The cost-effectiveness of banning highly hazardous pesticides to prevent suicides due to pesticide self-ingestion across 14 countries: an economic modelling study.

BACKGROUND: Reducing suicides is a key Sustainable Development Goal target for improving global health. Highly hazardous pesticides are among the leading causes of death by suicide in low-income and middle-income countries. National bans of acutely toxic highly hazardous pesticides have led to substantial reductions in pesticide-attributable suicides across several countries. This study evaluated the cost-effectiveness of implementing national bans of highly hazardous pesticides to reduce the burden of pesticide suicides. METHODS: A Markov model was developed to examine the costs and health effects of implementing a national ban of highly hazardous pesticides to prevent suicides due to pesticide self-poisoning, compared with a null comparator. We used WHO cost-effectiveness and strategic planning (WHO-CHOICE) methods to estimate pesticide-attributable suicide rates for 100 years from 2017. Country-specific costs were obtained from the WHO-CHOICE database and denominated in 2017 international dollars (I$), discounted at a 3% annual rate, and health effects were measured in healthy life-years gained (HLYGs). We used a demographic projection model beginning with the country population in the baseline year (2017), split by 1-year age group and sex. Country-specific data on overall suicide rates were obtained for 2017 by age and sex from the Global Burden of Disease Study 2017 Data Resources. The analysis involved 14 countries spanning low-income to high-income settings, and cost-effectiveness ratios were analysed at the country-specific level and aggregated according to country income group and the proportion of suicides due to pesticides. FINDINGS: Banning highly hazardous pesticides across the 14 countries studied could result in about 28 000 (95% uncertainty interval [UI] 24 000-32 000) fewer suicide deaths each year at an annual cost of I$0·007 per capita (95% UI 0·006-0·008). In the population-standardised results for the base case analysis, national bans produced cost-effectiveness ratios of $94 per HLYG (95% UI 73-123) across low-income and lower-middle-income countries and $237 per HLYG (95% UI 191-303) across upper-middle-income and high-income countries. Bans were more cost-effective in countries where a high proportion of suicides are attributable to pesticide self-poisoning, reaching a cost-effectiveness ratio of $75 per HLYG (95% UI 58-99) in two countries with proportions of more than 30%. INTERPRETATION: National bans of highly hazardous pesticides are a potentially cost-effective and affordable intervention for reducing suicide deaths in countries with a high burden of suicides attributable to pesticides. However, our study findings are limited by imperfect data and assumptions that could be improved upon by future studies. FUNDING: WHO.

Socioeconomic position and suicidal behaviour in rural Sri Lanka: a prospective cohort study of 168,000+ people.

PURPOSE: Lower socioeconomic position (SEP) is associated with an increased risk of suicidal behaviour in high income countries, but this association is not established in low- and middle-income countries (LMIC). METHODS: We investigated the association of SEP with suicidal behaviour in a prospective cohort study of 168,771 Sri Lankans followed up for episodes of attempted suicide and suicide. SEP data were collected at baseline at the household and individual level at the start of the follow-up period. We used multilevel Poisson regression models to investigate the association of SEP at community, household and individual levels with attempted suicide/suicide. RESULTS: Lower levels of asset ownership [IRR (95% CI) suicide 1.74 (0.92, 3.28); attempted suicide 1.67 (1.40, 2.00)] and education [suicide 3.16 (1.06, 9.45); attempted suicide 2.51 (1.70, 3.72)] were associated with an increased risk of suicidal behaviour. The association of these measures of SEP and attempted suicide was stronger in men than women. Individuals living in deprived areas [1.42 (1.16, 1.73)] and in households with a young female head of household [1.41 (1.04, 1.93)] or a temporary foreign migrant [1.47 (1.28, 1.68)] had an elevated risk of attempted suicide. Farmers and daily wage labourers had nearly a doubling in risk of attempted suicide compared to other occupations. CONCLUSIONS: Improved employment opportunities, welfare and mental health support services, as well as problem-solving skills development, may help support individuals with poorer education, farmers, daily wage labourers, individuals in young female-headed households and temporary foreign migrant households.

Is socioeconomic position associated with risk of attempted suicide in rural Sri Lanka? A cross-sectional study of 165†000 individuals.

BACKGROUND: Lower socioeconomic position (SEP) is associated with an increased risk of suicidal behaviour in high-income countries, but this association is unclear in low-income and middle-income countries. METHODS: We investigated the association of SEP with attempted suicide in a cross-sectional survey of 165 233 Sri Lankans. SEP data were collected at the household (assets, social standing (highest occupation of a household member), foreign employment and young (≤40 years) female-headed households) and individual level (education and occupation). Respondent-reported data on suicide attempts in the past year were recorded. Random-effects logistic regression models, accounting for clustering, were used to investigate the association of SEP with attempted suicide. RESULTS: Households reported 398 attempted suicides in the preceding year (239 per 100 000). Fewer assets (OR 3.2, 95% CI 2.4 to 4.4) and having a daily wage labourer (ie, insecure/low-income job; OR 2.3, 95% CI 1.6 to 3.2) as the highest occupation increased the risk of an attempted suicide within households. At an individual level, daily wage labourers were at an increased risk of attempted suicide compared with farmers. The strongest associations were with low levels of education (OR 4.6, 95% CI 2.5 to 8.4), with a stronger association in men than women. CONCLUSIONS: We found that indicators of lower SEP are associated with increased risk of attempted suicide in rural Sri Lanka. Longitudinal studies with objective measures of suicide attempts are needed to confirm this association. TRIAL REGISTRATION NUMBER: NCT01146496; Pre-results.

The role of private drug vendors as malaria treatment providers in selected malaria endemic areas of Sri Lanka.

BACKGROUND AND OBJECTIVES: The involvement of private drug vendors in malaria treatment is particularly high in developing countries and understanding their practices and knowledge about antimalarials and malaria treatment will aid in devising strategies to increase the correct use of antimalarials and improve adherence to the government's malaria drug policy. Results of a study on the knowledge and practices of the private drug vendors conducted in seven districts in Sri Lanka, mostly in malarious areas are presented. METHODS: Data on awareness of government's malaria drug policy, practice of issuing antimalarials, knowledge about malaria and antimalarial drugs were collected from the drug vendors using pre-tested questionnaire in vernacular language. Data were statistically analysed using Stata 8.2. Chi-square test was carried out for individual explanatory variables and a logistic regression model was applied taking all response variables as binary outcome. RESULTS: Vendors' knowledge on antimalarials was poor with 58% of the vendors being unaware of the government malaria drug policy in the country. Also, the advice provided to customers buying antimalarials was limited. However, the majority of the private vendors emphasised that they were aware of the importance of case confirmation before treatment as stressed in the national policy. Although, the vendors did not have a high awareness of national drug policies they were only found selling chloroquine and primaquine as recommended by the Ministry of Health. INTERPRETATION AND CONCLUSION: In recent years Sri Lanka, as a whole, has experienced very little malaria. The reduction in demand for antimalarials due to low incidence levels may have influenced the knowledge and awareness on antimalarials and government drug policies. However, since low levels of malaria do not guarantee that epidemics will not occur, attempts to educate private drug vendors as a part of an organised control programmes are of major importance.

Practice of using human excreta as fertilizer and implications for health in Nghean Province, Vietnam.

The ancient practice of applying latrine wastes to agricultural land has maintained soil fertility in Vietnam for several centuries but may be associated with health risks if the wastes are inadequately treated before usage. This study aimed at investigating the perceptions and handling practices using latrine wastes as fertilizers in a community in central Vietnam. Information was collected through structured questionnaire interviews administered to 75 farming households, focus group discussions, and key informant interviews. The majority (64%) of households had a single vault latrine, a possession that was associated with low income (chi2= 12.45; p < 0.05). Most households (85%) used latrine waste in agriculture that was composted before usage (98%). Households often mixed the composted excreta with kitchen ashes and powdered lime likely to increase pH and pathogen die-off. About 28% of households that were applying latrine waste as fertilizer composted three to six months, and only 11 (18%) households composted human excreta for more than the recommended six months. Households with double vault latrines were 7.8 (chi2= 9.4; p<0.05) times more likely to compost human excreta more than six months as compared with households having single vault latrine. Most farmers distributed the latrine wastes with bare hands (66%) because of convenience during application. Respondents with a high educational level used protective gloves more often when distributing latrine wastes in the fields compared to respondents with a low educational level (chi2 = 7.6; p<0.05). If any negative health impacts of latrine waste use in agriculture are to be reduced, then it is suggested that sustainable interventions should take into consideration farmers current excreta-use practices.

A village treatment center for malaria: community response in Sri Lanka.

Early diagnosis and treatment of malaria cases is one of the basic elements of the current global malaria control strategy. In order to provide this service to people in rural areas there is a need for new cost-effective approaches. To ensure that such new approaches are acceptable to the target communities, it is important to know the rationale for people's malaria treatment-seeking behavior. The present study provides insights into the reasons for people's preferences for different types of healthcare facilities and describes variation of these preferences within a rural community in Sri Lanka. The study reports on the experiences with the establishment of a village health facility and its effect on the treatment-seeking behavior of the population. After the introduction of the village treatment center it quickly took over the role of main provider for diagnosis and treatment of malaria from the government facilities. The treatment center did not improve the response time in seeking treatment for young children, but the delay for adults was reduced by 1-2 days. Mothers with small children often preferred the government facilities since they wanted a more qualified opinion than available from the locally recruited staff of the village treatment center. The treatment center significantly reduced the stress and discomfort experienced by the elderly and handicapped segment of the community. The study indicated that the effective catchment area of a village treatment center will be influenced by the degree of initial support from key individuals in the communities, the selection procedure and training of assistants, and the history of the relationships between different villages to be served by the center. The government health services and communities across the dry zone of Sri Lanka could benefit substantially from the establishment of more village treatment centers. To ensure the long-term sustainability of these type of facilities it is necessary to assess the feasibility of charging a user fee and establishing multi-purpose clinics. Government policies and administrative procedures will need to be adjusted to make the successful operation of village treatment centers possible.

Cost of malaria control in Sri Lanka.

The study provides estimates of the cost of various malaria control measures in an area of North-Central Province of Sri Lanka where the disease is endemic. We assumed that each measure was equally effective. In these terms, impregnating privately purchased bednets with insecticide was estimated to cost Rs 48 (US(40.87) per individual protected per year, less than half the cost of spraying houses with residual insecticides. Larviciding of vector breeding sites and especially the elimination of breeding habitats by flushing streams through seasonal release of water from upstream reservoirs was estimated to be cheaper than other preventive measures (Rs 27 (US$ 0.49) and Rs 13 (US$ 0.24) per individual protected, respectively). Inclusion of both operational and capital costs of treatment indicates that the most cost-effective intervention for the government was a centrally located hospital with a relatively large catchment area (Rs 71 (US$ 1.29) per malaria case treated). Mobile clinics (Rs 153 (US$ 2.78) per malaria case treated) and a village treatment centre (Rs 112 (US$ 2.04)) per malaria case treated) were more expensive options for the government, but were considerably cheaper for households than the traditional hospital facilities. This information can guide health planners and government decision-makers in choosing the most appropriate combination of curative and preventive measures to control malaria. However, the option that is cheapest for the government may not be so for the householders, and further studies are needed to estimate the effectiveness of the various preventive measures.

PIP: A large proportion of Sri Lanka's budget is spent on malaria control. Estimates are provided of the cost of various malaria control interventions in North-Central Province, Sri Lanka, where the disease is endemic and where ongoing research activities facilitated the cost-effectiveness assessment. Each measure considered was assumed to be equally effective. As such, impregnating privately purchased bednets with insecticide was estimated to cost Rs 48 (US$0.87) per person protected per year, less than half the cost of spraying houses with residual insecticides. The larviciding of vector breeding sites and eliminating breeding habitats by flushing streams through the seasonal release of water from upstream reservoirs was estimated to be cheaper than other preventive measures, at Rs 27 and Rs 13 per person protected, respectively. Including both the operational and capital costs of treatment indicates that the most cost-effective intervention for the government was a centrally located hospital with a relatively large catchment area, at Rs 71 per malaria case treated. Mobile clinics and a village treatment center approach cost Rs 153 and Rs 112, respectively, per malaria case treated. These latter 2 strategies were the more expensive options for the government, but were less expensive for households compared to the cost of treatment at traditional hospital facilities.

Measuring the economic cost of malaria to households in Sri Lanka.

The economic cost at the household level of labor days lost due to malaria and other illnesses was estimated in a rural community in Sri Lanka. Over a one-year period, 223 episodes of malaria were recorded from the 298 inhabitants of the village. Based on daily activity records, the economically active age group was defined as 14-60 years. In this age group, 1.8% of working days were lost due to malaria and 5.2% due to all other illnesses. The value of a labor day lost was based on the actual rural wage rate for children, women, and men, with weeks during periods of high labor demand weighting more than weeks during lean agricultural periods. In this way the annual economic loss per household amounted to US $15.56 for malaria and US $47.46 for all other illnesses. This corresponded to a loss of 6% and 18% of annual household net income, respectively. Although the overall economic impact was limited, malaria cases were concentrated in an important agricultural season. During this season, 5.6% of working days were lost due to malaria. In addition, children, who were not part of the economically active population, lost 10% of school days due to malaria during the high transmission season. In estimating the socioeconomic impact of malaria and in measuring cost-benefits of malaria control interventions, these costs have to be considered together with direct expenditures incurred by households such as on treatment and travel and with costs for the service providers.

Household responses to malaria and their costs: a study from rural Sri Lanka.

A study of the cost of malaria at the household level, community perceptions, preventive measures and illness behaviour linked to the disease was undertaken in 5 villages in the dry zone of Sri Lanka. The surveyed community had a high knowledge of malaria, although side effects of antimalarial drugs were often confused with symptoms of the disease. The community sought prompt diagnosis and treatment at 'western-type' facilities, with 84% making use of government facilities as their first choice and 16% preferring private facilities. The preventive measures used were burning coils (54% of families) and special leaves (69% of families), and 93% of the families had their houses sprayed with insecticides. Average direct expenditure on a single malaria episode was $3 US, with some families spending more than 10% of the annual household net income per episode. The highest expenditure was on special diets for the sick person, to neutralize the perceived heating effect of the disease and its treatment.

PIP: Knowledge of community perceptions of malaria, treatment-seeking behaviors, and the household costs of illness is essential to the planning of sustainable malaria control interventions. These factors were investigated in household surveys conducted in 5 villages in Sri Lanka's dry zone in February 1995. 95% of the 216 families interviewed regarded malaria as their main health problem, followed by diarrhea and eye diseases. Malaria was ranked as the third most important community concern, following lack of water for cultivation and poverty. Overall knowledge of malaria's causes, symptoms, and treatment was high, although the side effects of antimalarial drugs were often confused with symptoms of the disease. Reported for the 3-month period preceding the survey were 178 episodes of malaria involving 160 families. Home treatment with paracetamol was the first step taken in 85% of cases; however, all families sought prompt treatment from Western-type facilities, especially government hospitals (48%) and mobile clinics (30%). No families consulted indigenous or ayurvedic physicians, despite their availability in the area. This utilization of prompt, effective treatment is presumed to reflect high knowledge about malaria, the perceived seriousness of the disease, and good transport facilities in the area. The total direct expenditure on a single episode of malaria averaged US $3; the median net annual income was $258. Special foods for malaria patients aimed at neutralizing the perceived heating effect of malaria and antimalarial drugs (e.g., sodas, oranges) were the most costly item. Adults lost an average of 7.8 days of work per episode and those accompanying them to health facilities lost 2.9 days. Preventive measures used by families included bed nets (23%), mosquito coils (54%), and insecticides (93%).