Personal and family attributes of pregnant teenagers: findings from a community-based study in Sri Lanka.

BACKGROUND: Teenage pregnancies are associated with negative outcomes. Prevention requires understanding them and their families. OBJECTIVES: This study aimed to describe personal and family attributes of pregnant teenagers in Sri Lanka. METHODS: This was a community-based study in Sri Lanka among 510 pregnant teenagers. RESULTS: Half (50%) of the subjects were 19 years of age at the time of pregnancy. A majority (79.8%) had studied up to grades 6-11. Confidence in decision-making (80.7%) and in refusing unnecessary requests (88.3%) was "excellent" in a majority. Mean age of marriage/co-habiting was 17.6 years. For 31%, marriage/cohabiting was a sudden decision taken jointly with their partner (81.6%) and 83% reported being "legally" married. Substantial proportions of mothers (17.6%) and fathers (13.9%) had not attended school, and 33.1% mothers had worked abroad. Teenagers reported the death of a parent (14.1%), parental separation (10.9%) and being brought up by relatives (20%). Only a few rated strictness of rules/regulations (32.4%), freedom to discuss problems regarding puberty (25.5%), love affairs (12.7%) and sexuality (26.7%) as excellent/good. Of the spouses, 12.9% were <20 years, 71.9% had low education and 98.8% were employed. A majority had "planned" the pregnancy, and for 79.8%, the reason was "husband's wish to have a baby". CONCLUSIONS: Pregnant teenagers were mostly in their late teens, from poor families and with low formal education. Though teenagers showed confidence in decision-making, the decision to have a pregnancy had mostly been their spouses. Parents and spouses of the teenagers were also young, less educated and poor. There was evidence of poor parenting 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.

Paradox in treatment seeking: an experience from rural Sri Lanka.

Sri Lanka has had a pluralist health care system for centuries, in which Western biomedicine coexists with the Ayurveda system. However, recent studies suggest a declining trend in the use of the Ayurveda system. This study provides insights into the reasons for the low utilization of the Ayurveda system at present. The study findings reveal that low utilization of the Ayurveda system can be attributed to several factors, including the quick effect of Western medicines, the perception of being accustomed to Western medicines, a lack of competent Ayurveda practitioners, the high cost and low quality of Ayurveda medicines, and the rapidly changing lifestyles of villagers. However, for certain conditions such as fractures, snakebite, and paralysis, the majority of the Sri Lankan population still uses Ayurveda treatment. In conclusion, we suggest that health authorities should take into account these changes for future health planning in Sri Lanka.

Supplementation of micronutrients in children and food fortification initiatives in Sri Lanka: benefits versus risks.

In recent decades, Sri Lanka has made substantial progress in reducing the burden of micronutrient deficiencies in children by the provision of vitamin A megadose and micronutrient supplementation programs for children of 6-23 months, along with universal iodization of salt. Consumption of voluntarily fortified foods by children was also considerably increased. The objective of our study here was to review such interventions, which are beneficial in childhood, and to assess the risk of toxicity due to excessive intakes of iron, vitamin A, and iodine. Our analysis was performed using data from two national micronutrient surveys, market surveys, and key informant interviews. Data on coverage, usage, and nutrient content of certain foods were compiled to gauge consumption of iron, vitamin A, and iodine among children. We found that the severity of anemia and vitamin A and iodine deficiencies declined from moderate-to-severe and that supplementation and fortification can lead to an excess of vitamin A that may cause toxicity, while iron and iodine deficiency appears to be no longer a public health concern in Sri Lanka. We recommend review and scaling back of national supplementation programs and monitoring of fortification initiatives to prevent micronutrient toxicity in the future.

mHealth nutrition and lifestyle intervention (mHENAL) to reduce cardiovascular disease risk in a middle-aged, overweight and obese population in Sri Lanka: Study protocol for a randomized controlled trial.

Mobile phone-based health interventions (mHealth) are viewed as an attractive approach to foster behaviour change, and found to be effective in promoting physical activity and healthy diets. The present study aims to investigate whether mHealth with advice for dietary and lifestyle modifications would reduce 10-year cardio vascular disease (CVD) risk among overweight or obese adults aged 35-64 years in Sri Lanka. A two-group parallel-arm randomized controlled trial (RCT) was conducted in Colombo district, recruiting 1200 individuals aged 35-64 years with a body mass index (BMI) of ≥25 kgm-2. Participants were randomly assigned either to mHealth package (intervention arm, n = 600) or usual care (control arm, n = 600). The intervention package contains a series of dietary and lifestyle improvement messages, a mobile application to register participants, and a web application to deliver these messages. Participants in the intervention arm receive 2 voice and 2 text messages per week to their mobile phones for a period of 12 months. The primary outcome (10-year CVD risk) will be assessed according to sex, age, smoking status, blood pressure, serum cholesterol and glycaemic status. Data are collected at enrollment and after 12 months of intervention on: dietary practices, physical activity, smoking, anthropometry, body composition, blood pressure, fasting plasma glucose, HbA1c and lipid profile. Analysis of effect will be performed by intention-to-treat principle, comparing the outcomes between intervention and control arms. The study resulted in a comprehensive mHealth nutrition and lifestyle package (mHENAL) and successfully completed recruitment and baseline assessment of participants. The message delivery is in progress.

Factors associated with maternal knowledge of newborn care among hospital-delivered mothers in Sri Lanka.

The aim of this study was to assess mothers' knowledge on newborn care as well as factors associated with poor knowledge. A cross-sectional study sampled 446 mother-newborn pairs from five hospitals in the Puttalam district of Sri Lanka by stratified random sampling. Maternal knowledge on newborn care was assessed using a questionnaire with 50 statements via exit interview. A knowledge score was created by allocating 1 point for each correct response, which was dichotomised as 'satisfactory' or 'poor' by the median score. Only 21.7% correctly answered that 'surgical spirit' (70% isopropyl alcohol) should not be applied on the umbilical stump. More than 90% of mothers knew about breastfeeding on demand, the advantages of colostrum and the duration of exclusive breastfeeding. Except for a few conditions, mothers demonstrated a satisfactory knowledge in recognising danger signs of the newborn. According to multivariate analysis, primiparae (odds ratio (OR)=2.31; 95% CI 1.53-3.50), unemployed women (OR=3.31; 95% CI 1.89-5.80) and those with delayed antenatal booking visits (OR=2.02; 95% CI 1.26-2.23) were more likely to have poor knowledge. In conclusion, mothers had a satisfactory level of knowledge about breastfeeding and recognition of danger signs, but knowledge about care of the umbilical cord was poor. Maternal education programmes should place more emphasis on first-time mothers, unemployed women and those with delayed booking visits.

Effect of training for care providers on practice of essential newborn care in hospitals in Sri Lanka.

OBJECTIVE: To evaluate the effectiveness of a training program for care providers in improving practice of essential newborn care in obstetric units. DESIGN: Before-and-after study with an intervention and a control group. SETTING: Five hospitals in the Puttalam district in Sri Lanka. PARTICIPANTS: Eight hundred and ninety-two mother-newborn pairs (446 before and 446 three months after). INTERVENTION: A 4-day training program on essential newborn care for doctors, nurses, and midwives of the obstetric units in two hospitals. MAIN OUTCOME MEASURES: By direct observation, practices of essential newborn care at delivery in the labor room on a subsample. By interviewing mothers, immediate skin-to-skin contact and early initiation of breastfeeding. From health records, "undesirable health events" of the newborns. RESULTS: Practices of cleanliness, thermal protection, and neonatal assessment improved significantly in the intervention group. The intervention was effective in improving skin-to-skin contact by 1.5 times and early initiation of breastfeeding by 3.4 times. Undesirable health events declined from 32 to 21 per 223 newborns in the intervention group and from 20 to 17 per 223 newborns in the control group. CONCLUSION: A comprehensive 4-day training program can be followed by a significant improvement in essential newborn care practices in obstetric units.

Development of birth weight for gestational age charts in a Sri Lankan setting - methodological issues.

BACKGROUND: This study was taken up to identify the main types of low birth weight (LBW) for the development of weight for gestational age charts relevant to the country/regional level for the formulation of preventive strategies. MATERIALS AND METHODS: A sample of mothers registered by Public Health Midwives (PHMs) from two Medical Officers of Health (MOH) areas in Colombo district were followed up until delivery in five selected hospitals. Period of gestation (POG) was assessed between 10 and 12 weeks using ultrasonography. Records of 474 mother/newborn pairs were used for development of gestational age-related birth weight charts for each sex and POG. Mothers with one or more risk factors for LBW were excluded. Mothers with POG less than 38 weeks and more than 40 weeks were limited. Information on all possible risk factors contributing to LBW were assessed. RESULTS: Incidence of small for gestational age (SGA) assessed using the 10 th centile value for each POG, was 19.0% for males and 18.0% for females. Percentages of symmetrical and asymmetrical SGA newborns were 72.1% and 27.9%, respectively. CONCLUSION: The charts were developed paying attention to all methodological aspects that highlighted the key issues relevant to development of weight for gestational age charts in a developing country setting. As action was taken to minimize the biases introduced by such issues, the charts developed could be used for assessment of incidence and risk factors for SGA until charts based on national level data are available.

The Child Behaviour Assessment Instrument: development and validation of a measure to screen for externalising child behavioural problems in community setting.

BACKGROUND: In Sri Lanka, behavioural problems have grown to epidemic proportions accounting second highest category of mental health problems among children. Early identification of behavioural problems in children is an important pre-requisite of the implementation of interventions to prevent long term psychiatric outcomes. The objectives of the study were to develop and validate a screening instrument for use in the community setting to identify behavioural problems in children aged 4-6 years. METHODS: An initial 54 item questionnaire was developed following an extensive review of the literature. A three round Delphi process involving a panel of experts from six relevant fields was then undertaken to refine the nature and number of items and created the 15 item community screening instrument, Child Behaviour Assessment Instrument (CBAI). Validation study was conducted in the Medical Officer of Health area Kaduwela, Sri Lanka and a community sample of 332 children aged 4-6 years were recruited by two stage randomization process. The behaviour status of the participants was assessed by an interviewer using the CBAI and a clinical psychologist following clinical assessment concurrently. Criterion validity was appraised by assessing the sensitivity, specificity and predictive values at the optimum screen cut off value. Construct validity of the instrument was quantified by testing whether the data of validation study fits to a hypothetical model. Face and content validity of the CBAI were qualitatively assessed by a panel of experts. The reliability of the instrument was assessed by internal consistency analysis and test-retest methods in a 15% subset of the community sample. RESULTS: Using the Receiver Operating Characteristic analysis the CBAI score of >16 was identified as the cut off point that optimally differentiated children having behavioural problems, with a sensitivity of 0.88 (95% CI = 0.80-0.96) and specificity of 0.81 (95% CI = 0.75-0.87). The Cronbach's alpha exceeded Nunnaly's criterion of 0.7 for items related to inattention, aggression and impaired social interaction. CONCLUSIONS: Preliminary data obtained from the study indicate that the Child Behaviour Assessment Instrument is a valid and reliable screening instrument for early identification of young children at risk of behavioural problems in the community setting.

Newborn care practices at home: effect of a hospital-based intervention in Sri Lanka.

The aim of the present study was to evaluate the effect of an essential newborn care (ENC) training programme for maternity ward staff in improving newborn care practices after hospital discharge. A before-and-after study was conducted in the community involving mothers who had given birth in two hospitals in the Puttalam district in Sri Lanka. The intervention was a 4-day training programme and primarily aimed at increasing knowledge and skills of ENC among health care providers in the maternity units of these hospitals. Before the intervention, 144 mother-newborn pairs were followed-up and interviewed at their households within 28-35 days of delivery. Three months after the intervention, 150 mother-newborn pairs were interviewed at home. Results revealed that there was a significant improvement in umbilical cord care practices at home following the intervention. Application of 'surgical spirit' on umbilical cord has declined from 71.5% in the pre-intervention to 45.3% in the post-intervention samples (p < 0.001). Pre-intervention breastfeeding rates were high, and there wasn't any further improvement in the post-intervention. There was a 35% reduction in the proportion of newborns who developed any undesirable health events at home (p < 0.05). Findings suggest that the implementation of a comprehensive 4-day training programme of ENC for maternity ward health professionals can be followed by a significant improvement in mothers' practices on care of umbilical cord and clinical outcomes of newborns.

Factors determining client satisfaction with hospital-based perinatal care in Sri Lanka.

OBJECTIVES: To describe mothers' satisfaction with perinatal care received during hospitalization for delivery, and to identify sociodemographic and health-care-related factors associated with satisfaction. METHOD: A cross-sectional study of 446 mother-newborn pairs from five hospitals in Puttalam district, Sri Lanka, was carried out by stratified randomization. Client satisfaction was measured using a 16-item survey instrument with high internal consistency (Cronbach's alpha=0.81), through exit interview. RESULTS: The proportion of mothers who were fully satisfied varied from 10.8% to 31.4% for interpersonal aspects, and from 10.1% to 28.9% for technical aspects of care. The satisfaction rates were lower with physical environment (6.1-10.1%) and higher with outcome of care (41.0-48.0%). Multivariate analyses indicated that mothers were more satisfied with the services available from lower level hospitals. Multiparae were more satisfied than primiparae. Determinants of satisfaction included providing immediate mother-newborn contact, information after examination and counselling on family planning. Higher satisfaction with the physical environment was associated with being Moor or Tamil as opposed to Sinhalese and with lower family income. CONCLUSIONS: The factors associated with client satisfaction identified in this study may be helpful in improving quality of care. Hospital staff should ensure that these are addressed and develop interpersonal relationships, especially with the first-time mothers and in higher level hospitals. Maternity units of lower level institutions should be upgraded with essential facilities.