has built one of Africas most progressive and comprehensive HIV programs. While public health infrastructure has responded remarkably to the HIV epidemic, the prevalence of non-communicable diseases (NCDs), particularly diabetes mellitus and cardiovascular disease, in both HIV-infected and non-infected individuals, is increasing rapidly. Applying lessons learned from the scale-up of HIV/AIDS services may help with the implementation of an effective response to the challenges of the emerging NCD epidemic. We suggest that a successful response should include integrated service delivery, capacity building to provide disease-specific care, and strong partnerships to mobilize communities.

High Levels of Post-Abortion Complication in a Setting Where Abortion Service Is Not Legalized

Background Maternal mortality due to abortion complications stands among the three leading causes of maternal death in Botswana where there is a restrictive abortion law. This study aimed at assessing the patterns and determinants of post-abortion complications. Methods A retrospective institution based cross-sectional study was conducted at four hospitals from January to August 2014. Data were extracted from patients’ records with regards to their socio-demographic variables, abortion complications and length of hospital stay. Descriptive statistics and bivariate analysis were employed. Result A total of 619 patients’ records were reviewed with a mean (SD) age of 27.12 (5.97) years. The majority of abortions (95.5%) were reported to be spontaneous and 3.9% of the abortions were induced by the patient. Two thirds of the patients were admitted as their first visit to the hospitals and one third were referrals from other health facilities. Two thirds of the patients were admitted as a result of incomplete abortion followed by inevitable abortion (16.8%). Offensive vaginal discharge (17.9%), tender uterus (11.3%), septic shock (3.9%) and pelvic peritonitis (2.4%) were among the physical findings recorded on admission. Clinically detectable anaemia evidenced by pallor was found to be the leading major complication in 193 (31.2%) of the cases followed by hypovolemic and septic shock 65 (10.5%). There were a total of 9 abortion related deaths with a case fatality rate of 1.5%. Self-induced abortion and delayed uterine evacuation of more than six hours were found to have significant association with post-abortion complications (p-values of 0.018 and 0.035 respectively). Conclusion Abortion related complications and deaths are high in our setting where abortion is illegal. Mechanisms need to be devised in the health facilities to evacuate the uterus in good time whenever it is indicated and to be equipped to handle the fatal complications. There is an indication for clinical audit on post-abortion care to insure implementation of standard protocol and reduce complications.

Developing the Botswana Primary Care guideline: an integrated, symptom-based primary care guideline for the adult patient in a resource‑limited setting

Background Botswana’s health care system is based on a primary care model. Various national guidelines exist for specific diseases. However, most of the guidelines address management at a tertiary level and often appear nonapplicable for the limited resources in primary care facilities. An integrated symptom-based guideline was developed so as to translate the Botswana national guidelines to those applicable in primary care. The Botswana Primary Care Guideline (BPCG) integrates the care of communicable diseases, including HIV/AIDS and noncommunicable diseases, by frontline primary health care workers. Methods The Department of Family Medicine, Faculty of Medicine, University of Botswana, together with guideline developers from the Knowledge Translation Unit (University of Cape Town) collaborated with the Ministry of Health to develop the guideline. Stakeholder groups were set up to review specific content of the guideline to ensure compliance with Botswana government policy and the essential drug list. Results Participants included clinicians, academics, patient advocacy groups, and policymakers from different disciplines, both private and public. Drug-related issues were identified as necessary for implementing recommendations of the guideline. There was consensus by working groups for updating the essential drug list for primary care and expansion of prescribing rights of trained nurse prescribers in primary care within their scope of practice. An integrated guideline incorporating common symptoms of diseases seen in the Botswana primary care setting was developed. Conclusion The development of the BPCG took a broad consultative approach with buy in from relevant stakeholders. It is anticipated that implementation of the BPCG will translate into better patient outcomes as similar projects elsewhere have done.

Clinical use of blood and blood components in post‐abortion care in Botswana

Understanding the pattern and gaps in blood product utilisation in post‐abortion care is crucial for evidence‐based planning and priority setting.

New family medicine residency training programme: Residents' perspectives from the University of Botswana

Background Family Medicine (FM) training is new in Botswana. No previous evaluation of the experiences and opinions of residents of the University of Botswana (UB) Family Medicine training programme has been reported. Aims This study explored and assessed residents’ experiences and satisfaction with the FM training programme at the UB and solicited potential strategies for improvement from the residents. Methods A descriptive survey using a self-administered questionnaire based on a Likert-type scale and open-ended questions was used to collect data from FM residents at the UB. Results Eight out the 14 eligible residents participated to this study. Generally, residents were not satisfied with the FM training programme. Staff shortage, inadequate supervision and poor programme organisation by the faculty were the main reasons for this. However, the residents were satisfied with weekly training schedules and the diversity of patients in the current training sites. Residents’ potential solutions included an increase in staff, the acquisition of equipment at teaching sites and emphasis on FM core topics teachings. They had different views regarding how certain future career paths will be. Conclusions Despite the general dissatisfaction among residents because of challenges faced by the training programme, we have learnt that residents are capable of valuable inputs for improvement of their programme when engaged. There is need for the Department of Family Medicine to work with the Ministry of Health to set a clear career pathway for future graduates and to reflect on residents’ input for possible implementation.

Clinical challenges in the co-management of diabetes mellitus and tuberculosis in southern Africa

Abstract Over the past 20 years, tuberculosis incidence in southern Africa has increased at an alarming rate, fuelled primarily by the human immunodeficiency virus epidemic. The emerging prevalence of diabetes mellitus in the region represents a new threat to tuberculosis control. The intersecting double burden is a cause for concern since diabetes mellitus increases the risk of tuberculosis and results in poor treatment outcomes. This review article discusses the evidence of a causal association between these two conditions, and examines the numerous clinical challenges that relate to tuberculosis and diabetes mellitus co-management. Diabetes is associated with a more advanced age and body weight in patients with tuberculosis, although not with a specific clinical presentation of tuberculosis. Rifampicin adversely alters glycaemic control by lowering the concentrations of most oral antidiabetic drugs. Poor glycaemic control, possibly exacerbated by tuberculosis and anti-tuberculous therapy, is an important contributing factor to tuberculosis case fatality and relapse. Clinicians need to be aware of these clinical and pharmacological challenges when co-managing these complex diseases.

Use of oxytocin during Caesarean section at Princess Marina Hospital, Botswana : an audit of clinical practice.

Abstract Background Oxytocin is widely used for the prevention of postpartum haemorrhage. In the setting of Caesarean section (CS), the dosage and mode of administrating oxytocin differs according to different guidelines. Inappropriate oxytocin doses have been identified as contributory to some cases of maternal deaths. The main aim of this study was to audit the current standard of clinical practice with regard to the use of oxytocin during CS at a referral hospital in Botswana. Methods A clinical audit of pregnant women having CS and given oxytocin at the time of the operation was conducted over a period of three months. Data included indications for CS, oxytocin dose regimen, prescribing clinicians designation, type of anaesthesia for the CS and estimated blood loss. Results A total of 139 case records were included. The commonest dose was 20 IU infusion (31.7%). The potentially dangerous regimen of 10 IU intravenous bolus of oxytocin was used in 12.9% of CS. Further doses were utilized in 57 patients (41%). The top three indications for CS were fetal distress (36 patients, 24.5%), dystocia (32 patients, 21.8%) and a previous CS (25 patients, 17.0%). Estimated blood loss ranged from 50 mL – 2000 mL. Conclusion The use of oxytocin during CS in the local setting does not follow recommended practice. This has potentially harmful consequences. Education and guidance through evidence based national guidelines could help alleviate the problem.

Screening for tuberculosis in a diabetes clinic in Gaborone, Botswana.

The tuberculosis (TB) case notification rate in Botswana is one of the highest in Africa.1 While more than 63% of cases occur in individuals infected with the human immunodeficiency virus (HIV),1 there is growing concern that diabetes mellitus (DM) may characterize another under-recognized high risk group in this setting.2,3 Research from high-income settings has demonstrated that DM patients are at increased risk of TB.3 However, there are no data describing the burden of TB disease among patients with DM in Botswana, despite the fact that approximately 10% of Batswana have DM.4 We sought to determine the burden of TB disease in the main DM clinic in Gaborone, Botswana. After providing consent, eligible patients attending the clinic were enrolled and screened for TB symptoms (cough .2 weeks, fever, night sweats, and weight loss); those screening positive for one or more symptom were then sent for sputum smear microscopy and chest radiograph (CXR) in accordance with national guidelines. The study was approved by Institutional Review Boards of Botswana’s Ministry of Health, University of Botswana and University of Pennsylvania. Of 823 DM patients routinely screened between 5 August and 6 September 2013, 47 (5.7%) had one or more TB symptoms. Of the 177 enrolled in the study, 43 screened positive, while 134 were asymptomatic for TB. Sputum samples were collected from 30% (n 1⁄4 14) of those individuals screening positive; CXR was performed on 28% (n 1⁄4 13). We found no difference in HIV infection rates between those with and those without TB symptoms (13% [6/43] vs. 10% [14/134], P 1⁄4 0.53), nor were there significant differences in the proportion with a history of TB (12% [5/43] vs. 8% [11/134], P1⁄4 0.50). No patients enrolled in the study were diagnosed with TB. Despite the very high reported case notification rates in Botswana,1 we detected zero cases of TB. While this might suggest that TB need not be a public health concern in Botswana’s DM clinics, we argue that the data tell another story. Notably, CXR and smear microscopy were performed on a small fraction of those who screened positive. A lack of on-site diagnostic resources was partly responsible for such low numbers; participants had to travel to other clinics to undergo CXRs. However, even if more of those screening positive had undergone testing for TB, the data may have underestimated TB incidence among DM patients, as only about 20% of individuals with DM in Botswana know their DM diagnosis.4 It is not surprising that we did not see any cases of TB among the HIV-infected patients, given the small sample size and the fact that the HIV-infected patients attending the DM clinic were almost all on antiretroviral treatment. We acknowledge the limitations of our study: we only performed diagnostic tests on those individuals who screened positive and we only analyzed data over a short period of time. While the data do not suggest that TB is a problem among DM patients in Gaborone, this is not consistent with data from elsewhere in Africa.5 More research is warranted to investigate how the increasing incidence of DM impacts TB control efforts in Botswana.