Quality of Life, Physical Activity Participation, and Perceptions of Physical Rehabilitation Among Community-Reintegrated Veterans With Lower Limb Amputation in Sri Lanka: Convergent Parallel Mixed Methods Study.

BACKGROUND: Lower limb amputation (LLA) impacts physical activity (PA) participation and quality of life (QoL). To minimize the effects of these challenges, LLA survivors need to have opportunities to engage in appropriately tailored rehabilitation throughout their lives. However, in Sri Lanka, where a 3-decade civil war resulted in trauma-related LLA among young male soldiers, access to rehabilitation was limited to the immediate postinjury period. Developing rehabilitation interventions for these veterans requires an understanding of their current health status and rehabilitation perceptions. OBJECTIVE: This study was conducted to evaluate the QoL and PA participation of veterans with LLA and explore perceptions of factors influencing their PA participation and expectations for a future community-based physical rehabilitation (CBPR) intervention. METHODS: This mixed methods study combined a comparative cross-sectional quantitative survey with qualitative semistructured interviews in 5 districts of Sri Lanka. QoL and PA participation were assessed among community-reintegrated veterans with LLA (n=85) and compared with a matched able-bodied cohort (control; n=85) using Mann-Whitney U and Chi-square tests. PA was assessed in terms of metabolic equivalent of task (MET) minutes per week and was computed for walking, moderate-intensity, and vigorous-intensity activities. PA was classified as sufficiently active, low, or sedentary. The design of interview questions was guided by the Theoretical Domains Framework and followed a phenomenological approach. Interviews were conducted with 25 veterans and were analyzed thematically, and the perceptions regarding PA participation and CBPR were codified using the Consolidated Framework for Implementation Research (CFIR). RESULTS: Based on the quantitative survey findings, scores for both physical (P<.001) and psychological (P<.001) well-being and participation in walking (P=.004) and vigorous-intensity activities (P<.001) were significantly lower among veterans than among controls. A "sedentary" classification was made for 43% (34/79) of veterans and 12% (10/82) of controls. Veterans mostly engaged in moderate-intensity PA inside the house (49/79, 62%) and in the yard (30/79, 38%). Qualitative interviews revealed that barriers to PA exist at individual (eg, comorbidity burden), primary care (eg, absence of community rehabilitation services), and policy levels (eg, limited resources) and facilitators exist primarily at societal (eg, inclusive community) and individual levels (eg, preinjury activity baseline and positive attitudes toward exercise). Expectations regarding CBPR included individualized rehabilitation parameters; functional exercises; and involvement of peers, amputee societies, and community health care providers. The nonresponse rate for interviews was 7% (2/27). CONCLUSIONS: The findings of reduced PA participation, poor QoL, and physical and psychological impairments among relatively young veterans reveal the long-term impacts of living with LLA in the absence of long-term rehabilitation. Policy-level changes need to be implemented along with behavior-change strategies to promote PA participation and minimize physical inactivity-induced health issues. Veterans' perceptions regarding future CBPR programs were positive and centered on holistic, individualized, and peer-led activities.

Quality evaluation and future priorities for delivering acute myocardial infarction care in Sri Lanka.

AIM: This study evaluates the quality of care for patients admitted with acute myocardial infarction (AMI) in a tertiary hospital in Colombo using the European Society of Cardiology Quality of Care Working Group's guidelines (2017). METHODS: A recently implemented electronic AMI registry m-Health tool was used for prospective data collection. Each patient was assessed for eligibility for each of the six domains of quality. Global Registry of Acute Coronary Events Risk Model for predicted probability of mortality, and scores for risk of bleeding complications (CRUSADE) and severity of heart failure (Killip classification) were calculated as per published guidelines. A composite measure of quality was derived from compliance with the six domains. Patients were followed up via telephone at 30 days following discharge to evaluate outcome and satisfaction. Organisational information was assessed by administrative review and interview. RESULTS: Between March 2017 and April 2018, 934 patients with AMI presented to the cardiology department. The majority of patients (90.4%) presented with features of ST-elevation myocardial infarction (STEMI). Mean (SD) overall compliance with the composite quality indicator (CQI) was 44% (0.07). Compliance of ≥50% to the CQI was achieved in 9.8% of STEMI patients. The highest compliance was observed for antithrombotics during hospitalisation (79.1%) and continuous measure of patient satisfaction (76.1%). The lowest compliance was for organisational structure and care processes (22.4%). CONCLUSION: This study reports a registry-based continuous evaluation of the quality of AMI care from a low and middle-income country. Priorities for improvement include improved referral, and networking of primary and secondary health facilities with the percutaneous coronary intervention centre.