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.

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.

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.

Prediction of colorectal cancer risk among adults in a lower middle-income country.

BACKGROUND: Globally, colorectal cancer (CRC) is ranked as the third most common cancer in men and the second in women. Use of a simple, validated risk prediction tool will offer a low-cost mechanism to identify the high-risk individuals for CRC. This will increase efficient use of limited resources and early identification of patients. The aim of our study was to develop and validate a risk prediction model for developing CRC for Sri Lankan adults. METHODS: The risk predictors were based on the risk factors identified through a logistic regression model along with expert opinion. A case control design utilizing 65 CRC new cases and 65 hospital controls aged 30 years or more was used to assess the criterion validity and reliability of the model. The information was obtained using an interviewer administered questionnaire based on the risk prediction model. RESULTS: The developed model consisted of eight predictors with an area under the curve (AUC) of 0.849 (95% CI: 0.8 to 0.9, P<0.001). It has a sensitivity of 76.9%, specificity of 83.1%, positive predictive value (PPV) of 82.0%, negative predictive value (NPV) of 79.3%. Positive and negative likelihood ratios are 4.6 and 0.3. Test re-test reliability revealed a Kappa coefficient of 0.88. CONCLUSIONS: The model developed to predict the risk of CRC among adults aged 30 years and above was proven to be valid and reliable and it is an effective tool to be used as the first step to identify the high-risk population who should be referred for colonoscopy examination.

Prevalence and Correlates of Interpersonal Violence Among In-School Adolescents in Sri Lanka: Results From the 2016 Sri Lankan Global School-Based Health Survey.

Interpersonal violence among adolescents is an issue of global public health concern, leading to adverse physical and psychological outcomes among children and young people under the age of 18 years. This article discusses the prevalence of interpersonal violence and identifies their associated factors among school-going adolescents of ages 13 to 17 years using the data from the Sri Lankan Global School-Based Health Survey conducted in 2016. Of the 3262 students who participated, 35.1% (95% confidence interval = 31.0% to 39.5%) were physically attacked and 44.2% (95% confidence interval = 39.2% to 49.4%) were in a fight with peers, one or more times during the 12 months prior to the survey. Being bullied by peers, male sex, 13 to 15 years age group, smoking and alcohol use, considering or attempting suicide, missing classes without permission, and parents not being aware of students' activities were associated with violence. The study highlights the need for violence prevention programs to address the risk factors among school-going adolescents.

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.

Passive smoking: knowledge, exposure and responses among adolescents in a rural setting in Sri Lanka.

BACKGROUND: Passive smoking adversely affects the health of those exposed to it. Exposure to passive smoking among adolescents is also associated with early initiation to smoking. OBJECTIVE: This study aimed at determining the knowledge, exposure and response to passive smoking among adolescents in a rural setting in Sri Lanka. SUBJECT: Adolescents studying in grade 10 in seven rural schools in Polonnaruwa district. METHODS: A cross-sectional study, using a self-administered questionnaire, was conducted among 498 adolescents selected proportionate to the size of the student population using a multi-stage cluster sampling method. RESULTS: The response rate was 99.6% (498/500). Only 69.3%, (n=345) had heard of the term passive smoking. Of those who had heard of the term, 83.2%, (n=287) was accurate about what the term meant. Only 2.4% (n=12) of the study population was categorized as having a good level of knowledge on passive smoking. Self reported exposure levels to passive smoking was low among a majority (81%, n=406). On inquiring how they had reacted or will react to a situation of exposure to passive smoking, a majority (92.2%, n=459) indicated that they had/will rescind from the situation. CONCLUSION: The level of knowledge on passive smoking was poor among the adolescents in the rural setting in Sri Lanka. Despite the low level of exposure, the adolescents indicated that they were/will be assertive when faced with a situation of exposure to passive smoking. The study recommends that knowledge of adolescents on passive smoking be improved.

Women's autonomy in decision making for health care in South Asia.

This article aims to discuss women's autonomy in decision making on health care, and its determinants in 3 South Asian countries, using nationally representative surveys. Women's participation either alone or jointly in household decisions on their own health care was considered as an indicator of women's autonomy in decision making. The results revealed that decisions of women's health care were made without their participation in the majority of Nepal (72.7%) and approximately half of Bangladesh (54.3%) and Indian (48.5%) households. In Sri Lanka, decision making for contraceptive use was a collective responsibility in the majority (79.7%). Women's participation in decision making significantly increased with age, education, and number of children. Women who were employed and earned cash had a stronger say in household decision making than women who did not work or worked not for cash. Rural and poor women were less likely to be involved in decision making than urban or rich women.

Functional outcomes of unilateral lower limb amputee soldiers in two districts of Sri Lanka.

The purpose of this study was to describe functional outcomes of unilateral lower limb amputee soldiers, in comparison to nonamputee male subjects, and to identify factors affecting functional outcomes. Selected lower limb amputee soldiers of the Sri Lanka Army (n = 461) and matched nonamputee male subjects (n = 461) were evaluated with the prevalidated self-administered version of Short-Form Health Survey-36. A majority were below-knee amputees (n = 413; 89.6%), and the mean age was 30.2 +/- 4.6 years. Short-Form Health Survey-36 health profile scores of amputees were significantly lower than those of nonamputees (p < 0.001). The differences in profiles were largest in scales sensitive to physical health. Higher levels of amputation and problems with the stump and sound leg were significantly associated with poor physical and mental health scores. Amputee soldiers' assessment of changes in health over the past year was significantly worse than that of nonamputees (p < 0.001). The study concluded that amputees have comparatively poor functional outcomes, which could be improved by modifying some associated factors.