Effects of health educational and participatory consumer group interventions in improving food handling practices in regional director of health services area Kalutara, Sri Lanka: non-randomized controlled community trial.

INTRODUCTION: Safe and nutritious food is the key to sustaining life and promoting good health. Unsafe food creates a vicious cycle of disease and malnutrition, particularly affecting infants, young children, the elderly, and the sick. METHODS: The study consisted of two phases, a descriptive cross-sectional study, and an intervention study. Both studies were conducted in the Regional Director of Health Services area, Kalutara, Sri Lanka. The descriptive cross-sectional study [food handlers (n = 904), food establishments (n = 421)] was conducted with the objective of determining factors associated with food handling practices among food handlers and in food establishments. The interventional study was a three-arm non-randomized controlled community trial (n = 50 per arm) with interventions of a participatory consumer group, educational package group, and control group. RESULTS: The food establishments assessment tool (FEAT) contained 11 domains including 75 items with more than a hundred assessment points with a guide to conduct an assessment of food handling. The descriptive cross-sectional study found that food handlers' knowledge of food handling practices of storing milk, fish, and meat and fast-food items containing fish and meat was very poor (96.6%). Visibility of the last place of processing inside the food establishments to consumers was inadequate (19.2%) and the absence of the above-mentioned factor was significantly associated with an unsatisfactory level of food handling score in food establishments (p = 0.03). The unsatisfactory level of food handling was significantly higher among food establishments with non-personal ownership (p = 0.005), a low number of notices issued by legal authorities (p = 0.02), dereliction of duty by owners/managers on supervising (p < 0.001) and lack of medical certification to food handlers (p < 0.0001). Participatory consumer group intervention and educational package interventions were effective in improving food handling practices in food establishments and among food handlers (p < 0.0001). Two independent sample analysis using the Mann-Whitney U test showed, the best improvement in food handling practices was by participatory consumer group intervention (p < 0.0001) and the second was educational package intervention (p < 0.0001). CONCLUSIONS: Knowledge and practices of food handling among participants were poor. A participatory consumer group is more effective than an educational package on improving food handling practices both among food handlers and in food establishments.

Knowledge, Attitudes, and Practices of Adverse Drug Reaction Reporting Among Healthcare Professionals in Sri Lanka- A Cross Sectional Study.

Objectives: The objectives of this study were to describe the knowledge, attitudes and practices of Adverse Drug Reactions (ADR) reporting among healthcare professionals at Teaching Hospital Karapitiya (THK), a tertiary care hospital in Sri Lanka. Methodology: A descriptive cross-sectional study was conducted at THK. The healthcare professionals working in THK who were available during the study period were invited to the study. A self-administered pre-tested questionnaire was administered to the participants. Respondents were evaluated for their knowledge, attitudes and practices related to ADR reporting. The data were analyzed using SPSS statistical software. Results: Of the total 444 respondents, 31% were doctors and 69% were nurses. The majority of respondents, 90% (n = 400) were aware of the term ADR, while 64.8% (n = 288) could correctly define it. Among the respondents, 30.8% (n = 137) knew about the types of ADR and only 15.5% (n = 70) were able to mention a drug that is banned due to ADR correctly. Among the respondents, only 38.7% (n = 172) were aware of a formal process of reporting ADR and, only 35.3% (n = 157) stated that they had seen the ADR reporting form. Further, only 33.7% (n = 150) respondents have recognized ADR during their clinical practice and only a small proportion 18.2% (n = 81) have ever reported an ADR during their practice. Regarding attitudes toward ADR reporting, overall 84.1 (n = 373) had positive attitudes toward ADR reporting, while 13.54% (n = 60) of them stayed neutral and 2.25% (n = 10) had negative attitudes toward ADR reporting. Conclusions: Although the majority were aware of ADR , the knowledge and practices regarding spontaneous reporting of ADR are inadequate. However, most respondents have shown a positive attitude toward ADR reporting. A sincere and sustained effort should be made by concerned bodies to enhance the healthcare professionals' knowledge, attitudes, and practices regarding ADR reporting.

Economic cost of tobacco-related cancers in Sri Lanka.

INTRODUCTION: Cancer has a high mortality rate and morbidity burden in Sri Lanka. This study estimated the economic cost of smoking and smokeless tobacco (ST) related to cancers in Sri Lanka in 2015. METHODS: Prevalence-based cost of illness is calculated according to the guidelines of the WHO (2011). The direct costs are costs of curative care (costs of inward patients and outpatient care borne by the state and out of pocket expenditure by households) for tobacco-related cancers, weighted by the attributable fractions for these cancers. Indirect costs are lost earnings due to mortality and morbidity (absenteeism of both patient and carers resulting from seeking care and recuperation).Data were obtained from the Registrar General's Department, National Cancer Registry, Department of Census and Statistics and the Central Bank of Sri Lanka. Household and systemic costs and relative risks were extracted from research studies. Oncologists (working in both public and private sectors), other clinical specialists, medical administrators and economists were consulted during the estimation and validation processes. RESULTS: The total economic cost of tobacco-related cancers for Sri Lanka in 2015 was estimated to be US$121.2 million. The direct cost of smoking and ST-related cancers was US$42.1 million, which was 35% of the total cost, while the indirect cost was US$79.1 million, which was 65% of the total cost. CONCLUSION: Burden of tobacco smoking and ST-related cancers as reflected in these economic costs is enormous: affecting the healthcare system and country's economy. Policymakers should take note of this burden and address tobacco consumption control as a priority.

Development of educational package and participatory consumer groups to improve food handling practices in food establishments in Sri Lanka.

Objectives: Improper food handling contributes to many foodborne diseases and food outbreaks globally leading to witnessed morbidities and mortalities. The study aims to develop an educational package and participatory consumer groups to improve food handling practices among food handlers and in food establishments in the Regional Director of Health Services area, Kalutara, Sri Lanka. Methods: The study developed an educational package and participatory consumer groups to improve the food handling practices among food handlers and in food establishments. The critical knowledge gaps were identified during the first component of this study, which was conducted as a descriptive study, and the findings were further discussed in the Focus Group Discussion. Posters, info sheets, and workshops were used for educational packages, and four consumer groups were formed. The second component of the study following the development of the interventions was continued as a three-arm, non-randomized controlled community trial for 4 months in the Regional Director of Health Services, Kalutara. Results: The educational package for food handlers was introduced as a package of a workshop, info sheets, posters to display at workplaces, and short refresher training two weekly to direct good food handling practices in food establishments. Consumer groups were strengthened to exercise their legal rights on their purchases and the ratings showed improvements in the hygiene levels with repeated consecutive visits. Conclusions: The novel educational package and participatory consumer groups are designed and implemented to improve food handling practices among food handlers and in food establishments.

Development of a food handling practices assessment tool based on the Sri Lanka food regulations.

Objectives: Neither the current assessment tool of Sri Lanka for food establishments is based on prevailing Food Regulations 2011 nor did its focus cover serious adaptions for precautions upon prevention of the diseases. The study aims to develop a food handling practices assessment tool based on the Sri Lanka Food Regulations 2011 and to assess food handling practices using a developed tool in the Regional Director of Health Services area, Kalutara. Methods: The study consisted of developing food establishments' assessment tool (FEAT) in accordance with Food (Hygiene-1742/26) Regulations of Sri Lanka 2011 and assessing the food establishments using the developed tool in the Regional Director of Health Services area, Kalutara, Sri Lanka. The development of FEAT was carried out to mark inspection scores for food establishments conforming to Food Regulations, others reviewed international food safety protocols and agreements following key informant interviews and focus group discussions. Fully developed FEAT was transferred to a mobile application for ease of use, and assessments were conducted among 421 food establishments in three Medical Officer of Health areas. Results: FEAT contained 11 domains including 75 items with more than 100 assessment points including a guide to conducting an assessment of food handling, compared to the current version of the assessment tool in Sri Lanka. The majority of participants included in the qualitative assessment agreed to include a 1-5 scoring scale to report hygiene levels and to use hygiene regulation to develop FEAT as a legal basis. The highest percentage of food establishments (69.4%) in the "Good" category were in the Bandaragama Medical Officer of Health Area and the highest percentage of food establishments (54.5%) in the "very poor" category were in the Walallawita Medical Officer of Health Area. Food establishments taking precautionary measures, which are not assessed in the current tool, were good, but maintenance of processing area and installation of overhead structures and fitting were poor in food establishments in all three Medical Officer of Health Areas. Conclusions: The novel food assessment tool FEAT is a completely valid instrument for food establishments. It is designed for easy administration and supports reliable assessments. Overall food handling practices of food establishments in the Kalutara Regional Director of Health Services area following assessment with FEAT were in the "satisfactory" category.

Community-based alcohol education intervention (THEATRE) study to reduce harmful effects of alcohol in rural Sri Lanka: design and adaptation of a mixed-methods stepped wedge cluster randomised control trial.

INTRODUCTION: Alcohol consumption is a leading cause of mortality, morbidity and adverse social sequelae in Sri Lanka. Effective community-based, culturally adapted or context-specific interventions are required to minimise these harms. We designed a mixed-methods stepped wedge cluster randomised control trial of a complex alcohol intervention. This paper describes the initial trial protocol and subsequent modifications following COVID-19. METHODS AND ANALYSIS: We aimed to recruit 20 villages (approximately n=4000) in rural Sri Lanka. The proposed intervention consisted of health screening clinics, alcohol brief intervention, participatory drama, film, and public health promotion materials to be delivered over 12 weeks.Following disruptions to the trial resulting from the Easter bombings in 2019, COVID-19 and a national financial crisis, we adapted the study in two main ways. First, the interventions were reconfigured for hybrid delivery. Second, a rolling pre-post study evaluating changes in alcohol use, mental health, social capital and financial stress as the primary outcome and implementation and ex-ante economic analysis as secondary outcomes. ETHICS AND DISSEMINATION: The original study and amendments have been reviewed and granted ethical approval by Rajarata University of Sri Lanka (ERC/2018/21-July 2018 and February 2022) and the University of Sydney (2019/006). Findings will be disseminated locally in collaboration with the community and stakeholders.The new hybrid approach may be more adaptable, scalable and generalisable than the planned intervention. The changes will allow a closer assessment of individual interventions while enabling the evaluation of this discontinuous event through a naturalistic trial design. This may assist other researchers facing similar disruptions to community-based studies. TRIAL REGISTRATION: The trial is registered with the Sri Lanka Clinical Trials Registry; https://slctr.lk/trials/slctr-2018-037.

An Innovative Telemedicine Initiative From Sri Lanka: The Value of Volunteerism in a Resource-Constrained Scenario During the COVID-19 Pandemic.

The unprecedented rise in COVID-19 cases in Sri Lanka since July 2021 led to a situation where the health system was getting overwhelmed. The priority shifted toward triaging patients and identifying those who need immediate medical intervention and managing the rest in home settings. An integrated patient management system where patients could access a medical professional through a short messages service (SMS) and calling system was established. This service provided telephone triage, patient advice, and coordinated with the national ambulance system to evacuate ill patients. This integrated helpline system had a major impact on the management of the recent surge of COVID-19 pandemic in Sri Lanka by patients needing urgent care were directed for hospitalization and the rest managed at home with support, reassurance, and guidance. The numbers of oxygen-dependent patients and deaths declined rapidly and the number of available beds increased. The system played a major role in bringing the crisis under control. Despite many challenges, this innovative integrated system is a unique example of medical volunteerism. The pandemic catalyzed the utilization of information and communication technologies effectively by providing healthcare with a reduction of the burden on healthcare institutions and professionals.

A Sociological Analysis and Exploration of Factors Associated with Commercial Preparations of Smokeless Tobacco Use in Sri Lanka.

BACKGROUND: Use and addiction to commercial preparation of Smokeless Tobacco (CPSLT) is creating new socio-cultural issues and health challenges in Sri Lanka.  The objective of this sociological study is to investigate and analyse the socio-cultural factors that influence CPSLT use Sri Lanka to enable development of effective interventions.  Methods: This is a qualitative study for which data was collected through in-depth interviews in selected groups that use CPSLT. Thirty-five interviews were carried out in seven of the 24 districts in the country representing urban, rural, plantation communities and different livelihood and ethnic, gender and age groups in the year 2016. Purposive and snowball sampling techniques were used for selecting interviewees. The data was analysed by using qualitative data analysis techniques and sociological perspectives. RESULTS: This study reveals that the CPSLT use has integrated with the culture of several sociological and livelihood groups. Products such Thool (tobacco powder) and Maawa (dried areca-nut with flaked tobacco and some flavoured chemicals) were identified as the most popular forms of CPSLT.  Use of CPSLT has developed as a silent sub-culture specific to several social and livelihood groups. The informal CPSLT industry operating in the urban and sub-urban areas is influencing the school children and youth engaged in sports. Different groups of users express different reasons and justifications for its use. CONCLUSION: Use of CPSLT is closely integrated with the day to-day lifestyle and values of people of specific groups. and is an unseen part of life. Therefore, interventions will be urgently required to control the use of CPSLT to prevent its significant health impacts, considering the different contexts, symbolisms and justifications of its among the different groups. 
.

Economic costs of alcohol use in Sri Lanka.

AIM: Alcohol related disease conditions are responsible for a significant proportion of morbidity and mortality in Sri Lanka. This study quantified the economic cost of selected alcohol related disease conditions in Sri Lanka in 2015. METHODS: This study uses the prevalence-based cost of illness methodology specified by the World Health Organization, and uses the gross costing approach. The direct costs includes the costs of curative care (inpatient and outpatient care borne by the state and out of pocket expenditure borne by patients) for alcohol related diseases, weighted by the respective population attributable fractions. Indirect costs consist of lost earnings due to absenteeism of the patient and carers due to seeking care and recuperation, and the loss of income due to mortality. Data form the Ministry of Health, Registrar General's Department, Department of Census and Statistics and the National Cancer Registry was used. Systemic and house costs and population attributable fractions were obtained from research studies. Economists, Public Health Experts, Medical Administrators and Clinical Specialists were iteratively consulted during the estimation and validation of the costs and the results. RESULTS: The estimated present value of current and future economic cost of the alcohol-related conditions for Sri Lanka in 2015 was USD 885.86 million, 1.07% of the GDP of that year. The direct cost of alcohol related disease conditions was USD 388.35 million, which was 44% of the total cost, while the indirect cost was USD 497.50 million, which was 66% of the total cost. Road Injury cost was the highest cost category among the conditions studied. CONCLUSION: Addressing alcohol use and its harms through effective implementation of evidence-based polices and interventions is urgently required to address the economic costs of alcohol use in Sri Lanka as it imposes a significant burden to the country.

Universal health coverage and the health Sustainable Development Goal: achievements and challenges for Sri Lanka.

With state-funded health care that is free at the point of delivery, a sound primary health-care policy and widespread health-care services, Sri Lanka seems a good example of universal health coverage. Yet, health transition and disparities in provision and financing threaten this situation. Sri Lanka did well on the Millennium Development Goal health indicators, but the Sustainable Development Goal (SDG) for health has a wider purview, which is to "ensure healthy lives and promote well-being for all at all ages". The gender gap in life expectancy and the gap between life expectancy and healthy life expectancy make achievement of the health SDG more challenging. Although women and children do well overall, the comparative health disadvantage for men in Sri Lanka is a cause for concern. From a financing perspective, high out-of-pocket expenditure and high utilization of the private sector, even by those in the lowest income quintile, are concerns, as is the emerging "third tier", where some individuals accessing state health care that is free at the point of delivery actually bear some of the costs of drugs, investigations and surgery. This cost sharing is resulting in catastrophic health expenditure for individuals, and delays in and non-compliance with treatment. These concerns about provision and financing must be addressed, as health transition will intensify the morbidity burden and loss of well-being, and could derail plans to achieve the health SDG.

Constructing an action agenda for community empowerment at the 7th Global Conference on Health Promotion in Nairobi.

This report describes an action agenda for community empowerment developed by participants at the 7th Global Conference on Health Promotion in Nairobi. It outlines gaps and barriers in enabling community empowerment; including those related to institutional capacity, institutional relationships to the community, and institutional responses to the social structure of the community. The report features nine recommended actions to enhance community control of health promotion initiatives, develop sustainable resources for community health efforts, and support implementation and build evidence for health promotion effectiveness. Implementing these recommended actions can enhance community empowerment and help close the implementation gap in health promotion.

COVID-19 health system response monitor: Sri Lanka

The COVID-19 Health System Response Monitor presents findings from a systematic approach to collect and synthesize up-to-date information on Singapore’s policy response to the COVID-19 outbreak. This publication is part of the APO’s COVID-19 HSRM series which presents detailed information on country-specific responses to COVID-19, to facilitate easy comparisons of health systems and public health, and policy responses to COVID-19. It also aims to strengthen evidence on the global response to the pandemic and allow for easy comparison of activities at national and sub-national levels. The series is updated to reflect changes in the health systems and policies to the COVID-19 response.

Sri Lanka health system review

Sri Lanka has achieved strong health outcomes over and above what is commensurate with its income level. The country has made significant gains in essential health indicators, witnessed a steady increase in life expectancy among its people, and eliminated malaria, filariasis, polio and neonatal tetanus. The Sri Lanka HiT review presents a comprehensive overview of the different aspects of the country’s health system, and the background and context within which the health system is situated. The review also presents information on reforms to address emerging health needs such as the growing challenge of noncommunicable diseases (NCDs) and serving a rapidly ageing population.Health system in transition reviews (HiTs) provide a detailed description of a country’s health system, and policy and reform developments.