Study setting

The study was conducted in Kweneng District, Botswana, a Ministry of Health district providing care to a population of 387,983 individuals [17]. Kweneng District hosts a 350-bed public hospital, which is located approximately 60km from the country’s capital city and serves the village of Molepolole, one of three highly populated villages in the country (population ~ 75,000) [17]. The hospital receives referrals from a range of health facilities across the district, including a 25-bed primary hospital; a military hospital; 23 primary care clinics; and 38 health posts. As a secondary-care hospital, the public hospital provides specialist services (Pediatrics, Surgery, Obstetrics & Gynecology, and Medicine), laboratory services, pharmaceutical services, and basic radiography (x-ray and ultrasound). The hospital has limited sub-specialist presence and does not have advanced imaging services (e.g. computed tomography [CT] or magnetic resonance imaging [MRI]). Located on the edge of the Kalahari Desert, Kweneng District is expansive and sparsely populated, covering an area roughly the size of Taiwan. Healthcare facilities vary in distance to the referral hospital, ranging from less than a kilometer to 252 km from this facility. Kweneng West reports the highest poverty levels in Botswana at over 50%, with unemployment averaging 11.8% for males and 9.7% for females [17].

Survey development

A 25-item survey was developed by members of the research team, in consultation with other Kweneng District HCWs. Survey questions were informed by the extant published literature on PASC, as detailed in the Background section, then reviewed by members of the study team to establish face validity. The survey tool was initially developed using the Google Forms platform and was subsequently converted to a Word document to facilitate paper-based distribution (S1 Text). The survey tool was piloted on six nurses and adjustments were made as indicated to ensure clarity of questions and response options.

Subject population & recruitment

The target population included HCWs employed in patient-facing roles, including general nurses, nurse practitioners, medical officers (general practitioners), specialists, and district health management team staff working at government health facilities in Kweneng District. Inclusion criteria stipulated that participants be over 18 years old and literate in English (the standard language for medical care provision and documentation in Botswana). Participant recruitment took place 1^st August 2022 through 11^th February 2023. An electronic version of the survey, constructed on Google Forms, was initially disseminated electronically to HCWs across Kweneng District via pre-existing WhatsApp groups during August 2022, and only 13 respondents completed the survey. At the time of recruitment, an estimated 640 healthcare workers (including 581 nurses, 46 medical officers, six specialist doctors, and several healthcare leaders) were working in the district.

Given low response to the online survey, 80 paper copies of the survey were distributed to a convenience sample of clinics around the district between November 2022 and mid-February 2023. Specifically, study team members distributed paper copies to twenty primary care facilities throughout the main village in Kweneng District, Molepolole; these clinics included the larger primary care clinics typically staffed by both doctors and nurses (as opposed to nurses alone). The number of paper surveys distributed to each primary care facility corresponded to the number of HCWs on duty at that time. The remaining paper copies were allocated to points of entry to the district hospital (e.g. the Accident & Emergency and Outpatient Departments). Under existing referral mechanisms in the government sector, all clinics district-wide are allowed to refer patients to the district hospital utilizing government-supported medical transport, escorted by a HCW from the referring primary care facility. All escorting HCWs were invited to complete the survey. Surveys were conducted anonymously; no directly identifying data were collected from participants. Descriptive statistics were used to analyse quantitative data collected, including demographic data. Categorical variables were expressed as frequencies and percentages.

Ethics statement

This study was carried out in strict accordance with accepted human subjects research practice. The protocol was reviewed and approved by the Health Research & Development Committee, Health Research Unit, Botswana Ministry of Health (Protocol Number: 00950; Approval Number HPRD: 6/14/1), with a risk determination of “no greater than minimal risk.” Permission to conduct research within Kweneng District was obtained from the Scottish Livingstone Hospital Research Committee prior to initiation of data collection, a committee chaired by the hospital Chief Medical Officer and including representatives from multiple healthcare cadres. All potential survey participants received and were asked to review a Participant Information Sheet prior to agreeing to participate (either paper-based or electronic, according to the mode of survey delivery). To ensure anonymity of survey responses, participants were not asked to provide written consent with a name and signature. Instead, they received the following notification upon completion of Participant Information Sheet review: “By proceeding with this survey, you indicate your consent to participate in the study as described above.”

Inclusivity in global research

In addition to following standard human subjects research practice as outlined above, the study team endeavoured to demonstrate good practice for global health research, with emphasis on promoting equity in health through study design, dissemination of findings, and inclusion of community interests within the context where the research was conducted. Additional information regarding ethical, scientific, and cultural considerations specific to inclusivity in global research incorporated into the design and conduct of this study can be found in the (S2 Text).

PASC burden and characterization in Botswana

Findings from this study indicate that the large majority of HCWs in Kweneng District encounter patients presenting with symptoms consistent with PASC on a weekly basis. While PASC prevalence cannot be estimated from the survey responses, the reported frequency of patient encounters strongly suggests that PASC is prevalent in Botswana and that patients are seeking care at various levels of the public healthcare system. For regional context, epidemiological studies conducted in Africa have reported PASC prevalence estimates at two months post-infection ranging from 35% (South Africa) [18] to 51% (Zambia) [19] with studies from Nigeria and Morocco reporting 41% [20] and 47% respectively [21]. Prevalence of PASC symptoms differs according to severity of initial COVID-19 infection, with a South African study finding that 46.7% of patients hospitalised for COVID-19 and 18.5% of nonhospitalized patients experienced ≥ 1 symptoms at six months post-infection [22]. Official reports may underestimate the real PASC burden in Southern Africa; Mendelsohn et al. found that only 24% of South African patients self-reporting symptoms consulted a clinician for long COVID, and only 7% received care for PASC in the public sector [18]. To the best of our knowledge, no prevalence study has been conducted to date in Botswana to confirm whether PASC prevalence is similar across the subregion.

The need for targeted studies of the prevalence and impact of PASC in Botswana is further underscored by typical risk factors for PASC observed in similar populations. Factors associated with increased risk for development of PASC include older age, female sex, multiple comorbidities, and severe acute COVID-19 infection [23,24]. Notably, PASC burden in the region appears to vary according to baseline health. For instance, a regression analysis of observational data from Ghana found that patients with hypertension and diabetes mellitus had four times the odds of developing long COVID compared to those without comorbidities [25]. Karuna and colleagues conducted a multi-country observational cohort study of post-COVID conditions, finding that patients with a history of lung disease reported 45–58% longer duration of general, neurologic and respiratory symptoms [26]. These findings are highly relevant to the context in Kweneng District and Botswana as a whole, where combined death and disability due to diabetes increased over 40% from 2009 to 2019 (now ranking in the top ten causes of combined death and disability in the country), while hypertension rose to the fourth leading risk factor driving death and disability over the same time period [27]. Additionally, many people living in Kweneng District suffer from chronic lung disease related to high rates of background pneumoconioses, often linked to occupational exposures (particularly mining) [28] and complicated by high tuberculosis incidence, estimated at 235 per 100K population in 2021 [29].

Responses to this survey provide insight into typical patterns of PASC presentation in Botswana from the perspective of front-line HCWs in the public sector. The most frequently reported presenting PASC symptoms in Kweneng District—persistent cough, shortness of breath, fatigue, headache, and muscle or body aches—are similar to those reported in studies in the Southern African subregion, as well as globally. Findings from our study overlapped considerably with those reported by Pretorius et al [30], conducted in South Africa; this study found that the most commonly reported PASC symptoms locally were fatigue, brain fog, loss of concentration and forgetfulness, shortness of breath, joint and muscle pains. Fatigue was shown to be the most prevalent symptom and the primary cause for patients to seek medical attention across Africa [31,32].

The emergence of headache as the most frequently cited top PASC symptom in this study is notable, as this represents a potential shift in epidemiology of a common condition within the Botswana healthcare context. Chronic headache was a common indication for referral for specialist review in Botswana even prior to the onset of the COVID-19 epidemic, placing significant burden on a primary care system in which the per capita density of doctors (general doctors as well as specialists) is only 3.8 per 10,000 [33]. Differentiating PASC-related headache from other aetiologies of chronic headache is important to avoid placing additional stress on existing referral processes within the public sector and highlights the need for a clear definition of PASC for use by primary care practitioners within Botswana. Additionally, there may be a synergistic effect on patients with prior history of chronic headache before known infection with COVID-19, as the infection has been observed to exacerbate the symptoms of individuals who already had headaches before getting COVID-19 [34]. Chronic headaches attributed to prior COVID-19 infection have been shown to have a substantial negative influence on social and psychological activities; therefore, prompt and comprehensive management of these sequelae should be a priority [35]. Results from the present study reveal that chronic headache following COVID-19 infection is managed primarily with analgesia alone in Kweneng District, suggesting potential for improvement through development of multidisciplinary care processes for patients suffering from chronic headache and other PASC symptoms.

Interpretation of these results regarding the most common presenting symptoms of suspected PASC must consider the current lack of a clear, consistent case definition in use in the study context. All the reported common symptoms were frequently encountered in isolation in primary care settings across Kweneng District even prior to the advent of the COVID-19 pandemic. As such, primary HCWs—particularly nurses, who are the first point of contact for the majority of patients presenting to primary care facilities in Botswana—have established mental frameworks for diagnosing and providing basic management for these common complaints. In the absence of a common case definition for PASC, we suspect that attribution of these symptoms to possible PASC by study participants occurs in cases where typical treatment algorithms were unsuccessful. This is an area requiring further investigation to substantiate.

Uncertainty regarding PASC management

Survey results suggest that HCWs at various health system levels across Kweneng District lack confidence in managing common PASC symptoms, with approximately one-third of respondents indicating uncertainty regarding management of frequently encountered PASC symptoms (persistent cough, fatigue). Among respondents who completed free text responses detailing current practices for managing common PASC symptoms, most reported using management strategies more appropriate in the context of treating acute COVID-19 infection with potential bacterial superinfection, such as prescribing corticosteroids and antibiotics. These practice patterns raise concern related to the potential adverse effects of these treatments, which may directly contribute to endocrinologic complications, increased vulnerability to future infections, and antimicrobial resistance [36]. The potential negative impacts of unnecessary corticosteroid use on immune function are particularly relevant in Botswana where HIV is widespread, with an estimated 21% prevalence rate [37].

Equally concerning is the fact that these approaches appear to be utilised in place of appropriate evaluation and multidisciplinary management for PASC symptoms. For instance, no respondent indicated evaluating patients with chronic shortness of breath for either cardiac sequellae of COVID-19 infection or for potential pulmonary complications such as fibrosis or pulmonary embolism. In the absence of a clear case definition for PASC currently in use in Botswana, there is also a risk that HCWs might inadvertently attribute symptoms to PASC that are in fact related to other common pathologies. For instance, in a high-TB setting, chronic cough due to this infection could be misattributed to prior COVID-19 infection, placing patients and their communities at risk. Furthermore, survey respondents themselves indicated a clear desire for clinical decision-making support in diagnosing and managing PASC.

In parallel with uncertainty regarding accurate diagnosis of PASC in the absence of a standardized case definition, the findings regarding PASC management underscore the need for streamlined management pathways for common PASC symptoms. In the Botswana context, HCWs (particularly those working in health posts and primary care clinics) are trained and skilled in the application of standardized evaluation and treatment algorithms for common conditions. Given the lack of existing national guidelines for PASC evaluation and management, it is unsurprising that primary HCWs report managing potential PASC-related symptoms according to established practices for undifferentiated headache, shortness of breath, persistent cough, and fatigue. To the best of our knowledge, one training was conducted on long-COVID during 2022, sponsored by the Botswana Ministry of Health in conjunction with the University of Botswana and disseminated to interested HCWs across the country as a live, synchronous online event. Beyond this, the authors (as HCWs who worked in Kweneng District during the period the survey was conducted) are unaware of other trainings or campaigns specific to PASC that may have influenced participant responses.

Multidisciplinary care pathways

Beyond a need for training on appropriate identification and management of PASC symptoms, survey results demonstrate near unanimous demand among Kweneng District HCWs for multidisciplinary treatment pathways for patients suffering from PASC. This is well aligned with global recommendations for comprehensive PASC management [38,39]. Parkin and colleagues emphasise that primary health care systems globally must adopt a comprehensive and integrated multidisciplinary model of healthcare delivery to deal with the increasing number of post-COVID-19 cases effectively and efficiently [40]. In Botswana, plans for such models of integrated care delivery for PASC are in development but no such facility exists currently. The results of this survey demonstrate the clinical imperative to develop centres for multidisciplinary PASC care, which could also function as educational hubs for training and dissemination of management algorithms. In the absence of such guidance and facilities, HCWs across Botswana must rely on clinical reasoning, often in isolated contexts.

Future research

Although not explicitly explored in the survey, the expressed uncertainty regarding PASC management is likely due in part to the absence of a clear case definition for PASC currently in use in Botswana. This raises concerns, as indicated above, regarding the possible conflation of chronic symptoms of PASC with other disease entities prevalent in Botswana. In addition, the absence of a commonly agreed time criterion to differentiate acute COVID-19, persistent COVID-19 infection, and PASC in Botswana is an important gap and leads to confusion among HCWs in determining how best to manage presenting symptoms thought to be related to COVID-19. Given the high background prevalence rate of HIV, the known risk of persistent COVID-19 infection in people living with HIV [41,42], and the current lack of point-of-care tests for active COVID-19 infection in the government sector in Botswana, contextually appropriate criteria for defining PASC in this setting is even more imperative. Additionally, both retrospective and prospective surveillance should be conducted of patients previously admitted to hospitals across Botswana for acute COVID-19 care, to determine the rates of COVID-19 complications (including but not limited to PASC) in this population.

Findings from this study have been disseminated to district health care leadership across professional cadres, including Nursing, Medicine, and Public Health. This has spurred requests for further research on the direct impact of the COVID-19 pandemic on frontline HCWs. Stakeholders engaged in dissemination sessions, particularly primary HCWs, have voiced requests for development of case definitions and clinical management algorithms for PASC to be used within Kweneng District, linked to advocacy for further guidance from the national level.

Limitations

The generalizability of this study is limited to the context of Botswana. The initial response rate to online surveys was very low. This was attributed to lack of internet connectivity at workplaces in Kweneng District (particularly in rural areas), coupled with high cost of data for personal use. It is also possible that the low online survey response rate was related to lack of interest and/or sensitization among potential respondents. The relatively high response rate to the paper-based surveys, however, argues against self-selection or lack of interest among the target population, as the majority of HCWs offered the opportunity to complete the survey did so. Of note, in the few instances where HCWs invited to complete the paper survey declined to participate, they indicated that this was related to lack of relevance to current practice. Specifically, HCWs employed as midwives or engaged in inpatient duties outside of admitting roles stated that screening for potential PASC-related symptoms was not part of their routine workflow. In light of this, the total eligible target population is likely significantly lower than initially estimated, as it includes midwives and other HCWs who do not routinely manage PASC-related symptoms. Due to transportation barriers, the paper-based questionnaires were distributed to a convenience sample of HCWs, i.e. to primary facilities within Molepolole, which may have introduced bias by further limiting input from HCWs in more remote parts of the district. This risk was mitigated by also distributing the survey to HCWs escorting patients referred to the district hospital; these HCWs represented facilities up to 251km in distance from the district hospital. Following completion of the current rollout of cost-free Wi-Fi connections at government health facilities nationwide, we are hopeful that online surveys may help to address these gaps in future.

The survey was distributed several months following the conclusion of the most severe wave of acute COVID-19 infections in Botswana (the Delta wave, in mid-2021). This time point was selected intentionally, to allow for enough time to elapse for HCW participants to have some distance from managing acute COVID-19 cases and to increase the likelihood that participants were actively interacting with patients with possible long-term sequellae of infection. That said, the survey instrument asked HCWs to rely solely on their memory of patients treated for potential PASC symptoms to capture perceived importance of this problem, without triangulation from objective data sources. This represents an important source of likely recall bias. This limitation will be mitigated in future with the anticipated release of data prospectively collected from patients with confirmed prior COVID-19 infection.