Qualitative evaluation of smallholder and organic farmer decision support tool (DST) and its improvement by inclusion of a disease management component.

Thesis (M.Agric)-University of KwaZulu-Natal, Pietermaritzburg, 2011.Historically, South Africans, particularly small-scale farmers have had little support and hence lack tools and information when faced with production decisions. Information plays an important role in enlightening people, raising their level of knowledge and in turn improving their standard of living and participation in decision making process. Research shows that Information Communication Technology (ICT) like Decision support tools (DSTs) plays an important role in systematic dissemination of information in agriculture, thus improving the quality of farmers’ decisions. Decision support tools provide up-to-date data, procedures and analytical capacity leading to better-informed decisions, especially in rural areas. A body of research is emerging around issues of effectiveness of DSTs for farmers in the developed world. However, few studies have focused on issues around effectiveness of these tools for farmers in the developing world, particularly for resource-limited farmers. This study set out to evaluate the effectiveness of a new DST for organic and small-scale farmers with a group of extension officers and researchers in KwaZulu-Natal. As an extension to the DST, a crop disease management component linked to the DST was developed. The study also set to evaluate the effectiveness of the crop disease management component. Extension officers and researchers were purposively selected for this study because both groups play a major role as far as organising and disseminating information to organic and small-scale farmers is concerned. This study identified key measures for effectiveness of DSTs and crop disease management guides using literature from the study. Two frameworks for measuring effectiveness were developed to evaluate the effectiveness of the new DST and its crop disease management component with the extension officers and researchers. Focus group discussions were used for data collection. The frameworks were used as a base for the focus group discussions. Focus groups were conducted to explore and establish whether in the light the groups (extension officers and researchers), the new DST and its crop disease management component are effective. Results from the study revealed that extension officers and researchers felt that the DST and its crop disease management component are effective since they meet key measures for effectiveness identified in the framework. The groups agreed that the DST and its crop disease management component are relevant to small-scale farmers. They also agreed that the DST has the ability to improve access to information for small-scale farmers. Lastly, they also agreed that the DST and its crop disease management component are transparent (meaning flexible and user friendly) for small-scale farmers. Some of the areas for improvement identified by the groups included a need for information on pests and more diseases for the DST and the crop disease management component. Although the groups felt that both the DST and crop disease management were effective, they strongly recommended a need for another study that will aim at developing a pest management component of the DST as this was clearly requested by groups in this study. Results of this study showed that half the respondents felt that the DST was easy enough to be used by small-scale farmers without help from extension officers, while the other half believed that small-scale farmers will still need the help of extension officers to show them how to use the DST. Government and other relevant institutions need to provide appropriate training for these farmers, making the DST useful to them

Designing an implementation science clinical trial to integrate hypertension and cardiovascular diseases care into existing HIV services package in Botswana (InterCARE)

Background: Despite success in HIV treatment, diagnosis and management of hypertension (HTN) and cardiovascular disease (CVD) remains suboptimal among people living with HIV (PLWH) in Botswana, with an overall HTN control of only 19% compared to 98% HIV viral suppressed. These gaps persist despite CVD primary care national guidelines and availability of free healthcare including antihypertensive medications. Our study aims to develop and test strategies to close the HTN care gap in PLWH, through integration into HIV care, leveraging the successful national HIV care and treatment program and strategies. Methods: The InterCARE trial is a cluster randomized controlled hybrid type 2 effectiveness-implementation trial at 14 sites designed to enroll 4652 adults living with HIV and HTN plus up to 2326 treatment partners. Primary outcomes included effectiveness (HTN control) and implementation outcomes using the Reach Effectiveness Adoption Implementation and Maintenance framework, with explanatory mixed methods used to understand variability in outcomes. InterCARE trial’s main strategies include healthcare worker HTN and CVD care training plus long-term practice facilitation, electronic health record (EHR) documentation of key indicators and use of reminders, and use of treatment partners to provide social support to people living with HIV and HTN. InterCARE started with formative research to identify contextual factors influencing care gaps using the Consolidated Framework for Implementation Research. Results were used to adapt initial and develop additional implementation strategies to address barriers and leverage facilitators. The package was pilot tested in two clinics, with findings used to further adapt or add strategies for the clinical trial. Discussion: If successful, the InterCARE model can be scaled up to HIV clinics nationwide to improve diagnosis, management, and support in Botswana. The trial will provide insights for scale-up of HTN integration into HIV care in the region. Trial registration: ClinicalTrials.gov reference NCT05414526. Registered 18 May 2022, https://clinicaltrials.gov/study/NCT05414526?term=NCT05414526.&rank=1

Qualitative evaluation of smallholder farmer decisions, support systems, knowledge and disease management tools

Rural South African smallholder farmers are deprived of knowledge, relying on eroded indigenous  knowledge to support crop production. Modern technology can play a role in supporting production  decisions and packaging knowledge so it is easily accessible to all levels of users. Information  Communication Technologies, such as Decision Support Tools (DST) play an important role in systematic dissemination of information in agriculture, thus improving the quality of farmer  decisions, especially in  rural areas. These tools are constantly developed, improved and evaluated to assess their applicability  and efficacy. The article is based on the study that aimed at evaluating the effectiveness of a recently developed DST, with a disease management component, to enhance production decisions and  crop-disease management, among organic and small-scale farmers. Due to resource-limitations of most smallholder farmers in South Africa, production  practices, including disease control could be much improved, using indigenous-based, local knowledge about cultural methods of controlling crop diseases. A group of 15 extension officers and 12 researchers were purposively selected for the study because they play a major role in organising and disseminating information to the farmers. Participatory workshop sessions were conducted with groups, where tools were presented, explored and critiqued. The DST was found to have the potential to benefit both organic and smallholder farmers, the study recommends that government should support the development of agricultural DSTs, building on and improving eroded indigenous knowledge, to help farmers improve production and address problems with extension officers and within their resource means.Keywords: Organic farming, small-scale farming, Decision Support Tool (DST), disease management

Cytomegalovirus Immunoglobulin G Levels and Subclinical Arterial Disease among People Living with HIV in Botswana: A Cross-Sectional Study

Cytomegalovirus (CMV) has been linked with increased cardiovascular risk and monocyte activation in people living with HIV (PLWH). This cross-sectional study aimed to compare CMV immunoglobulin G (IgG) levels between combined antiretroviral therapy (cART)-treated PLWH versus ART-naïve PLWH and those without HIV, and to investigate their associations with biomarkers of endothelial injury and carotid atherosclerosis, in Gaborone, Botswana. All participants were between 30 and 50 years old. Carotid intimal media thickness (cIMT) and biomarkers of endothelial injury and monocyte activation were also assessed. The association between quantitative CMV IgG and cardiovascular disease risk was assessed in multivariate logistic regression analysis. The results showed that the mean CMV IgG level among ART-naïve participants was significantly higher than both the cART group and controls. However, CMV IgG levels did not differ significantly between the controls and cART groups. Among PLWH, CMV IgG levels were associated with ICAM-1 levels and cIMT. Increases in CMV IgG among ART-naïve participants were significantly associated with increases in log VCAM-1. In conclusion, CMV IgG levels are elevated among PLWH in sub-Saharan Africa, and higher levels are associated with biomarkers of endothelial injury and cIMT. Future research should investigate the long-term impact of elevated CMV IgG among PLWH

Quantitative outcomes of a type 2 single arm hybrid effectiveness implementation pilot study for hypertension-HIV integration in Botswana

Abstract Background Successful HIV treatment programs have turned HIV into a chronic condition, but noncommunicable diseases such as hypertension jeopardize this progress. Hypertension control rates among people with HIV (PWH) are low owing to gaps in patient awareness, diagnosis, effective treatment, and management of both conditions at separate clinic visits. Integrated management, such as in our study, InterCARE, can enhance HIV-hypertension integration and blood pressure (BP) control. Methods Our pilot study was conducted in two Botswana HIV clinics between October 2021 and November 2022. Based on our formative work, we adopted three main strategies; Health worker training on HTN/cardiovascular disease (CVD) management, adaptation of HIV Electronic Health Record (EHR) for HTN/CVD care, and use of treatment partners to support PWH with hypertension for implementation. We employed the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to assess implementation effectiveness and outcomes for BP control at baseline, 6 and 12 months. HIV viral load (VL) suppression was also measured to assess impact of integration on HIV care. Results We enrolled 290 participants; 35 (12.1%) were lost to follow-up, leaving 255 (87.9%) at 12-months. Median age was 54 years (IQR 46–62), and 77.2% were females. Our interventions significantly improved BP control to < 140/90 mmHg (or < 130/80 mmHg if diagnosis of diabetes or chronic kidney disease), from 137/290 participants, 47.2% at baseline to 206/290 participants, 71.0%, at 12 months (p < 0.001). Among targeted providers, 94.7% received training, with an associated significant increase in counseling on exercise, diet, and medication (all p < 0.001) but EHR use for BP medication prescribing and cardiovascular risk factor evaluation showed no adoption. In the intention-to-treat analysis, HIV VL suppression at 12 months decreased (85.5% vs 93.8%, p = 0.002) due to loss to follow-up but the per protocol analysis showed no difference in VL suppression between baseline and 12 months (97.3% vs 93.3%, p = 0.060). Conclusion The InterCARE pilot study demonstrated that low-cost practical support measures involving the integration of HIV and hypertension/CVD management could lead to improvements in BP control. These results support the need for a large implementation and effectiveness trial. Trial registration ClinicalTrials.gov NCT05414526. Registered 18th May 2022