A comparison of observed feeding practices of infants and young children aged 6-23 months to national responsive feeding recommendations in Sri Lanka.

To describe the extent to which Sri Lankan caregivers follow current national responsive feeding recommendations and the factors limiting and enabling those behaviours. Study design. This ethnographic substudy was conducted using a four-phase, mixed methods formative research design across rural, estate and urban sectors of Sri Lanka. Data collection methods. Data were collected using direct meal observations and semistructured interviews. Participants including infants and young children aged 6-23 months (n = 72), community leaders (n = 10), caregivers (n = 58) and community members (n = 37) were purposefully sampled to participate in this study. Data analysis. Observational data were summarized using descriptive statistics while textual data were analysed thematically using Dedoose. Findings were then interpreted vis-à-vis six national responsive feeding recommendations. During observed feeding episodes, caregivers were responsive to nearly all food requests (87.2% [34/39]) made by infants and young children. Many caregivers (61.1% [44/72]) also positively encouraged their infant and young child during feeding. Despite some responsive feeding practices being observed, 36.1% (22/61) of caregivers across sectors used forceful feeding practices if their infant or young child refused to eat. Interviews data indicated that force-feeding practices were used because caregivers wanted their infants and young children to maintain adequate weight gain for fear of reprimand from Public Health Midwives. Despite overall high caregiver knowledge of national responsive feeding recommendations in Sri Lanka, direct observations revealed suboptimal responsive feeding practices, suggesting that other factors in the knowledge-behaviour gap may need to be addressed.

Molecular mechanisms of antidiabetic effect of betulinic acid in lotus rhizome.

OBJECTIVES: To explain the bio-physiological mechanisms of the antidiabetic effect of betulinic acid in Lotus rhizome. BACKGROUND: Even though Sri Lankan native medicine uses Lotus rhizome as a medicinal food for diabetes mellitus, its antidiabetic property has not been scientifically explained yet. It is found to compose several medicinally active components with antidiabetic properties, including Betulinic acid. METHODS: A narrator review was conducted with a literature search in PubMed and Google Scholar databases using the search terms "Nelumbo nucifera rhizome", "Lotus rhizome", "phytochemicals", "antidiabetic effect", "hypoglycaemic effect" "Betulinic acid", and "molecular mechanism". RESULTS: The triterpenoid, Betulinic acid exerts its antidiabetic effect via seven bio-physiological mechanisms including, inhibiting α-glucosidase and α-amylase, upregulating the expression of peroxisome proliferator-activated receptor gamma coactivator-1 α, enhancing AS160 protein phosphorylation, stimulating adenosine monophosphate-activated protein kinase activation, stimulating Glucose transporter type 4 synthesis and translocation, inhibiting Protein Tyrosine Phosphatase 1 B activity preventing dephosphorylation of insulin receptor and stimulating Takeda-G-protein-receptor-5 resulting in an increased release of insulin from insulin-containing granulesCONCLUSION: The available scientific knowledge explains that betulinic acid in Lotus rhizome can improve glucose homeostasis contributing to the antidiabetic effect of this root (Tab. 1, Fig. 6, Ref. 29).

Risk factors for upper limb fractures due to unintentional injuries among adolescents: a case control study from Sri Lanka.

BACKGROUND: Injuries are the number one cause for morbidity and mortality among adolescents. Adolescent fractures are a hidden public health problem in Sri Lanka. Upper limb fractures are common in adolescents due to various risk factors. Many injuries are predictable and can be prevented by identifying the risk factors. The aim of the study was to determine the risk factors for upper limb fractures among adolescents in Sri Lanka. METHODS: A case control study was undertaken with 450 cases and 450 controls. Cases were recruited consecutively from all major hospitals among the adolescent victims who had admitted with newly diagnosed upper limb fractures in the district of Colombo. Controls were apparently healthy adolescents from the same district and excluded who had previous upper limb fractures. The age and gender were not matched in selecting controls since these two factors were potential risk factors for adolescent fractures according to previous literature. Risk factors for upper limb fractures were assessed by odds ratio (OR) with 95% confidence interval (CI) and adjusted for possible confounding by performing logistic regression analysis. RESULTS: The mean age of the cases was 13.62 years with a Standard Deviation (SD) of 2.8 and controls was 12.75 years (SD = 2.7) respectively. Having a high standard of living index (OR = 3.52; 95%CI: 2.3-5.2, p < 0.001), being in a high social class category (social class I & II) (OR = 2.58, 95%CI: 1.7-3.92, p < 0.001), engage in physical or sports activity (OR = 9.36; 95%CI: 3.31-26.47, p < 0.001), watching television (OR = 1.95; 95%CI: 1.18 -3.22, p = 0.009), playing video or computer games (OR = 2.35; 95%CI: 1.7-3.24, p < 0.001), and attending extra classes (OR = 1.82; 95%CI: 1.2-2.7, p = 0.007) were risk factors for having a upper limb fracture. Risk factors for upper limb fractures following adjusted for confounders were siblings in the family (aOR = 11.62, 95% CI: 6.95-41.29, p = 0.03) and attend extra classes after school hours (aOR = 2.51, 95%CI: 0.68-0.93, p = 0.04). Two significant effect modifications between being a Buddhist and low standard of living index (p < 0.001) and having one sibling in the family and attend extra classes after school hours (p = 0.01) were observed. CONCLUSIONS: Modifiable risk factors in relation to lifestyle factors and socioeconomic position were important determinants of upper limb fracture risk in adolescents. Many fractures can be prevented by strengthening awareness programmes in the community.

Is abdominal adiposity in healthy Sri Lankan neonates different from the rest of the world?

BACKGROUND AND OBJECTIVES: Adiposity at birth is a predictor of childhood obesity. Abdominal circumference (AC) at birth has been shown to correlate well with visceral adipose tissue and abdominal subcutaneous adipose tissue. Adiposity differs according to ethnicity and geography. The aim of this study was to describe the anthropometry derived adiposity phenotype in neonates from Colombo, Sri Lanka and compare it with global data. METHODS AND STUDY DESIGN: Birth anthropometry was performed within 12-24 hours by the same investigator as part of a prospective cohort study on healthy term babies, at a tertiary care hospital in Colombo, Sri Lanka, 2015-2019. The anthropometry derived adiposity phenotype was indicated by skinfold thickness, AC and upper arm fat area (UFA) derived from the mid-upper arm circumference (MUAC). RESULTS: Sri Lankan neonates had a significantly lower weight with significantly higher AC (n=337, 2.9±0.4 kg, 30.6±2.3 cm) compared to Canadian (n=389, 3.5±0.02 kg, 29.9±2.1 cm; p<0.001) and Australian (n=1270, 3.4±0.4 kg, 28.5±1.9 cm; p<0.001) neonates. Anthropometry derived adiposity at birth showed a significant correlation with weight and BMI of both mother and father (p<0.05) as opposed to their income or education (p>0.05). CONCLUSIONS: Healthy neonates from Colombo, Sri Lanka demonstrated significantly higher AC despite significantly lower weight, indicating increased abdominal adiposity compared to neonates from high-income countries as well as Indian neonates with the thin-fat phenotype.

Birth anthropometry from a tertiary care hospital in Sri Lanka: Differs from the WHO growth standards.

BACKGROUND AND OBJECTIVES: The nutritional status of infants is assessed using the WHO growth references, based on the Multicenter Growth Reference Study (MGRS) in many countries including Sri Lanka. Birth parameters define infant growth curves. The aim of this study was to compare the birth anthropometric data of a healthy population of babies born in Colombo, Sri Lanka with the WHO MGRS birth data and determine its suitability for assessment of growth in this population. METHODS AND STUDY DESIGN: Birth data were obtained as part of a study on longitudinal infant body composition from birth to 2 years from 2015-2019. Healthy babies, born to non-smoking mothers, >18 years old, with a singleton pregnancy at term, living in the study area and intending to breastfeed, were recruited. The Ethical Review Committee of the Faculty of Medicine, University of Colombo, approved the study. RESULTS: Compared to WHO data, the mean birth weight (2.9±0.4 kg), length (48.2±2.7 cm) and head circumference (33.6±1.2 cm) of our study population (n=337) was significantly lower with a left shift in the z score distribution. This was despite similar background characteristics except for significantly lower income (USD 200) and lower maternal (154.2±9.0 cm) and paternal height (165±11.6 cm) in our study population. A significant change in birth parameters was only seen with maternal height when disaggregated. CONCLUSIONS: WHO birth parameters were significantly higher and underestimated the growth of healthy babies in Sri Lanka.

Undiagnosed diabetes, hypertension, and hypercholesterolaemia in an overweight or obese population: implications for cardiovascular disease risk screening programme.

INTRODUCTION: Establishing the burden of undiagnosed CVD risk factors is critical to monitoring public health efforts related to screening and diagnosis. OBJECTIVE: To assess the proportion and determinants of undiagnosed diabetes, hypertension, and hypercholesterolaemia, among overweight or obese adults. METHODS: A sample of 1200 participants aged 35-64 years with a BMI ≥25 kg/m2 was selected from the Colombo district. Data were collected through a questionnaire, anthropometry, blood pressure measurement, and blood sampling for fasting plasma glucose, HbA1c, and lipid profile. Undiagnosed diabetes, hypertension, and hypercholesterolaemia were defined as fasting plasma glucose ≥126 mg/dL or HbA1c ≥6.5%; systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg; total cholesterol ≥240 mg/dl respectively, in a person without a previous diagnosis. Multiple logistic regression analyses were carried out to identify determinants. RESULTS: The prevalence (95%CI) of diabetes was 28% (25.5, 30.5), hypertension, 33.4% (30.7, 36.1) and hypercholesterolaemia, 31.9% (29.2, 34.5). The proportion of undiagnosed diabetes was 13.8% (11.9, 15.8), undiagnosed hypertension 11.3% (9.5, 13.1), and undiagnosed hypercholesterolaemia 17.8% (15.6, 19.9). Undiagnosed cases accounted for almost half of all diabetes cases, one-third of all hypertension cases, and more than half (56%) of all high cholesterol cases. The key determinants for undiagnosed CVD risk were: male sex, low or middle income, rural residence, and relatively younger age. CONCLUSION: CVD screening programmes should be tailored to target populations based on these determinants and provide basic diagnostic facilities in all health centres. The 'proportion undiagnosed' in the population may be a useful indicator to evaluate their effectiveness.

Health in rural Sri Lanka: A cross-sectional survey of three rural districts

Introduction: Sri Lanka has a predominantly rural population. However, there is a dearth of research on health and socioeconomic issues in this group. Objective: To describe basic socioeconomic characteristics and health profile in a rural population. Methods: A descriptive cross-sectional household survey was conducted in 1950 households in three rural districts, selected by a three-stage stratified cluster sampling method. Results: The population pyramid showed an ageing population (dependency ratio of 50%). Only 39% had completed GCE (ordinary level). Unemployment rates were high (25% males, 76% females). Agriculture and related work were main occupations. Most lacked amenities (e.g. 61% households lacked a refrigerator) and practiced inappropriate methods of waste disposal (e.g. open burning by 72%). Household illnesses were frequent: episodes of acute illness within two weeks, injuries within past year and chronic illness were reported from 35.9%, 14.9% and 48.3% households. The prevalence of chronic diseases in adults >20 years were high: diabetes 13.5%, hypertension 16.7% and overweight/obesity 28.2%. Of the males, 22.1% smoked and 12.3% took alcohol. Almost 25% adults chewed betel. Reports of snake bite, dog bites and suicide/attempted suicide were seen in 15.5%, 9.7% and 3.0% households respectively. Conclusions: This study shows a unique clustering of health-related problems in rural Sri Lanka. This was characterized by demographic transition, burden from snake bites, chronic diseases and acute illnesses. There were resource limitations and low levels of education. Cohort studies and comparisons with urban areas will enable further elucidation of determinants of health and other issues in rural Sri Lanka.

Health related quality of life of preterm born children at three years in a sub urban district in Sri Lanka: a retrospective cohort study.

BACKGROUND: Preterm birth leads to multiple morbidities affecting the health of a child. Lack of information on the health impact of prematurity hinders the possibility of any effective public health interventions in this regard. Our aim was to determine the association between preterm birth and Health-Related Quality of Life (HRQOL) among 3 years old children in the Gampaha district, Sri Lanka. METHODS: A community-based retrospective cohort study was conducted among 790 preterm and term born children who were 03 years old. Multi-stage cluster sampling technique was used to identify children. The exposure status, a preterm birth, was established using the maternal pregnancy records. Outcome status was measured using a validated health related quality of life questionnaire (prepared in Sinhala) for preschool-aged children. Mothers of the children responded to an interviewer-administered questionnaire which had variables on the exposure status, outcome and additional variables such as child development status and birth related information. Quality of life was measured in twelve different domains of health (subscales). The impact was analyzed using the multiple linear regression. RESULTS: Response rate was 95.5% (n = 379) for preterm group and 95.2% (n = 378) for term-born group. Health-Related Quality of Life scores obtained by preterm children were lower than the term born children in eight subscales. Preterm birth showed statistically significant association with subscales on sleep wellbeing, general wellbeing and abdominal symptoms in the adjusted analysis (p < 0.05). Among preterm children prolonged illness, delayed development status, socio economic status and maternal perception on the health status of the child were common predictors of quality of life. CONCLUSION: Preterm birth affected health related quality of life of preschool aged children.

Analysis of stakeholders networks of infant and young child nutrition programmes in Sri Lanka, India, Nepal, Bangladesh and Pakistan.

BACKGROUND: Effective public policies are needed to support appropriate infant and young child feeding (IYCF) to ensure adequate child growth and development, especially in low and middle income countries. The aim of this study was to: (i) capture stakeholder networks in relation to funding and technical support for IYCF policy across five countries in South Asia (i.e. Sri Lanka, India, Nepal, Bangladesh and Pakistan); and (ii) understand how stakeholder networks differed between countries, and identify common actors and their patterns in network engagement across the region. METHODS: The Net-Map method, which is an interview-based mapping technique to visualise and capture connections among different stakeholders that collaborate towards achieving a focused goal, has been used to map funding and technical support networks in all study sites. Our study was conducted at the national level in Bangladesh, India, Nepal, and Sri Lanka, as well as in selected states or provinces in India and Pakistan during 2013-2014. We analysed the network data using a social network analysis software (NodeXL). RESULTS: The number of stakeholders identified as providing technical support was higher than the number of stakeholders providing funding support, across all study sites. India (New Delhi site - national level) site had the highest number of influential stakeholders for both funding (43) and technical support (86) activities. Among all nine study sites, India (New Delhi - national level) and Sri Lanka had the highest number of participating government stakeholders (22) in their respective funding networks. Sri Lanka also had the highest number of participating government stakeholders for technical support (34) among all the study sites. Government stakeholders are more engaged in technical support activities compared with their involvement in funding activities. The United Nations Children's Emergency Fund (UNICEF) and the World Health Organization (WHO) were highly engaged stakeholders for both funding and technical support activities across all study sites. CONCLUSION: International stakeholders were highly involved in both the funding and technical support activities related to IYCF practices across these nine study sites. Government stakeholders received more support for funding and technical support activities from other stakeholders compared with the support that they offered. Stakeholders were, in general, more engaged for technical support activities compared with the funding activities.

Policy and stakeholder analysis of infant and young child feeding programmes in Sri Lanka.

BACKGROUND: Infant and young child feeding practices (IYCF) play a critical role in growth and development of children. A favourable environment supported by appropriate policies and positive contributions from all stakeholders are prerequisites for achieving optimal IYCF practices. This study aimed to assess the IYCF-related policy environment and role of stakeholders in policy making in Sri Lanka, in order to identify opportunities to strengthen the policy environment to better support appropriate IYCF and reduce childhood malnutrition. METHODS: We mapped national level policy-related documents on IYCF, and conducted a stakeholder analysis of IYCF policy making. A matrix was designed to capture data from IYCF policy-related documents using a thematic approach. A narrative synthesis of data from different documents was conducted to achieve the first objective. We then conducted an analysis of technical and funding links of stakeholders who shape IYCF policies and programmes in Sri Lanka using the Net-Map technique, to achieve the second objective. A total of 35 respondents were purposively selected based on their knowledge on the topic, and individual interviews were conducted. RESULTS: Twenty four policies were identified that contained provisions in line with global recommendations for best-practice IYCF, marketing of breast milk substitutes, strengthening health and non-health systems, maternity benefits, inter-sectoral collaboration, capacity building, health education and supplementation. However, there is no separate, written policy on IYCF in Sri Lanka. Participants identified 56 actors involved in shaping IYCF policies and programmes through technical support, and 36 through funding support. The Government Health Sector was the most connected as well as influential, followed by development partners. Almost all actors in the networks were supportive for IYCF policies and programmes. CONCLUSIONS AND RECOMMENDATIONS: All evidence-based recommendations are covered in related policies. However, advocacy should be targeted towards strategic support for IYCF in high-level policy documents. The stakeholder analysis confirmed a network led by the government health sector. Enhancing the multi-sectoral commitments stressed in policy documents is an opportunity to strengthen IYCF policy process in Sri Lanka.

Opportunities for strengthening infant and young child feeding policies in South Asia: Insights from the SAIFRN policy analysis project.

BACKGROUND: South Asian countries experience some of the highest levels of child undernutrition in the world, strongly linked to poor infant and young child feeding (IYCF) practices. Strong and responsive policy support is essential for effective interventions to improve IYCF. This study aimed to identify opportunities for strengthening the policy environment in the region to better support appropriate infant and young child feeding. METHODS: We mapped policies relevant to infant and young child feeding in India, Pakistan, Bangladesh, Sri Lanka and Nepal, based on a common matrix. The matrix described potentially relevant policies ranging from high-level strategic policy documents to implementation-level guidelines. We analyzed the data based on themes focused on caregiver interactions with IYCF interventions: provision of correct information to mothers, training of frontline workers, enabling mothers to engage with service providers and strategic support for IYCF. RESULTS: Policy support for IYCF was present in relation to each of the themes assessed. In all countries, there was support for nutrition in National Development Plans, and all countries had some level of maternity protection and restrictions on marketing of breast milk substitutes. Sectoral and implementation-level policy documents contained provisions for system strengthening for IYCF and for training of frontline workers. CONCLUSIONS: The key opportunities for strengthening IYCF policy support were in relation to translating strategic directives into implementation level documents; improving multi-sectoral support and coordination; and increased clarity regarding roles and responsibilities of frontline workers interacting with mothers. These findings can support efforts to strengthen IYCF policy at the national and regional level.

Associations between disc space narrowing, anterior osteophytes and disability in chronic mechanical low back pain: a cross sectional study.

BACKGROUND: Radiographic features of lumbar disc degeneration (LDD) are common findings in patients with chronic mechanical low back pain; however, its role in disability and intensity of pain is debatable. This study aims to investigate the associations of the x-ray features of LDD and lumbar spondylolisthesis with severity of disability and intensity of pain. METHODS: A cross-sectional study was conducted on 439 patients with chronic mechanical low back pain who attended the rheumatology clinic, National Hospital of Sri Lanka, Colombo, from May 2012 to May 2014. Severity of disability was measured using Modified Oswestry Disability Index and intensity of pain was assessed using numeric rating scale (0-100). X-ray features of LDD (disc space narrowing, anterior osteophytes and overall LDD) and spondylolisthesis were assessed in lateral recumbent lumbar x-rays (L1/L2 to L5/S1) and graded by a consultant radiologist blinded to clinical data. Generalised linear model with linear response was used to assess the associations of x-ray features of LDD with severity of disability and intensity of pain adjusting for age, gender, body mass index and pain radiating into legs. RESULTS: Mean age was 48.99 ± 11.21 and 323 (73.58%) were females. 87 (19.82%) were obese. Mean severity of disability was 30.95 ± 13.67 and mean intensity of pain was 45.50 ± 20.37. 69 (15.72%), 26 (5.92%) and 85 (19.36%) patients had grade 2 disc space narrowing, anterior osteophytes and overall LDD, respectively. 51 (11.62%) patients had lumbar spondylolisthesis. Grade of disc space narrowing and overall LDD were not associated with severity of disability or intensity of pain. The presence of lumbar spondylolisthesis was associated with severity of disability. Female gender and pain radiating into legs were associated with severity of disability and intensity of pain. Advancing age was associated with x-ray features of LDD and lumbar spondylolisthesis. CONCLUSIONS: Lumbar spondylolisthesis is associated with severity of disability in patients with chronic mechanical low back pain. Associations of x-ray features of LDD with severity of disability and intensity of pain are inconclusive. Female gender and pain radiating into legs are significant confounders.

Emotional intelligence and academic performance of medical undergraduates: a cross-sectional study in a selected university in Sri Lanka.

BACKGROUND: Emotional intelligence (EI) has been linked with academic and professional success. Such data are scarce in Sri Lanka. This study was conducted to describe the pattern of EI, to determine its predictors and to determine the effect of EI on academic performance at the final MBBS examination, in medical undergraduates of a Sri Lankan university. METHODS: This is a cross-sectional study in a selected university, involving those who did final MBBS examination in 2016. Consecutive sampling was done. EI was assessed with self-administered Genos Emotional Intelligence Full Version (7 domains; 70 questions equally weighted; total score 350). Socio-demographic data were obtained using a self-administered questionnaire. Academic performance was assessed with final MBBS results in the first attempt. RESULTS: Of 148 eligible students 130 responded (response rate-88%); 61.5% were females; mean age was 26.3 ± 1 years. Mean total EI score was 241.5 (females-245.5, males-235.1; p = 0.045).Among different domains, mean score was highest for Emotional Self-Awareness (36.8/50) and lowest for Emotional Expression (32.6/50). Multiple linear regression analysis indicated that having good family support (p = 0.002), socializing well in university (p = 0.024) and being satisfied with facilities available for learning (p = 0.002), were independent predictors of EI. At the final MBBS examination 51.6% obtained classes, 31.5% passed the examination without classes and 16.9% got repeated. Females had better academic performance than males (p = 0.009). Mean EI of second-class upper division, second-class lower division, pass and repeat groups were 249.4, 246.6, 240.2 and 226.9, respectively (with one-way ANOVA p = 0.015). After adjusting for gender, ordinal regression analysis indicated that, total EI score was an independent predictor of final MBBS results [ß-0.018 (95% CI 0.005-0.031); p = 0.006]. CONCLUSIONS: In the study population, both EI and academic performance were higher among females. Independent of gender, academic performance was better in those who were more emotionally intelligent. Several psychosocial factors were found to be independent predictors of EI. These results suggest that emotional skills development might enhance academic performance of medical undergraduates in Sri Lanka. Further research is needed in this under-explored area.

Prevalence of depression and its associated factors among patients attending primary care settings in the post-conflict Northern Province in Sri Lanka: a cross-sectional study.

BACKGROUND: In Sri Lanka, civilians in the Northern Province were affected by a long-term armed conflict that ended in 2009. This study aims to describe the prevalence of depression and its associated factors among adult patients attending primary care settings in the Northern Province in Sri Lanka. METHODS: We report data from a cross-sectional patient morbidity registry established in 16 primary care facilities (12 Divisional Hospitals and 4 Primary Medical Care Units) in four districts of the Northern Province. The Patient Health Questionnaire-9 (PHQ-9) was used to assess depression among all patients aged ≥ 18 years, between March and May 2013. A sample of 12,841 patient records was included in the analysis. A total score of ≥ 10 in the PHQ-9 was considered as major depression. Factors associated with major depression were tested using multivariable logistic regression analysis. RESULTS: The prevalence of major depression was 4.5% (95% CI: 4.1-4.9) and mild depression was 13.3% (95% CI: 12.7-13.9). The major depression was significantly higher in females than males (5.1% vs. 3.6%) and among unpaid family workers (6.0%) than any other category who earned an income (varied between 1.2% and 3.2%). The prevalence was rising significantly with advancing age, and ranged from 0.3% in the youngest to 11.6% in the elderly.Multivariable regression analysis revealed that the females have a higher risk for major depression than males (OR = 1.4; 95% CI: 1.1-1.7). Older patients were more likely to be depressed than younger patients, OR (95% CI) were 4.9 (1.9-12.5), 5.6 (2.2-14.0), 5.7 (2.3-14.2) and 4.7 (1.8-11.9) for the age groups 25-34, 35-49, 50-64, and ≥ 65 years respectively, in contrast to 18-24 year group. Disability in walking (OR = 7.5; 95% CI: 5.8-9.8), cognition (OR = 4.5; 95% CI: 3.6-5.6), self-care (OR = 2.6; 95% CI: 1.7-4.0), seeing (OR = 2.3; 95% CI: 1.8-3.0), and hearing (OR = 2.0; 95% CI: 1.5-2.5) showed significant associations with depression. CONCLUSIONS: Depression is a common issue at primary care settings in a post-conflict population, and the elders, women and persons with disability are at a greater risk. Strengthening capacity of primary care facilities and community mental health services is necessary for early detection and management.

Validity and reliability of the Sinhalese version of the perceived stress scale questionnaire among Sri Lankans.

Introduction: Despite the availability of validated psychometrics tools to assess depression, there has not been any validated and reliable tool established to test perceived stress among Sri Lankans. The objective of this study is to test the validity and reliability of the Sinhalese Version of the Sheldon Cohen Perceived Stress Scale. Materials and methods: Standard and systematic procedures were adopted to translate the original English version of the Perceived Stress Scale-10 questionnaire into Sinhalese. Consecutive sampling was employed to recruit the Type 2 Diabetes mellitus (T2DM) sample (n = 321), and a convenient sampling was used to recruit the Age and Sex matched Healthy Controls (ASMHC) (n = 101) and the Healthy Community Controls (HCC) groups (n = 75). Cronbach alpha was used to assess internal consistency and reliability was determined using test-retest method utilizing Spearman's correlation coefficient. Sensitivity was evaluated by comparing the mean scores of the Sinhalese Perceived Stress Scale (S-PSS-10) and Sinhalese Patient Health Questionnaire (S-PHQ-9) scores. Post-hoc comparisons were done using Bonferroni's method. Mean scores were compared between the T2DM, ASMHC, and HCC groups using the independent t-test. Explanatory Factor Analysis (EFA) was conducted using the principal component and Varimax rotation while the Confirmatory Factor Analysis (CFA) was performed to assess the goodness-of-fit of the factor structure extracted from the EFA. Concurrent validity was assessed using the Pearson correlation between the S-PSS-10 and Patient Health Questionnaire measured by S-PHQ-9 (p < 0.05). Results: Cronbach alpha values of the three groups T2DM, ASMHC and HCC were 0.85, 0.81, and 0.79, respectively. Results of the ANOVA test suggested that there was a significant difference in the mean scores between groups (p < 0.00). EFA analysis revealed the existence of two factors with eigenvalues greater than 1.0. The factor loadings for the items ranged from 0.71-0.83. The CFA analysis demonstrated a good model fit for the two-factor model S-PSS-10. The S-PSS-10 significantly correlated with S-PHQ-9, indicating an acceptable concurrent validity. Conclusion: Findings revealed that the S-PSS-10 questionnaire can be used to screen perceived stress among the majority of the Sri Lankan Sinhalese-speaking population specially with chronic illnesses. Further studies with higher sample sizes across different populations would enhance the validity and reliability of S-PSS-10.

Complementary feeding practices in South Asia: analyses of recent national survey data by the South Asia Infant Feeding Research Network.

South Asian region has the highest global burden of child undernutrition, with almost 41% of children stunted, 16% wasted and 33% underweight. Improved feeding of children less than 2 years of age is particularly important because they experience rapid growth and development, and are vulnerable to illnesses such as acute respiratory infections and diarrhoeal diseases. The present supplement aimed to describe complementary feeding practices in five South Asian countries - Bangladesh, India, Nepal, Pakistan and Sri Lanka - using the new and updated global complementary feeding indicators and to identify determinants of inappropriate complementary feeding practices. The South Asia Infant Feeding Research Network held a series of workshops to study and discuss the operational guidelines for the new complementary feeding indicators in consultation with regional and international experts. The latest Demographic and Health Surveys for Bangladesh, Nepal, Pakistan and Sri Lanka, and the National Family Health Survey of India were used as data sources. Four key indicators were calculated: introduction of solid, semisolid or soft foods in 6-8 months aged, minimum dietary diversity, minimum meal frequency and minimum acceptable diet in 6-23-month-aged children. Univariate and multivariate logistic regression analyses were performed to identify determinants of poor complementary feeding practices. The papers in this supplement present results of these analyses for each individual country and a comparison between countries. The results have important implications for policies, programmes and research on infant and young child feeding in the region, especially for targeting groups at high risk for suboptimal practices.

Determinants of breastfeeding practices: an analysis of the Sri Lanka Demographic and Health Survey 2006-2007.

Identification of factors that predict a woman's infant feeding choice is important for breastfeeding promotion programmes. We analysed a subsample of children under 2 years of age from the most recent Sri Lanka Demographic and Health Survey (SLDHS) to assess breastfeeding practices and factors associated with suboptimal practices. SLDHS 2006-2007 used a stratified two-stage cluster sample of ever-married women aged 15-49 years. Breastfeeding indicators were estimated for the last-born children (n = 2735). Selected indicators were examined against independent variables through cross-tabulations and multivariate analyses. Of the sample, 83.3% initiated breastfeeding within 1 h of birth. Continuation rates declined from 92.6% in first year to 83.5% in second year. Exclusive breastfeeding (EBF) rate under 6 months of age was 75.8%, with median duration being 4.8 months. Delayed initiation of breastfeeding was associated with low birthweight [odds ratio (OR) = 2.24] and caesarean delivery (OR = 3.30), but less likely among female infants (OR = 0.75), mothers from 'estate' sector (OR = 0.61) or richer wealth quintile (OR = 0.60). Non-EBF was associated with children from urban areas (OR = 1.72) and estate sector (OR = 4.48) and absence of post-natal visits by a public health midwife (OR = 1.89). A child was at risk for not currently breastfeeding if born in a private hospital (OR = 3.73), delivered by caesarean section (OR = 1.46) or lived in urban areas (OR = 2.80) or estate sector (OR = 3.23). Those living in estates (OR = 11.4) and not receiving post-natal home visits (OR = 2.62) were more likely to discontinue breastfeeding by 1 year. Breastfeeding indicators in Sri Lanka were higher compared with many countries and determined by socio-economic and health care system factors.

Determinants of inappropriate complementary feeding practices in young children in Nepal: secondary data analysis of Demographic and Health Survey 2006.

Inappropriate complementary feeding increases the risk of undernutrition, illness and mortality in infants and children. This study uses a subsample of 1428 children of 6-23 months from Nepal Demographic and Health Survey (NDHS), 2006. The 2006 NDHS was a multistage cluster sample survey. The complementary feeding indicators were estimated according to the 2008 World Health Organization recommendations. The rate of introduction of solid, semi-solid or soft foods to infants aged 6-8 months was 70%. Minimum meal frequency and minimum dietary diversity rates were 82% and 34%, respectively, and minimum acceptable diet for breastfed infants was 32%. Multivariate analysis indicated that working mothers and mothers with primary or no education were significantly less likely to give complementary foods, to meet dietary diversity, minimum meal frequency and minimum acceptable diet. Children living in poor households were significantly less likely to meet minimum dietary diversity and minimum acceptable diet. Mothers who had adequate exposure to media, i.e. who watch television and who listen to radio almost every day, were significantly more likely to meet minimum dietary diversity and meal frequency. Infants aged 6-11 months were significantly less likely to meet minimum acceptable diet [adjusted odds ratio (OR)=3.13, confidence interval (CI)=2.16-4.53] and to meet minimum meal frequency (adjusted OR=4.46, CI=2.67-7.46). In conclusion, complementary feeding rates in Nepal are inadequate except for minimum meal frequency. Planning and promotion activities to improve appropriate complementary feeding practices should focus on illiterate mothers, those living in poor households, and those not exposed to media.

Determinants of inappropriate complementary feeding practices in young children in Sri Lanka: secondary data analysis of Demographic and Health Survey 2006-2007.

Inappropriate complementary feeding increases risk of undernutrition, illness and mortality in infants and children. This paper aimed to determine the factors associated with inappropriate complementary feeding practices in Sri Lanka. The Sri Lanka Demographic and Health Survey 2006-2007 used a stratified two-stage cluster sample of ever-married women 15-49 years, and included details about foods given to children aged 6-23 months during the last 24 h. The new World Health Organization indicators for infant and young child feeding (IYCF) - (introduction of solid/semi-solid or soft foods; minimum dietary diversity; minimum meal frequency; and minimum acceptable diet) were calculated for 2106 children aged 6-23 months. These indicators were examined against explanatory variables with multivariate analyses to identify factors associated with inappropriate practices. Eighty-four per cent of infants aged 6-8 months were introduced to complementary food. The proportion of infants aged 6-8 months who consumed eggs (7.5%), fruits and vegetables other than those rich in vitamin A (29.6%) and flesh foods (35.2%) was low. Of children aged 6-23 months, minimum dietary diversity was 71%, minimum meal frequency 88% and minimum acceptable diet 68%. Children who lived in tea estate sector had a lower dietary diversity and minimum acceptable diet than children in urban and rural areas. Other determinants of not receiving a diverse or acceptable diet were lower maternal education, shorter maternal height, lower wealth index, lack of postnatal visits, unsatisfactory exposure to media and acute respiratory infections. In conclusion, complementary feeding indicators were adequate except in the 6-11 months age group. Subgroups with inappropriate feeding practices should be the focus of IYCF promotion programs.

Determinants of inappropriate timing of introducing solid, semi-solid or soft food to infants in Pakistan: secondary data analysis of Demographic and Health Survey 2006-2007.

Inappropriate timing of introducing complementary food deprives the infant of optimum nutrition, leading to undernutrition, and increased mortality and morbidity. The aim of this analysis was to identify determinants of inappropriate timing of introduction of solid, semi-solid and soft foods in Pakistan. Data on 941 infants 3.00 to 8.99 months were obtained from the Pakistan Demographic and Health Survey 2006-2007. The prevalence of introduction of foods among infants aged 3.00-5.99 months and 6.00-8.99 months was examined against a set of individual, household and community level variables using univariate analysis. Adjusted odds ratio (AOR) for early introduction in age 3.00-5.99 months and non-introduction in 6.00-8.99 months of age were calculated using backward stepwise logistic regression models. The prevalence of early introduction of complementary foods among 3.00- to 5.99-month-old and timely introduction among 6.00- to 8.99-month-old infants were 10.6% and 39.2%, respectively. Multivariate analyses revealed that mothers who had four or more antenatal clinic visits (AOR=2.68) and who lived in the provinces of Sindh (AOR=2.89) and Baluchistan (AOR=6.75) were more likely to introduce complementary foods early. Mothers from middle-level households (AOR=7.82), poorer households (AOR=4.84) and poorest households (AOR=5.72) were significantly more likely to delay introduction of complementary foods. In conclusion more than half (60.8%) of Pakistani infants do not receive complementary foods at recommended time. Public health interventions to improve the timing of introduction of complementary food are needed at national level with special focus on high risk groups.