Quality of life among community-dwelling older adults: evidence from a large population-based study in rural Sri Lanka.

PURPOSE: Against the backdrop of the ever-increasing aging population in Sri Lanka and the scarcity of local evidence on quality of life (QoL) among rural elderly, this study was conducted to assess the QoL of the community-dwelling older adults in rural Sri Lanka. METHODS: This cross-sectional study was conducted among community-dwelling older adults (60-74 years) in a selected rural setting in Sri Lanka. K-means cluster analysis was used to stratify participants into 'low' and 'high' levels of QoL and then significant associations between these clusters and underlying socio-demographic and self-reported health related factors were estimated using bivariate and subsequent multivariable binary logistic regression models. RESULTS: The final sample consisted of 3573 community-dwelling older adults (response rate 97.8%). The mean (SD) age of the sample was 66.7 (4.3) years and the majority were females (n = 2130, 59.6%). Amongst the six QoL domains assessed (physical, psychological, social, functional, environmental and spiritual domains), the highest and the lowest mean (SD) scores were reported for the functional [63.4 (16.9)] and the physical [52.9 (15.0)] domains, respectively. Aged 70 years or more, either unmarried/widowed/divorced, lower educational levels and having chronic illnesses were statistically significant associations of QoL (p < 0.05). CONCLUSION: The QoL among community-dwelling older adults in rural Sri Lanka is moderate. As having social support, absence of chronic diseases and good education level were found to be associated with better QoL, strengthening community-based interventions to improve these aspects by incorporating the evidence generated by other longitudinal studies is recommended.

Early pregnancy metabolic syndrome and risk for adverse pregnancy outcomes: findings from Rajarata Pregnancy Cohort (RaPCo) in Sri Lanka.

BACKGROUND: Despite the intergenerational effects of metabolic disorders, evidence is greatly lacking on early pregnancy metabolic syndrome (MetS) and its effects on pregnancy outcomes from low- and middle-income countries. Thus, this prospective cohort of South Asian pregnant women aimed to evaluate how early pregnancy MetS would affect pregnancy outcomes. METHODS: A prospective cohort study was conducted among first-trimester (T1) pregnant women of Anuradhapura district, Sri Lanka recruited to the Rajarata Pregnancy Cohort in 2019. MetS was diagnosed by the Joint Interim Statement criteria before 13 weeks of gestational age (GA). Participants were followed up until their delivery, and the major outcomes measured were large for gestational age (LGA), small for gestational age (SGA), preterm birth (PTB) and miscarriage (MC). Gestational weight gain, gestational age at delivery and neonatal birth weight were used as measurements to define the outcomes. Additionally, outcome measures were re-assessed with adjusting fasting plasma glucose (FPG) thresholds of MetS to be compatible with hyperglycemia in pregnancy (Revised MetS). RESULTS: 2326 T1 pregnant women with a mean age of 28.1 years (SD-5.4), and a median GA of 8.0 weeks (IQR-2) were included. Baseline MetS prevalence was 5.9% (n = 137, 95%CI-5.0-6.9). Only 2027 (87.1%) women from baseline, had a live singleton birth, while 221(9.5%) had MC and 14(0.6%) had other pregnancy losses. Additionally, 64(2.8%) were lost to follow-up. A higher cumulative incidence of LGA, PTB, and MC was noted among the T1-MetS women. T1-MetS carried significant risk (RR-2.59, 95%CI-1.65-3.93) for LGA, but reduced the risk for SGA (RR-0.41, 95%CI-0.29-0.78). Revised MetS moderately increased the risk for PTB (RR-1.54, 95%CI-1.04-2.21). T1-MetS was not associated (p = 0.48) with MC. Lowered FPG thresholds were significantly associated with risk for all major pregnancy outcomes. After adjusting for sociodemographic and anthropometric confounders, revised MetS remained the only significant risk predictor for LGA. CONCLUSION: Pregnant women with T1 MetS in this population are at an increased risk for LGA and PTB and a reduced risk for SGA. We observed that a revised MetS definition with lower threshold for FPG compatible with GDM would provide a better estimation of MetS in pregnancy in relation to predicting LGA.

Determinants of birthweight in rural Sri Lanka; a cohort study.

BACKGROUND: Identifying determinants of birthweight among disadvantaged communities is critical to further reducing the inequitable burden of perinatal health issues in low-and-middle income settings. Therefore, we adopted a bio-psycho-social approach to identify the determinants of birthweight in a mother-infant cohort from a rural setting in Sri Lanka, a lower-middle-income country. METHODS: All third-trimester pregnant women with a singleton pregnancy registered for the national antenatal care programme at Ipalogama health division in 2017 were invited for a prospective cohort study. Data was collected using a self-completed questionnaire and data extraction from health records. The mother-infant cohort was followed up until one month after delivery. A principal component analysis was performed using economic, social, and psychological variables, and two composite variables were achieved. Care from husband and household members, perceived wellbeing, frequency of abuse, and affect during the third trimester strongly loaded to the variable 'psychosocial wellbeing'. Monthly income, husband's education level, and use of biomass fuel strongly loaded to the variable 'socioeconomic status'. Hierarchical logistic regression was used to predict factors associated with birthweight. Maternal age, parity, baby's sex, and gestational period at pregnancy registration were entered at the first step. BMI, psychosocial wellbeing, socioeconomic status, hypertensive disorders, and gestational/chronic diabetes were entered at step two. Preterm birth was entered at step three. RESULTS: 532 women were recruited, and 495 were retained at the postpartum follow-up. 421 (74.8%) had reported being abused at least once during the preceding month. Birthweight was approximately normally distributed (mean 2912 g, SD 456.6 g). Low birthweight was present in 72 (14.6%, 95% CI 11.7,17.9), and 46 (9.3%, 95% CI 7.0,12.1) had birthweights > 3500 g. The regression model explained 13.2% of the variance in birthweight. Preterm birth, maternal BMI, and mid-pregnancy psychosocial wellbeing could explain 6.9%(p < 0.001), 3.9(p < 0.001), and 1.2%(p = 0.02) of unique variance, respectively. CONCLUSIONS: In a setting where a large proportion of pregnant women suffer 'abuse' in their homes, psychosocial wellbeing during pregnancy was an important determinant of birthweight of babies. Expanding routine maternal care services, especially at the primary care level, to cater to the psychosocial issues of pregnant women would help reduce inequities in perinatal health.

The magnitude of out-of-pocket expenditure for antenatal care in low and middle-income countries: A systematic review and meta-analysis.

BACKGROUND: Owing to the lack of compiled global evidence on out-of-pocket expenditure (OOPE) for antenatal care (ANC), this systematic review and meta-analysis estimated the magnitude of OOPE for ANC in low and middle-income countries (LMICs). METHODS: An electronic search was conducted using 10 databases and a hand search of the eligible studies' reference lists. Studies on OOPE for ANC in LMICs, published in English without time restriction, were included. The comparability of OOPE values was improved using inflation and exchange rate adjustment to the year 2019. Random-effects meta-analysis was performed to generate pooled estimates. RESULTS: Among the 9766 articles retrieved, 32 were selected. Only 13/137 (9.5%) countries reported evidence of OOPE during pregnancy in LMICs. The majority of the studies (n = 2779.4%) were from lower-middle-income settings. Ten (31.3%) studies from African region, 21 (65.6%) studies from South-East-Asian region, 1 (3.1%) study from region of Americas and none from the other regions were included. The average OOPE for ANC and single ANC visit ranged from United States Dollar (USD) 2.41 to USD 654.32 in LMICs, the lowest in Tanzania and the highest in India. The pooled OOPEs were USD 63.29 (95% confidence interval [CI] = 51.93-74.65) and USD 12.93 (95%CI = 4.54-21.31) for ANC and single ANC visit in LMICs, respectively. CONCLUSION: The study revealed that the pooled estimates of OOPE for ANC throughout pregnancy and per visit were high in some countries, with a wide variability observed across countries. There was a lack of evidence on OOPE for ANC from many LMICs, and filling the evidence gap in LMICs is highlighted.

Prevalence and aetiologies of anaemia among first trimester pregnant women in Sri Lanka; the need for revisiting the current control strategies.

BACKGROUND: The Sustainable development goals, which focus strongly on equity, aim to end all forms of malnutrition by 2030. However, a significant cause of intergenerational transfer of malnutrition, anaemia in pregnancy, is still a challenge. It is especially so in the low- and middle-income settings where possible context-specific aetiologies leading to anaemia have been poorly explored. This study explores the prevalence of etiological factors significantly contributing to anaemia in pregnancy in Sri Lanka, a lower-middle-income country with a high prevalence of malnutrition albeit robust public health infrastructure. METHODS: All first-trimester pregnant women registered in the public maternal care programme in the Anuradhapura district from July to September 2019 were invited to participate in Rajarata Pregnancy Cohort (RaPCo). After a full blood count analysis, high-performance liquid chromatography, peripheral blood film examination, serum B12 and folate levels were performed in anaemic participants, guided by an algorithm based on the red cell indices in the full blood count. In addition, serum ferritin was tested in a random subsample of 213 participants. Anaemic women in this subsample underwent B12 and folate testing. RESULTS: Among 3127 participants, 14.4% (95%CI 13.2-15.7, n = 451) were anaemic. Haemoglobin ranged between 7.4 to 19.6 g/dl. 331(10.6%) had mild anaemia. Haemoglobin ≥13 g/dl was observed in 39(12.7%). Microcytic, normochromic-normocytic, hypochromic-normocytic and macrocytic anaemia was observed in 243(54%), 114(25.3%), 80(17.8%) and two (0.4%) of full blood counts in anaemic women, respectively. Microcytic anaemia with a red cell count ≥5 * 106 /µl demonstrated a 100% positive predictive value for minor haemoglobinopathies. Minor hemoglobinopathies were present in at least 23.3%(n = 105) of anaemic pregnant women. Prevalence of iron deficiency, B12 deficiency and Southeast Asian ovalocytosis among the anaemic was 41.9% (95%CI 26.4-59.2), 23.8% (95%CI 10.6-45.1) and 0.9% (95%CI 0.3-2.3%), respectively. Folate deficiency was not observed. CONCLUSION: Even though iron deficiency remains the primary cause, minor hemoglobinopathies, B 12 deficiency and other aetiologies substantially contribute to anaemia in pregnancy in this study population. Public health interventions, including screening for minor hemoglobinopathies and multiple micronutrient supplementation in pregnancy, should be considered in the national programme for areas where these problems have been identified.

Social determinants of health pave the path to maternal deaths in rural Sri Lanka: reflections from social autopsies.

BACKGROUND: Ending preventable maternal deaths remains a challenge in low- and middle-income countries (LMICs). Society perceived causes and real-life observations can reveal the intangible causes of maternal deaths irrespective of formal maternal death investigations. This study reports complex patterns in which social determinants act towards paving the path to maternal deaths in a rural Sri Lankan setting. METHODS: We conducted social autopsies for 15/18 maternal deaths (in two consecutive years during the past decade) in district A (pseudonymized). In-depth interviews of 43 respondents and observations were recorded in the same field sites. During thematic analysis, identified themes were further classified according to the World Health Organization framework for social determinants of health (SDH). The patterns between themes and clustering of social determinants based on the type of maternal deaths were analyzed using mixed methods. RESULTS: Discernable social causes underpinned 12 out of 15 maternal deaths. Extreme poverty, low educational level, gender inequity, and elementary or below-level occupations of the husband were the characteristic structural determinants of most deceased families. Social isolation was the commonest leading cause manifesting as a reason for many other social factors and resulted in poor social support paving the path to most maternal deaths. A core set of poverty, social isolation, and poor social support acted together with alcohol usage, and violence leading to suicides. These core determinants mediating through neglected self-health care led to delay in health-seeking. Deficits in quality of care and neglect were noted at health institutions and the field. CONCLUSION: Social autopsies of maternal deaths revealed complex social issues and social determinants of health leading to maternal deaths in Sri Lanka, indicating the need for a socially sensitive health system.

Help-seeking intention for depression and suicidal ideation during pregnancy and postpartum in rural Sri Lanka, a cross-sectional study.

INTRODUCTION: Suicides are a leading cause of maternal deaths. Depression, the commonest mental illness during pregnancy, amidst its numerous morbidities, can precipitate suicides. So, early detection and treatment of maternal depression and suicidal thoughts are important for reducing maternal morbidity and mortality. Pregnant women's help-seeking patterns play a crucial role in this. Limited availability and accessibility of potential sources, poor knowledge, and perceptions of the condition and the help-seeking process itself ,would act as barriers for help-seeking, especially in resource-constrained settings. This study explores the help-seeking intention, preferred sources, and factors influencing help-seeking for depression and suicidal thoughts among pregnant women in rural Sri Lanka. METHODS: A cross-sectional study was conducted among pregnant women attending antenatal clinics in Anuradhapura, Sri Lanka. A multistage cluster sampling technique with probability proportionate to size was used. A self-completed, vignette-based questionnaire was developed, validated and pretested for the study. The vignette described the experience of a postpartum mother with symptoms of peripartum depression without suicidal ideation (part A) and the same mother developing suicidal ideation (part B). RESULTS: Out of 624 participants, 202 (33.8%, 95%CI 30.0-37.7%) and 206 (36.7%, 95%CI 32.7-40.8%) reported they would seek help soon if they experienced symptoms of depression and suicidal ideations, respectively, while 181 (30.3%, 95%CI 26.6-34.1%) and 161 (28.6%, 95%CI 24.9-32.6%) said they would so if symptoms or suicidal thoughts did not resolve with time. Women were most likely to seek help from their husbands for symptoms of depression (n=445, 72.6%) and for suicidal thoughts (n=406, 71.1%). A public health midwife (n=346, 57.9%) was preferred over other formal or semiformal sources. If they were to seek help, 467 (49.2%) would contact a doctor or midwife specifically. The majority did not perceive that the described emotions could be symptoms of an illness (n=300, 50.1%) or that having suicidal ideation can be a threat to the life of the affected person (n=308, 52.1%) or that there was a probability for them to develop a mental illness during a current pregnancy (n=379, 65%). The majority perceived that positive responses were likely to be received, and negative responses were less likely to be received, if they were to seek help from their husband, another family member and midwife. CONCLUSION: Using a vignette approach allowed an exploration of how the 'at risk population' would construct meaning to symptoms of depression and suicidal ideation during pregnancy and the postpartum period, and what their actions would likely be if they were in a similar situation. It was observed that symptoms of depression and suicidal thoughts were regarded as normal by the pregnant women in this rural community, and they also perceived a low threat of getting a similar condition. This is a crucial point to intervene at for improving help-seeking. Informal and semiformal sources of help preferred by these women, especially husbands and public health midwives, should be empowered to respond effectively and facilitate further help-seeking from mental health professionals.

Feasibility of using telephone interviews and internet-based message services during the COVID-19 pandemic in rural Sri Lanka: experiences of the Rajarata Pregnancy Cohort.

The COVID-19 pandemic has challenged population health researchers to use remote data collection methods to avoid face-to-face interaction. A proper assessment of the feasibility of these methods in low-resource settings is lacking. We share our experience from telephone interviews conducted among pregnant women in the Rajarata Pregnancy Cohort in Sri Lanka. Among 3374 participants, 3284 (98.4%) and 496 (14.7%) had mobile and fixed-access phones respectively. During interviews, 1576 (51.9%) of participants were non-contactable. Of these, there were 157 (5.1%) wrong numbers, 889 (29.1%) were unavailable/phone switched off and 479 (15.7%) didn't answer their phone. Telephone interviews were completed only among 1438 (42.6%). Of these, 476 (33.1%) used messaging apps. In this local setting, these methods led to selection bias and inequity in health message delivery. If other ways to target vulnerable people in rural areas are not in place, the adoption of a telephone-based strategy to health message delivery may worsen health disparity during the COVID-19 pandemic. These facts aid in the planning and implementation of research and health promotion initiatives in rural areas of low- and middle-income nations throughout the world.

The hidden burden of adolescent pregnancies in rural Sri Lanka; findings of the Rajarata Pregnancy Cohort.

BACKGROUND: Adolescent fertility is a main indicator of the Sustainable Developmental Goal (SGD) three. Although Sri Lanka is exemplary in maternal health, the utilization of Sexual and Reproductive Health services (SRH) by adolescents is less documented. We describe the hidden burden, associated biological and psychosocial factors and utilization patterns of pre-conceptional services among pregnant adolescents in rural Sri Lanka. METHODS: The study is based on the baseline assessment of the Rajarata Pregnancy Cohort (RaPCo) in Anuradhapura. Pregnant women newly registered from July to September 2019 were recruited to the study. The period of gestation was confirmed during the second follow-up visit (around 25-28 weeks of gestation) using ultra sound scan data. A history, clinical examination, anthropometric measurements, blood investigations were conducted. Mental health status was assessed using the Edinburgh Postpartum Depression Scale (EPDS). RESULTS: Baseline data on gestation was completed by 3,367 pregnant women. Of them, 254 (7.5%) were adolescent pregnancies. Among the primigravida mothers (n = 1037), 22.4% (n = 233) were adolescent pregnancies. Maternal and paternal low education level, being unmarried, and less time since marriage were statistically significant factors associated with adolescent pregnancies (p < 0.05). Contraceptive usage before pregnancy, utilization of pre-conceptional health care services, planning pregnancy and consuming folic acid was significantly low among adolescents (p < 0.001). They also had low body mass index (p < 0.001) and low hemoglobin levels (p = 0.03). Adolescent mothers were less happy of being pregnant (p = 0.006) and had significantly higher levels of anxiety (p = 0.009). CONCLUSION: One fifth of women in their first pregnancy in this study population are adolescents. Nulli-parous adolescents exert poor social stability and compromised physical and mental health effects. The underutilization and/or unavailability of SRH services is clearly associated with adolescent pregnancies.

How costly is the first prenatal clinic visit? Analysis of out-of-pocket expenditure in rural Sri Lanka - a country with free maternal health care.

BACKGROUND: This study aimed to determine the magnitude of and factors associated with out-of-pocket expenditure (OOPE) during the first prenatal clinic visit among pregnant women in Anuradhapura district, Sri Lanka, which provides free maternal healthcare. METHODS: The study design was a cross-sectional study, and the study setting was 22 Medical Officers of Health (MOOH) areas in Anuradhapura District, Sri Lanka. Data of 1389 pregnant women were analyzed using descriptive statistics and non-parametric tests. RESULTS: The mean OOPE of the first prenatal clinic visit was USD 8.12, which accounted for 2.9 and 4.5% of the household income and expenditure, respectively. Pregnant women who used only government-free health services (which are free of charge at the point of service delivery) had an OOPE of USD 3.49. A significant correlation was recorded between household expenditure (rs = 0.095, p = 0.002) and the number of pregnancies (rs = - 0.155, p < 0.001) with OOPE. Education level less than primary education is positively contributed to OOPE (p < 0.05), and utilizing government-free maternal health services lead to a decrease in the OOPE for the first prenatal clinic visit (p < 0.05). CONCLUSION: Despite having free maternal services, the OOPE of the first prenatal clinic visit is high in rural Sri Lanka. One-fifth of pregnant women utilize private health services, and pregnant women who used only government-free maternal health services also spend a direct medical cost for medicines/micronutrient supplements.

The Rajarata Pregnancy Cohort (RaPCo): study protocol.

BACKGROUND: Ending preventable maternal deaths remains a global priority and in the later stages of obstetric transition, identifying the social determinants of maternal health outcomes is essential to address stagnating maternal mortality rates. Countries would hardly achieve the Sustainable Development Goal (SGD) targets on maternal health, unless the complex and context-specific socio-economic aetiologies associated with maternal mental health and suicide are identified. The Rajarata Pregnancy Cohort (RaPCo) is a prospective cohort study, designed to explore the interactions between social determinants and maternal mental health in determining pregnancy and new-born outcomes. METHODS: The study will recruit all eligible pregnant women in the maternal care programme of Anuradhapura district, Sri Lanka from July to September 2019. The estimated sample size is 2400. We will assess the socio-demographic and economic status, social capital, gender-based violence and mental health, including a clinical examination and biochemical investigations during the first trimester. Participants will undergo four follow-ups at 2nd and 3rd trimesters, at delivery and in early postpartum. The new-borns will be followed up at birth, neonatal period, at 6 six months and at 1 year. Pregnancy and child outcome data will be collected using direct contact. Qualitative studies will be carried out to understand the complex social factors and behavioural dimensions related to abortion, antenatal depression, maternal deaths and near misses. DISCUSSION: This is the first reported maternal cohort in Sri Lanka focusing on social determinants and mental health. As a country in stage four of obstetric transition, these findings will provide generalizable evidence on achieving SGD targets in low- and middle-income countries. The study will be conducted in a district with multi-cultural, multi-ethnic and diverse community characteristics; thus, will enable the evidence generated to be applied in many different contexts. The study also possesses the strength of using direct participant contact, data collection, measurement, examination and biochemical testing to minimise errors in routinely collected data. The RaPCo study will be able to generate evidence to strengthen policies to further reduce maternal deaths in the local, regional and global contexts particularly focusing on social factors and mental health, which are not optimally addressed in the global agenda.

An outbreak of leptospirosis with predominant cardiac involvement: a case series.

BACKGROUND: Severe leptospirosis is known to cause multi organ dysfunction including cardiac involvement. In the clinical setting with limited resources, high degree of suspicion is needed to diagnose cardiac involvement including myocarditis. Although myocarditis is not reported as a common complication due to lack of diagnostic facilities, there are evidence to support myocarditis is more prevalent in post mortem studies of patients died due to leptospirosis. We present a case series of severe leptospirosis with cardiac involvement observed during a period of one month at Colombo-North Teaching Hospital, Sri Lanka. CASE PRESENTATION: We report here five patients with severe leptospirosis complicated with cardiac involvement, admitted to a single medical ward, Colombo-North Teaching Hospital, Sri Lanka during a one-month period. Out of six suspected leptospirosis patients admitted during that period, five in a raw developed severe leptospirosis with cardiac involvement. In this case series, four patients were confirmed serologically or quantitative PCR and one patient had possible leptospirosis. All patients developed shock during their course of illness. Two patients developed rapid atrial fibrillation. One patient had dynamic T wave changes in ECG and the other two had sinus tachycardia. Two patients had evidence of myocarditis in 2D echocardiogram, whereas other two patients had nonspecific findings and one patient had normal 2D echocardiogram. All five patients had elevated cardiac troponin I titre and it was normalized with the recovery. All five patients developed acute kidney injury. Four patients needed inotropic/vasopressor support to maintain mean arterial pressure and one patient recovered from shock with fluid resuscitation. All patients were recovered from their illness and repeat 2D echocardiograms after recovery did not show residual complications. One patient had serologically proven dengue co-infection with leptospirosis. CONCLUSIONS: Myocarditis and cardiac involvement in leptospirosis may be overlooked due to non-specific clinical findings and co-existing multi-organ dysfunction. Atypical presentation of this case series may be due to micro-geographic variation and unusual outbreak of leptospirosis. Co-infection of dengue with leptospirosis should be considered in managing patients especially in endemic areas.

Suicidal ideation and intentional self-harm in pregnancy as a neglected agenda in maternal health; an experience from rural Sri Lanka.

BACKGROUND: Suicide only present the tip of the iceberg of maternal mental health issues. Only a fraction of pregnant women with suicidal ideation proceeds to intentional self-harm (ISH) and even a smaller proportion are fatal. The purpose of the present study was to determine the prevalence of depression, suicidal ideation (present and past) and history of ISH among pregnant mothers in rural Sri Lanka. METHODS: We have conducted a hospital based cross sectional study in the third largest hospital in Sri Lanka and an another tertiary care center. Pregnant women admitted to hospital at term were included as study participants. The Edinburgh Postpartum Depression Scale (EPDS), a self-administered questionnaire for demographic and clinical data and a data extraction sheet to get pregnancy related data from the pregnancy record was used. RESULTS: The study sample consisted of 475 pregnant women in their third trimester. For the tenth question of EPDS "the thought of harming myself has occurred to me during last seven days" was answered as "yes quite a lot" by four (0.8%), "yes sometimes" by eleven (2.3%) and hardly ever by 13 (2.7%). Two additional pregnant women reported that they had suicidal ideation during the early part of the current pregnancy period though they are not having it now. Four (0.8%) pregnant women reported having a history of ISH during the current pregnancy. History of ISH prior to this pregnancy was reported by eight women and five of them were reported to hospitals, while others were managed at home. Of the 475 pregnant females included in the study, 126 (26.5%) had an EPDS score more than nine, showing probable anxiety and depression. Pregnant women who had primary/post-primary or tertiary education compared to those who were in-between those two categories were at higher risk of high EPDS score with a OR of 1.94 (95% CI 1.1-3.3). Reported suicidal ideation prior to pregnancy was also associated with high EPDS with a OR of 6.4 (95% CI 2.3-17.5). CONCLUSIONS: Based on our data, we conservatively estimate around 500 pregnant women each year having suicidal ideation and, 130 ISH annually in Anuradhapura, which should be considered as a high priority for an urgent intervention.

Factors associated with anemia among Sri Lankan primary school children in rural North Central Province.

BACKGROUND: Despite interventions, childhood anemia is still a major public health problem in low and middle income countries. Purpose of the present study is to determine factors associated with anemia among rural primary school children in Sri Lanka, a country undergoing rapid socioeconomic changes. METHODS: Multi stage cluster sampling was used to select 100 rural schools in NCP and a maximum of 50 children aged 60-131 months were enrolled from each school. Self-administered questionnaires were sent to parents. Anthropometric measurements and blood samples were obtained by trained investigators. Blood reports were analyzed in a commercial laboratory with external quality control measures. RESULTS: Total of 4412 children were included in the analysis. A Multiple regression was performed for hemoglobin. Only 4.2% of the change in hemoglobin could be explained by the model. District (p > 0.001), age (p > 0.001), timing of warm treatment(p = 0.026) and BMI for age (p = 0.002) uniquely contributed 1.12%, 1.19%, 0.13% and 0.26% to change in hemoglobin level respectively whereas, sex, monthly family income and frequency of meat and green leaf consumption didn't contribute significantly. Peripheral blood film analyses were available for 146 anemic children. Blood film was reported as normal in 19.9% while evidence of iron deficiency (18.5%), early iron deficiency (32.5%) and thalassemia trait with iron deficiency (29.5%) were reported in the rest. Serum ferritin level was available for 417 children with hemoglobin less than 12 g/dl. Mean ferritin level was 63.7 microgram/l. Only 0.5% had depleted iron stores. A multiple regression was performed for serum ferritin and R2 was 0.123 (p < 0.001). Area under the curve for serum ferritin and anemia was 0.436. CONCLUSION: Anemia among rural primary school children in NCP cannot be well explained by routinely assessed socioeconomic characteristics which mainly provide clues to access for food. Commonly used anemia related investigations have low validity in detecting and explaining anemia in this population. Since behavioral factors have been shown to affect nutrition of younger children in Sri Lanka, studying weather behaviors are related to anemia in primary school children is important. Possible etiologies including but not limited to nutritional deficiencies need to be studied further.

Social capital and health during pregnancy; an in-depth exploration from rural Sri Lanka.

BACKGROUND: Dimensions of social capital relevant to health in pregnancy are sparsely described in the literature. This study explores dimensions of social capital and the mechanisms in which they could affect the health of rural Sri Lankan pregnant women. METHODS: An exploratory qualitative study of solicited diaries written by pregnant women on their social relationships, diary interviews and in-depth interviews with key informants was conducted. A framework approach for qualitative data analysis was used. RESULTS: Pregnant women (41), from eight different communities completed diaries and 38 post-diary interviews. Sixteen key informant interviews were conducted with public health midwives and senior community dwellers. We identified ten cognitive and five structural constructs of social capital relevant to health in pregnancy. Domestic and neighborhood cohesion were the most commonly expressed constructs. Social support was limited to support from close family, friends and public health midwives. A high density of structural social capital was observed in the micro-communities. Membership in local community groups was not common. Four different pathways by which social capital could influence health in pregnancy were identified. These include micro-level cognitive social capital by promoting mental wellbeing; micro-level structural social capital by reducing minor ailments in pregnancy; micro-level social support mechanisms promoting physical and mental wellbeing through psychosocial resources and health systems at each level providing focused maternal care. CONCLUSION: Current tools available may not contain the relevant constructs to capture the unique dimensions of social capital in pregnancy. Social capital can influence health during pregnancy, mainly through improved psychosocial resources generated by social cohesion in micro-communities and by the embedded neighborhood public health services.

The psychosocial burden of cutaneous leishmaniasis in rural Sri Lanka: A multi-method qualitative study.

Leishmaniasis is a tropical infectious disease affecting some of the world's most economically disadvantaged and resource-poor regions. Cutaneous leishmaniasis (CL) is the most common out of the three clinical types of Leishmaniasis. Since 1904 this disease has been endemic in Sri Lanka. CL is considered a disfiguring stigmatising disease with a higher psychosocial burden. However, there needs to be a more in-depth, holistic understanding of the psychosocial burden of this disease, both locally and internationally. An in-depth understanding of the disease burden beyond morbidity and mortality is required to provide people-centred care. We explored the psychosocial burden of CL in rural Sri Lanka using a complex multimethod qualitative approach with community engagement and involvement. Data collection included participant observation, an auto-ethnographic diary study by community researchers with post-diary interviews, and a Participant Experience Reflection Journal (PERJ) study with post-PERJ interviews with community members with CL. The thematic analysis revealed three major burden-related themes on perceptions and reflections on the disease: wound, treatment, and illness-experience related burden. Fear, disgust, body image concerns, and being subjected to negative societal reactions were wound-related. Treatment interfering with day-to-day life, pain, the time-consuming nature of the treatment, problems due to the ineffectiveness of the treatment, and the burden of attending a government hospital clinic were the treatment-related burdens. Anxiety/worry due to wrongly perceived disease severity and negative emotions due to the nature of the disease made the illness experience more burdensome. Addressing the multifaceted psychosocial burden is paramount to ensure healthcare seeking, treatment compliance, and disease control and prevention. We propose a people-centred healthcare model to understand the contextual nature of the disease and improve patient outcomes.

The stigma associated with cutaneous leishmaniasis (CL) and mucocutaneous leishmaniasis (MCL): A protocol for a systematic review.

Leishmaniasis is a neglected tropical disease with three main clinical types; cutaneous leishmaniasis (CL), mucocutaneous leishmaniasis (MCL), and visceral leishmaniasis (VL). CL and MCL are considered to be highly stigmatizing due to potentially disfiguring skin pathology. CL and MCL-associated stigma are reported across the world in different contexts assimilating different definitions and interpretations. Stigma affects people with CL, particularly in terms of quality of life, accessibility to treatment, and psycho-social well-being. However, evidence on CL- and MCL-associated stigma is dispersed and yet to be synthesized. This systematic review describes the types, measurements, and implications of the stigma associated with CL and MCL and identifies any preventive strategies/interventions adopted to address the condition. This study was developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement which is registered in the International Platform of Registered Systematic Review and Meta-analysis Protocols PROSPERO (ID- CRD42021274925). We will perform an electronic search in MEDLINE, Embase, Scopus, PubMed, EBSCO, Web of Science, Global Index Medicus, Trip, and Cochrane Library databases, and in Google Scholar, using a customized search string. Any article that discusses any type of CL- and/or MCL-associated stigma in English, Spanish and Portuguese will be included. Articles targeting veterinary studies, sandfly vector studies, laboratory-based research and trials, articles focusing only on visceral leishmaniasis, and articles on diagnostic or treatment methods for CL and MCL will be excluded. Screening for titles and abstracts and full articles and data extraction will be conducted by two investigators. The risk of bias will be assessed through specific tools for different study types. A narrative synthesis of evidence will then follow. This review will identify the knowledge gap in CL-associated stigma and will help plan future interventions.

Impact of COVID-19 pandemic on health service utilisation and household economy of pregnant and postpartum women: a cross-sectional study from rural Sri Lanka.

OBJECTIVES: This study aims to describe how household economies and health service utilisation of pregnant and postpartum women were affected during the pandemic. DESIGN: A cross-sectional study. SETTING: This study was conducted in the Anuradhapura district, Sri Lanka. PARTICIPANTS: The study participants were 1460 pregnant and postpartum women recruited for the Rajarata Pregnancy Cohort during the initial stage of the COVID-19 pandemic. PRIMARY AND SECONDARY OUTCOME MEASURES: Household economic (income, poverty, nutritional and health expenditures) and health service utilisation details during the COVID-19 pandemic were gathered through telephone interviews. Sociodemographic and economic data were obtained from the cohort baseline and analysed with descriptive and non-parametric analysis. RESULTS: Out of the 1460 women in the sample, 55.3% (n=807) were pregnant and 44.7% (n=653) were postpartum women. Of the total sample, 1172 (80.3%) women participated in the economic component. The monthly household income (median (IQR)=212.39 (159.29-265.49)) reduced (median (IQR)=159.29 (106.20-212.39)) in 50.5% (n=592) families during the pandemic (Z=-8.555, p<0.001). Only 10.3% (n=61) of affected families had received financial assistance from the government, which was only 46.4% of the affected income. The nutritional expenditure of pregnant women was reduced (Z=-2.023, p=0.043) by 6.7%. During the pandemic, 103 (8.8%) families with pregnant or postpartum women were pushed into poverty, and families who were pushed into poverty did not receive any financial assistance. The majority of women (n=1096, 83.3%) were satisfied with the free public health services provided by the public health midwife during the pandemic. CONCLUSION: During the early stages of the pandemic, healthcare utilisation of pregnant women was minimally affected. Even before the country's current economic crisis, the household economies of pregnant women in rural Sri Lanka were severely affected, pushing families into poverty due to the pandemic. The impact of COVID-19 and the aftermath on pregnant women will have many consequences if the policies and strategies are not revised to address this issue.

Out-of-Pocket Expenditure for Antenatal Care Amid Free Health Care Provision: Evidence From a Large Pregnancy Cohort in Rural Sri Lanka.

INTRODUCTION: Global evidence suggests that high out-of-pocket (OOP) expenditure negatively affects health service utilization and creates an economic burden on households during pregnancy. This study aimed to estimate the magnitude and associated factors of OOP expenditure for antenatal care (ANC) in a rural Sri Lankan setting by following up with a large pregnancy cohort (The Rajarata Pregnancy Cohort [RaPCo]) in Anuradhapura District, Sri Lanka. METHODS: Data were collected from July 2019 to May 2020. An interviewer-administered questionnaire was used to collect socioeconomic data and OOP expenditures in the first trimester. Self-administered questionnaires were used monthly to collect OOP expenditures in the second and third trimesters. In-depth financial information of 1,558 pregnant women was analyzed using descriptive statistics, nonparametric statistics, and a multiple linear regression model. RESULTS: The majority of participants used both government and private health facilities for ANC. The mean (standard deviation [SD]) OOP expenditure per ANC visit was US$4.18 (US$4.19), and the mean (SD) OOP expenditure for total ANC was US$57.74 (US$80.96). Pregnant women who used only free government health services also spent 28% and 14% of OOP expenditure on medicines and laboratory investigations. Household income (P<.001), household expenditure (P<.1), used health care mode (P<.05), maternal morbidities (P<.05), and the number of previous pregnancies (P<.1) were the statistically significant independent predictors of OOP expenditure. OOP expenditure per visit for ANC equals half of the daily household expenditure. CONCLUSION: Despite having freely available government health facilities, most pregnant women tend to use both government and private health facilities and incur higher OOP expenditure. Free government health care users also incur a direct medical OOP expenditure for medicines and laboratory investigations. Monthly household income, expenditure, used health care mode, maternal morbidities, and the number of previous pregnancies are independent predictors of OOP expenditure.

Stigma associated with cutaneous and mucocutaneous leishmaniasis: A systematic review.

BACKGROUND: Cutaneous (CL) and mucocutaneous leishmaniasis (MCL) are parasitic diseases caused by parasites of the genus leishmania leading to stigma caused by disfigurations. This study aimed to systematically review the dimensions, measurement methods, implications, and potential interventions done to reduce the CL- and MCL- associated stigma, synthesising the current evidence according to an accepted stigma framework. METHODS: This systematic review followed the PRISMA guidelines and was registered in PROSPERO (ID- CRD42021274925). The eligibility criteria included primary articles discussing stigma associated with CL and MCL published in English, Spanish, or Portuguese up to January 2023. An electronic search was conducted in Medline, Embase, Scopus, PubMed, EBSCO, Web of Science, Global Index Medicus, Trip, and Cochrane Library. The mixed methods appraisal tool (MMAT) was used for quality checking. A narrative synthesis was conducted to summarise the findings. RESULTS: A total of 16 studies were included. The studies report the cognitive, affective, and behavioural reactions associated with public stigma. Cognitive reactions included misbeliefs about the disease transmission and treatment, and death. Affective reactions encompass emotions like disgust and shame, often triggered by the presence of scars. Behavioural reactions included avoidance, discrimination, rejection, mockery, and disruptions of interpersonal relationships. The review also highlights self-stigma manifestations, including enacted, internalised, and felt stigma. Enacted stigma manifested as barriers to forming proper interpersonal relationships, avoidance, isolation, and perceiving CL lesions/scars as marks of shame. Felt stigma led to experiences of marginalisation, rejection, mockery, disruptions of interpersonal relationships, the anticipation of discrimination, fear of social stigmatisation, and facing disgust. Internalised stigma affected self-identity and caused psychological distress. CONCLUSIONS: There are various manifestations of stigma associated with CL and MCL. This review highlights the lack of knowledge on the structural stigma associated with CL, the lack of stigma interventions and the need for a unique stigma tool to measure stigma associated with CL and MCL.