Sri Lanka's COVID-19 response and maintaining health services: implications for future pandemics.

This study examines how Sri Lanka, a lower-middle income country, managed its COVID-19 response and maintained health services. It draws on an extensive document review, key informant interviews and a national survey of public experience and opinion to assess what Sri Lanka did, its effectiveness and why.Owing to a strong health system and luck, Sri Lanka stopped the first wave of COVID-19 infections, and it adopted a 'Zero-COVID' approach with the explicit goal of stopping outbreaks. This was initially effective. Outbreaks reduced healthcare use, but with minimal impact on health outcomes. But from end-2020, Sri Lanka switched its approach to tolerating transmission and mitigation. It took proactive actions to maintain healthcare access, and it pursued a COVID-19 vaccination effort that was successful in covering its adult population rapidly and with minimal disparities. Despite this, widespread transmission during 2021-2022 disrupted health services through the pressure on health facilities of patients with COVID-19 and infection of healthcare workers, and because COVID-19 anxiety discouraged patients from seeking healthcare. This led to substantial mortality and more than 30 000 excess deaths by 2022.We find that Sri Lanka abandoned its initially successful approach, because it failed to understand that its chosen strategy required symptomatic PCR testing in primary care. Failure to invest in testing was compounded by groupthink and a medical culture averse to testing.Sri Lanka's experience confirms that strong public health capacities, robust healthcare systems and intersectoral action are critical for pandemic response. It shows that civilian-military collaboration can be beneficial but contested, and that lack of fiscal space will undermine any response. It also demonstrates that pandemic preparedness cannot guarantee a successful pandemic response. Policy and research must pay more attention to improving decision-making processes when faced with pandemics involving novel pathogens, rapid spread, and substantial scientific uncertainty.

Prevalence of diabetes and pre-diabetes in Sri Lanka: a new global hotspot-estimates from the Sri Lanka Health and Ageing Survey 2018/2019.

INTRODUCTION: This study's objective was to produce robust, comparable estimates of the prevalence of diabetes and pre-diabetes in the Sri Lankan adult population, where previous studies suggest the highest prevalence in South Asia. RESEARCH DESIGN AND METHODS: We used data on 6661 adults from the nationally representative 2018/2019 first wave of the Sri Lanka Health and Ageing Study (SLHAS). We classified glycemic status based on previous diabetes diagnosis, and either fasting plasma glucose (FPG), or FPG and 2-hour plasma glucose (2-h PG). We estimated crude and age-standardized prevalence of pre-diabetes and diabetes and by major individual characteristics weighting the data to account for study design and subject participation. RESULTS: Crude prevalence of diabetes in adults was 23.0% (95% CI 21.2% to 24.7%) using both 2-h PG and FPG, and age-standardized prevalence was 21.8% (95% CI 20.1% to 23.5%). Using only FPG, prevalence was 18.5% (95% CI 7.1% to 19.8%). Previously diagnosed prevalence was 14.3% (95% CI 13.1% to 15.5%) of all adults. The prevalence of pre-diabetes was 30.5% (95% CI 28.2% to 32.7%). Diabetes prevalence increased with age until ages ≥70 years and was more prevalent in female, urban, more affluent, and Muslim adults. Diabetes and pre-diabetes prevalence increased with body mass index (BMI) but was as high as 21% and 29%, respectively, in those of normal weight. CONCLUSIONS: Study limitations included using only a single visit to assess diabetes, relying on self-reported fasting times, and unavailability of glycated hemoglobin for most participants. Our results indicate that Sri Lanka has a very high diabetes prevalence, significantly higher than previous estimates of 8%-15% and higher than current global estimates for any other Asian country. Our results have implications for other populations of South Asian origin, and the high prevalence of diabetes and dysglycemia at normal body weight indicates the need for further research to understand the underlying drivers.

Sexual and reproductive knowledge, attitudes and behaviours in a school going population of Sri Lankan adolescents.

The reproductive and sexual health of adolescents is an important health concern and a focus of global attention. In Sri Lanka, a lack of understanding about adolescent reproductive and sexual health needs is a matter of national concern. A survey was undertaken to examine the sexual knowledge, attitudes and behaviours of school going adolescents in Sri Lanka. A random sample of schools was selected from one district. Data were collected by a self-completion questionnaire and analysed using SPSS. Response rate was 90%. 2020 pupils (26% boys, 74% girls) aged 16-19 years (mean=16.9) participated, the majority Sinhalese (97%). Most reported a good parent-child relationship (88%). A minority (34%) discussed sexual issues with parents. Health professionals were the preferred source of sexual information (32%) rather than parents (12.5%) or friends (5.6%). Less than 1% demonstrated satisfactory sexual and reproductive knowledge levels. 1.7% were sexually active (30 boys vs 5 girls), the majority with same age partners. 57% used contraception at first intercourse. There is an imperative to address the lack of sexual and reproductive knowledge. A minority of school going adolescents become sexually active. These individuals are potentially vulnerable and services need to be developed to meet their needs.

A quantitative exploration of the sociocultural context of teenage pregnancy in Sri Lanka.

BACKGROUND: In common with other countries, teenage pregnancy is attracting policy attention in Sri Lanka because of the risks it poses to maternal and infant health and social and economic well-being. This study aimed to increase understanding of the context of teenage pregnancy, by (1) describing the socio-economic and demographic characteristics of pregnant teenagers and their partners; (2) exploring whether teenage pregnancies are planned and how they are received; and (3) exploring factors associated with unplanned teenage pregnancy. METHODS: A population health-register based sample survey was conducted in Badulla District, Sri Lanka. Interviewer-administered questionnaires were administered to two samples: 450 pregnant women aged less than 20 years; and 150 male partners of pregnant women aged less than 20 years. Bivariate statistics described the characteristics and context of teenage pregnancy. Multivariate logistic regression explored correlates of unplanned pregnancy. RESULTS: Over 60% of pregnant teenagers and male partners indicated that the current pregnancy was planned; while 79% of pregnant teenagers and 85% of male partners welcomed the pregnancy. Most pregnant teenagers were living within stable and supportive family environments, with 94% reporting that they felt 'very well supported'. Nevertheless, a sub-group of pregnant teenagers appeared to be vulnerable, reporting unplanned and unhappy pregnancy; factors that were also associated with first intercourse being reported as not wanted. Levels of reproductive and contraceptive knowledge were poor among both pregnant teenagers and male partners. Just 46% of teenagers and 64% of male partners knew that pregnancy was possible at first intercourse. Mothers appear to be an important source of information and support for young women, with peers being reported far less often. CONCLUSIONS: Intervention to reduce teenage pregnancy must recognise the normative nature of early childbearing for the majority of girls who currently conceive and their families. Avoiding such pregnancies will require a fundamental shift in life chances such that delaying pregnancy offers significant socioeconomic advantages. Meanwhile, improved provision of contraceptive information and services is needed to support the delay of second pregnancies for young mothers. In addition, strategies to identify and protect those girls who are vulnerable to unwanted sexual activity are needed.