Publications by authors named "Tonya Arscott-Mills"

27 Publications

  • Page 1 of 1

Stigma, Structural Vulnerability, and "What Matters Most" Among Women Living With HIV in Botswana, 2017.

Am J Public Health 2021 Jun 10:e1-e9. Epub 2021 Jun 10.

Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the Department of Psychology, University of Botswana, Gaborone, Botswana. Marlene M. Eisenberg and Michael B. Blank are with the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Lyla S. Yang is with the Columbia School of Social Work, Columbia University. Thi Xuan Dai Cao is with the Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada. Lilo I. Blank is with the College of Arts and Sciences, University of Rochester, Rochester, NY. Timothy D. Becker is with the Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY. Bruce G. Link is with the Department of Sociology, University of California Riverside. Patlo Entaile is with the Botswana‒UPenn Partnership, Gaborone. Philip R. Opondo is with the Department of Psychiatry, University of Botswana. Tonya Arscott-Mills is with the Perelman School of Medicine, University of Pennsylvania. Ari R. Ho-Foster is with the Faculty of Medicine, University of Botswana.

To explore whether beneficial health care policies, when implemented in the context of gender inequality, yield unintended structural consequences that stigmatize and ostracize women with HIV from "what matters most" in local culture. We conducted 46 in-depth interviews and 5 focus groups (38 individuals) with men and women living with and without HIV in Gaborone, Botswana, in 2017. Cultural imperatives to bear children bring pregnant women into contact with free antenatal services including routine HIV testing, where their HIV status is discovered before their male partners'. National HIV policies have therefore unintentionally reinforced disadvantage among women with HIV, whereby men delay or avoid testing by using their partner's status as a proxy for their own, thus facilitating blame toward women diagnosed with HIV. Gossip then defines these women as "promiscuous" and as violating the essence of womanhood. We identified cultural and structural ways to resist stigma for these women. Necessary HIV testing during antenatal care has inadvertently perpetuated a structural vulnerability that propagates stigma toward women. Individual- and structural-level interventions can address stigma unintentionally reinforced by health care policies. (. Published online ahead of print June 10, 2021: e1-e9. https://doi.org/10.2105/AJPH.2021.306274).
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http://dx.doi.org/10.2105/AJPH.2021.306274DOI Listing
June 2021

Identifying "What Matters Most" to Men in Botswana to Promote Resistance to HIV-Related Stigma.

Qual Health Res 2021 Mar 25:10497323211001361. Epub 2021 Mar 25.

Columbia University, New York, New York, USA.

Despite a comprehensive national program of free HIV services, men living with HIV in Botswana participate at lower rates and have worse outcomes than women. Directed content analysis of five focus groups ( = 38) and 50 in-depth interviews with men and women with known and unknown HIV status in Gaborone, Botswana in 2017 used the "what matters most" (WMM) and "structural vulnerability" frameworks to examine how the most valued cultural aspects of manhood interact with HIV-related stigma. WMM for manhood in Botswana included fulfilling male responsibilities by being a capable provider and maintaining social status. Being identified with HIV threatened WMM, which fear of employment discrimination could further exacerbate. Our findings indicate how cultural and structural forces interact to worsen or mitigate HIV-related stigma for urban men in Botswana. These threats to manhood deter HIV testing and treatment, but interventions could capitalize on cultural capabilities for manhood to promote stigma resistance.
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http://dx.doi.org/10.1177/10497323211001361DOI Listing
March 2021

Reply to authors.

Clin Infect Dis 2020 Oct 26. Epub 2020 Oct 26.

Botswana-UPenn Partnership, Gaborone, Botswana.

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http://dx.doi.org/10.1093/cid/ciaa1628DOI Listing
October 2020

'Mothers moving towards empowerment' intervention to reduce stigma and improve treatment adherence in pregnant women living with HIV in Botswana: study protocol for a pragmatic clinical trial.

Trials 2020 Oct 7;21(1):832. Epub 2020 Oct 7.

New York University, New York, NY, United States.

Background: With high rates of HIV and multiple vulnerable subgroups across diverse settings, there is a need for culturally based, HIV stigma reduction interventions. Pregnant women who are living with HIV are especially in need of services to protect not only their own but also their children's lives. Uptake of HIV services worldwide is hindered by stigma towards persons living with HIV/AIDS. While cultural context plays a key role in shaping HIV stigma, these insights have not yet been fully integrated into stigma reduction strategies. By utilizing the "What Matters Most" stigma framework, we propose that an intervention to counter culturally salient aspects of HIV stigma will improve treatment adherence and other relevant outcomes. A pragmatic clinical trial in Botswana will evaluate the "Mothers Moving towards Empowerment" (MME) intervention, which seeks to address HIV stigma in Botswana and to specifically engage pregnant mothers so as to promote antiretroviral therapy (ART) adherence in the postpartum period.

Methods: This study will test MME against treatment as usual (TAU) among pregnant mothers diagnosed with HIV and their infants. Outcomes will be assessed during pregnancy and 16 weeks postpartum. Women who meet eligibility criteria are assigned to MME or TAU. Women assigned to MME are grouped with others with similar estimated delivery dates, completing up to eight intervention group sessions scheduled before week 36 of their pregnancies. Primary outcomes among mothers include (i) reducing self-stigma, which is hypothesized to mediate improvements in (ii) psychological outcomes (quality of life, depression and social functioning), and (iii) adherence to antenatal care and ART. We will also examine a set of follow-up infant birth outcomes (APGAR score, preterm delivery, mortality (at < 16 weeks), birth weight, vaccination record, and HIV status).

Discussion: Our trial will evaluate MME, a culturally based HIV stigma reduction intervention using the "What Matters Most" framework, to reduce stigma and improve treatment adherence among pregnant women and their infants. This study will help inform further refinement of MME and preparation for a future large-scale, multisite, randomized controlled trial (RCT) in Botswana.

Trial Registration: ClinicalTrials.gov NCT03698981 . Registered on October 8, 2018.
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http://dx.doi.org/10.1186/s13063-020-04676-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542742PMC
October 2020

Pediatric Spectrum of Allergic Diseases and Asthma in a Tertiary Level Hospital in Botswana: an Exploratory Retrospective Cross-Sectional Study.

J Asthma Allergy 2020 1;13:213-223. Epub 2020 Jul 1.

Department of Pediatrics and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana.

Purpose: This study aims to describe the spectrum of allergic diseases of children and adolescents in a single allergy treatment centre in Botswana, over a period of 8 years.

Patients And Methods: A retrospective cross-sectional study was conducted using medical records of all patients aged 18 years or younger, seen at an allergy treatment centre in Botswana. Data were presented descriptively. Association between variables was explored by -test.

Results: Four hundred and seven patients with a mean age of 5.8 years (SD 4.4) at the time of presentation included 239 (58.7%) females and 365 (87.5%) black Africans. The most common diseases were asthma (n=249, 61.2%) followed by allergic rhinitis (AR) (n=232, 57.0%) and atopic dermatitis (AD) (n=165, 40.5%). One hundred and fifteen cases (46.2%) of asthmatic patients were skin prick test positive; sensitized to grass, moulds, dust mites and animal dander, in decreasing frequency, whereas those with allergic rhinitis (AR) and allergic conjunctivitis (AC) were sensitized to trees and all allergens identified in asthmatics. Concomitant asthma was diagnosed in 171 (73.7%) with AR, 71 (68.3%) with AC, 75 (45.5%) with AD and 42 (47.7%) with food allergy. The most common triggers for asthma exacerbations include upper respiratory tract infections, weather changes, and exposure to passive cigarette smoke. Paternal allergy and allergic disease in grandparents are predisposing factors for asthma (=0.016 and =0.001, respectively). Paternal allergy is also predisposed to AR (=0.007), while maternal history of allergic disease was associated with AD (=0.019).

Conclusion: The most common chronic pediatric conditions seen in our allergic disease study were asthma, allergic rhinitis and atopic dermatitis with the most common triggers being viral upper respiratory tract infections, weather changes and exposure to cigarette smoke, all of which are modifiable risk factors. This exploratory study lays the foundation for future interventional studies that may be directed towards the spectrum of allergic diseases.
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http://dx.doi.org/10.2147/JAA.S253618DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342389PMC
July 2020

Effect of Haemophilus influenzae Type b and 13-Valent Pneumococcal Conjugate Vaccines on Childhood Pneumonia Hospitalizations and Deaths in Botswana.

Clin Infect Dis 2021 Jul;73(2):e410-e416

Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina, USA.

Background: Globally, pneumonia is the leading cause of death among children. Few data exist regarding the effect of Haemophilus influenzae type b (Hib) vaccine and 13-valent pneumococcal conjugate vaccine (PCV-13) on the burden of childhood pneumonia in African settings.

Methods: We collected data on children aged 1 to 59 months at 3 hospitals in Botswana. Hib vaccine and PCV-13 were introduced in Botswana in November 2010 and July 2012, respectively. We compared pneumonia hospitalizations and deaths prevaccine (January 2009 to October 2010) with postvaccine (January 2013 to December 2017) using seasonally adjusted, interrupted time-series analyses.

Results: We identified 6943 pneumonia hospitalizations and 201 pneumonia deaths. In the prevaccine period, pneumonia hospitalizations and deaths increased by 24% (rate, 1.24; 95% CI, .94-1.64) and 59% (rate, 1.59; 95% CI, .87-2.90) per year, respectively. Vaccine introduction was associated with a 48% (95% CI, 29-62%) decrease in the number of pneumonia hospitalizations and a 50% (95% CI, 1-75%) decrease in the number of pneumonia deaths between the end of the prevaccine period (October 2010) and the beginning of the postvaccine period (January 2013). During the postvaccine period, pneumonia hospitalizations and deaths declined by 6% (rate, .94; 95% CI, .89-.99) and 22% (rate, .78; 95% CI, .67-.92) per year, respectively.

Conclusions: Pneumonia hospitalizations and deaths among children declined sharply following introduction of Hib vaccine and PCV-13 in Botswana. This effect was sustained for more than 5 years after vaccine introduction, supporting the long-term effectiveness of these vaccines in preventing childhood pneumonia in Botswana.
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http://dx.doi.org/10.1093/cid/ciaa919DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8282259PMC
July 2021

Interpretation of pediatric chest radiographs by non-radiologist clinicians in Botswana using World Health Organization criteria for endpoint pneumonia.

Pediatr Radiol 2020 06 10;50(7):913-922. Epub 2020 Jun 10.

Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Background: In low- and middle-income countries, chest radiographs are most frequently interpreted by non-radiologist clinicians.

Objective: We examined the reliability of chest radiograph interpretations performed by non-radiologist clinicians in Botswana and conducted an educational intervention aimed at improving chest radiograph interpretation accuracy among non-radiologist clinicians.

Materials And Methods: We recruited non-radiologist clinicians at a referral hospital in Gaborone, Botswana, to interpret de-identified chest radiographs for children with clinical pneumonia. We compared their interpretations with those of two board-certified pediatric radiologists in the United States. We evaluated associations between level of medical training and the accuracy of chest radiograph findings between groups, using logistic regression and kappa statistics. We then developed an in-person training intervention led by a pediatric radiologist. We asked participants to interpret 20 radiographs before and immediately after the intervention, and we compared their responses to those of the facilitating radiologist. For both objectives, our primary outcome was the identification of primary endpoint pneumonia, defined by the World Health Organization as presence of endpoint consolidation or endpoint effusion.

Results: Twenty-two clinicians interpreted chest radiographs in the primary objective; there were no significant associations between level of training and correct identification of endpoint pneumonia; concordance between respondents and radiologists was moderate (κ=0.43). After the training intervention, participants improved agreement with the facilitating radiologist for endpoint pneumonia from fair to moderate (κ=0.34 to κ=0.49).

Conclusion: Non-radiologist clinicians in Botswana do not consistently identify key chest radiographic findings of pneumonia. A targeted training intervention might improve non-radiologist clinicians' ability to interpret chest radiographs.
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http://dx.doi.org/10.1007/s00247-020-04625-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7539136PMC
June 2020

Botswana's HIV response: Policies, context, and future directions.

J Community Psychol 2020 04 17;48(3):1066-1070. Epub 2020 Jan 17.

Social and Behavioral Sciences, New York University College of Global Public Health, New York, New York.

This brief report describes key periods in the history of the national public health response to the human immunodeficiency virus (HIV) epidemic in Botswana. It reveals the context leading to the development of HIV policies presently in place and current challenges that remain. The report concludes with opportunities for future directions, initiatives, and policy changes to reduce the high rates of HIV.
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http://dx.doi.org/10.1002/jcop.22316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7103557PMC
April 2020

The prevalence and clinical characteristics of pertussis-associated pneumonia among infants in Botswana.

BMC Pediatr 2019 11 16;19(1):444. Epub 2019 Nov 16.

Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.

Background: There are scant data on the prevalence and clinical course of pertussis disease among infants with pneumonia in low- and middle-income countries. While pertussis vaccination coverage is high (≥90%) among infants in Botswana, human immunodeficiency virus (HIV) infection affects nearly one-third of pregnancies. We aimed to evaluate the prevalence and clinical course of pertussis disease in a cohort of HIV-unexposed uninfected (HUU), HIV-exposed uninfected (HEU), and HIV-infected infants with pneumonia in Botswana.

Methods: We recruited children 1-23 months of age with clinical pneumonia at a tertiary care hospital in Gaborone, Botswana between April 2012 and June 2016. We obtained nasopharyngeal swab specimens at enrollment and tested these samples using a previously validated in-house real-time PCR assay that detects a unique sequence of the porin gene of Bordetella pertussis.

Results: B. pertussis was identified in 1/248 (0.4%) HUU, 3/110 (2.7%) HEU, and 0/33 (0.0%) HIV-infected children. All pertussis-associated pneumonia cases occurred in infants 1-5 months of age (prevalence, 1.0% [1/103] in HUU and 4.8% [3/62] in HEU infants). No HEU infants with pertussis-associated pneumonia were taking cotrimoxazole prophylaxis at the time of hospital presentation. One HUU infant with pertussis-associated pneumonia required intensive care unit admission for mechanical ventilation, but there were no deaths.

Conclusions: The prevalence of pertussis was low among infants and young children with pneumonia in Botswana. Although vaccination against pertussis in pregnancy is designed to prevent classical pertussis disease, reduction of pertussis-associated pneumonia might be an important additional benefit.
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http://dx.doi.org/10.1186/s12887-019-1820-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858628PMC
November 2019

Placental Transfer of Respiratory Syncytial Virus Antibody Among HIV-Exposed, Uninfected Infants.

J Pediatric Infect Dis Soc 2020 Jul;9(3):349-356

Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina.

Background: Maternal human immunodeficiency virus (HIV) infection is associated with lower placental transfer of antibodies specific to several childhood pathogens. Our objective for this study was to evaluate the effect of maternal HIV infection on the placental transfer of respiratory syncytial virus (RSV)-neutralizing antibodies.

Methods: We conducted a cross-sectional study of mothers and their newborn infants at a tertiary hospital in Gaborone, Botswana, between March 2015 and December 2015. We measured serum RSV antibody levels by using a microneutralization assay. We used multivariable linear regression to evaluate the effect of maternal HIV infection on maternal RSV antibody levels, placental transfer of RSV antibodies, and newborn RSV antibody levels.

Results: Of 316 mothers, 154 (49%) were infected with HIV. The placental transfer ratios for RSV antibodies to HIV-exposed, uninfected (HEU) and HIV-unexposed, uninfected infants were 1.02 and 1.15, respectively. The geometric mean titer (95% confidence interval) of RSV-neutralizing antibodies was 2657 (2251-3136) among HEU newborns and 2911 (2543-3331) among HIV-unexposed, uninfected newborns. In multivariable analyses, maternal HIV infection was associated with lower placental transfer of RSV antibodies (P = .02) and a lower level of RSV antibodies among newborns (P = .002). Among HEU newborns, higher birth weight (P = .004) and an undetectable maternal antenatal viral load (P = .01) were associated with more effective placental transfer of RSV antibodies.

Conclusions: Maternal human immunodeficiency virus (HIV) infection is associated with lower mother-to-fetus transfer of serum RSV-neutralizing antibodies. HEU infants should be prioritized for preventive interventions for RSV. Maternal viral suppression through combination antiretroviral therapy has the potential to improve immunity to RSV among HIV-exposed infants.
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http://dx.doi.org/10.1093/jpids/piz056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358043PMC
July 2020

Evaluation of Anatomically Designed Flocked Rectal Swabs for Use with the BioFire FilmArray Gastrointestinal Panel for Detection of Enteric Pathogens in Children Admitted to Hospital with Severe Gastroenteritis.

J Clin Microbiol 2019 12 22;57(12). Epub 2019 Nov 22.

Department of Pathology and Laboratory Medicine, BC Children's Hospital, Vancouver, British Columbia, Canada

Diagnosing diarrheal disease is difficult in part due to challenges in obtaining and transporting a bulk stool specimen, particularly in resource-limited settings. We compared the performance of flocked rectal swabs to that of traditional bulk stool samples for enteric pathogen detection using the BioFire FilmArray gastrointestinal panel in children admitted to four hospitals in Botswana with community onset severe gastroenteritis. Of the 117-matched flocked rectal swab/stool pairs, we found no significant difference in pathogen detection rates between the flocked rectal swab samples and traditional bulk stool sampling methods for any bacterial (168 versus 167, respectively), viral (94 versus 92, respectively), or protozoan (18 versus 18, respectively) targets. The combination of flocked rectal swab samples with FilmArray testing allows for the rapid diagnosis of infectious gastroenteritis, facilitating a test-and-treat approach for infections that are life-threatening in many resource-limited settings. The culture recovery rates for bacterial pathogens utilizing this approach need to be assessed.
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http://dx.doi.org/10.1128/JCM.00962-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6879274PMC
December 2019

Investigating Outcomes of Adolescents and Young Adults (10-24 Years of Age) Lost to Follow-up from Tuberculosis Treatment in Gaborone, Botswana.

Pediatr Infect Dis J 2019 10;38(10):e271-e274

From the Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

This retrospective study investigated outcomes among lost to follow-up (LTFU) adolescents and young adults (AYAs: 10-24 years of age) with tuberculosis (TB) registered from 2008 to 2014 in Gaborone, using surveillance data. Of 68 LTFU AYAs, 16 repeated treatment; 8 completed and 6 were again LTFU. Of 4 confirmed deaths, 3 had TB/HIV coinfection. Approaches to improve AYA retention in TB care are needed.
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http://dx.doi.org/10.1097/INF.0000000000002369DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6768719PMC
October 2019

Maintenance of Certification: You Can Make Your Global Health Work Count.

Pediatrics 2019 06 9;143(6). Epub 2019 May 9.

American Board of Pediatrics, Chapel Hill, North Carolina.

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http://dx.doi.org/10.1542/peds.2018-3887DOI Listing
June 2019

High Rate of Serotype V Carriage in Pregnant Women in Botswana.

Am J Trop Med Hyg 2019 05;100(5):1115-1117

Department of Microbiology, New York University School of Medicine, New York, New York.

Maternal rectovaginal colonization is the major risk factor for early-onset neonatal sepsis due to Group B (GBS), a major cause of early life morbidity and mortality. Transmission generally occurs perinatally from colonized mothers to infants. Vaccines targeting a subset of GBS serotypes are under development, but GBS epidemiology remains poorly understood in many African nations. We performed a cross-sectional study of GBS colonization among pregnant women at two sites in Botswana, a country with minimal prior GBS carriage data. We found a rectovaginal colonization rate of 19%, comparable with studies in other regions; however, we also noted a striking predominance of serotype V (> 45% of strains). Although further studies are required to delineate the burden of invasive GBS disease in Botswana and the generalizability of type V epidemiology, these data provide a useful baseline for understanding the potential local impact of GBS prevention strategies, including vaccines.
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http://dx.doi.org/10.4269/ajtmh.18-0847DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6493924PMC
May 2019

Predictors of Poor Outcomes Among Infants With Respiratory Syncytial Virus-associated Acute Lower Respiratory Infection in Botswana.

Pediatr Infect Dis J 2019 05;38(5):525-527

Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina.

Among children 1-23 months of age with respiratory syncytial virus-associated acute lower respiratory infection in Botswana, young age (<6 months), household use of wood as a cooking fuel, moderate or severe malnutrition and oxygen saturation <90% on room air were independent predictors of clinical nonresponse at 48 hours. Among HIV-uninfected infants less than six months of age, HIV exposure was associated with a higher risk of in-hospital mortality.
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http://dx.doi.org/10.1097/INF.0000000000002168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6465100PMC
May 2019

Pneumococcal Colonization and the Nasopharyngeal Microbiota of Children in Botswana.

Pediatr Infect Dis J 2018 11;37(11):1176-1183

Division of Pediatric Infectious Diseases, Ann and Robert Lurie Children's Hospital, Chicago, IL.

Background: Nasopharyngeal colonization precedes infections caused by Streptococcus pneumoniae. A more detailed understanding of interactions between S. pneumoniae and the nasopharyngeal microbiota of children could inform strategies to prevent pneumococcal infections.

Methods: We collected nasopharyngeal swabs from children 1 to 23 months of age in Botswana between August 2012 and June 2016. We tested samples for S. pneumoniae and common respiratory viruses using polymerase chain reaction. We sequenced the V3 region of the bacterial 16S ribosomal RNA gene and used random forest models to identify clinical variables and bacterial genera that were associated with pneumococcal colonization.

Results: Mean age of the 170 children included in this study was 8.3 months. Ninety-six (56%) children were colonized with S. pneumoniae. Pneumococcal colonization was associated with older age (P = 0.0001), a lack of electricity in the home (P = 0.02) and household use of wood as a cooking fuel (P = 0.002). Upper respiratory symptoms were more frequent in children with S. pneumoniae colonization (60% vs. 32%; P = 0.001). Adjusting for age, nasopharyngeal microbiota composition differed in colonized and noncolonized children (P = 0.001). S. pneumoniae colonization was associated with a higher relative abundance of Moraxella (P = 0.001) and lower relative abundances of Corynebacterium (P = 0.001) and Staphylococcus (P = 0.03). A decision tree model containing the relative abundances of bacterial genera had 81% sensitivity and 85% specificity for the determination of S. pneumoniae colonization status.

Conclusions: S. pneumoniae colonization is associated with characteristic alterations of the nasopharyngeal microbiota of children. Prospective studies should determine if nasopharyngeal microbial composition alters the risk of pneumococcal colonization and thus could be modified as a novel pneumonia prevention strategy.
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http://dx.doi.org/10.1097/INF.0000000000002174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6181769PMC
November 2018

Investigating Mediators of the Poor Pneumonia Outcomes of Human Immunodeficiency Virus-Exposed but Uninfected Children.

J Pediatric Infect Dis Soc 2019 Mar;8(1):13-20

Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina.

Background: Human immunodeficiency virus-exposed but uninfected (HIV-EU) children have a higher mortality rate than the children of HIV-negative mothers (HIV-unexposed). Causal mediators of the poor health outcomes of HIV-EU children remain poorly defined.

Methods: We conducted a hospital-based prospective cohort study of children aged 1 to 23 months with clinically defined pneumonia. The children were recruited at a referral hospital in Gaborone, Botswana, between April 2012 and June 2016. The primary outcome, treatment failure at 48 hours, was assessed by an investigator blinded to the children's HIV-exposure status. We examined associations between HIV exposure and pneumonia outcomes in HIV-uninfected children. We next determined whether the effect of HIV exposure on outcomes was mediated by low-birth-weight status, nonbreastfeeding, malnutrition, in utero exposure to combination antiretroviral therapy, or pneumonia severity.

Results: A total of 352 HIV-uninfected children were included in these analyses, including 245 (70%) HIV-unexposed and 107 (30%) HIV-EU children. Their median age was 7.4 months, and 57% were male. Treatment failure occurred in 111 (32%) children, and 19 (5.4%) children died. HIV-EU children were more likely to fail treatment (risk ratio [RR], 1.57 [95% confidence interval (CI), 1.19-2.07]; P = .002) and had a higher in-hospital mortality rate (RR, 4.50 [95% CI, 1.86-10.85]; P = .001) than HIV-unexposed children. Nonbreastfeeding mediated 47% of the effect of HIV exposure on the risk of in-hospital death.

Conclusions: HIV-EU children have worse pneumonia outcomes than HIV-unexposed children. Nonbreastfeeding mediates nearly half of the effect of HIV exposure on pneumonia mortality. Our findings provide additional evidence for a mortality benefit of breastfeeding by HIV-EU children.
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http://dx.doi.org/10.1093/jpids/pix092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6437836PMC
March 2019

The Nasopharyngeal Microbiota of Children With Respiratory Infections in Botswana.

Pediatr Infect Dis J 2017 Sep;36(9):e211-e218

From the *Botswana-UPenn Partnership, Gaborone, Botswana; †Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina; ‡Department of Medicine, McMaster University, §Department of Pathology and Molecular Medicine, McMaster University, ¶St. Joseph's Healthcare, and ‖Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada; **Global Health Center, and ††Division of Pediatric Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; ‡‡Department of Pathology and Laboratory Medicine, BC Children's Hospital, Vancouver, British Columbia, Canada; §§University of Botswana School of Medicine, Gaborone, Botswana; ¶¶Department of Molecular Genetics and Microbiology, Center for the Genomics of Microbial Systems, Duke University Medical Center, Durham, North Carolina; and ‖‖Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

Background: Nearly half of child pneumonia deaths occur in sub-Saharan Africa. Microbial communities in the nasopharynx are a reservoir for pneumonia pathogens and remain poorly described in African children.

Methods: Nasopharyngeal swabs were collected from children with pneumonia (N = 204), children with upper respiratory infection symptoms (N = 55) and healthy children (N = 60) in Botswana between April 2012 and April 2014. We sequenced the V3 region of the bacterial 16S ribosomal RNA gene and used partitioning around medoids to cluster samples into microbiota biotypes. We then used multivariable logistic regression to examine whether microbiota biotypes were associated with pneumonia and upper respiratory infection symptoms.

Results: Mean ages of children with pneumonia, children with upper respiratory infection symptoms and healthy children were 8.2, 11.4 and 8.0 months, respectively. Clustering of nasopharyngeal microbiota identified 5 distinct biotypes: Corynebacterium/Dolosigranulum-dominant (23%), Haemophilus-dominant (11%), Moraxella-dominant (24%), Staphylococcus-dominant (13%) and Streptococcus-dominant (28%). The Haemophilus-dominant [odds ratio (OR): 13.55; 95% confidence interval (CI): 2.10-87.26], the Staphylococcus-dominant (OR: 8.27; 95% CI: 2.13-32.14) and the Streptococcus-dominant (OR: 39.97; 95% CI: 6.63-241.00) biotypes were associated with pneumonia. The Moraxella-dominant (OR: 3.71; 95% CI: 1.09-12.64) and Streptococcus-dominant (OR: 12.26; 95% CI: 1.81-83.06) biotypes were associated with upper respiratory infection symptoms. In children with pneumonia, HIV infection was associated with a lower relative abundance of Dolosigranulum (P = 0.03).

Conclusions: Pneumonia and upper respiratory infection symptoms are associated with distinct nasopharyngeal microbiota biotypes in African children. A lower abundance of the commensal genus Dolosigranulum may contribute to the higher pneumonia risk of HIV-infected children.
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http://dx.doi.org/10.1097/INF.0000000000001607DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5555803PMC
September 2017

Rural exposure during medical education and student preference for future practice location - a case of Botswana.

Afr J Prim Health Care Fam Med 2016 Jun 10;8(1):e1-6. Epub 2016 Jun 10.

Botswana-UPenn Partnership, Botswana and Department of Paediatrics, Perelman School of Medicine, University of Pennsylvania, USA and Department of Paediatrics, University of Botswana, Faculty of Medicine.

Background: Botswana's medical school graduated its first class in 2014. Given the importance of attracting doctors to rural areas the school incorporated rural exposure throughout its curriculum.

Aim: This study explored the impact of rural training on students' attitudes towards rural practice.

Setting: The University of Botswana family medicine rural training sites, Maun and Mahalapye.

Methods: The study used a mixed-methods design. After rural family medicine rotations, third- and fifth-year students were invited to complete a questionnaire and semi-structured interview. Data were analysed using descriptive statistics and thematic analysis.

Results: The thirty-six participants' age averaged 23 years and 48.6% were male. Thirtythree desired urban practice in a public institution or university. Rural training did not influence preferred future practice location. Most desired specialty training outside Botswana but planned to practice in Botswana. Professional stagnation, isolation, poorly functioning health facilities, dysfunctional referral systems, and perceived lack of learning opportunities were barriers to rural practice. Lack of recreation and poor infrastructure were personal barriers. Many appreciated the diversity of practice and supportive staff seen in rural practice. Several considered monetary compensation as an enticement for rural practice. Only those with a rural background perceived proximity to family as an incentive to rural practice.

Conclusion: The majority of those interviewed plan to practice in urban Botswana, however, they did identify factors that, if addressed, may increase rural practice in the future. Establishing systems to facilitate professional development, strengthening specialists support, and deploying doctors near their home towns are strategies that may improve retention of doctors in rural areas.Keyords: rural health, student perceptions.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926713PMC
http://dx.doi.org/10.4102/phcfm.v8i1.1039DOI Listing
June 2016

Treatment Failures and Excess Mortality Among HIV-Exposed, Uninfected Children With Pneumonia.

J Pediatric Infect Dis Soc 2015 Dec 8;4(4):e117-26. Epub 2014 Oct 8.

Divisions of Global Health Infectious Diseases, The Children's Hospital of Philadelphia, Pennsylvania Perelman School of Medicine, University of Pennsylvania, Philadelphia.

Background: Human immunodeficiency virus (HIV)-exposed, uninfected (HIV-EU) children are at increased risk of infectious illnesses and mortality compared with children of HIV-negative mothers (HIV-unexposed). However, treatment outcomes for lower respiratory tract infections among HIV-EU children remain poorly defined.

Methods: We conducted a hospital-based, prospective cohort study of N = 238 children aged 1-23 months with pneumonia, defined by the World Health Organization. Children were recruited within 6 hours of presentation to a tertiary hospital in Botswana. The primary outcome--treatment failure at 48 hours--was assessed by an investigator blinded to HIV exposure status.

Results: Median age was 6.0 months; 55% were male. One hundred fifty-three (64%) children were HIV-unexposed, 64 (27%) were HIV-EU, and 20 (8%) were HIV-infected; the HIV exposure status of 1 child could not be established. Treatment failure at 48 hours occurred in 79 (33%) children, including in 36 (24%) HIV-unexposed, 30 (47%) HIV-EU, and 12 (60%) HIV-infected children. In multivariable analyses, HIV-EU children were more likely to fail treatment at 48 hours (risk ratio [RR]: 1.83, 95% confidence interval [CI]: 1.27-2.64, P = .001) and had higher in-hospital mortality (RR: 4.31, 95% CI: 1.44-12.87, P = .01) than HIV-unexposed children. Differences in outcomes by HIV exposure status were observed only among children under 6 months of age. HIV-EU children more frequently received treatment with a third-generation cephalosporin, but this did not reduce the risk of treatment failure in this group.

Conclusions: HIV-EU children with pneumonia have higher rates of treatment failure and in-hospital mortality than HIV-unexposed children during the first 6 months of life. Treatment with a third-generation cephalosporins did not improve outcomes among HIV-EU children.
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http://dx.doi.org/10.1093/jpids/piu092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4681380PMC
December 2015

Chest Radiographic Findings and Outcomes of Pneumonia Among Children in Botswana.

Pediatr Infect Dis J 2016 Mar;35(3):257-62

From the *Botswana-UPenn Partnership, Gaborone, Botswana; †Division of Global Health, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; ‡Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina; §Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; ¶Department of Epidemiology, ‖Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; **Division of Infectious Diseases, The Children's Hospital of Philadelphia; ††Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ‡‡Department of Pediatrics and Adolescent Health, Faculty of Medicine, University of Botswana; §§Ministry of Health, Gaborone, Botswana; and ¶¶Division of Hospital Medicine and ‖‖Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

Background: Chest radiography is increasingly used to diagnose pneumonia in low-income and middle-income countries. Few studies examined whether chest radiographic findings predict outcomes of children with clinically suspected pneumonia in these settings.

Methods: This is a hospital-based, prospective cohort study of children 1-23 months of age meeting clinical criteria for pneumonia in Botswana. Chest radiographs were reviewed by 2 pediatric radiologists to generate a consensus interpretation using standardized World Health Organization criteria. We assessed whether final chest radiograph classification was associated with our primary outcome, treatment failure at 48 hours, and secondary outcomes.

Results: From April 2012 to November 2014, we enrolled 249 children with evaluable chest radiographs. Median age was 6.1 months, and 58% were male. Chest radiograph classifications were primary endpoint pneumonia (35%), other infiltrate/abnormality (42%) or no significant pathology (22%). The prevalence of endpoint consolidation was higher in children with HIV infection (P = 0.0005), whereas endpoint pleural effusions were more frequent among children with moderate or severe malnutrition (P = 0.0003). Ninety-one (37%) children failed treatment, and 12 (4.8%) children died. Primary endpoint pneumonia was associated with an increased risk of treatment failure at 48 hours (P = 0.002), a requirement for more days of respiratory support (P = 0.002) and a longer length of stay (P = 0.0003) compared with no significant pathology. Primary endpoint pneumonia also predicted a higher risk of treatment failure than other infiltrate/abnormality (P = 0.004).

Conclusions: Chest radiograph provides useful prognostic information for children meeting clinical criteria for pneumonia in Botswana. These findings highlight the potential benefit of expanded global access to diagnostic radiology services.
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http://dx.doi.org/10.1097/INF.0000000000000990DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4752380PMC
March 2016

Correlation of Clinical Outcomes With Multiplex Molecular Testing of Stool From Children Admitted to Hospital With Gastroenteritis in Botswana.

J Pediatric Infect Dis Soc 2016 Sep 16;5(3):312-8. Epub 2015 May 16.

Division of Infectious Disease, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada Botswana-UPenn Partnership, Gaborone Department of Pediatrics, University of Botswana, Gaborone Division of Microbiology, Department of Pathology, University of British Columbia, Vancouver, Canada.

Background: Diarrheal disease is a leading cause of death for young children. Most pediatric gastroenteritis is caused by viral pathogens; consequently, current recommendations advocate against routine antibacterial therapy if children present without bloody stools.

Methods: In this prospective cohort study, we enrolled children with severe acute gastroenteritis admitted to hospital in Botswana. Details of presenting history, physical examination, and course in the hospital were recorded. Stool samples were characterized using a 15 pathogen polymerase chain reaction assay.

Results: There were 671 participants with a median age of 8.3 months; 77 (11%) had severe acute malnutrition. Only 74 children had bloody stools, of whom 48 (65%) had a detectable bacterial pathogen, compared to 195 of 592 (33%) of those without. There were 26 deaths (3.9%). Covariates associated with death in multivariable logistic regression were the detection of any of Campylobacter/Shigella/enterotoxigenic Escherichia coli (odds ratio [OR] 2.57, 95% confidence interval [CI] 1.07-6.17), severe acute malnutrition (OR 4.34, 95% CI 1.79-10.5), and antibiotic therapy (OR 8.82, 95% CI 2.03-38.2). There was no significant association between bloody stools and death, and the effect of Campylobacter/Shigella/enterotoxigenic E. coli infection on death was not modified by the presence of bloody stools.

Conclusions: Detection of bacterial enteropathogens is associated with increased mortality in children in sub-Saharan Africa. Unfortunately, most children with these infections do not have bloody stools, and bloody dysentery was not found to be associated with worse outcomes. Clinical trials evaluating outcomes associated with more aggressive diagnostic strategies in children presenting with severe acute gastroenteritis in sub-Saharan Africa should be undertaken.
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http://dx.doi.org/10.1093/jpids/piv028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5125452PMC
September 2016

Association of respiratory viruses with outcomes of severe childhood pneumonia in Botswana.

PLoS One 2015 14;10(5):e0126593. Epub 2015 May 14.

Global Health Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America; Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.

Background: The highest incidence of childhood acute lower respiratory tract infection (ALRI) is in low- and middle-income countries. Few studies examined whether detection of respiratory viruses predicts ALRI outcomes in these settings.

Methods: We conducted prospective cohort and case-control studies of children 1-23 months of age in Botswana. Cases met clinical criteria for pneumonia and were recruited within six hours of presentation to a referral hospital. Controls were children without pneumonia matched to cases by primary care clinic and date of enrollment. Nasopharyngeal specimens were tested for respiratory viruses using polymerase chain reaction. We compared detection rates of specific viruses in matched case-control pairs. We examined the effect of respiratory syncytial virus (RSV) and other respiratory viruses on pneumonia outcomes.

Results: Between April 2012 and August 2014, we enrolled 310 cases, of which 133 had matched controls. Median ages of cases and controls were 6.1 and 6.4 months, respectively. One or more viruses were detected from 75% of cases and 34% of controls. RSV and human metapneumovirus were more frequent among cases than controls, but only enterovirus/rhinovirus was detected from asymptomatic controls. Compared with non-RSV viruses, RSV was associated with an increased risk of treatment failure at 48 hours [risk ratio (RR): 1.85; 95% confidence interval (CI): 1.20, 2.84], more days of respiratory support [mean difference (MD): 1.26 days; 95% CI: 0.30, 2.22 days], and longer duration of hospitalization [MD: 1.35 days; 95% CI: 0.20, 2.50 days], but lower in-hospital mortality [RR: 0.09; 95% CI: 0.01, 0.80] in children with pneumonia.

Conclusions: Respiratory viruses were detected from most children hospitalized with ALRI in Botswana, but only RSV and human metapneumovirus were more frequent than among children without ALRI. Detection of RSV from children with ALRI predicted a protracted illness course but lower mortality compared with non-RSV viruses.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0126593PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4431806PMC
February 2016

Use of Xpert for the diagnosis of pulmonary tuberculosis in severely malnourished hospitalized Malawian children.

Pediatr Infect Dis J 2014 Nov;33(11):1200-2

From the *Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA; †UNC Project, Lilongwe, Malawi; ‡Department of Pediatrics, Baylor College of Medicine, Houston, TX; §University of North Carolina, Chapel Hill, NC; ¶Botswana-UPenn Partnership, Gaborone, Botswana; ‖Division of Pulmonology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD; and **Department of Medicine, Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC.

Background : Pulmonary tuberculosis contributes to increased morbidity and mortality in severely malnourished children in endemic settings. Despite high clinical suspicion, few tuberculosis prevalence estimates exist in malnourished African children. Diagnostics such as Xpert MTB/RIF may help to determine pulmonary tuberculosis prevalence, however its performance in severely malnourished children is largely unknown.

Methods: We conducted a prospective observational study evaluating Xpert compared to smear microscopy and liquid culture on induced sputums among severely malnourished children (aged 6 to 60 months) at Kamuzu Central Hospital in Lilongwe, Malawi. From February 1 to May 30, 2012, children who met World Health Organization 2006 guidelines for severe acute malnutrition were evaluated using clinical symptoms, tuberculin skin tests, chest radiographs, and induced sputums. National Institute of Health (NIH) consensus case definitions were used to estimate tuberculosis prevalence.

Results: Three hundred severely malnourished children (median age 18.5 months, IQR 12.1-25.6) had one induced sputum performed; 295 (98.3%) received two. Fifty-two (17.6%) were HIV-infected. Over 25% had tuberculosis exposure with 48/297 (16.2%) reporting contact and 40/287 (13.9%) with positive TST. Two (0.7%) patients had confirmed tuberculosis by Xpert and culture, but only one had positive smear microscopy. Twenty (6.7%) patients fulfilled probable and 97 (66%) met possible tuberculosis NIH case definitions. Overall mortality was 9.7%.

Conclusions: Microbiologic confirmation likely underestimates the prevalence of pulmonary tuberculosis in severely malnourished children. In our study, Xpert on induced sputums did not increase case finding. Future studies are needed using Xpert among targeted groups of severely malnourished children and on non-sputum specimens.
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http://dx.doi.org/10.1097/INF.0000000000000384DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4217085PMC
November 2014

Yield of screening for TB and HIV among children failing to thrive in Botswana.

J Trop Pediatr 2014 Feb 27;60(1):27-32. Epub 2013 Aug 27.

Botswana-UPenn Partnership, Gaborone, Botswana.

Background: Failure to thrive (FTT) is a sign of tuberculosis (TB) and human immunodeficiency virus (HIV) infection. We assessed TB and HIV prevalence in children with FTT at one clinic in Botswana.

Methods: In July 2010, we screened all children attending a 'Well Child' clinic for FTT. Children with FTT were referred to a paediatrician who: (i) assessed causes of FTT, (ii) evaluated for HIV and TB and (iii) reviewed the patient chart for evaluations for TB and HIV.

Results: Of 919 children screened, 176 (19%) had FTT. One hundred eighteen (67%) children saw a paediatrician, and of these, 95 (81%) completed the TB evaluation. TB was newly diagnosed in 6 of 95 (6%). At review, HIV status was known in 23 of 118 (19%). Ninety-five had an unknown HIV status. Forty-five (47%) tested for HIV; all tested HIV-negative.

Conclusion: TB and HIV screening among children with FTT diagnosed TB in 6% of cases completing an evaluation, but no new HIV infections.
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http://dx.doi.org/10.1093/tropej/fmt072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3907793PMC
February 2014

Hospital-based surveillance for rotavirus gastroenteritis using molecular testing and immunoassay during the 2011 season in Botswana.

Pediatr Infect Dis J 2013 May;32(5):570-2

Botswana-UPenn Partnership, Gaborone, Botswana.

We describe rotavirus testing and clinical characteristics for children admitted with acute gastroenteritis during Botswana's 2011 rotavirus season. The rotavirus season extended from June to October with rotavirus-specific case fatality being 2.8%. Using molecular testing as reference, the immunochromatographic test had a sensitivity of 76.5% and specificity of 68.0%. Rotavirus vaccine may significantly reduce childhood morbidity and mortality in Botswana.
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http://dx.doi.org/10.1097/INF.0b013e3182847295DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3874800PMC
May 2013

Factors associated with parental readiness to make changes for overweight children.

Pediatrics 2005 Jul;116(1):e94-101

Department of Pediatrics, Division of General Pediatrics, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts 02118, USA.

Objective: The prevalence of childhood obesity is increasing in the United States. However, it has been difficult to help children successfully lose weight and maintain weight loss. Parental involvement in this effort is important. Currently, little is known about parents' readiness to make behavior changes to help their children lose weight. The objective of this study was to describe demographic factors and parental perceptions associated with parents' readiness to make weight-reducing lifestyle changes for their overweight and at-risk-for-overweight children.

Methods: A total of 151 parents of children who were aged 2 to 12 years and had BMIs >or=85th percentile for age and gender completed a 43-item self-administered questionnaire. Parental stage of change, defined as precontemplation stage, contemplation stage, and preparation/action stage, was determined using an algorithm involving current parental practices and future intentions. Parents in the preparation/action stage were considered to be ready to make behavior changes to help their child lose weight. Maximum-likelihood multinomial logistic regression was used to identify demographics and perceptions associated with parental stage of change.

Results: Sixty-two percent of the children had a BMI >or=95th percentile. Their mean age was 7.5 years, and 53% were male. Of the 151 parents, 58 (38%) were in the preparation/action stage of change, 26 (17%) were in the contemplation stage, and 67 (44%) were in the precontemplation stage. Factors associated with being in the preparation/action stage of change were having overweight or older (>or=8 years) children, believing that their own weight or child's weight was above average, and perceiving that their child's weight was a health problem. After controlling for multiple factors, having an older child (odds ratio [OR]: 2.99; 95% confidence interval [CI]: 1.18-7.60), believing that they themselves were overweight (OR: 3.45; 95% CI: 1.36-8.75), and perceiving that their child's weight was a health problem (OR: 9.75; 95% CI: 3.43-27.67) remained significantly associated with being in the preparation/action stage of change.

Conclusions: Several demographic factors and personal perceptions are associated with a parent's readiness to help his or her child lose weight. Knowledge of these factors may be beneficial to providers and program developers when addressing pediatric overweight with parents and initiating new interventions.
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http://dx.doi.org/10.1542/peds.2004-2479DOI Listing
July 2005