Adaptation and validation of the Longer-term Unmet Needs after Stroke (LUNS) monitoring tool in Sri Lanka.

BACKGROUND: Globally, stroke is a leading cause of mortality and morbidity. Unmet needs are defined as expressed needs that are not fulfilled by services provided and are considered an important indicator of the adequacy and quality of stroke follow-up care. This study aimed to culturally adapt, modify, translate and validate, the Longer-term Unmet Needs after Stroke (LUNS) monitoring tool, to Sri Lanka. Currently, there is no validated tool in Sri Lanka to assess unmet needs among stroke survivors and unmet needs are not systematically assessed. METHODS: A phased approach followed to culturally adapt, translate, establish its factorial validity and evaluate the convergent and divergent validity, reliability, and overall acceptability. The process of culturally adapting the tool was carried out using two rounds of the modified Delphi technique. The modified tool was translated to Sinhala and pretested among 10 stroke survivors. A descriptive cross-sectional study was conducted among 119 stroke survivors to establish the factorial validity and convergent and discriminant validity using the GHQ-12 and Barthel Index. The Socio-demographic characteristics of the study participants are presented. Communalities were assessed for 21 items and 2 items were dropped. Factor structure was confirmed with varimax and oblique rotations. The correlation coefficient was calculated to assess convergent and divergent validity. Cronbach's alpha value was calculated to assess internal reliability. RESULTS: Following the modified Delphi technique, 5 items of LUNS tool were removed, and 5 items were modified. Three new items were added based on expert recommendation. One item related to driving also removed as it does not fit with the factor structure emerged. In establishing factorial validity 5 factors emerged from the exploratory factor analysis. In assessing the convergent and discriminant validity, test results revealed that both General Health Questionnaire-12 (GHQ-12) and Barthel Index significantly correlated as expected with unmet needs. The results of Cronbach's alpha showed that all the factors were moderately high confirming the reliability of the tool. CONCLUSIONS: The Sinhala version of the LUNS monitoring tool is a valid and reliable instrument to assess the unmet needs of stroke survivors. Assessment of unmet needs will add new insight into evaluation of the quantity, quality, and effectiveness of healthcare interventions received by stroke survivors in Sri Lanka.

Evolution of the joint International Atomic Energy Agency (IAEA), International Agency for Research on Cancer (IARC), and WHO cancer control assessments (imPACT Reviews).

Before 2005, cancer and other non-communicable diseases were not yet health and development agenda priorities. Since the 2005 World Health Assembly Resolution, which encouraged WHO, the International Agency for Research on Cancer (IARC), and the International Atomic Energy Agency (IAEA) to jointly work on cancer control, progress was achieved in low-income and middle-income countries on a small scale. Recently, rapid acceleration in UN collaboration and global cancer activities has focused attention in global cancer control. This Policy Review presents the evolution of the IAEA, IARC, and WHO joint advisory service to help countries assess needs and capacities throughout the comprehensive cancer control continuum. We also highlight examples per country, showcasing a snapshot of global good practices to foster an exchange of experiences for continuous improvement in the integrated mission of Programme of Action for Cancer Therapy (imPACT) reviews and follow-up support. The future success of progress in cancer control lies in the high-level political and financial commitments. Linking the improvement of cancer services to the strengthening of health systems after the COVID-19 pandemic will also ensure ongoing advances in the delivery of care across the cancer control continuum.

Coverage and equity of essential care services among stroke survivors in the Western Province of Sri Lanka: a community-based cross-sectional study.

BACKGROUND: Stroke survivors require continuing services to limit disability. This study assessed the coverage and equity of essential care services received during the first six months of post-stroke follow-up of stroke survivors in the Western Province of Sri Lanka. METHODS: A multidisciplinary team defined the essential post-stoke follow-up care services and agreed on a system to categorize the coverage of services as adequate or inadequate among those who were identified as needing the said service. We recruited 502 survivors of first ever stroke of any type, from 11 specialist hospitals upon discharge. Six months following discharge, trained interviewers visited their homes and assessed the coverage of essential services using a structured questionnaire. RESULTS: Forty-nine essential post-stroke follow-up care services were identified and categorized into six domains: monitoring of risk conditions, treatment, services to limit disabilities, services to prevent complications, lifestyle modification and supportive services. Of the recruited 502 stroke survivors, 363 (72.3%) were traced at the end of 6 months. Coverage of antiplatelet therapy was the highest (97.2% (n = 289, 95% CI 95.3- 99.1)) while referral to mental health services (3.3%, n = 12, 95% CI 1.4-5.1) and training on employment for the previously employed (2.2%, n = 4, 95% CI- 0.08-4.32), were the lowest among the six domains of care. In the sample, 59.8% (95% CI 54.76-64.48) had received an 'adequate' level of essential care services related to treatment while none received an 'adequate' level of services in the category of support services. Disaggregated service coverage by presence and type of limb paralysis within the domain of services to prevent complications, and by sex and education level within the domain of education level, show statistically significant differences (p < 0.05). CONCLUSIONS: Apart from treatment services to limit disabilities, coverage of essential care services during the post-stroke period was inadequate. There were no apparent inequities in the coverage of vast majority of services. However focused policy decisions are required to address these gaps in services.

Development and validation of a set of patient reported outcome measures to assess effectiveness of asthma prophylaxis.

BACKGROUND: In the local setting, asthma control is assessed by symptoms and signs elicited by clinicians because of the limited availability of spirometry. Hence, we intended to develop a patient reported outcome measure (PROM) with more holistic interpretation that could also serve as a tool to measure the asthma control in resource limited settings. Therefore, this study was carried out in Northern Sri Lanka to develop and validate the Asthma Control PROM (AC-PROM) Tamil to measure the effectiveness of asthma prophylaxis based on symptoms, exacerbation and limitation of activity which could also serve as an easy measure of asthma control to the provider. METHODS: The AC-PROM Tamil was developed in 3 steps: item generation, item reduction and psychometric evaluation. Items were generated through thematic analysis from focus group discussions among patients with asthma. Items were converted to an interviewer administered questionnaire in Tamil in the format of 5-point Likert scale. Item reduction was done by two rounds of online Delphi surveys among 10 experts and an exploratory factor analysis among 200 patients with asthma. The face and content validity were assessed by a panel of experts during Delphi survey and patients during the pre-test of the tool. Criterion validity of the tool was assessed against the forced expiratory volume in one second of 187 patients with asthma. The cut-off value to assess the asthma control was determined by receiver operating characteristic curve. Reliability was verified by Cronbach's alpha coefficient. RESULTS: From thematic analysis of focus group discussions 10 items were generated. One item was removed during Delphi survey. Exploratory factor analysis indicated removal of another item with 8 items categorised into two factors. Cronbach's alpha coefficient of factors 1 and 2 were 0.821 and 0.903 respectively, indicating good reliability. Observations made by experts and responses made by patients were incorporated to improve the clarity and relevance of the items. Criterion validity was demonstrated by significant correlation between the AC-PROM Tamil and forced expiratory volume in one second (r = 0.66, p = 0.001). The cut-off value of the AC-PROM Tamil to detect asthma control was 28.5 with 79% (95% CI 71.3-86.9) sensitivity and 71% (95% CI 61.9-79.6) specificity. The AC-PROM Tamil showed moderate accuracy (the area under the receiver operating characteristic curve = 0.796; 95% CI 0.73-0.86). Response rate of the AC-PROM Tamil was 100% and time taken to complete was 3-4 min. CONCLUSION: The AC-PROM Tamil is a simple, feasible and reasonably accurate tool to assesses the effectiveness of asthma prophylaxis, particularly in resource limited settings.

Health related quality of life in chronic kidney disease; a descriptive study in a rural Sri Lankan community affected by chronic kidney disease.

INTRODUCTION: The current epidemic of chronic kidney disease (CKD) in Sri Lanka is ascribed to the exponential increase in the number of CKD patients, which cannot be attributed to any known etiology (CKDu). The aim of this study is to describe the health related quality of life (HRQOL) and the associated factors among CKD/CKDu patients in a rural district in Sri Lanka. METHODS: A community based cross-sectional study included 1174 CKD/CKDu patients. Kidney Disease Quality of Life-Short Form was used to assess the HRQOL, while Centre for Epidemiologic Studies Depression Scale, General Health Questionnaire (GHQ) 12 and CKD Symptom Index - Sri Lanka were used to assess presence of depression, psychological distress and symptom burden respectively. Three summary scores; kidney disease (KDSC), physical (PCS) and mental (MCS) are derived from Kidney Disease Quality of Life-Short Form (KDQOL-SF™). RESULTS: Mean age of the study population was 58.3 years (standard deviation (SD) 10.7). Median KDSC (58.4; inter-quartile range (IQR) 54.2-63.4), was higher than the median scores of PCS (35.0; IQR 26.2-41.9) and MCS (58.4; IQR 54.2-63.4). Multiple linear regression revealed low income, advanced stages of CKD, symptom burden, being positive for depression and psychological distress were significantly associated with low HRQOL. CONCLUSION: The HRQOL of the CKD patients in this rural Sri Lankan population was found to be poor. Superior socio-economic status, less physical and psychological symptom burden were found to be independently associated with better HRQOL. Periodical screening of the CKD patients for depression and psychological distress and measures to alleviate symptom burden seem to be important to improve the HRQOL of these patients.

Serious non-fatal unintentional injuries among in-school adolescents in Sri Lanka: results from the 2016 Sri Lankan global school-based health survey.

BACKGROUND: Unintentional injuries among adolescents is a major public health problem the world over. A great majority of the annual deaths among adolescents is due to unintentional injuries; it is also the leading cause of death among adolescents in the world. The aim of this study was to estimate the incidence of injuries and their associated factors among school going adolescents aged 13-17 years using data from the most recent Global School-Based Health Survey (GSHS) conducted in Sri Lanka. METHODS: A cross-sectional survey was conducted using a self-administered questionnaire, among 3262 adolescents attending government schools. The sample was selected through a two-staged cluster sampling technique. In the first stage, 40 schools were selected using probabilities proportional to school enrollment size, from all schools in the country that have classes in grades 8-12. Then, from the selected schools, classes were selected using systematic equal probability sampling with a random start. The weighted prevalence was calculated, and logistic regression analysis was conducted in order to determine the correlates. RESULTS: During the 12 months before the survey, 35.8% (95% CI-30.7 - 41.1) of the students reported being seriously injured one or more times. The injuries were more common among males, but were equally common among the two different age groups (13-15 age group vs 16-17 age group). The most common type of injury was cut or stab wounds (5.5%), followed by broken bones/dislocated joints (5.3%). Multivariable analysis revealed that only a few factors were associated with injury, such as being of the male sex, being bullied, being physically attacked, and/or being in a physical fight. CONCLUSION: This study demonstrated that the prevalence of serious unintentional injuries among school going adolescents is a major public health problem in Sri Lanka. This timely and comprehensive survey would help policy makers and researchers identify the unmet needs related to adolescent injuries. Furthermore, evidence generated form the study should be given due consideration when designing school-based interventions to prevent adolescent injuries.

Correction to: The effect of youths as change agents on cardiovascular disease risk factors among adult neighbours: a cluster randomised controlled trial in Sri Lanka.

It was highlighted that in the original article [1] the selection process was not described clearly enough to avoid confusion under the heading of the Target of Outcomes in the Methods section.

The effect of youths as change agents on cardiovascular disease risk factors among adult neighbours: a cluster randomised controlled trial in Sri Lanka.

BACKGROUND: Mobilising non-professional health workers has been successful in improving community health, but the effectiveness of an education program targeting youths in a community-based approach remains unclear. The objective of this study was to investigate the effect of an intervention with youth on cardiovascular disease risk factors of community adults. METHODS: A 12-month cluster randomised trial was conducted in a semi-urban area of Colombo in Sri Lanka. Facilitators trained youth club members aged 15-29 years to assess cardiovascular disease risk factors and take actions in the community to address relevant issues. The control group received no intervention. Body weight and blood pressure as primary outcomes and lifestyle of adults as secondary outcomes were measured pre- and post-intervention. Multilevel linear and logistic regressions were used to assess the effects of the intervention on changes in continuous and binary outcomes, respectively, from baseline to endpoint. RESULTS: Of 512 participants at baseline, 483 completed the final assessment after the intervention. Regarding primary outcomes, the intervention group showed a significantly greater decrease in body weight after intervention than the control group. The mean (95% confidence interval) difference of body weight change for intervention versus control group was - 2.83 kg (- 3.31, - 2.35). There was no statistically significant difference in blood pressure between the two groups. Turning to the secondary outcomes, in diet, the intervention group had a higher probability of consuming at least one serving/day of fruits (p = 0.02) and a lower probability of consuming snacks twice/day or more (p < 0.001) than the control group. CONCLUSIONS: An intervention employing youths as change agents was effective in lowering body weight among community adults in Sri Lanka. TRIAL REGISTRATION: Trial registration number: SLCTR/2017/002 , Name of registry: Sri Lanka Clinical Trials Registry, Date of registration: 19th January 2017, Date of enrolment of the first participant to the trial: 1st February 2017.

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.

"Appropriateness of colonoscopy according to EPAGE II in a low resource setting: a cross sectional study from Sri Lanka".

BACKGROUND: Due to finite resources, the clinical decision to subject a patient to colonoscopy needs to be based on the evidence, regardless of its availability, affordability and safety. This study assessed the appropriateness of colonoscopies conducted in selected study settings in Sri Lanka. In the absence of local guidelines, audit was based on European Panel on Appropriateness of Gastrointestinal Endoscopy II (EPAGE II) criteria. METHODS: This cross-sectional study assessed consecutive patients who underwent colonoscopy between June to August 2015 at four main hospitals in Sri Lanka. Interviewer administered questionnaire and secondary data were collected by trained health staff. Indications were assessed according to EPAGE II criteria. RESULTS: Out of 325 patients, male female proportions were 57.2 and 42.8%. Mean (SD) age was 54.9 (12.1) years. Colonoscopies were appropriate in 61.2% (95% CI 55.8-66.3), uncertain in 28.6% (95% CI 23.9-33.7) and inappropriate in 10.2% (95% CI 7.3-13.9). Colonoscopy to evaluate abdominal pain has highest percentage of inappropriateness of 10.0%. However, 9.5% of these colonoscopies revealed Colo-Rectal Cancer (CRC), reflecting differences in the profile of local CRC patients. Colonoscopies with appropriate or uncertain indications are three times more likely to have a relevant finding than inappropriate indications (42.5% vs. 18.2%; OR 3.32, 95% CI 1.33-8.3; P = 0.008). CONCLUSIONS: Majority of colonoscopies are appropriate. However, it cannot be neglected that every one in ten patients undergo inappropriate colonoscopy. Proportion of inappropriateness was highest for the indication of chronic abdominal pain, of which, 9.5% of patients were diagnosed with CRC. This may reflect the different profile of local CRC patients in terms of symptom manifestation and other characteristics. In conclusion, the authors recommend formulation of national guidelines for colonoscopy indications based on current best evidence and local patient profile. Use of such prepared local guidelines will improve the efficient use of finite resources.

Prevalence and associated factors of wheezing illnesses of children aged three to five years living in under-served settlements of the Colombo Municipal Council in Sri Lanka: a cross-sectional study.

BACKGROUND: A rising trend in Sri Lanka for asthma and wheezing illness is observed with higher morbidity in younger children and a paucity of related research. 'Under-served settlements' (USS) of Colombo Municipal Council (CMC) have poor living environments conducive to childhood wheezing. The objective was to describe the prevalence and associated factors of wheezing illnesses of three to five year old children living in low-income settlements in CMC. METHODS: A cross-sectional study was conducted on 460 three to five year old children and their caregivers using cluster sampling among residents of two randomly selected USSs of CMC. An interviewer-administered questionnaire, observation checklist and data extraction form were used in data collection. A physician's diagnosis of wheezing/whistling of the chest in their lifetime and a physician's diagnosis of wheezing/whistling within the past twelve months were considered as 'ever-wheezing illness' and 'current-wheezing illness' respectively. RESULTS: Mean age was 3.98 years (SD = ±0.64 years). A majority were males (51.3%) and Tamils (39.8%). Prevalence of 'ever wheezing illness' and 'current wheezing illness' were 38% (95% confidence interval (CI); 33.6%-42.5%) and 21.3% (95%CI; 17.6%-25.0%), respectively. Maternal (p < 0.001) and paternal (p < 0.001) histories of wheezing, playing with soft toys in the sleeping area (p = 0.004), place of cooking combined with the living area (p = 0.03), unsatisfactory ventilation in the sleeping area (p < 0.001) were found to be significantly associated with increased 'current wheezing' through multivariate analysis in this study. Use of formula milk before six months of age (p = 0.014) was found to be protective through multivariate analysis. CONCLUSIONS: The magnitude of wheezing illnesses among three to five year old children residing in urban low-income settlements was found to be high. Children with a history of maternal and/or paternal wheezing should be targeted for early interventions to prevent wheezing illnesses. Interventions to avoid exacerbations should focus on the indoor environmental factors that were found to be associated with wheezing illnesses.

Validity and reliability of the Sri Lankan version of the kidney disease quality of life questionnaire (KDQOL-SF™).

BACKGROUND: The disabling symptoms, various food and fluid restrictions, restrictions to social life and stigma and taboos attached to Chronic Kidney Disease (CKD), have shown to pose a significant bearing on a patient's Quality of Life (QOL). In the present study the Kidney Disease QOL-Short Form (KDQOL-SF™) was culturally adapted, modified and translated into Sinhala and validity and reliability were assessed. METHOD: The process to culturally adapt the Kidney Disease Specific Component (KDSC) of KDQOL-SF™ was carried out by the modified Delphi process with a group of experts. The construct validity of the KDSC was assessed using Exploratory Factor Analysis (EFA). Appraising construct validity of SF-36 component of KDQOL-SF™ was done by assessing the convergent and discriminant validity using the Multitrait-Multimethod Matrix technique (MTMM). Randomly selected 250 CKD patients attending the five renal clinics in Polonnauwa were used to assess the construct validity. To assess the test-retest reliability of the instrument, within a period of one week, 30 randomly selected study participants were visited at their households. RESULTS: Two hundred and fifty adults with documented evidence of CKD participated. The EFA carried out using principal component factoring method and rotated by Varimax orthogonal method resulted in 14 factors with Eigen values ranging from 1.062-8.746. This 14 factor model explained 84.1% of total variance of the initial system. The communalities extracted for domains were all close to one. All the items were loaded to one or more domains with factor coefficients of more than 0.4, not requiring any of the items to be dropped. Few items which showed similarly high factor coefficients in more than one factor were assigned to a factor ensuring the pattern in the theoretical framework of the questionnaire based on expert opinion and vigorous analysis of literature. Convergent and divergent validity assessed using MTMM, revealed satisfactory construct validity. Cronbach's alpha of all domains of KDQOL-SF™ except for cognitive function and Social function, exceeded Nunnally's criteria of 0.7. The Intra class Correlation Coefficients (ICC) were more than 0.8 for all the domains, which indicated good test re-test reliability. CONCLUSIONS: KDQOL-SF™ is a valid and reliable instrument which can be used to assess QOL of CKD patients in Sri Lanka.

Symptom burden in chronic kidney disease; a population based cross sectional study.

BACKGROUND: Physical and psychological symptoms are among main manifestations of Chronic Kidney Disease (CKD). This study aimed to assess the symptom burden and self-perceived severity of symptoms among CKD patients living in a district in Sri Lanka. METHOD: A community based cross-sectional study included a sample of randomly selected 1174 CKD patients from all 19 Medical Officer of Health areas in the district of Anuradhapura. Trained para-medical staff visited the households and administered the locally validated questionnaire to assess the presence and severity of symptoms. The inquiry was on 25 symptoms in a 5 point Likert scale indicating the severity during the previous week. Symptom burden score was constructed by summing each symptom severity score which ranged from 0 to 125. RESULTS: A total of 1118 CKD patients participated with a response rate of 95.2%. The mean age was 58.3 (SD 10.8) years and 62.7% were males. A majority were in CKD stage 4 (58.3%). Bone/joint pain was the most experienced symptom (87.6%; 95%CI 85.6-89.5). Loss of libido was the most severe symptom. The median symptom burden score was 35.0 (IQR 20.0-50.0). Multiple linear regression revealed education up to Advanced Level (ß -9.176), CKD stage V (ß 3.373), being dialyzed (ß 20.944), comorbidities (ß 4.241) and being employed (ß -9.176) to be significant predictors of symptom burden. CONCLUSIONS: Patients in all stages of CKD experience high symptom burden warranting rigorous measures to relieve symptoms and to improve the well-being of CKD patients.

Level of health literacy and factors associated with it among school teachers in an education zone in Colombo, Sri Lanka.

BACKGROUND: Health literacy refers to people's competencies to access, understand, judge and apply health information in healthcare, disease prevention and health promotion. This study aimed to describe the level of health literacy and the factors associated with it among school teachers in an Education Zone in Colombo, Sri Lanka. METHODS: A cross-sectional study among 520 teachers measured health literacy using the selfadministered, culturally adapted Sinhalese translation of Health Literacy Survey-European Union (HLS-EU). Health literacy assessment was based on self-reported competencies to access, understand, judge and apply health information in the domains of disease prevention, healthcare and health promotion. Based on a score, respondents were divided into four levels of health literacy as 'inadequate', 'problematic', 'sufficient' and 'excellent' as well as into two levels as 'limited' and 'adequate'. Factors associated with 'limited' health literacy was determined by using univariate analysis and assessing their associations using chi square test. Multivariate analysis was also done using multiple logistic regression to determine factors associated with limited health literacy controlled for confounding effects. A p value of 0.05 determined the significance. RESULTS: The response rate was 96.5%. Mean age was 43years (SD = +9.75), 81.7% (n = 410) were females and 66.1% (n = 332) were graduates. Only 3.6% (n = 18) taught the subject health while 18.3% (n = 92) taught science. 'Limited' health literacy was found in 32.5% (95% CI 28.4%-36.6%) while 67.5% (95% CI 63.4%-71.6%), 61.2% (95% CI 56.9%-65.5%) and 6.4% (95% CI 4.3%-8.5%) showed 'adequate', 'sufficient' and 'excellent' levels, respectively. 'Problematic' and 'inadequate' health literacy were 31.5% (95% CI 27.4%-35.6%) and 1% (95% CI 0.1%-1.9%). Univariate analysis showed not being a member of health club/welfare group (p = 0.002), having not done any special course on health (p = 0.009), not getting an opportunity to participate/being exposed to a health awareness program (p = 0.007), visit to a medical practitioner/preventive health staff for six months (p = 0.049), not accessing print media to obtain general information (p = 0.007) and not accessing print media to obtain health information for six months (p = 0.009) and poor health knowledge (p = 0.036) to be factors associated with 'limited' health literacy that are modifiable. Nonmodifiable factors were age being ≤ 45 years (p = 0.025) and service as a teacher being ≤ 10 years (p = 0.012). When multivariate analysis was performed, service as a teacher being ≤ 10 years (p = 0.042), monthly income ≤ Rs.50,000.00 (p = 0.024), not being a member of health club/welfare group (p = 0.034) and visit to a medical practitioner/preventive health staff for six months (p = 0.002), were found to be associated with limited health literacy among school teachers when adjusted to the effect of confounding of the other factors in the model. CONCLUSIONS: The high proportions of 'limited' health literacy among school teachers in the Colombo Education Zone and the need of interventional programmes should be brought to the attention of the policy makers in the education and health sectors. Improving health literacy among teachers and adoption of the Health Promoting School concept as a evidence based path to improve health literacy should be highlighted in the advocacy efforts. Identified factors associated with 'limited' health literacy should be taken into in the interventional efforts.

School-based intervention to enable school children to act as change agents on weight, physical activity and diet of their mothers: a cluster randomized controlled trial.

BACKGROUND: School health promotion has been shown to improve the lifestyle of students, but it remains unclear whether school-based programs can influence family health. We developed an innovative program that enables school children to act as change agents in promoting healthy lifestyles of their mothers. The objective of this study was to examine the effect of the child-initiated intervention on weight, physical activity and dietary habit of their mothers. METHODS: A 12-month cluster randomized trial was conducted, with school as a cluster. Participants were mothers with grade 8 students, aged around 13 years, of 20 schools in Homagama, Sri Lanka. Students of the intervention group were trained by facilitators to acquire the ability to assess noncommunicable disease risk factors in their homes and take action to address them, whereas those of the comparison group received no intervention. Body weight, step count and lifestyle of their mothers were assessed at baseline and post-intervention. Multi-level multivariable linear regression and logistic regression were used to assess the effects of intervention on continuous and binary outcomes, respectively. RESULTS: Of 308 study participants, 261 completed the final assessment at 12 month. There was a significantly greater decrease of weight and increase of physical activity in the intervention group. The mean (95% confidence interval) difference comparing the intervention group with the control group was -2.49 (-3.38 to -1.60) kg for weight and -0.99 (-1.40 to -0.58) kg/m(2) for body mass index. The intervention group had a 3.25 (95% confidence interval 1.87-5.62) times higher odds of engaging in adequate physical activity than the control group, and the former showed a greater number of steps than the latter after intervention. The intervention group showed a greater reduction of household purchase of biscuits and ice cream. CONCLUSIONS: A program to motivate students to act as change agents of family's lifestyle was effective in decreasing weight and increasing physical activity of their mothers. TRIAL REGISTRATION: Sri Lanka Clinical Trials Registry SLCTR/2013/011 .

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.

Knowledge and self-reported practices regarding leptospirosis among adolescent school children in a highly endemic rural area in Sri Lanka.

INTRODUCTION: Leptospirosis is a zoonotic disease, which has become a major public health threat in Sri Lanka. A majority of patients are farmers in rural endemic areas. The purpose of the present study is to describe the level of knowledge and frequencies of risky practices related to leptospirosis among a sample of rural school adolescents in Galgamuwa, Kurunegala district, a highly endemic area in Sri Lanka. METHODS: A descriptive cross-sectional study was conducted among 460 adolescents studying in grades 9 and 10 of government schools. Study participants were selected using a multistage cluster sampling technique. A structured, pretested, self-administered questionnaire was used to collect data on sociodemographic characteristics, knowledge on leptospirosis, and frequency of associated risky practices related to leptospirosis. RESULTS: The response rate was 100%. Fifty-two percent of respondents had a 'good' level of knowledge of leptospirosis. In the assessment of practices, 62% were involved in rice paddy cultivation either 'frequently' or 'rarely'. Seventy percent of the fathers and 50% of the mothers of the students were involved in paddy cultivation. Thirteen percent reported that they swam, bathed, or washed in ponds of stagnant water. Of the students involved in paddy cultivation, only 18% said they usually used gloves and boots 'frequently'. Among the 9% of students who handled cattle or buffalo, 61% reported washing their hands and feet after handling the animals. Good level of knowledge was significantly associated with involvement in paddy cultivation among the adolescents (p=0.45), fathers (p<0.001), and mothers (p=0.012). The level of knowledge was not significantly associated with practicing preventive measures for leptospirosis. CONCLUSIONS: Although the respondent's overall level of knowledge regarding leptospirosis was satisfactory, the study identified several important gaps in specific areas. Those who were involved or had parents involved in paddy cultivation had better knowledge. However, this knowledge was not translated into practice of personal preventive measures. Use of protective attire in paddy farming needs to be facilitated by health authorities.

Low- Versus High-dose Cyclophosphamide in Class III/IV Lupus Nephritis: A Retrospective Study from South Asia.

Introduction: The comparative efficacy of low-dose cyclophosphamide (LD-CYC) and high-dose cyclophosphamide (HD-CYC) for treatment of lupus in South Asians is not well established. We aimed to compare treatment outcomes in South Asian patients with class III and IV lupus nephritis treated with either regimen. Method: This was a single-center, retrospective study conducted in Sri Lanka. Patients with biopsy-proven class III or IV lupus nephritis were recruited. The HD-CYC group was defined as having received ≥6 doses of 0.5-1 g/m2 cyclophosphamide (CYC) followed by quarterly doses. The LD-CYC group was defined as having received six doses of 500 mg CYC at two-weekly intervals. The primary outcome was treatment failure defined as persistent nephrotic range proteinuria or renal impairment at 6 months. Results: Sixty-seven patients were recruited (HD-CYC 34, LD-CYC 33), all South Asian ethnicity. The HD-CYC group had received treatment between 2000 and 2013, and the LD-CYC group from 2013 onward. The HD-CYC and LD-CYC groups had 30/33 (90.9%) and 31/34 (91.2%) females, respectively. Nephrotic syndrome and nephrotic range proteinuria on presentation were seen in 22/33 (67%) and 20/32 (62%) in the HD-CYC and LD-CYC groups, respectively, and renal impairment was seen in 5/33 (15%) of the HD-CYC group and 7/32 (22%) of the LD-CYC group (P > 0.05). Treatment failure and complete or partial remission occurred in 7/34 (21%) and 28/34 (82%), respectively, of HD-CYC and 10/33 (30%) and 24/33 (73%), respectively, of LD-CYC (P > 0.05). Adverse events rates were similar. Conclusion: This study suggests that LD-CYC and HD-CYC induction is comparable in South Asian patients with class III and IV lupus nephritis.

Students' perception of school environment and life satisfaction at Sinhala-medium secondary schools in the Colombo District, Sri Lanka.

The objective of this study was to examine the associations between students' perception of physical and psychosocial school environment and satisfaction with life among secondary school students in Colombo District, Sri Lanka. Data were collected from 20 Sinhala-medium secondary schools between January and February in 2010. A questionnaire-based survey was conducted with students in grade seven (n = 342) and grade ten (n = 446). Multivariate logistic regression analysis, adjusted for confounding variables, was used to assess the associations between students'satisfaction with life measured by Cantril ladders, and scores of perceived physical and psychosocial school environment that focused on school cleanliness and attractiveness, relations with teachers and peers, satisfaction with school and bullying. Students in the highest quartile of school environment score were significantly more likely to have high life satisfaction, compared to those in the lowest quartile (adjusted odds ratio 2.32; 95% confidence interval 1.35-3.99). Odds ratio of high life satisfaction increased with increasing school environment scores (p for trend<0.001). In conclusion, students who perceived positive school environment were significantly more likely to have high life satisfaction. Positive changes in the focused areas of school environment have the potential to lead to improved life satisfaction of students.

A systematic review and meta-analysis of the effectiveness of individual-level interventions to reduce occupational stress perceptions among teachers.

Teachers are largely affected by OS, during their most productive years, leading to catastrophic physical, psychological, and economic burden on themselves, families and society by large. Teachers are responsible for producing the workforce of any nation, and thus have a major impact indirectly on the economy and health of a nation. There are several individual-level interventions conducted to reduce occupational stress (OS) among teachers. This study was conducted to systematically review and conduct a meta-analysis of the effectiveness of individual-level interventions to reduce occupational stress among teachers. This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO; Registration ID: CRD42020149277) and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Scopus, Cochrane, PsycInfo, and Web of Science databases were searched using predefined search strategies covering the eligibility criteria. Studies were selected in four rounds. Risk of bias assessments were conducted with GRADE recommendations and ROBINS-I criteria for randomized and non-randomized interventions, respectively. Study selection, data extraction and bias assessments were performed independ ently by two reviewers with a third reviewer to resolve conflicts. Narrative synthesis of the findings were also performed. Clinical, methodological, and statistical heterogeneity assessments were conduct ed. Meta-analyses were performed with Review Manager 5.3 software using the "generic inverse variance method" with mean difference as the pooled estimate. Sensitivity analyses of the findings was also performed. At the initial search, 293 articles were identified and 29 subsequently selected for synthesis of findings. The findings of the meta-analysis indicated that Cognitive Behavioral Therapy (CBT) and relaxation interventions significantly reduced OS among teachers with an effect size of 6.2 (p < 0.001). Effect size was highest for combined CBT and relaxation interventions which was 6.57 (p < 0.001). Relaxation interventions only and CBT interventions only had effect sizes of 3.35 (p < 0.001) and 3.12 (p = 0.002) respectively. In sensitivity analysis, after removing low-quality studies, CBT interventions only, combined CBT and relaxation interventions and overall effect size were 6.31 (p < 0.00001), 17.36 (p < 0.00001), and 14.55 (p < 0.00001), respectively, ie, substantially greater than with low-quality studies included. Inconclusion, CBT and relaxation interventions reduce OS among teachers and it's most effective when those individual-level interventions are conducted together.