Metabolic Syndrome and Health‑Seeking Behaviour in Botswana Prisons: Behavioural, Institutional, and Systemic Determinants

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Evidence from sub–Saharan African prisons on barriers to screening, diagnosis, and chronic care is limited. This study examined behavioural, institutional, and systemic determinants of health seeking for metabolic syndrome among incarcerated adults in Botswana Methods: A qualitative cross-sectional study guided by an interpretivist paradigm was conducted across eight custodial facilities in Botswana. Purposive sampling recruited 47 incarcerated adults aged 19–46 between 03 February and 12 February 2025. Semi structured interviews were conducted in private rooms and recorded in writing in real time by the lead researcher; reflexive field notes were maintained. Interview guides probed knowledge of metabolic risk, prior screening for blood pressure and blood glucose, access to chronic medications, diet and physical activity, and barriers to care. Data were analysed thematically using Braun and Clarke’s six step framework with coding supported by QDA Miner Lite. Trustworthiness was supported through reflexive journaling, peer debriefing, and an audit trail. Results: Participants described monotonous, low diversity diets and limited opportunities for exercise, conditions likely to increase metabolic risk. Routine screening for metabolic syndrome components was rare and typically reactive rather than routine. Access to care was frequently delayed and officer dependent, with medicine shortages, referral delays, and dismissive staff attitudes discouraging help seeking. Knowledge of noncommunicable diseases was limited but inmates framed care seeking as a fundamental right. Institutional and systemic deficits in nutrition, infrastructure, and supply chains undermined preventive and chronic care for metabolic conditions. Conclusions: Targeted interventions are needed to address metabolic syndrome in custodial settings: routine screening for blood pressure and glucose, nutrition and physical activity programs aligned with national NCD guidelines, reliable medication supply chains, and integration of prison health into national health systems. These reforms are both a human rights obligation and a public health priority. Ethics: Approval obtained from the Ministry of Health of Botswana HPRD:6/14/I and University of Pretoria HREC 25/2025. Participants provided informed consent. Custodial health Metabolic syndrome Hypertension Diabetes Health‑seeking behaviour Prison health systems Botswana Background Custodial populations represent one of the most neglected domains of public health, despite their disproportionate burden of disease and vulnerability to systemic inequities[ 1 ]. Incarcerated individuals are subject to restricted autonomy, limited access to preventive and curative services, and heightened exposure to environmental stressors such as overcrowding, poor nutrition, inadequate sanitation, and psychosocial strain[ 2 , 3 ]. These conditions exacerbate metabolic risk factors, accelerate the onset of noncommunicable diseases (NCDs), and undermine health-seeking behaviour[ 2 – 4 ]. The prison environment, by design, constrains individual agency, yet health outcomes within custodial settings are not solely determined by personal choices they are shaped by the interplay of behavioural, institutional, and systemic forces[ 5 , 6 ]. Globally, prison health reflects broader inequities in health systems[ 1 , 7 , 8 ]. Institutional constraints within custodial facilities such as inadequate staffing, fragmented service delivery, and rigid disciplinary cultures mirror challenges faced by resource-limited health systems[ 9 ]. At the systemic level, policy neglect and underinvestment perpetuate disparities in access and outcomes, reinforcing cycles of exclusion[ 10 , 11 ]. The World Health Organization has emphasized that addressing the health needs of vulnerable populations, including those deprived of liberty, is essential for achieving universal health coverage and advancing the Sustainable Development Goals[ 8 ]. Custodial health is therefore not only a matter of human rights but also a public health imperative, given the permeability of prison walls and the continuous movement of individuals between prisons and communities[ 12 ]. This study narrows the focus to metabolic syndrome a cluster of conditions including hypertension, hyperglycaemia, dyslipidaemia, and central obesity because these risk factors are modifiable, under‑screened in prisons, and have major implications for long‑term morbidity and health system costs[ 13 ]. Despite this recognition, custodial health remains underprioritized in both research and policy. Existing literature is heavily concentrated in high-income countries, where prison health systems are relatively better resourced and documented[ 1 ]. In contrast, evidence from sub-Saharan Africa is sparse, limiting understanding of how systemic inequities manifest in custodial contexts characterized by resource constraints[ 14 ]. Moreover, research has predominantly focused on infectious diseases such as HIV and tuberculosis, reflecting both epidemiological priorities and donor-driven agendas[ 15 , 16 ]. While these conditions remain critical, the growing burden of NCDs and lifestyle-related risks in prisons has received far less attention, despite its implications for long-term health outcomes and system resilience[ 17 ]. Equally underexplored is the complex interplay of behavioural, institutional, and systemic determinants of health-seeking behaviour in custodial settings[ 18 ]. Behavioural factors such as stigma, mistrust of health services, and coping strategies interact with institutional dynamics, including prison policies, disciplinary practices, and resource allocation[ 18 , 19 ]. These, in turn, are embedded within systemic structures of health financing, governance, and policy integration[ 20 , 21 ]. Understanding this layered interplay requires qualitative inquiry that captures the lived experiences of inmates, healthcare staff, and administrators[ 20 , 21 ]. Yet, qualitative evidence in this domain remains scarce, constraining efforts to design reforms that are both contextually grounded and equity-oriented. This study seeks to explore how behavioural, institutional, and systemic factors shape health‑seeking behaviour for metabolic syndrome and its component risk factors (hypertension, hyperglycaemia, dyslipidaemia, and central obesity) among incarcerated adults in Botswana, and to identify actionable reforms to improve detection, management, and continuity of care. By situating custodial health within the broader discourse on equity and systemic reform, the research illuminates’ barriers to care and generates evidence-based recommendations for prison health reform. In doing so, it contributes to the global dialogue on advancing rights-based approaches to health in constrained environments, while offering insights relevant to sub-Saharan Africa and other resource-limited settings where custodial health has long remained at the margins of public health scholarship and policy. Materials and Methods This qualitative study was designed to generate rich, context-specific insights into the determinants of health in custodial environments in Botswana. A cross-sectional qualitative design was employed to capture diverse perspectives across multiple prison facilities. The study was guided by an interpretivist paradigm, recognizing that health-seeking behaviour is socially constructed and shaped by institutional and systemic contexts. Sampling and participants Purposive sampling targeted incarcerated adults capable of providing varied perspectives on health behaviours and systemic barriers. Although the study protocol anticipated recruiting 30–45 participants, data collection yielded 47 incarcerated participants across eight facilities (see Table 1). No healthcare staff or administrators were interviewed for this analysis; references to staff perspectives in the Methods have been removed to avoid confusion. Recruitment occurred between 03/02/2025 and 12/02/2025. Participation was voluntary and informed consent was obtained from all participants. Data collection Semi‑structured interviews were conducted in private rooms within custodial facilities. Interview guides included prompts on prior screening for blood pressure and blood glucose, access to chronic medications, diet and physical activity, and understanding of metabolic risk. Due to institutional constraints and participant preference, interviews were recorded in writing in real time by the lead researcher; reflexive field notes were also maintained. Average interview length was approximately 25–40 minutes. Partial interviews (n=4) were retained and included in analysis where usable data were present; missing items were noted during coding. A semi‑structured interview guide was developed specifically for this study to explore behavioural, institutional, and systemic determinants of health‑seeking behaviour among incarcerated persons. The English language version of the interview guide has been provided as a supplementary file (Supplementary File 1) to ensure transparency and reproducibility. The guide was not previously published elsewhere. Data Analysis Data were analysed using Braun and Clarke’s six-step thematic framework: familiarization, coding, theme development, review, definition, and reporting[22]. Coding was facilitated by QDA Miner Lite, with supervisory review of a subset of transcripts to enhance credibility and inter-coder reliability[23]. Themes were developed to illuminate how behavioural, institutional, and systemic factors interact to shape health outcomes in custodial settings. Trustworthiness and Rig or Methodological rigor was ensured through multiple strategies tailored to the custodial context. Credibility was enhanced by triangulating perspectives across diverse inmate groups, and by engaging in peer debriefing to validate emerging interpretations. Dependability was supported through the maintenance of a detailed audit trail that documented coding decisions, theme development, and analytic reflections, thereby providing transparency and consistency in the research process. Confirmability was strengthened through reflexive journaling, which enabled the researcher to critically examine positionality, acknowledge potential biases, and account for the influence of researcher perspectives on data interpretation. Transferability was facilitated by providing thick description of custodial environments, inmate experiences, and institutional conditions, allowing readers to assess the applicability of findings to similar settings. Collectively, these strategies ensured that the study’s qualitative insights were both rigorous and contextually grounded, offering a reliable basis for understanding the determinants of health-seeking behaviour among incarcerated populations. Ethical Consideration This study was conducted in accordance with established ethical principles for research involving human participants. Ethical approval was obtained from the Ministry of Health of Botswana (Department of Health Policy, Research and Development (HPRD), HPRD:6/14/I) and the University of Pretoria Human Research Ethics Committee (approval number 25/2025). Permissions were also granted by the Botswana Prison Service. All participants provided informed consent. Participants consented to anonymized quotations being used in publications. Participation was entirely voluntary, and informed consent was obtained after the study purpose, advantages, limitations, and implications of consenting were explained to participants. No minors were included in the study; therefore, parental or guardian consent was not required. The ethics committee did not waive the need for consent. Confidentiality was maintained by conducting interviews in secure rooms, anonymizing transcripts, and removing identifying details from all records. Findings were reported in aggregate to prevent identification of individuals or specific facilities. Reflexive journaling and field notes were used to account for positionality, power dynamics, and potential biases arising from conducting research in custodial environments. The study adhered to principles of respect, beneficence, and justice, ensuring that participants’ dignity was upheld and that findings would contribute to improving health equity in custodial settings Results Participant Demographics A total of 47 incarcerated adults (ages 19–46) participated across two divisions (North and South), with representation from both sexes and eight facilities (Table 1). Four interviews were partial but retained for analysis where data were usable. Table 1. Demographic Profile of Participants (N=47) Name of Prison facility Security Level Location (Division) Number of Participants Lobatse High South 6 Central High South 6 Mochudi Low South 3 Moshupa Medium South 4 Francistown High North 2 Selibe phikwe Medium North 8 Machaneng Low North 4 Mahalapye High North 14 Total 47 Diet, Physical Activity, and Metabolic Risk Monotonous, low‑diversity diets and minimal exercise opportunities described by participants create conditions that likely increase risk for metabolic syndrome (hypertension, hyperglycaemia, dyslipidaemia, central obesity). Food was frequently described as poorly prepared and nutritionally inadequate, contributing to gastrointestinal complaints and potential nutrient deficits; female wings reported especially limited recreation and disrupted rest due to overcrowding and duties. “ Participants consistently described monotonous diets dominated by maize meal, sorghum, samp, and occasional meat, with fruits and vegetables largely absent or restricted to medical prescriptions .” Screening, Diagnosis, and Treatment of Metabolic Conditions Routine screening for metabolic syndrome components (blood pressure, blood glucose, lipids, and waist circumference) was rare and typically reactive conducted during outbreaks, campaigns, or external oversight visits rather than as standard practice. Participants reported inconsistent diagnosis and management: long waits for clinical review, intermittent medication supply, and limited continuity of care for chronic conditions, undermining early detection and long‑term control of metabolic risk factors. Institutional Access and Gatekeeping Access to healthcare was described as difficult, delayed, and officer‑dependent, with appointments scheduled by diaries rather than clinical urgency. Staff attitudes and gatekeeping discouraged help‑seeking; inmates reported ignored medical letters, unmet dental needs, and inappropriate or repeated prescriptions, which eroded trust and reduced engagement with available services. “ Access to healthcare was consistently described as difficult, delayed, and dependent on escorts or officer discretion .” Environmental and Systemic Barriers Affecting Metabolic Health Overcrowding, poor ventilation, and inadequate sanitation increased infection risk and psychosocial stress, while seasonal extremes worsened living conditions. Medicine shortages, referral delays, and constrained food budgets were recurrent problems that sometimes resulted in untreated illness; inmates repeatedly called for structural improvements (better food, bedding, protective clothing, and exercise facilities) that would support metabolic health. Perceptions, Knowledge, and Health ‑ Seeking Norms for Metabolic Risk Knowledge of NCDs and metabolic syndrome was limited and sometimes inaccurate, yet motivation to seek care remained strong and framed as a fundamental right. Discouragement arose from delays, dismissive officer behaviour, and systemic neglect, producing widespread distrust in custodial health services; nonetheless, most inmates expected better access and outcomes after release. Participants’ accounts indicate that behavioural factors (limited knowledge, stress), institutional practices (gatekeeping, reactive screening), and systemic failures (nutrition, supply chains, infrastructure) interact to increase metabolic risk and impede timely detection and management of metabolic syndrome in Botswana’s prisons. These findings directly align with the study objective to examine how behavioural, institutional, and systemic determinants shape health‑seeking for metabolic syndrome and to identify targets for reform. Discussion This study documents the lived experiences of incarcerated individuals across multiple custodial facilities in Botswana, revealing systemic neglect in nutrition, healthcare access, environmental conditions, and psychosocial support. The findings align with global literature identifying prisons as sites of structural disadvantage and heightened vulnerability to disease and poor wellbeing [24, 25]. Nutrition and Lifestyle Participants’ accounts revealed monotonous diets dominated by maize meal, sorghum, and samp, with limited access to fruits and vegetables. These findings highlight nutritional inadequacies that contribute to malnutrition, gastrointestinal complaints, and increased risk of noncommunicable diseases (NCDs) [26, 27]. The restriction of fruits and vegetables to special diets prescribed by doctor’s underscores inequities in access to basic nutrition. Similar patterns have been documented in other sub‑Saharan African custodial environments, reinforcing the need for reforms that align prison food provision with national dietary guidelines and international standards [28, 29]. Healthcare Access and Institutional Constraints Healthcare access was consistently described as delayed, inconsistent, and dependent on officer discretion. Inmates reported long waits, diary‑based scheduling, and shortages of medical staff and medicines. These findings align with global evidence that prison healthcare is often reactive rather than preventive, with chronic conditions underdiagnosed and undertreated [30]. Comparable barriers have been reported in South Africa, Kenya, and Uganda, where escort shortages and officer gatekeeping hinder timely care [31-33]. Integrating prison health services into national health systems is critical to improve continuity of care, accountability, and equity[1, 12]. Environmental and Systemic Barriers Overcrowding, poor ventilation, and inadequate sanitation were recurrent themes, directly linked to infections, respiratory problems, and mental distress. Seasonal extremes exacerbated discomfort, while medicine shortages and delays in referrals resulted in untreated illnesses and, in some cases, deaths. These conditions mirror global findings that poor prison environments are key drivers of communicable disease transmission[34, 35]. Addressing these systemic failures requires investment in infrastructure, reliable medicine procurement systems, and improved sanitation facilities. Psychosocial Dimensions and Perceptions of Risk Participants demonstrated limited knowledge of NCDs, with some misclassifying them as “transmitted diseases.” Motivation to seek care was strong, framed as a fundamental right, but discouragement stemmed from systemic neglect and officer behaviour. The widespread perception that “there is no health in prison” illustrates profound distrust in institutional systems. Yet, optimism about health after release suggests that inmates view incarceration as a temporary suspension of health rights. This highlights the need for health education programs within prisons and reforms to build trust in custodial health systems. Strengths and Limitations A key strength of this study lies in its relatively large sample size (N=47) across multiple facilities, capturing diverse perspectives from both male and female inmates. Semi-structured interviews allowed participants to articulate lived experiences, strengthening authenticity. However, limitations include partial interviews, reliance on self-reported accounts, and absence of triangulation with staff perspectives or clinical records. Findings therefore reflect inmate perceptions rather than a comprehensive institutional assessment. Future research should incorporate multi-stakeholder perspectives and mixed-methods approaches to enhance validity and generalizability. Policy Implications and Human Rights The findings of this study underscore the reality that prisons are not only sites of confinement but also critical arenas for public health intervention and human rights protection. International frameworks, most notably the United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules), affirm that individuals deprived of liberty are entitled to healthcare equivalent to that available in the wider community. Yet, the systemic neglect documented in Botswana’s custodial settings manifested in poor diets, delayed and inconsistent healthcare, overcrowding, and inadequate sanitation represents a clear violation of these standards. Addressing these inequities requires a comprehensive policy response that moves beyond piecemeal interventions. Integration of prison health into national health systems is essential to ensure continuity of care and accountability. Investment in nutrition, infrastructure, and medicine supply chains must be prioritized to address the structural deficiencies that undermine inmate wellbeing. Equally important are training and accountability mechanisms for prison officers and healthcare staff, which can help shift institutional cultures toward respect, responsiveness, and equity. Finally, health literacy and psychosocial support programs tailored to incarcerated populations are needed to empower inmates, reduce stigma, and foster trust in custodial health services. Taken together, these reforms would not only advance the rights and dignity of incarcerated individuals but also strengthen public health resilience more broadly. Given the permeability of prison walls and the continuous movement of individuals between custodial facilities and communities, improving prison health is both a moral obligation and a pragmatic necessity for achieving health equity and sustainable development. Global Relevance By situating custodial health within the broader discourse on equity and systemic reform, this study contributes to the global dialogue on advancing rights-based approaches to health in constrained environments. The findings resonate with challenges documented in other sub-Saharan African countries, underscoring the need for regional collaboration and comparative research. Addressing custodial health inequities is essential not only for Botswana but also for strengthening public health resilience across resource-limited settings. Conclusion This study shows that behavioural, institutional, and systemic factors jointly hinder detection, management, and help‑seeking for metabolic syndrome in Botswana’s prisons. Monotonous diets, limited physical activity, inconsistent screening, medicine shortages, and officer‑dependent access create elevated metabolic risk and distrust in custodial health services. Priority actions are routine screening (BP, glucose, lipids), improved nutrition and exercise programs, reliable medication and referral systems, and integration of prison health into the national NCD response. These reforms are a human rights obligation and a public health necessity to protect inmates and the wider community. Declarations Ethics approval and consent to participate: Ethics approvals: Ethical approval was obtained from the Department of Health Policy, Research and Development (HPRD), Ministry of Health of Botswana (HPRD:6/14/I) and the University of Pretoria Human Research Ethics Committee (approval number 25/2025). Permissions to conduct the study in custodial facilities were granted by the Botswana Prison Service. Informed consent: Participation was voluntary and all participants provided informed consent after the study purpose, procedures, risks, benefits, and confidentiality measures were explained. Participants consented to anonymized quotations being used in publications. Vulnerable population safeguards: Given the custodial setting, additional protections were implemented: interviews were conducted in private rooms; no incentives or coercive inducements were offered; recruitment and consent procedures were overseen by independent ethics committees and custodial authorities to minimise perceived coercion; and identifying information was removed from transcripts and reports. Confidentiality and data security: Transcripts and field notes were anonymized at source. Deidentified data are stored on password protected institutional servers with access restricted to the research team. Any requests for deidentified transcripts or coding frameworks will be processed in accordance with custodial clearance procedures and applicable institutional policies. Compliance with ethical standards: The study adhered to international ethical standards for research with human participants, including the Declaration of Helsinki and relevant national regulations governing research in custodial settings. Consent for publication: Participants consented to the publication of anonymized quotations; no individual identifiers are reported. Contact for ethics queries: Questions about the study’s ethical approvals or participant protections may be directed to the corresponding author, Dr Lebapotswe Bahumi Tlale ( [email protected] ), or the University of Pretoria Human Research Ethics Committee. Consent for publication: Not applicable beyond anonymized quotations; participants consented to publication of anonymized quotes. Availability of data and materials Deidentified transcripts and the coding framework are available from the corresponding author on reasonable request and subject to custodial approvals. Requests should be sent to [email protected] and will be processed in accordance with custodial clearance procedures. Competing interests: The authors declare no competing interests. Funding: This research received no specific grant from any funding agency. Acknowledgements: The author gratefully acknowledges Ms Lethabo Phefadu (University of Pretoria) for facilitation and support. Special thanks to the Commissioner of Prisons, Mr Antony Mokento, and the Deputy Commissioner, Mr Lethata Manne, for permission to undertake this project. The author thanks Superintendent Alber Mandendemuka, Superintendent Sharon Simon, APO Banga, APO Mokone Mabe, and Sergeant Itumeleng Taziba for assistance with data collection. 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International Journal of Business Ecosystem & Strategy (2687-2293) 2025, 7 (6):486-493. Simpson PL, Simpson M, Adily A, Grant L, Butler T: Prison cell spatial density and infectious and communicable diseases: a systematic review . BMJ Open 2019, 9 (7):e026806. Herbert K, Plugge E, Foster C, Doll H: Prevalence of risk factors for non-communicable diseases in prison populations worldwide: a systematic review . Lancet 2012, 379 (9830):1975-1982. Additional Declarations No competing interests reported. Supplementary Files COREQchecklist.docx InterviewGuideSemiStructured.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 21 Apr, 2026 Editor assigned by journal 20 Apr, 2026 Editor invited by journal 01 Apr, 2026 Submission checks completed at journal 31 Mar, 2026 First submitted to journal 31 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9220291","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":630921703,"identity":"fcd29c95-895f-4e7f-be53-8f86ad68c4cc","order_by":0,"name":"Lebapotswe Tlale","email":"data:image/png;base64,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","orcid":"","institution":"University of Pretoria","correspondingAuthor":true,"prefix":"","firstName":"Lebapotswe","middleName":"","lastName":"Tlale","suffix":""},{"id":630921704,"identity":"1c9fd0a0-0afe-4161-8d74-a070ce2f5c1a","order_by":1,"name":"Yogan Pillay","email":"","orcid":"","institution":"University of Pretoria","correspondingAuthor":false,"prefix":"","firstName":"Yogan","middleName":"","lastName":"Pillay","suffix":""},{"id":630921705,"identity":"cdeebf77-e72c-419e-b6be-d68581f4ef4d","order_by":2,"name":"Debashis Basu","email":"","orcid":"","institution":"University of Pretoria","correspondingAuthor":false,"prefix":"","firstName":"Debashis","middleName":"","lastName":"Basu","suffix":""}],"badges":[],"createdAt":"2026-03-25 08:26:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9220291/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9220291/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108184196,"identity":"d428a6c2-3396-4843-89c6-106143df7b84","added_by":"auto","created_at":"2026-04-30 09:03:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":274427,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9220291/v1/90ebd2a7-672c-472b-8fdf-13853cbc29a3.pdf"},{"id":108122965,"identity":"ed00f69c-7b2b-4088-8a82-2f87acfc4184","added_by":"auto","created_at":"2026-04-29 14:52:22","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19713,"visible":true,"origin":"","legend":"","description":"","filename":"COREQchecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-9220291/v1/ee7748ca1b62b46032c78d4a.docx"},{"id":108182400,"identity":"60851726-5b43-46db-b38e-3226bba2ec72","added_by":"auto","created_at":"2026-04-30 08:59:21","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15637,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewGuideSemiStructured.docx","url":"https://assets-eu.researchsquare.com/files/rs-9220291/v1/2864b03ec1216773b3037828.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Metabolic Syndrome and Health‑Seeking Behaviour in Botswana Prisons: Behavioural, Institutional, and Systemic Determinants","fulltext":[{"header":"Background","content":"\u003cp\u003eCustodial populations represent one of the most neglected domains of public health, despite their disproportionate burden of disease and vulnerability to systemic inequities[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Incarcerated individuals are subject to restricted autonomy, limited access to preventive and curative services, and heightened exposure to environmental stressors such as overcrowding, poor nutrition, inadequate sanitation, and psychosocial strain[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These conditions exacerbate metabolic risk factors, accelerate the onset of noncommunicable diseases (NCDs), and undermine health-seeking behaviour[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The prison environment, by design, constrains individual agency, yet health outcomes within custodial settings are not solely determined by personal choices they are shaped by the interplay of behavioural, institutional, and systemic forces[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGlobally, prison health reflects broader inequities in health systems[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Institutional constraints within custodial facilities such as inadequate staffing, fragmented service delivery, and rigid disciplinary cultures mirror challenges faced by resource-limited health systems[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. At the systemic level, policy neglect and underinvestment perpetuate disparities in access and outcomes, reinforcing cycles of exclusion[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The World Health Organization has emphasized that addressing the health needs of vulnerable populations, including those deprived of liberty, is essential for achieving universal health coverage and advancing the Sustainable Development Goals[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Custodial health is therefore not only a matter of human rights but also a public health imperative, given the permeability of prison walls and the continuous movement of individuals between prisons and communities[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This study narrows the focus to metabolic syndrome a cluster of conditions including hypertension, hyperglycaemia, dyslipidaemia, and central obesity because these risk factors are modifiable, under‑screened in prisons, and have major implications for long‑term morbidity and health system costs[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite this recognition, custodial health remains underprioritized in both research and policy. Existing literature is heavily concentrated in high-income countries, where prison health systems are relatively better resourced and documented[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In contrast, evidence from sub-Saharan Africa is sparse, limiting understanding of how systemic inequities manifest in custodial contexts characterized by resource constraints[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Moreover, research has predominantly focused on infectious diseases such as HIV and tuberculosis, reflecting both epidemiological priorities and donor-driven agendas[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. While these conditions remain critical, the growing burden of NCDs and lifestyle-related risks in prisons has received far less attention, despite its implications for long-term health outcomes and system resilience[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEqually underexplored is the complex interplay of behavioural, institutional, and systemic determinants of health-seeking behaviour in custodial settings[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Behavioural factors such as stigma, mistrust of health services, and coping strategies interact with institutional dynamics, including prison policies, disciplinary practices, and resource allocation[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These, in turn, are embedded within systemic structures of health financing, governance, and policy integration[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Understanding this layered interplay requires qualitative inquiry that captures the lived experiences of inmates, healthcare staff, and administrators[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Yet, qualitative evidence in this domain remains scarce, constraining efforts to design reforms that are both contextually grounded and equity-oriented.\u003c/p\u003e \u003cp\u003eThis study seeks to explore how behavioural, institutional, and systemic factors shape health‑seeking behaviour for metabolic syndrome and its component risk factors (hypertension, hyperglycaemia, dyslipidaemia, and central obesity) among incarcerated adults in Botswana, and to identify actionable reforms to improve detection, management, and continuity of care. By situating custodial health within the broader discourse on equity and systemic reform, the research illuminates\u0026rsquo; barriers to care and generates evidence-based recommendations for prison health reform. In doing so, it contributes to the global dialogue on advancing rights-based approaches to health in constrained environments, while offering insights relevant to sub-Saharan Africa and other resource-limited settings where custodial health has long remained at the margins of public health scholarship and policy.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis qualitative study was designed to generate rich, context-specific insights into the determinants of health in custodial environments in Botswana. A cross-sectional qualitative design was employed to capture diverse perspectives across multiple prison facilities. The study was guided by an interpretivist paradigm, recognizing that health-seeking behaviour is socially constructed and shaped by institutional and systemic contexts.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eSampling and participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePurposive sampling targeted incarcerated adults capable of providing varied perspectives on health behaviours and systemic barriers. Although the study protocol anticipated recruiting 30\u0026ndash;45 participants, data collection yielded 47 incarcerated participants across eight facilities (see Table 1). No healthcare staff or administrators were interviewed for this analysis; references to staff perspectives in the Methods have been removed to avoid confusion. Recruitment occurred between 03/02/2025 and 12/02/2025. Participation was voluntary and informed consent was obtained from all participants.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eData collection \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSemi‑structured interviews were conducted in private rooms within custodial facilities. Interview guides included prompts on prior screening for blood pressure and blood glucose, access to chronic medications, diet and physical activity, and understanding of metabolic risk. Due to institutional constraints and participant preference, interviews were recorded in writing in real time by the lead researcher; reflexive field notes were also maintained. Average interview length was approximately 25\u0026ndash;40 minutes. Partial interviews (n=4) were retained and included in analysis where usable data were present; missing items were noted during coding.\u003c/p\u003e\n\u003cp\u003eA semi‑structured interview guide was developed specifically for this study to explore behavioural, institutional, and systemic determinants of health‑seeking behaviour among incarcerated persons. The English language version of the interview guide has been provided as a supplementary file (Supplementary File 1) to ensure transparency and reproducibility. The guide was not previously published elsewhere.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eData \u003c/strong\u003e\u003cstrong\u003eAnalysis \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analysed using Braun and Clarke\u0026rsquo;s six-step thematic framework: familiarization, coding, theme development, review, definition, and reporting[22]. Coding was facilitated by QDA Miner Lite, with supervisory review of a subset of transcripts to enhance credibility and inter-coder reliability[23]. Themes were developed to illuminate how behavioural, institutional, and systemic factors interact to shape health outcomes in custodial settings.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eTrustworthiness and Rig\u003c/strong\u003e\u003cstrong\u003eor\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMethodological rigor was ensured through multiple strategies tailored to the custodial context. Credibility was enhanced by triangulating perspectives across diverse inmate groups, and by engaging in peer debriefing to validate emerging interpretations. Dependability was supported through the maintenance of a detailed audit trail that documented coding decisions, theme development, and analytic reflections, thereby providing transparency and consistency in the research process. Confirmability was strengthened through reflexive journaling, which enabled the researcher to critically examine positionality, acknowledge potential biases, and account for the influence of researcher perspectives on data interpretation. Transferability was facilitated by providing thick description of custodial environments, inmate experiences, and institutional conditions, allowing readers to assess the applicability of findings to similar settings. Collectively, these strategies ensured that the study\u0026rsquo;s qualitative insights were both rigorous and contextually grounded, offering a reliable basis for understanding the determinants of health-seeking behaviour among incarcerated populations.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEthical Consideration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with established ethical principles for research involving human participants. Ethical approval was obtained from the Ministry of Health of Botswana (Department of Health Policy, Research and Development (HPRD), HPRD:6/14/I) and the University of Pretoria Human Research Ethics Committee (approval number 25/2025). Permissions were also granted by the Botswana Prison Service. All participants provided informed consent. Participants consented to anonymized quotations being used in publications.\u003c/p\u003e\n\u003cp\u003eParticipation was entirely voluntary, and informed consent was obtained after the study purpose, advantages, limitations, and implications of consenting were explained to participants. No minors were included in the study; therefore, parental or guardian consent was not required. The ethics committee did not waive the need for consent.\u003c/p\u003e\n\u003cp\u003eConfidentiality was maintained by conducting interviews in secure rooms, anonymizing transcripts, and removing identifying details from all records. Findings were reported in aggregate to prevent identification of individuals or specific facilities. Reflexive journaling and field notes were used to account for positionality, power dynamics, and potential biases arising from conducting research in custodial environments. The study adhered to principles of respect, beneficence, and justice, ensuring that participants\u0026rsquo; dignity was upheld and that findings would contribute to improving health equity in custodial settings\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Demographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 47 incarcerated adults (ages 19\u0026ndash;46) participated across two divisions (North and South), with representation from both sexes and eight facilities (Table 1). Four interviews were partial but retained for analysis where data were usable.\u003c/p\u003e\n\u003cp\u003eTable 1. Demographic Profile of Participants (N=47)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"661\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eName of Prison facility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecurity Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation (Division)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003eLobatse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eSouth \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003eCentral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eSouth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003eMochudi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eSouth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003eMoshupa \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eSouth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003eFrancistown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eNorth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003eSelibe phikwe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eNorth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003eMachaneng\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eNorth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003eMahalapye\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eNorth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 472px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e47\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\n\u003cp\u003e\u003cstrong\u003eDiet, Physical Activity, and Metabolic Risk \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMonotonous, low‑diversity diets and minimal exercise opportunities described by participants create conditions that likely increase risk for metabolic syndrome (hypertension, hyperglycaemia, dyslipidaemia, central obesity). Food was frequently described as poorly prepared and nutritionally inadequate, contributing to gastrointestinal complaints and potential nutrient deficits; female wings reported especially limited recreation and disrupted rest due to overcrowding and duties. \u0026ldquo;\u003cem\u003eParticipants consistently described monotonous diets dominated by maize meal, sorghum, samp, and occasional meat, with fruits and vegetables largely absent or restricted to medical prescriptions\u003c/em\u003e.\u0026rdquo; \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eScreening, Diagnosis, and Treatment of Metabolic Conditions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRoutine screening for metabolic syndrome components (blood pressure, blood glucose, lipids, and waist circumference) was rare and typically reactive conducted during outbreaks, campaigns, or external oversight visits rather than as standard practice. Participants reported inconsistent diagnosis and management: long waits for clinical review, intermittent medication supply, and limited continuity of care for chronic conditions, undermining early detection and long‑term control of metabolic risk factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Access and Gatekeeping \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccess to healthcare was described as difficult, delayed, and officer‑dependent, with appointments scheduled by diaries rather than clinical urgency. Staff attitudes and gatekeeping discouraged help‑seeking; inmates reported ignored medical letters, unmet dental needs, and inappropriate or repeated prescriptions, which eroded trust and reduced engagement with available services. \u0026ldquo;\u003cem\u003eAccess to healthcare was consistently described as difficult, delayed, and dependent on escorts or officer discretion\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnvironmental and Systemic Barriers Affecting Metabolic Health \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOvercrowding, poor ventilation, and inadequate sanitation increased infection risk and psychosocial stress, while seasonal extremes worsened living conditions. Medicine shortages, referral delays, and constrained food budgets were recurrent problems that sometimes resulted in untreated illness; inmates repeatedly called for structural improvements (better food, bedding, protective clothing, and exercise facilities) that would support metabolic health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceptions, Knowledge, and Health\u003c/strong\u003e\u003cstrong\u003e‑\u003c/strong\u003e\u003cstrong\u003eSeeking Norms for Metabolic Risk \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKnowledge of NCDs and metabolic syndrome was limited and sometimes inaccurate, yet motivation to seek care remained strong and framed as a fundamental right. Discouragement arose from delays, dismissive officer behaviour, and systemic neglect, producing widespread distrust in custodial health services; nonetheless, most inmates expected better access and outcomes after release.\u003c/p\u003e\n\u003cp\u003eParticipants\u0026rsquo; accounts indicate that behavioural factors (limited knowledge, stress), institutional practices (gatekeeping, reactive screening), and systemic failures (nutrition, supply chains, infrastructure) interact to increase metabolic risk and impede timely detection and management of metabolic syndrome in Botswana\u0026rsquo;s prisons. These findings directly align with the study objective to examine how behavioural, institutional, and systemic determinants shape health‑seeking for metabolic syndrome and to identify targets for reform.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study documents the lived experiences of incarcerated individuals across multiple custodial facilities in Botswana, revealing systemic neglect in nutrition, healthcare access, environmental conditions, and psychosocial support. The findings align with global literature identifying prisons as sites of structural disadvantage and heightened vulnerability to disease and poor wellbeing [24, 25].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNutrition and Lifestyle\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants\u0026rsquo; accounts revealed monotonous diets dominated by maize meal, sorghum, and samp, with limited access to fruits and vegetables. These findings highlight nutritional inadequacies that contribute to malnutrition, gastrointestinal complaints, and increased risk of noncommunicable diseases (NCDs) [26, 27].\u0026nbsp;The restriction of fruits and vegetables to special diets prescribed by doctor\u0026rsquo;s underscores inequities in access to basic nutrition. Similar patterns have been documented in other sub‑Saharan African custodial environments, reinforcing the need for reforms that align prison food provision with national dietary guidelines and international standards\u0026nbsp;[28, 29].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealthcare Access and Institutional Constraints\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare access was consistently described as delayed, inconsistent, and dependent on officer discretion. Inmates reported long waits, diary‑based scheduling, and shortages of medical staff and medicines. These findings align with global evidence that prison healthcare is often reactive rather than preventive, with chronic conditions underdiagnosed and undertreated [30]. Comparable barriers have been reported in South Africa, Kenya, and Uganda, where escort shortages and officer gatekeeping hinder timely care [31-33]. Integrating prison health services into national health systems is critical to improve continuity of care, accountability, and equity[1, 12].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnvironmental and Systemic Barriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOvercrowding, poor ventilation, and inadequate sanitation were recurrent themes, directly linked to infections, respiratory problems, and mental distress. Seasonal extremes exacerbated discomfort, while medicine shortages and delays in referrals resulted in untreated illnesses and, in some cases, deaths. These conditions mirror global findings that poor prison environments are key drivers of communicable disease transmission[34, 35]. Addressing these systemic failures requires investment in infrastructure, reliable medicine procurement systems, and improved sanitation facilities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePsychosocial Dimensions and Perceptions of Risk\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants demonstrated limited knowledge of NCDs, with some misclassifying them as \u0026ldquo;transmitted diseases.\u0026rdquo; Motivation to seek care was strong, framed as a fundamental right, but discouragement stemmed from systemic neglect and officer behaviour. The widespread perception that \u0026ldquo;there is no health in prison\u0026rdquo; illustrates profound distrust in institutional systems. Yet, optimism about health after release suggests that inmates view incarceration as a temporary suspension of health rights. This highlights the need for health education programs within prisons and reforms to build trust in custodial health systems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA key strength of this study lies in its relatively large sample size (N=47) across multiple facilities, capturing diverse perspectives from both male and female inmates. Semi-structured interviews allowed participants to articulate lived experiences, strengthening authenticity. However, limitations include partial interviews, reliance on self-reported accounts, and absence of triangulation with staff perspectives or clinical records. Findings therefore reflect inmate perceptions rather than a comprehensive institutional assessment. Future research should incorporate multi-stakeholder perspectives and mixed-methods approaches to enhance validity and generalizability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePolicy Implications and Human Rights\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings of this study underscore the reality that prisons are not only sites of confinement but also critical arenas for public health intervention and human rights protection. International frameworks, most notably the United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules), affirm that individuals deprived of liberty are entitled to healthcare equivalent to that available in the wider community. Yet, the systemic neglect documented in Botswana\u0026rsquo;s custodial settings manifested in poor diets, delayed and inconsistent healthcare, overcrowding, and inadequate sanitation represents a clear violation of these standards.\u003c/p\u003e\n\u003cp\u003eAddressing these inequities requires a comprehensive policy response that moves beyond piecemeal interventions. Integration of prison health into national health systems is essential to ensure continuity of care and accountability. Investment in nutrition, infrastructure, and medicine supply chains must be prioritized to address the structural deficiencies that undermine inmate wellbeing. Equally important are training and accountability mechanisms for prison officers and healthcare staff, which can help shift institutional cultures toward respect, responsiveness, and equity. Finally, health literacy and psychosocial support programs tailored to incarcerated populations are needed to empower inmates, reduce stigma, and foster trust in custodial health services.\u003c/p\u003e\n\u003cp\u003eTaken together, these reforms would not only advance the rights and dignity of incarcerated individuals but also strengthen public health resilience more broadly. Given the permeability of prison walls and the continuous movement of individuals between custodial facilities and communities, improving prison health is both a moral obligation and a pragmatic necessity for achieving health equity and sustainable development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGlobal Relevance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy situating custodial health within the broader discourse on equity and systemic reform, this study contributes to the global dialogue on advancing rights-based approaches to health in constrained environments. The findings resonate with challenges documented in other sub-Saharan African countries, underscoring the need for regional collaboration and comparative research. Addressing custodial health inequities is essential not only for Botswana but also for strengthening public health resilience across resource-limited settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study shows that behavioural, institutional, and systemic factors jointly hinder detection, management, and help‑seeking for metabolic syndrome in Botswana\u0026rsquo;s prisons. Monotonous diets, limited physical activity, inconsistent screening, medicine shortages, and officer‑dependent access create elevated metabolic risk and distrust in custodial health services. Priority actions are routine screening (BP, glucose, lipids), improved nutrition and exercise programs, reliable medication and referral systems, and integration of prison health into the national NCD response. These reforms are a human rights obligation and a public health necessity to protect inmates and the wider community.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approvals: Ethical approval was obtained from the Department of Health Policy, Research and Development (HPRD), Ministry of Health of Botswana (HPRD:6/14/I) and the University of Pretoria Human Research Ethics Committee (approval number 25/2025). Permissions to conduct the study in custodial facilities were granted by the Botswana Prison Service.\u003c/p\u003e\n\u003cp\u003eInformed consent: Participation was voluntary and all participants provided informed consent after the study purpose, procedures, risks, benefits, and confidentiality measures were explained. Participants consented to anonymized quotations being used in publications.\u003c/p\u003e\n\u003cp\u003eVulnerable population safeguards: Given the custodial setting, additional protections were implemented: interviews were conducted in private rooms; no incentives or coercive inducements were offered; recruitment and consent procedures were overseen by independent ethics committees and custodial authorities to minimise perceived coercion; and identifying information was removed from transcripts and reports.\u003c/p\u003e\n\u003cp\u003eConfidentiality and data security: Transcripts and field notes were anonymized at source. Deidentified data are stored on password protected institutional servers with access restricted to the research team. Any requests for deidentified transcripts or coding frameworks will be processed in accordance with custodial clearance procedures and applicable institutional policies.\u003c/p\u003e\n\u003cp\u003eCompliance with ethical standards: The study adhered to international ethical standards for research with human participants, including the Declaration of Helsinki and relevant national regulations governing research in custodial settings.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Participants consented to the publication of anonymized quotations; no individual identifiers are reported.\u003c/p\u003e\n\u003cp\u003eContact for ethics queries: Questions about the study\u0026rsquo;s ethical approvals or participant protections may be directed to the corresponding author, Dr Lebapotswe Bahumi Tlale ([email protected]), or the University of Pretoria Human Research Ethics Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable beyond anonymized quotations; participants consented to publication of anonymized quotes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeidentified transcripts and the coding framework are available from the corresponding author on reasonable request and subject to custodial approvals. Requests should be sent to [email protected] and will be processed in accordance with custodial clearance procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research received no specific grant from any funding agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author gratefully acknowledges Ms Lethabo Phefadu (University of Pretoria) for facilitation and support. Special thanks to the Commissioner of Prisons, Mr Antony Mokento, and the Deputy Commissioner, Mr Lethata Manne, for permission to undertake this project. The author thanks Superintendent Alber Mandendemuka, Superintendent Sharon Simon, APO Banga, APO Mokone Mabe, and Sergeant Itumeleng Taziba for assistance with data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: LBT, YP, DB\u003c/p\u003e\n\u003cp\u003eMethodology: LBT, YP, DB\u003c/p\u003e\n\u003cp\u003eData collection: LBT\u003c/p\u003e\n\u003cp\u003eFormal analysis: LBT, YP, DB\u003c/p\u003e\n\u003cp\u003eWriting \u0026mdash; original draft: LBT\u003c/p\u003e\n\u003cp\u003eWriting \u0026mdash; review \u0026amp; editing: LBT, YP, DB\u003c/p\u003e\n\u003cp\u003eSupervision: YP, DB\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMcLeod KE, Butler A, Young JT, Southalan L, Borschmann R, Sturup-Toft S, Dirkzwager A, Dolan K, Acheampong LK, Topp SM: \u003cstrong\u003eGlobal prison health care governance and health equity: a critical lack of evidence\u003c/strong\u003e. \u003cem\u003eAmerican journal of public health \u003c/em\u003e2020, \u003cstrong\u003e110\u003c/strong\u003e(3):303-308.\u003c/li\u003e\n\u003cli\u003eGideon L: \u003cstrong\u003eHealth and Corrections: A Public Health Approach to Incarcerated Populations\u003c/strong\u003e: Taylor \u0026amp; Francis; 2025.\u003c/li\u003e\n\u003cli\u003eMahlangu VP: \u003cstrong\u003eExamining the Influence of Prison on the Mental Conditions of Incarcerated Inmates\u003c/strong\u003e. \u003cem\u003eSocial Sciences and Education Research Review \u003c/em\u003e2025, \u003cstrong\u003e12\u003c/strong\u003e(1):84-93.\u003c/li\u003e\n\u003cli\u003eZulu T: \u003cstrong\u003eSocioeconomic inequalities in non-communicable diseases in South Africa\u003c/strong\u003e. 2019.\u003c/li\u003e\n\u003cli\u003eRubin AT: \u003cstrong\u003eResistance as agency? 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In: \u003cem\u003eCorrectional Facilities-Policies, Practices, and Challenges.\u003c/em\u003e edn.: IntechOpen; 2024.\u003c/li\u003e\n\u003cli\u003eSithuga NP, Goliada N: \u003cstrong\u003eExploring the barriers to offender rehabilitation: The experiences of correctional officers in Limpopo correctional centres\u003c/strong\u003e. \u003cem\u003eInternational Journal of Business Ecosystem \u0026amp; Strategy (2687-2293) \u003c/em\u003e2025, \u003cstrong\u003e7\u003c/strong\u003e(6):486-493.\u003c/li\u003e\n\u003cli\u003eSimpson PL, Simpson M, Adily A, Grant L, Butler T: \u003cstrong\u003ePrison cell spatial density and infectious and communicable diseases: a systematic review\u003c/strong\u003e. \u003cem\u003eBMJ Open \u003c/em\u003e2019, \u003cstrong\u003e9\u003c/strong\u003e(7):e026806.\u003c/li\u003e\n\u003cli\u003eHerbert K, Plugge E, Foster C, Doll H: \u003cstrong\u003ePrevalence of risk factors for non-communicable diseases in prison populations worldwide: a systematic review\u003c/strong\u003e. \u003cem\u003eLancet \u003c/em\u003e2012, \u003cstrong\u003e379\u003c/strong\u003e(9830):1975-1982.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Custodial health, Metabolic syndrome, Hypertension, Diabetes, Health‑seeking behaviour, Prison health systems, Botswana","lastPublishedDoi":"10.21203/rs.3.rs-9220291/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9220291/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eCustodial populations face elevated and under recognized risk for metabolic syndrome and related noncommunicable diseases. Evidence from sub–Saharan African prisons on barriers to screening, diagnosis, and chronic care is limited. This study examined behavioural, institutional, and systemic determinants of health seeking for metabolic syndrome among incarcerated adults in Botswana\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA qualitative cross-sectional study guided by an interpretivist paradigm was conducted across eight custodial facilities in Botswana. Purposive sampling recruited 47 incarcerated adults aged 19–46 between 03 February and 12 February 2025. Semi structured interviews were conducted in private rooms and recorded in writing in real time by the lead researcher; reflexive field notes were maintained. Interview guides probed knowledge of metabolic risk, prior screening for blood pressure and blood glucose, access to chronic medications, diet and physical activity, and barriers to care. Data were analysed thematically using Braun and Clarke’s six step framework with coding supported by QDA Miner Lite. Trustworthiness was supported through reflexive journaling, peer debriefing, and an audit trail.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eParticipants described monotonous, low diversity diets and limited opportunities for exercise, conditions likely to increase metabolic risk. Routine screening for metabolic syndrome components was rare and typically reactive rather than routine. Access to care was frequently delayed and officer dependent, with medicine shortages, referral delays, and dismissive staff attitudes discouraging help seeking. Knowledge of noncommunicable diseases was limited but inmates framed care seeking as a fundamental right. Institutional and systemic deficits in nutrition, infrastructure, and supply chains undermined preventive and chronic care for metabolic conditions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eTargeted interventions are needed to address metabolic syndrome in custodial settings: routine screening for blood pressure and glucose, nutrition and physical activity programs aligned with national NCD guidelines, reliable medication supply chains, and integration of prison health into national health systems. These reforms are both a human rights obligation and a public health priority.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics: \u003c/strong\u003eApproval obtained from the Ministry of Health of Botswana HPRD:6/14/I and University of Pretoria HREC 25/2025. Participants provided informed consent.\u003c/p\u003e","manuscriptTitle":"Metabolic Syndrome and Health‑Seeking Behaviour in Botswana Prisons: Behavioural, Institutional, and Systemic Determinants","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-29 14:52:18","doi":"10.21203/rs.3.rs-9220291/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-21T12:56:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-20T13:04:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-01T06:53:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-31T13:59:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-03-31T13:54:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e2c95f39-739c-48d3-bc17-55171469efd6","owner":[],"postedDate":"April 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T14:52:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-29 14:52:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9220291","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9220291","identity":"rs-9220291","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}