Citation
Past and Future Development Trends in Rural Botswana and their Potential Impact on Community Health

Material Information

Title:
Past and Future Development Trends in Rural Botswana and their Potential Impact on Community Health
Creator:
Pazos, Camila
Place of Publication:
[Gainesville, Fla.]
Publisher:
University of Florida
Publication Date:
Language:
English
Physical Description:
Project in lieu of thesis

Thesis/Dissertation Information

Degree:
Master's ( Master of Sustainable Development Practice)
Degree Grantor:
University of Florida
Committee Chair:
Schmink, Marianne C

Subjects

Subjects / Keywords:
Cities ( jstor )
Community health ( jstor )
Diseases ( jstor )
Health care services ( jstor )
Health status ( jstor )
Predisposing factors ( jstor )
Recommendations ( jstor )
Tourism ( jstor )
Urbanization ( jstor )
Villages ( jstor )

Notes

Abstract:
Challenges that poor communities in rural Botswana have faced in the past involve diversifying livelihood options available to households given the context of the community and the characteristics of the land. Information about the health status of a rural community is a critical component to take into consideration when assessing the livelihood opportunities of which people may be able to take advantage, given the consequences that these opportunities may have on their health. It is important to consider the social and environmental impacts that economic development might have on a community if the goal is to achieve a sustainable future (Calberth, 2003). ( ,, )
Abstract:
The purpose of this project was to expand on the work conducted during the summer of 2011 by the Master’s in Sustainable Development Practice (MDP) team in northwest Botswana and assess development trends in two rural communities (Sankuyo and Shorobe) in hopes of identifying the potential impact that development trends may have on the community’s health. The potential direction of development trends and their impact on health was evaluated through a Health Impact Assessment which examined literature on the current health situation and economic development of Botswana, as well as qualitative and quantitative data collected in both communities in 2010 and 2011 by researchers from the University of Florida.
Abstract:
The questions that were discussed include: 1) What is the current health situation? 2) How might development changes affect health? 3) What are some recommendations for reduction of the health burden in rural communities?
General Note:
sustainable development practice (MDP)
General Note:
The MDP Program is administered jointly by the Center for Latin American Studies and the Center for African Studies.

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Source Institution:
University of Florida Institutional Repository
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University of Florida
Rights Management:
Copyright Camila Pazos. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Resource Identifier:
1039729394 ( OCLC )

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! ! ! ! ! ! ! ! PAST AND FUTURE DEVELOPMENT TRENDS IN RURAL BOTSWANA AND THEIR POTENTIAL IMPACT ON COMMUNITY HEALTH ! ! ! ! A final project report submitted in partial fulfillment of the requirements for the degree of Master in Sustainable Development Practice (MDP) ! ! Camila Pazos University of Florida 2012

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1 ! Table of Contents Figures ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""" ! # ! Tables ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """"""""""""""""""""""""" ! # ! Acknowledgements ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """ ! $ ! Abstract ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""" ! % ! Introduction ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""" ! & ! Context of Botswana """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """"""""""""""""""""""""""""" ! & ! MDP Field Practicum ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""" ! ' ! Conceptual Framework ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""" ! ( ! Justification for a Health Impact Assessment (HIA) ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """"""""""" ! )* ! Methods ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""" ! )# ! Results ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""" ! )$ ! Conditions Profile ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" ! )$ ! Evaluating Potential Impacts ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """"""""""""" ! )+ ! Recommendations ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" "" ! #$ ! Conclusions ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """"""""""""" ! #+ ! References ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """"""""""""""" ! $* ! ! ! ! ! ! !

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2 ! Figures Figure 1: Map of Botswana (Department of State) ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""""""""" ! & ! Figure 2: Conceptual Framework Development Trajectories and their Impact on Health ! """""""""""""" ! ( ! Figure 3: Social and Environmental Determinants of Health (Human Impact Partners, 2011) ! """ ! )) ! Tables Table 1: Health Situation in Sankuyo and Shorobe (2010 & 2011 Livelihood Surveys) ! """"""""""""""" ! )% ! Table 2: Development Trends in Sankuyo and Shorobe ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" "" ! )' ! Table 3: Evaluating Impacts of Development Trends ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """""""" ! ## ! Table 4: Recommendations for Sankuyo and Shorobe ! """""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""" """"" ! #% !

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3 ! A cknowledgements I wish to express sincere appreciation to Dr. Richard Rheingans and Dr. Marianne Schmink for their assistance in the preparation of this report. Thank you to the faculty , students , and staff of the Master in Sustainable Development Practice (MDP) program, the MDP 2011 Bo tswana Field Practicum Team, the Center for African Studi es at the University of Fl orida, and the John D. & Catherine T. MacArthur Foundation. Finally, thank you to the Southern African Regiona l Environmental Program (SAREP), the Sankuyo Tshwaragano Management Trust (STMT) and the communities of Sankuyo and Shorobe in Botswana .

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4 ! Abstract Challenges that poor communities in rural Botswana have faced in the past involve diversifying livelihood options available to households given the context of the community and the characteristics of t he land . I nformation about the health status of a rural community is a critical component to take into consideration when assessing the livelihood opportunities of which people may be able to take advantage , given the consequences that these opportunities may have on their health. It is important to consider the social and environmental impacts that economic development might have on a community if the goal is to achieve a sustainable future (Calberth, 2003) . The purpose of this project was to expand on the work conducted during the summer of 2011 by the M aster's in Sustainable Development Practice (M DP ) team in northwest Botswana and assess development trends in two rural communities (Sankuyo and Shorobe) in hopes of identifying the potential i mpact that development trends may have on the community's health . The potential direction of development trends and their impact on health was evaluated through a Health Impact Assessment which examined literature on the current health situation and economic development of Botswana , as well as qu alitative and quantitative data collected in both communities in 2010 and 2011 by researchers from the University of Florida. The q uestions that were discussed include: 1) W hat is the current health situation ? 2) How might development changes affect health ? 3) What are some recommendations for reduction of the health burden in rural communities ?

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5 ! Introduction Context of Botswana The Republic of Botswana is a small land locked country located in the southern part of Africa . Botswana is a former British colony who achieved independence on September 30 th 1966. The country shares borders with Namibia, Zimbabwe and South Africa and is internally divided into nine districts and five town councils. The Okavango Delta, th e world's lar gest inland delta is located towards the northwestern part of the country and has been central to the history and livelihoods of its people (Ngwenya, 2007) (Central Intelligence Agency, 2012) . In the 2011 Population & Housing Census Botswana's population was said to be approximate ly at 2,038,228 million people (Central Statistics Office, 2011) . Most of the population is concentrated in cities in the eastern part of the country. There are several major ethnic groups however 79% of its population considers themselves to be direct Tswana descendants. The Tswana people originally came from South Africa duri ng the early 1800s and prior to independence lived as herders and farmers under tribal rule (Department of State, 2011) . Today, Botswa na is a Parliamentary Republic with a dual legal system; that is Roman Dutch law (civil law) as well as customary and common law (Government of Botswana, n.d.) Diamond mining and extraction of other minerals provides many jobs for the citizens of Botswana . Since the early 1980 ' s Botswana has been considered the world's largest producer of gem quality diamonds (Department of State, 2011) . Mining has fueled much of the economic growth in the country and currently accounts for more than one third of GDP and a bout a half of the government's revenues (Central Intelligence Agency, 2012) . Mining is, however, a limited resource . Recently, attention has been paid by the country to invest in other sources of income including subsistence farming, cattle keeping, priva te sector development and tourism. Figure 1 : Map of Botswana (Department of State)

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6 ! Although more than one half of the population of Botswana lives in rural areas and largely depends on livestock farming, tourism has emerged as an increasingly im portant industry and a key livelihood option for communities located in wildlife abundant areas . T oday, t he tourism industry is considered the second largest economic sector in Botswana after mining (Mbaiwa, 2011) . Tourism has been growing at an annual rate of 14% in the past 8 years and currently a ccounting for 11% of GDP (Department of State, 2011) . Discussing development in Botswana would not be complete without considering the health status of the population , given the fact that h ealth exerts a considerable impact on t he social and economic fronts. The World Health Organization explains that the major challenge today is for the government of Botswana to obtain a clear understanding of the magnitude and types of diseases affecting the citizens to begin to systematically address them at both th e national and community levels. Botswana has one of the world's highest known rates for HIV/AIDS and the disease poses a serious risk to development in the country . In 2009 it was reported that adult prevalence rates for the country were 24.8% and that th ere were approximately 320,000 people living with HIV/AIDS (World Health Organization , 2010) (Central Intelligence Agency, 2012) . R isk factors for the disease include multiple and concurrent sexual partnerships, gender based inequalities, alcohol consumpt ion, stigma and discrimination (USAID, 2010) early onset of sexual activity (before the age of 15), multi locat ional households, urbanization and access to health services (Van Donk, 2006) . In the 2010 Health Statistics Profile , the World Health Organizat ion reported that other major health problems in Botswana include d lower respiratory illnesses, diarrheal diseases and malaria. The W orld H ealth O rganization also reported that in recent years there has been a steady increase of non communicable diseases such as hypertension, cancers and diabetes across the population. Malnutrition was also a big problem for childre n under the age of 5 ; 11% of the se chil dren w ere considered to be moderately to severely underweight and 31% to be suffering from moderate to severe stunting (UNICEF, 2010) . There has been great success in government attempts to provide safe water and sanitation for the population of Botswana. I n 20 08, 95% of the total population had access to improved drinking water sources and 60% of the total population had access to improved sanitation facilities (UNICEF, 2010) .

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7 ! MDP Field Practicum During the summer of 2011, a team of four MDP students and two faculty members travelled to Botswana to carry out a collective field practicum as a requirement for the Masters in Sustainable Development Practice (MDP) program. The purpose for the field practicum, as outlined by the MDP program guidelines , was for students to gain hands on experience in the field of development practice through cross cultura l and interdisciplinary work alongside different levels of stakeholders . The MDP team worked in two villages located in the district of Ngamiland in northwe st Botswana called Sankuyo and Shorobe. The Sankuyo village is approximately 95km from the city of Maun and lies on the way to the Okavango Delta in the district concession areas NG 33& 34 . In 2002, the population of Sankuyo was said to be approximately 37 2 people (Central Statistics Office, 2002) . Shorobe village is located approximately 26km from Maun and due to its close location to the city its economy is very much intertwined with that of the city. In the 2001 Botswana census, the population of Shorobe was estimated to be approximately 955 people (University of Botswana, 2008) . Many community members in this village live in Shorobe but work in Maun. The MDP team first partnered with the Sankuyo Tshwaragano Management Trust (STMT), the Southern African Regional Environmental Program (SAREP) and the community of Sankuyo to design a sustainable development management plan for the Sankuyo community . Given Botswana's mixed legal system with both civil law and common law, the comm unity is required to submit a management plan to the government outlining the different ways in which the district concession areas w ill be used in the near future. This particular management plan was required for the renewal of a 15 year head lease from the Government of Botswana. Previous management plans had focused solely on natural resource management of district areas NG 33 & 34 and gave little attention to the well being and livelihoods of the local community. The main objec tive for this particular "sustainable development" plan was to reconcile the livelihoods of the people along with the need to protect the environment. The team explored commercial and sustainable uses of natural resources to increase economic value and red uce poverty in the community. Tourism options were explored give n the community's close location to the Okavango Delta, the high incidence of crop loss , and the many dis cussions regarding the government's desire to ban hunting which would eliminate trophy hunting in the community. After working with Sankuyo, the MDP t eam worked in the neighboring Shorobe village and conducted a series of livelihood surveys . The team sampled 40 households in five different areas in the village ( Shorobe Central, The Cattle P ost, Riverside, Mochaba and Sephane ) . The surveys were conducted using activity based sampling, with high, middle and low income respondents chosen from different livelihood activities in the different

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8 ! areas of the village . The MDP team worked closely with members of the Shorobe community to determine the different households which would fit the sampling method. The purpose for conducting these surveys was to determine the demographics and livelihood strategies for households in Shorobe. The villages of Sa nkuyo and Shorobe have been closely linked throughout their history . During the 1980's, howev er, a Veterinary Cordon Fence or "buffalo fence" was erected between two villages due to the spread of foot and mouth disease by cattle and this marked a separation of the villages. Sankuyo is now located on the side of the fence which leads to the Okavango Delta. In this area there is wildlife and therefore tourism options are an important component of the livelihood s of the com munity . Shorobe is located on the opposite side which leads to the city of Maun. On this side people are allowed to keep cattle and other livestock and therefore ha ve different livelihood options. During the field practicum, t he MDP team was particularly i nterested in how the liv elihoods of Sankuyo and Shorobe were impacted by the fact that they lie on opposite sides of the buffalo fence . The MDP team was also interested in how both communities were impacted by their village's location with respect to the c ity of Maun. Many households in both communities reported to the MDP team that they had family members living and working in Maun. Development Changes and their Impact on Health The sustainable future of any community requires improvements in, and most importantly, maintenance of its health status along with the consideration of future economic opportunities (Calberth, 2003) . During the MDP field practicum , there was a strong focus o n considering the community's well being when outlini ng different livelihood options. This was the case for the Sankuyo management plan and when conducting the livelihood surveys in Shorobe . The question , however, regarding how different development trajec tories would affect community health , emerged afterwards. The purpose of this project became to explore the health status of Sankuyo and Shorobe, in order to identify the potential impact that changes in development trajectories could have on both communi ties and their health situation. In Sankuyo, the development trajectories considered were employment in and impact of tourism for the community. In Shorobe, the development trajectories explored were the rapid urbanization of the village and the close dist anc e and link to the city of Maun. More specifically, for the Sankuyo community it can be predicted that employment in tourism would lead to an increase in risk factors and risky behaviors related to HIV/AIDS and other diseases and then affect the health status and well being of the community. On the other hand, employment in tourism could lead to an increase in access to health

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9 ! services and other socioeconomic factors such as income, which would then lead to an on overall improvement in health and well be ing of the community. For Shorobe, the rapid urbanization of the village can also be predicted to affect risk factors and risky behaviors for illness and disease affecting the health status and well being of the community . However, urbanization may lead t o an increase in employment opportunities in the city and an increase in access to essential health services which would positively affect the health status and well being of the community. Conceptual Framework In order to analyze the impact that different development trajectories may have on the health of a commu nity, a conceptual framework was developed to illustrate the relationships and assumptions from different actors. Figure 2 : Conceptual Framework Development Trajectories and their Impact on Healt h Development Changes Tourism Urbanization Risk Factors Divided Households Alcohol Consumption Stigma Lack of water & sanitation Illness & Disease Access to Health Services Facilities Treatment Counseling Socioeconomic Factors Income Social Capital Education Roads Health and WellBeing

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10 ! The conceptual framework illustrates differing sides to the relationship between development trajectories and health. On one side of the framework, development changes or trends, such as employment in tourism and urb anization, may increase or decrease risk factors and risky behaviors that could potentially lead to an increase in illness and disease and therefore affect the health and well being of the community . These risk factors may include divided households, alcoh ol consumption, stigma and discrimination as well as inadequate access to water and sanitation. On the other hand, development changes may increas e the access to health services including treatment, counseling and facilities which would then lead to an ove rall improved health status of the population. Development changes may also lead to an increase or decrease in socioeconomic factors such as household income , education, and community infrastructure which could potentially improve the health status of the community. As Sankuyo and Shorobe's livelihood strategies transition in today's economic arena, the potential impact that these changes in development trends have on the health status of the communi ties must also be considered. On one hand, r isk factors for different diseases, including HIV/AIDS, may increase or decrease as development trajectories change and therefore increase or decrease the health burden of the communities. On the other hand, as d evelopment trajectories change so does the access to health services including facilities, treatment and counseling and this may lead to an overall improved health status of the population. ! J ustification for a Health Impact Assessment (HIA) ! In the field o f development practice , a strategic planning tool which is used to consider the relationship between the social and environmental determinants of health is a Health Impact Assessment (HIA). A Health Impact Assessment is defined as a method to estimate of the effects of a specified action on the health of a defined population (Scott Samuel, 1998) . More specifically it is considered as "a combination of procedures, methods and tools that system atically judge the potential and sometimes unintended effects of a policy, plan, program or project on the health of a population and the distribution of those effects within the population " (Human Impact Partners, 2011) . In their Health Impact Assessment Toolkit , Human Impact Partners explain that there are different social an d environmental determinants that could affect health. The development trajectories discussed in this paper fit in t hree different categories at the outermost levels which are the "p ublic services and infrastructure", the "liv ing and working conditions" and the "social, econo mic and political factors." It is important to therefore not only focus on a person's individual characteristics such as age, gender

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11 ! and genetics or his or her behaviors, but also to consider broader factors that may affect health. Figure 3 : Social and Environmental Determinants of Health (Human Impact Partners, 2011) A Health Impact Assessment is different from conducting a post hoc a ssessment of a program or action. It is a planning method that is used to evaluate the potential effects of a program or trend, such as a development trajector y, on the health of a community before the program has been established. Past studies have shown that development projects can indeed have health impacts by initiating significant changes in the health status of local communities (Scott Samuel, 1998) and one could argue that there is certainly a case for decision makers to use this planning method when considering the impacts that development trends may have on a community. An example of a past study where a Health Impact Assessment was used with relation to tourism is in the development of a sustainable future for Small Island Stat es and Territories (SIDSTs). In these islands, tourism, whether it was mass tourism or eco tourism, became a significant proportion of the GDP and the tendency was for decision makers to focus only on the economic benefits of proposed development projects (Douglas, 2003). The fact is that since SIDSTs are characterized by having ecological fragility due to their relatively small size and limited resources, it gave cause for environmental and health impact concerns which then provide d a case for the applica tion of the Health Impact Assessment methodology (Douglas, 2003). Another example is in Cuba where a community created programs and improved infrastructure that sustained population health , despite changes and burdens on lifestyles and environments from t he rapidly growing tourism sector (Spiegel, 2008) . In

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12 ! this study , participants who were interviewed mentioned that there were psycho social, occupational, environmental, infectious , and chronic disease concerns all which could be related back to tourism and that needed to be addressed (Spiegel, 2008) . In the 2011 Sustainable Development Management P lan, future economic opportunities for the Sankuyo community were explored and then pr oposed. After conducting livelihood surveys in the community of Shorobe an in depth analysis was made regarding the economy of the village and its link to the city of Maun. However the impact that these opportunities may have on the community was not addressed beyond the different economic gains that would result from the proposed livelihood strategies . Methods Specifically related to this project, the methodology behind a Health Impact Assessment will be used to address the following questions: 1) W hat is the current health situation? 2) How might development changes affect health? 3) What are some recommendations for reduction of the health burden in communities? A Health Impact Assessment is made up of several different phases. These include screening, scoping, assessment, recommendations, reporting and monitoring (Human Impact Partners, 2011) . For this specific project there will be a focus on working through the assessment and recommendations phases. In the assessment phase, the purpose is to synthesiz e and critically assess information in order to prioritize health impacts. In the recommendations phase the goal is to make decisions to reach a set of final recommendations for acting on the HIA's findings (Wise, 2009) . The assessment phase of a HIA occurs in two steps. First, one has to create a conditions pr ofile for a geographic area and/ or population in order to understand baseline conditions and eventually to be able to predict change. Second, one has to evaluate potential health impacts, includi ng magnitude and direction , and this can be done both using quantitative and qualitative data (Human Impact Partners, 2011) .The conditions profile for the Sankuyo and Shorobe villages was divided into two parts: the health situation profile and the develop ment trends . The conditions prof ile was assembled through a literature review on the district of Ngamiland as well as an examination of qualitative and quan titative data collected from two different livelihoods surveys conducted by researchers from the Un iversity of Florida in 2010 and 2011 . Both livelihood surveys asked similar questions about household demographics and livelihoods, but they were not equal instruments and had different sampling methods. The work conducted by the MDP team in the 2011 Susta inable

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13 ! Development Management Plan and the livelihood analysis in Shorobe also played an important role when identifying both threats to the Sankuyo and Shorobe communities as well as development trends . K ey informant interviews in both communities with he alth post workers, social workers, famers, tourism employees, and basket makers , among others provided qualitative data which was also used to support the conditions profile. The second part of the assessment phase of the Health Impact Assessment deals with the evaluation of t he potential health impacts that the development trends may have on community health. These effects were evaluated through an in depth literature review on how development trends may affect health status. The literature review inclu ded information on risk factors for major diseases in Botswana, access to health services , and case studies where similar development trends had an effect on health status of communities. After the assessment the following phase addressed in this project was the recommendations phase. During this phase, it is explained that a series of recommendations need to be developed to improve the project, plan, or policy and/or to mitigate any negative health impacts (Human Impact Partners, 2011) . The recommendations phase was compiled based on the evaluation of the potential health impacts and discussion on how development changes affect the health status of each of the different communities . A literature review was also conducted to determine re commendations for important next steps to follow and indicators to monitor in each community for reduction of the health burden. Results Conditions Profile Current Health Threats Information about the health situation and access to health services in rural communities often illustrate s the overall picture and the extent to which health services effectively address health and livelihood needs of the community. The health services for Sankuyo and Shorobe are closely linked. Sankuyo village has a health p ost which provides outpatient services to the community. After interviewing the nurse at Sankuyo health post in 2011 it was estimated that he attends an average of 13 patients per day. The closest clinic to the health post is located in the village of Shor obe (approximately 35km) and the nearest hospital is in Maun (approximately 90km). According to the livelihood surveys conducted in 2010, t he average distance each household walks to the Health Post in Sankuyo is 0.8km (approximately 15 minutes). Since Sh orobe is a bigger village, the 2011 livelihood

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14 ! surveys determined that the average distance households in Shorobe walk to the clinic is approximately 2.2km (average of 45 minutes). The cost of a visit to the health post or clinic is 5 Pula. Healthcare in B otswana is, however, free with ID card. HEALTH IN SANKUYO HEALTH IN SHOROBE ! Cost for visit to clinic was P5; or Free with ID Card ! Average distance to health post was 0.8km ! The average time it took a resident to walk to the health post was 15.4 minutes ! The drinking water source for households was 73% house/standpipe; 24% public tap; 2.7% other ! Cost for visit to clinic was P5; or Free with ID Card ! Av erage distance to the Shorobe Clinic was 2.2km ! The average time to walk to clinic was 47 minutes ! The drinki ng water source for households was 48% in house/standpipe; 42% public tap; 5% well borehole and 5% river Table 1 : Health Situation in Sankuyo and Shorobe (2010 & 2011 Livelihood Surveys) According to the nurse, m ost people visit t he health post in Sankuyo for common colds/influenza, and headaches , along with some minor accidents. Occasi onally a doctor visits Sankuyo, brought to the community by joint venture partners , such as tourism operators and researchers , who work in the area. More s erious conditions are treated in the clinic at Shorobe or the hospital in Maun. P eople from Shorobe have better access to health services than people in Sankuyo given the fact that the clinic at Shorobe is the mother clinic to the health post in Sankuyo. However, the time and distance to the clinic was over twice as great for people in Shorobe. For both Sankuyo and Shorobe, people living with HIV/AIDS are seen in Shorobe every two weeks for their ARV treatments . The state of the ro ad to the clinic in Shorobe and to the Sankuyo health post as well as the availability of transport is considered an obstacle for those seeking more serious medical services n ot available at the health post or clinic. In both the 2010 and 2011 livelihood surveys , human death and disease were two of the major events and threats of concern reported by the surveyed households. This fact is not surprising given the fact that HIV is considered to be a major health threat to the

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15 ! population in Botswana. When the MDP 2011 team was in the Sankuyo village, community members said that 65% of women in the district (Ngamiland) were considered to be HIV positive. This is a statistic significant for both Sankuyo and Shorobe since both villages are located in this particular district. Both communities reported that HIV/AIDS was therefore considered one of the biggest health threats affecting their livelihoods. Recent surveys at the national level show the rate of new infections could be slowing (USAID, 2010) . According to testing done in the Sankuyo health post, since 2007, only 1 out of 18 children of HIV positive mothers was found to be HIV positive . The stigma related to HIV/AIDS is a serious problem in both communities ; however , stigma is more prevalent in Sankuyo . This could be a ttributed to the smaller size of the community and their limited access to healthcare . The stigma and discrimination that often accompany the epidemic of HIV/AIDS can, unfortunately, create circumstances for spreading the HIV virus since people with HIV/AI DS fear getting tested for the virus because they may become stigmatized, ostracized, rejected and shunned (Letamo, 2003) . Many HIV positive people even report experiencing sanctions, harassment, and violence because of their infection. During the 2010 livelihoods survey conducted in Sankuyo, people in the community were reluctant to identify HIV/AIDS as a cause of death, but in a meeting attended by the MDP Team in 2011, young people from the community insisted that HIV issues should not be avoided and should instead be talked about openly and addressed . In Shorobe, on the other hand, community members interviewed during the 2011 livelihood survey specifically mentioned HIV/AIDS as a major problem for the deaths of many of their relatives . Several different community members even openly discusse d their HIV status with both the MDP 2011 team and other village members . The different levels of stigma in both communities could be affected by the ir access to healthcare and the village's level of urbanization. People living with HIV/AIDS in both communities are treated in Shorobe every two weeks due to the fact that it is a bigger village and is closer to the city of Maun . In Shorobe, since tre atment is readily available the disease could potent ially not be seen as a death sentence but instead be considered as something that can be managed . Another possible reason for the lesser degree of stigma in Shorobe is the fact that the village is larger and closer to Maun and therefore the number of people infected with HIV/AIDS in the village and city is higher . This could potentially indicate that urbanization is having a positive effect allowing for greater access to health services and decreasing the stigma of the disease. Hunger was also mentione d as a concern by 31% of households in Sankuyo interviewed in 2010 a s well as during many conversations with community members in Shorobe in 2011 . The health post worker in Sankuyo , however, explained that there are

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16 ! government problems attempting to addres s nutrition problems. S ince health issues are the responsibility of the government , children under 5 are to visit the health post in Sankuyo or clinic at Shorobe every month to be weighed and measured , in order to track their development and nutrition al st atus. Food is provided for these children and double rations are given to those considered undernourished. When food is not available, education and counseling is provided to their caretakers. In the 2010 and 2011 livelihood surveys it was found that none of the interviewed househ olds had children suffering from Kwashiorkor. Kwashiorkor is a form of malnutrition that occurs when there is not enough protein in the diet and is common in very poor countries . Kwashiorkor is commonly associated with children characterized by having a large protruding belly (A.D.A.M. Medical Encyclopedia, 2012) . Development Trends Today Sankuyo and Shorobe are two different villages with very distinct livelihood strategies, wil dlife and livestock keeping, however this has not always been the case. Both Sankuyo and Shorobe are located in the northwest district of Ngamiland and were very closely linked until the 1980's when the "buffalo fence" was erected and physically separated both villages and their livelihood options. As was described in the management plan, the people of Sankuyo are of Bayei origin and have been in NG 33 & 34 since the late 18 th century when they moved south from the Caprivi region in response to the expandin g prevalence of the tsetse fly. In 1980, through the national villagization programme, the community moved and established a new village in what is now the current location of Sankuyo , which lies along the road which connects Maun to Kasane. The national v illagization programme provided the community with infrastructure and services , including schooling and healthcare (MDP, 2011) . Traditionally, the livelihoods practiced by people in Sankuyo were based on farming of secondary floodplains, hunting and the use of wild products. Through personal communication in the village, the MDP 2011 team found that the introduction of Community Ba sed Natural Resource Management ( CBNRM ) played an important role in shaping the current livelihoods of the people in Sankuyo. Community members , reported that in 1986 after the Wildlife Policy was introduced there was a shift in livelihood strategies towar ds focusing on wildlife conservation (MDP, 2011) . Trophy hunting became very important to the livelihoods of th e people of Sankuyo, providing 49% of household in come and large amounts of meat (MDP, 2011) . In the 2010 livelihood survey, w ildlife and tourism were found to make up 56% of the household production (livelihoods) in the Sankuyo community. Agriculture on the other hand, was found to only make up 12% due to factors such as the high risk for cro p loss

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17 ! and variability (MDP, 2011) . It is important to note that in 2010 wildlife and tourism contri buted to the livelihoods of most households in Sankuyo. In the 2011 management plan, a series of new tourism options were outli ned as via ble future livelihood options for the community. High end tourism lodges, safari lodges, and camps in the area were explained to potentially result in an increase in employment opportunities for members of the community. Sankuyo Shorobe ! Farming ! Hunting ! Use of wild products CBNRM Ñ 1986 Wildlife Policy ! Wild life conservation ! Commercial hunting ! Tourism ! Farming ! Livestock (cattle & other) ! Fishing ! Basket making ! Mochema (Palm wine) Urbanization ! Small business activities ! Cleaning ! Tuck shop ! Drivers Table 2 : Development Trends in Sankuyo and Shorobe More than one half of the population that lives in rural Botswana is largely dependent on subsistence crop and livestock farming (Department of State, 2011) . Traditionally, the livelihoods of the people of Shorobe were similar to those of Sankuyo in that there were based on farming and the use of wild produc ts but, contrary to Sankuyo, Shorobe lies on the side of the buffalo fence which allows people to keep cattle and other livest o c k . In the 2011 livelihoods survey, the MDP 2011 team found that l ivelihoods for people in Shorobe include cattle keeping, fish ing, agriculture, basket making and weaving, and mochema (palm wine) production , along with other small business activiti es such as cleaning, driving and administrating a tuck shop. People reported to not be limited to a single livelihood activity but rather have a combination of many . In the 2011 livelihood survey most people who described themselves as being a farmer practiced both agriculture and livestock keeping.

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18 ! Shorobe is a peri urban village and because of its close distance from the city of Maun the livelihoods of the people of Shorobe are also closely tied to the economy of the city and have greater variation t han in Sankuyo. There are many members of households in Shorobe that divide d their time between working in Maun and in the village. Community members in Shorobe reported in the 2011 livelihood survey that death of cattle and drought s have constantly affect ed their livelihood strategies , resulting in the displacement of farmers from one place to another as well as the diversification of their livelihood strategies . In 2011, community members explained to the MDP 2011 team that villagers may move to less fert ile areas if those that are fertile flood. Tourism also has an impact for the Shorobe village. Because the Shorobe village is located along the main road from Maun to the Okavango Delta, the village is very well known among tourists for their small busine ss activities includi ng traditional Shorobe baskets. Many households in the community reported being part of a basket making cooperative which sells directly to tourists who pass the village as they drive to their lodges and camps. Evaluating Potential Impacts There are two distinct development trends to be evaluated in each village. For Sankuyo, the development trend which could potentially have a positive or negative impact on the health of the community is tourism . For Shorobe the development trend wo uld be is urbanization. Tourism Tourism is a rapidly growing industry worldwide, however despite the promise of economic prosperity there is increasing concern about the potentially negative health impacts on the health and wellbeing of local communities (Spiegel, 2008) . As mentioned in the 2011 management plan, in the future the Sankuyo community will be operating a series of high end tourism lodges, safari lodges, and camps which me ans that the community will have more employment opportunities in the tourism industry (MDP, 2011) . As was explained to the MDP 2011 team through personal communication in the village of Sankuyo , employment in tourism lodges means that the person s employed will divide their time between living in the lodges and their household in the community , s pending approximately three months away at certain periods of time . This is important because i n Botswana, the old nuclear and/or ext ended family structures have been gradually replaced by zero cou ple or single parent families due to many different factors (Gaisie, 2000) . The reasons for the existence of a single parent family are: divorce, death, never

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19 ! having been married or living far away from the family due to labor migration (Dintwat, 2010) . In both the 2010 and 2011 livelihood surveys showed that there was a trend of households having non core members (males or females) living elsewhere who were sending money to their families. This could be attributed to employment opportunities in current lodg es and/ or other activities in the city of Maun. For the purpose of both the 2010 and 2011 livelihoods survey s , a non core member was defined as any one who spent less than six months in the community . Potential l abor migration , in this particular case through employment in tourism, weakens the family structure by separating husbands from wives for long periods of time (Dintwat, 2010) . Multi locational households due to labor migration and prolonged separation from spouses have been found to be risk factors for HIV/AIDS (Van Donk, 2006) . Prolonged separation from spouses has been found to be related t o a laxity of sexual morals and an increase in extra marital relationships . Having mult iple sexual partnerships is a risky sexual behavior associated with the spread of HIV/AIDS (Dintwat, 2010) . Prostitution is also common in these settings and is considered to be a general problem of tourism (Spiegel, 2008) . Botswana is considered to be a patriarchal society with unequal power relations in which men are considered to be t he "senior partner" in marriage and have power over women. As a result, a gender specific health concern is that men control the sexual decision making norms , which could have harmful effects on the health of the entire household. Men decide whether t o have multiple sexual partners when away from the household and also make decisions regarding adherence to contraceptive use both in the household and outside the household (P haladze, 2006) . Men decide whether they will use safer sex practices with their wives and extra marital relationships and women and girls , given their lower social status, are less likely to be able to negotiate safer sex (Dintwat, 2010)(Phaladze, 2006) . T here are also several other gender specific health concerns regarding employment in tourism. First, women suffer a great burden by working in the tourism industry if they continue working well into their pregnancy (Spiegel, 2008) . This is a detrimental factor to both their and their baby's health because of factors such as fetal exposure to cleaning chemicals, pelvic disease, varicose veins, and back problems (Spiegel, 2008) . In essence, the strain that women may put their bodies in by overworking themse lves may be very harmful. F amily tensions may also result since there has been a historical dependency on men , and there is a perceived reversal of gender roles in families where women have higher income than men given the fact that they are employed in t he tourism industry (Spiegel,

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20 ! 2008) . These tensions could potentially lead to a higher incidence of domestic violence including battery and rape which could lead to several health problems including STD's and HIV/AIDS (Phaladze, 2006) . It has also been rep orted that tourism may affect the mental health of the community in general . Positive community attitudes towards conservation and tourism are the first building blocks towards achieving conservation in nature based tourism destinations (Mbaiwa, 2011) ; how ever they may also have a negative effect. In a 2008 case study in Cuba, mental health stress was attributed to the "prominent economic difference" between the members of the community who were employed in tourism and the rest of the community (Spiegel, 2008) . In a way people felt great stress if they were not enjoying the benefits from tourism and as a result most young people yearned to work in the tourism industry . This is particularly relevant to the community of Sankuyo given the fact tha t for many young people the most lucrative avenue to find work in is in the tourism industry and they may choose to drop out of school in order to be able to work and enjoy the benefits. Urbanization Urbanization in Africa is unprecedented in its effects on poverty and health, and unlike in other parts of the world the trend towards urbanization is not associated with falling poverty rates or improved healthcare (Greif, 2011) . Due to its close location to the city of Maun, Shorobe's economic strategies a re affected by the rate of urbanization of the village and the employment opportunities people may find in the city. While it has long been known that urban levels of HIV infection are usually appreciably higher than rural levels within different countries, urban levels of HIV infection are typically 4 10 times higher than those of rural areas in sub Saharan Africa (Dyson, 2003) . HIV/AIDS and other STD's are often concentrated in larger towns a nd settlements where there is higher population density and greater numbers of different commercial activities (Van Donk, 2006) (Dyson, 2003) . As the MDP learned from the young people in Shorobe , the bars and nightclubs they like to frequent are located in the city of Maun. Also, p eople who live in urban areas (or close to them) tend to marry later due to employment and other factors. This in turn increases the number of sexual partners they may have , as well as their chances of contracting a sexually trans mitted disease which are usually more prevalent in towns. Having a sexually transmitted disease sometimes facilitate s HIV transmission (Dyson, 2003) . Women i n East and Southern Africa lack access to socially recognized jobs in towns because of what their traditional occupation used to be in their rural households . During Colonial times it was men who would travel in search for job opportunities. Women left at home may choose to engage in trades that will allow for them to care for the

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21 ! household. Some women may become prostitutes or brewers and sellers of illicit beer (Caldwell, 1993) (Larson, 1989) (Barnett, 2006) . Both of which are trades said to be very closely linked (Caldwell, 1993). Although people interviewed in the 2010 and 2011 livelihood survey s reported that they did not purchase alcohol , many members in Shorobe reported palm wine production as a secondary livelihood option. There was certainly more mentioning of alcohol in Shorobe , due to the production of palm wine and the close location to th e city of Maun where bars and nightclubs are found . This fact could potentially lead to an increase in heavy episodic drinking and therefore aff ect the health of the community in several ways. Alcohol is the most common form of substance abuse in sub Sahar an Africa and it is associated with risky sexual behaviors since it relaxes the brain and body, reduces inhibitions, diminishes risk perception, and has suppressive effects on the immune system (Weiser, 2006) . Women in both rural and urban areas have repor ted to have had sexual intercourse while intoxicated under alcohol (Dintwa, 2010) . It may also be one of the most common and potentially modifiable HIV risk factors. Among men and women, heavy alcohol use was associated with higher incidence of risky sexua l behaviors including having multiple sexual partnerships, paying for or selling sex in exchange for money or resources, and having unprotected sex (Weiser, 2006) . Development Trend Impact Negative Positive Tourism Increase risk factors for HIV/AIDS ! Labor migration ! Multiple sexual partners ! Commercial sexual activities Gender specific concerns ! Pregnancy ! Overwork ! Domestic violence Mental health ! Stress ! School drop out rates Increase household income ! Improved health status ! Stimulate village economy ! Employment opportunities Access to essential health services ! Improving essential services (roads, clinic) ! Promote rural development

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22 ! Urbanization Increase risk factors for HIV/AIDS ! Higher population density ! Commercial sexual activities ! Late a ge of first marriage ! Increased risk for other STD's Alcohol abuse ! Bars and nightclubs in city ! Heavy episodic drinking ! Risky sexual behaviors Increase household income ! Improved health status ! Stimulate village economy ! E mployment opportunities Access to essential health services ! Dis tance to city hospital is shorter Table 3 : Evaluating Impacts of Development Trends Promoting Rural Development: Access to income and health services Development trends such as tourism and urbanization can also have positive effects on communities. First, employment in tourism would consequently increase household income and therefore can have an effect on the health status of a household and the overal l community. If people are receiving a salary due to employment opportunities then they are able to purchase food and invest resources where they are needed. This is the same case for urbanization, by having greater connectivity with the city and a greater variety of economic opportunities in both the city of Maun and in the village, the income of households in Shorobe could potentially increase which would in turn also affect the health status of the village. Tourist visits in both Sankuyo and Shorobe cou ld have a positive impact on the overall well being of the community. In villages near the Okavango Delta there is great support for tourist visits and common consideration of tourism to be a positive factor affecting their livelihoods. Tourism not only br ings income to their village but also promotes rural development. Some examples include the creation and maintenance of roads, access to essential services, and employment opportunities, as well as buying crafts made in the villages (Mbaiwa, 2011). In Sank uyo and Shorobe tourist visits stimulate the village economy since tourists spend money in the villages. For example, as tourists drive from Maun to the Okavango Delta they must pass Shorobe and the many stores which sell crafts, including their renowned S horobe baskets.

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23 ! Whether it is in a rural or peri urban village, in order to be socio economically viable, families must have access to basic necessities that promote health including food, shelter, clean water and a safe physical environment (Akinsola, 2002). Despite the high prevalence of HIV/AIDS and other diseases in rural households in Botswana, the most affected households tend to not have adequate access to healthcare facilities (Ngwenya, 2007). HIV/AIDS support facilities are said to be provided o n the basis of population size and status of the settlement (urban, urban village, rural, remote) (Ngwenya, 2007). This is particularly important to Sankuyo and Shorobe and their access to healthcare because 50% of the Okavango Delta's population live in s ettlements of less than 500 people, and thus, receive health services indirectly through major population centers whose own capacity to deliver timely services is limited (Ngwenya, 2007). One of the biggest threats in Sankuyo which was identified after wo rking with the community to write the 2011 Sustainable Development Management plan was the inadequate access to health services in the village. Since Sankuyo has a small health post that depends on the Shorobe clinic and Hospital in Maun, access to health services are limited and very vulnerable. The tourism options outlined may lead to better access to essential services needed by the community. This might also be the case for the community of Shorobe. Since the village is so closely linked to Maun, as urb anization takes its course and the distance between the city of Maun and the village gets shorter, the access to health services may increase as well. Recommendations In view of the potential effects that development trends such as tourism opportunities a nd urbanization may have on the health of community members, it is of utmost importance to take these trends into consideration. These development changes may have both positive and /or negative effects in the community. These effects may include an increase in risk factors that lead to illness and disease or an increase in access to income and health services which improve overall health and well being. In the recommendations section o f a Health Impact Assessment, it is very important that for each impact identified in the assessment phase that there is an evidence based recommendation proposed and prioritized by stakeholders. Recommendations, in this context, are alternative ways to de sign a project, plan or policy, to benefit health. The ultimate goals for these recommendations are to mitigate negative and maximize positive health impacts (Human Impact Partners, 2011).

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24 ! Based on this project, the following recommendations can be outlin ed for the Sankuyo and Shorobe communities: Sankuyo Shorobe ! Consider the effects that tourism has on the health of the community ! Inform major stakeholders (Chief, Tourism Operator, and Trust Manager) of the positive and negative effects of tourism ! Include Health Impact Assessment in next Management Plan ! Increase community access to prevention and education campaigns ! Social and environmental factors ! Inclusion of men ! Improve access to health services in the community ! Monitor the health status of the community ! Health system responsive to needs of wildlife communities ! Consider the effects that urbanization has on the health of the community ! Inform major stakeholders (Chief, Chairman of village, leaders) of the positive and negative effects of urbanization ! Increase community access to prevention and education campaigns ! Integrate alcohol abuse in prevention campaigns ! Improve access to health services in the community ! Monitor the health status of the community ! Health system responsive to needs of peri urban villages ! Table 4 : Recommendations for Sankuyo and Shorobe Consider the effects that tourism and urbanization may have on the health of a community After outlining tourism options in the 2011 Sustainable Development Management Plan, there should be a focus now towards considering the implications of employment opportunities in tourism. The community of Sankuyo and other tourism based villages in Botsw ana need to consider both the positive and negative effects that tourism may have on the health of the community. On one hand, employment in tourism is a beneficial strategy because it increases household and community income as well as the

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25 ! community's acc ess to essential health services. Tourism also stimulates the village's economy. However, on the other hand, tourism in Botswana may also exacerbate risk factors for diseases such as HIV/AIDS and have a negative impact on the health and well being of the c ommunity. Urbanization is a fundamental feature of socioeconomic development yet there has been little consideration of how it may impact the worst affected populations (Dyson, 2003) . For the Shorobe village, it is imperative to consider the effects that urbanization and close ties to the city of Maun have on the health of the community. Although economic opportunities may have been increasing for the people of Shorobe and providing people with access to services and resources that would positively impact their health status, risk factors for illness and disease could have potentially also been increasing since the village is so close to the city of Maun . Major stakeholders are aware of the positive and negative effects that to urism and urbanization may have, and should support initiativ es that help address the problem. When the MDP 2011 team was working in Sankuyo to write the sustainable development management plan and in Shorobe while conducting the livelihood surveys , one of the most important factors that played as an advantage was having the support of the village chief s and other important players . Major stakeholders need to understand t hat their support is invaluable to the success of any initiative hoping to address th e problem. In Sankuyo, major stakeholders such as the village chief, the tourism operators and the trust manager, should be made aware of the potential impact that tourism may have on community health. It is important for these stakeholders to know and und erstand the risk factors that lead to an increase in illness and disease so that they propose and support initiatives that address the problem. In Shorobe, the village chief and the major stakeholders should also be made aware of the risks that urbanizati on poses to the village. It is important for these village leaders to know that there are many risks that are particular to peri urban villages, such as Shorobe. With knowledge comes the power to address these risks and maximize the benefits that inherentl y come with urbanization, while minimizing the consequences that may result. One could also argue, for example, that if the findings of a Health Impact Assessment are presented to a joint venture partner who will be running the tourism lodges, he/she coul d set in place preventive programs that will serve as protective factors to a detrimental health outcome that might otherwise result. Tourism operators need to understand that it is to their advantage that the community is healthy so that they are able to work in their lodges.

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26 ! I ncrease community access to prevention and education campaigns in Sankuyo and Shorobe Ñ and focus on specific areas relevant to each community Prevention and education campaigns have traditionally been used to target a number of diffe rent health concerns across the world. Prevention campaigns can act as protect ive factors for risky behaviors and have been commonly used in the prevention of HIV/AIDS in Africa. The argument is that with proper education the risk for illness and disease decreases. In Sankuyo and Shorobe there should be prevention campaigns focusing on the social and environmental factors that affect illness and disease in addition to individual r isky behaviors. Early responses to the HIV epidemic were focused on the identification of individual risk behaviors and the prevention of new infection through modification of these individual behaviors. One example is how a priority in HIV/AIDS prevention in Botswana has been to reduce multiple concurrent sexual partnerships through the reduction of the number of sexual partnerships, in particular the number of concurrent ones (Ho Foster, 2010). There are many social and environmental factors which can hav e a significant impact on health. Therefore, more recently there has been a recognition that individual behaviors need to be considered within their specific economic, social and cultural context; otherwise, efforts to alter them will ultimately fail (Fent on, 2004). In the context of the communities of Sankuyo and Shorobe this is the precise case. It is important to increase public understanding of the dangers that can result out of multiple partnerships as well as un safe sexual practices, so that regardle ss of the social and environmental context these risk factors are taken into consideration. For Sankuyo, it is especially important to include men in prevention campaigns. T raditionally, the role that heterosexual men have played in the transmission of HI V has been neglected by prevention programs (Phaladze, 2006). One example is how HIV/AIDS prevention campaigns focusing on safe sex practices focus on creating awareness of the disease among women and girls and this is explained to perpetuate men's ignoran ce of HIV/AIDS and other very important health information. The problem, as it was explained before, is that in Botswana men make the decisions about what sexual practices are acceptable and men tend to be not necessarily keen on using condoms. The exclusi on of males therefore has serious disadvantages for women due to the fact that they cannot initiate HIV/AIDS prevention strategies without their spouses' or partners' approval (Phaladze, 2006). A key recommendation is to include men in all prevention strat egies so that both men and women are aware of the situation.

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27 ! For Shorobe, it is very important to integrate alcohol abuse in prevention campaigns. While alcohol is strongly associated with HIV infection in Africa, few population based studies have characte rized the association of alcohol use with specific high risk sexual behaviors (Weiser, 2006). In Shorobe, especially, there was a strong prevalence of alcohol consumption and a preference for attending bars and nightclubs in Maun. Programs need to take alc ohol consumption into consideration. As was explained earlier, consumption of alcohol leads to many risky sexual behaviors (having unprotected sex with a non monogamous partner, having multiple sexual partners, paying for or selling sex) which could potent ially lead to detrimental health outcomes. Integration of alcohol abuse and HIV prevention efforts in Botswana and elsewhere is of great importance (Weiser, 2006). Improve the access to health services in Sankuyo and Shorobe and monitor community health Despite the high prevalence of HIV, for example, the most affected households in rural communities tend to not have adequate access to HIV/AIDS support facilities (Ngwenya, 2007). Since about 50% of the population near the Okavango Delta lives in settlemen ts of less than 500 people, they receive health services indirectly through major population centers whose capacity is sometimes limited (Ngwenya, 2007). The government of Botswana and the health system of the country should be responsive of the different needs that communities have. A key recommendation would be to take this factor into consideration and attempt to improve the access to health services in small wildlife communities such as Sankuyo or peri urban villages such as Shorobe , due to the fact th at in order to be socio economically viable, families in rural communities must have adequate access to basic necessities that promote health including food, shelter, clean water, and a safe physical environment (Akinsola, 2002) . Small villages such as Sankuyo desperately need access to essential services and resources that larger villages such as Shorobe already have. It is important for the health system to take this fact into consideration and provide the resources needed in the most remote areas as well as supply larger health centers. It is also important to monitor community health so that risks are addressed and health status is improved. Monitoring tracks the effects of the Health Impact Assessment on the decision making pro cess and the decision, the implementation of the decision, and the impacts of the decision on health determinants (Human Impact Partners, 2011). Indicators to examine the health status of communities which are important to continuously monitor include (McC oy, 1998): Mortality rates (infant, under 5, maternal)

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28 ! Low birth weight rate and nutrition status % of children who are underweight for age Proportion of primary school entrants who are stunted TB cases Sexually Transmitted Disease rates Teenage pregnancy rate Proportion of children under 2 years old who are fully immunized Exclusive breastfeeding rate HIV prevalence in the community Conclusions Conducting a Health Impact Assessment of any policy, program, or project is important when working with communiti es for reduction of their health burden. A Health Impact Assessment is a strategic planning tool that is cond ucted to improve the quality of decision making through recommendations to enhance predicted positive health impacts and minimize the negative ones (Barnes, 2000) . A Health Impact Ass essment is therefore a key competency to learn and practice as a development practitioner. Actions , policies or programs that are proposed by organizations or institutions may have un expected impacts on the health of a c ommunity and the results gathered through a Health Impact Assessment could lead to valuable adaptive strategies . The information gathered through a Health Impact Assessment can be scaled up to be used with stakeholders across many different levels including communities, organizations and governments. In order to adapt the data collected through the assessment it is important to consider the different audiences and what use they would find for the d ata. A Health Impact Assessment could lead to prevention campaigns focusing on specific risk factors and at the same time affect policy. The findings from a Health Impact Assessment can serve to motivate decision makers to incorporate health promoting chan ges to projects or policies and reduce the health burden in rural communities. A Health Impact Assessment can also increase the public understanding of the causes of an illness while at the same time create new strategic opportunities for prevention of the disease (Human Impact Partners, 2011) . It is important to note , however, that ideally a Health Impact Assessment is conducted before the action, policy, program or project is set in place , in order to judge the potential effects that such action may have on the population , as one of its major goals is to identify harms and benefits before decisions are made (Human Impact Partners, 2011) . In practice, however, this is not always possible, and a Health Impact Assessment may be carried out concurrently with t he project or retrospectively (Barnes, 2000) . Regardless of the timing of the Health Impact Assessment, the idea behind it should always be considered when working in development practice.

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29 ! T he relationship between disease and employment is not an unusual n otion to be considered in the field of international development. If there are people who are sick and impoverished as a result of an affliction, because they are not able to work in any sort of productive livelihood , many people and organizations across t he world become concerned. However there is another side to that disease to employment relationship. The different livelihood options or employment opportunities that people underta ke, and the development trends that affect their communities, can also pote ntially impact their health. If the ultimate goal as a development practitioner is to achieve sustainable development of rural communities , then conducting a Health Impact Assessment of any policy program or project is an import ant planning process to foll ow. This, if the goal is to maximize the benefits and minimize the negative effects that development programs or policies may have on health . As the development trajectories of a community transition in today's economic arena, it is important to think about the impact that these may have on the health of the community when considering adopting or fostering new economic strategies.

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30 ! Reference s USAID . (2010, September). Retrieved June 14, 2011, from http://www.usaid.gov/our_work/global_health/aids/Countries/africa/botswana.html A.D.A.M. Medical Encyclopedia. (2012, February 1). Kwashiorkor. Retrieved April 12, 2012, from Diseases and Conditions: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002571/ Akinsola, H. A. (2002). The Quality of Life of Families of Female Headed Households in Botswana: A Secondary Analysis of Case Studies. Healthcare for Women International , 761 772. Barnes, R. S. S. (2000). Health Impact Assessment a Ten Minute Guide. Liverpool: Liverpool Public Health Observatory. Barnett, T. W. (2006). AIDS in the Twenty first century: Disease and globalization 2nd ED. UK: Palgrave Macmillan. Calberth, H. D. (2003). Developing Health Impact Assessment for Sustainable Futures in Small Island States and Territories. Journal of Environmental Assessment Policy and management , 447 502. Caldwell, J. C. (1993). The Nature and Limits of the sub Saharan African AIDS Epidemic: Evidence from Geographic and other Patterns. Population and Development Review , 817 848. Central Intelligence Agency. (2012, April 5). Botswana . Retrieved March 28, 2012, from The World Factbook: https://www.cia.gov/libra ry/publications/the world factbook/geos/bc.html Central Statistics Office. (2002). National Population and Housing Census. Gaborone: Ministry of Finance and Development Planning. Central Statistics Office. (2011). 2011 Population & Housing Census: Preliminary Results Brief. Gaborone: Central Statistics Office. Department of State. (2011, November 17). Botswana . Retrieved March 20, 2012, from Country Profiles: http://www.state.gov/r/pa/ei/bgn/1830.htm Dintwa, F. (2010). Factors Associated with Nonuse of Condom for Sexually Active Botswana Women. Health Care for Women International , 37 52. Dintwat, F. K. (2010). Changing Family Structure in Botswana. Journal of Comparative Family Studies , 281 297. Douglas, C. (2003). Developing Health Impact Assessment for Sustainable Futures in Small Island States and Territories. Journal of Environmental Assessment Policy and Management , 477 502.

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31 ! Dyson, T. (2003). HIV/AIDS and Urbanization. Population Council , 427 442. Fenton, L. (2004). Preventing HIV/AIDS through po verty reduction: the only sustainable solution. Lancet , 1186 1187. Gaisie, S. (2000). Family structure, gender and fertility in Botswana, Pula. Botswana Journal of African Studies , 130 147. Government of Botswana. (n.d.). Background of the Judiciary . Retri eved April 13, 2012, from Administration of Justice (AO): http://www.gov.bw/en/Ministries -Authorities/Ministries/Administration of Justice AOJ/Background Traditions Court/Background of the Judiciary/ Greenberg, S. (2011, May). Presentation HIV Prevention CDC Botswana. (M. Team, Interviewer) Greif, M. N. A. (2011). Urbanisation, Poverty and Sexual Behaviour: The Tale of Five African Cities. Urban Studies , 947 957. Ho Foster, A. L. (2010). Gender Specific Patterns of Multiple Concurrent Sexual Partnerships: A national cross sectional survey in Botswana. AIDS Care , 1006 1011. Human Impact Partners. (2011). A Health Impact Assessment Toolkit: A Handbook to Conducting HIA, 3rd Edition. Oakland, CA: Human Impact Partners. Larson, A. (1989). Social context of Huma n Immunodeficiency Virus transmission in Africa: Historical and cultural bases of East and Central African sexual relations. Reviews of Infectious Diseases , 716 731. Letamo, G. (2003). Prevalence of, and Factors associated with, HIV/AID related Stigma and Discriminatory Attitudes in Botswana. J Health Popul Nutr , 347 357. Mbaiwa, J. E. (2011). Changes in resident attitudes towards tourism development and conservtion in the Okavango Delta, Botswana. Journal of Environmental Management , 1950 1959. McCoy, D. ( 1998). How to conduct a rapid situation analysis: a guide for health districts in South Africa. Durban:Health Systemss Trust . MDP. (2011). Sustainable Development Plan for Sankuyo & Management Plan for NG 33 and NG 34. Maun: Under Revision. Ngwenya, B. M. (2007). HIV/AIDS, artisanal fishing and food security in the Okavango Delta, Botswana. Physics and Chemistry of the Earth , 1339 1349. Phaladze, N. T. (2006). Gender and HIV/AIDS in Botswana: A Focus on Inequalities and Discrimination. Gender and Development , 23 35.

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32 ! Scott Samuel, A. (1998). Health Impact Assessment -Theory into Practicy. Journal of Epidemiology and Community Health , 704 705. Spiegel, J. G. (2008). Promoting health in response to global tourism expansion in Cuba. Health Promotion International , 60 69. UNICEF. (2010). Botswana . Retrieved April 12, 2012, from Country Profile: http://www.unicef.org/infobycountry/botswana_statistics.html University of Botswana. (2008). Population Projections for Botswana: 2001 2031. Gaborone: Universit y of Botswana. USAID. (2010). USAID HIV/AIDS Health Profile for Botswana. Gaborone: USAID. Van Donk, M. (2006). Positive Urban Features in Sub Saharan Africa: HIV/AIDS and the need for ABC (A Broader Conceptualization). Environment and Urbanization , 155 17 5. Weiser, S. L. d. (2006). A population based study on alcohol and high risk sexual behaviors in Botswana. PLoS Med , 1940 1948. Wise, M. H. R. (2009). The role of Health Impact Assessment in population and health equity. Health Promotion Journal of Austra lia , 172 179. World Health Organization . (2010). Botswana: Health Statistics Profile 2010. Atlas of Health Statistics.


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