Stigma associated with cutaneous leishmaniasis in rural Sri Lanka: development of a conceptual framework.

BACKGROUND: There is limited knowledge about the stigma associated with cutaneous leishmaniasis (CL) in Sri Lanka. To ensure that leishmaniasis researchers focus on CL-associated stigma, we provide an evidence-based framework that can be used in future research. METHODS: We conducted a systematic review on CL-associated stigma using international evidence and carried out a multimethod qualitative study in the Anuradhapura district in Sri Lanka. Based on that, we identified manifestations of stigma, drivers and facilitators that we synthesised to develop a conceptual framework on CL-associated stigma. RESULTS: Our framework consists of drivers, facilitators and self-stigma experienced by people with CL. Stigma drivers included fear, misbeliefs and misconceptions about CL; the belief that wounds are disfiguring; the treatment burden and implied blame. Facilitators that reduced stigma included knowledge of the curability of CL and awareness that CL is not contagious. The nature of social interactions in rural communities enhanced stigma formation. We identified various enacted, felt and internalised stigma experiences of people with CL. CONCLUSIONS: We developed a conceptual framework of the stigma associated with CL that can be used to develop targeted interventions to increase CL awareness, address stigma and improve the quality of life for CL patients.

Community Engagement in Cutaneous Leishmaniasis Research in Brazil, Ethiopia, and Sri Lanka: A Decolonial Approach for Global Health.

Cutaneous leishmaniasis (CL) is a parasitic skin disease endemic in at least 88 countries where it presents an urgent, albeit often "neglected" public health problem. In this paper, we discuss our model of decolonial community engagement in the ECLIPSE global health research program, which aims to improve physical and mental health outcomes for people with CL. The ECLIPSE program has four interlinked phases and underpinning each of these phases is sustained and robust community engagement and involvement that guides and informs all activities in ECLIPSE. Our decolonial approach implies that the model for community engagement will be different in Brazil, Ethiopia and Sri Lanka. Indeed, we adopt a critical anthropological approach to engaging with community members and it is precisely this approach we evaluate in this paper. The data and material we draw on were collected through qualitative research methods during community engagement activities. We established 13 Community Advisory Groups (CAGs): in Brazil (n = 4), Ethiopia (n = 6), and Sri Lanka (n = 3). We identified four overarching themes during a thematic analysis of the data set: (1) Establishing community advisory groups, (2) CAG membership and community representation, (3) Culturally appropriate and context-bespoke engagement, and (4) Relationships between researchers and community members. During our first period of ECLIPSE community engagement, we have debunked myths (for instance about communities being "disempowered"), critiqued our own practices (changing approaches in bringing together CAG members) and celebrated successes (notably fruitful online engagement during a challenging COVID-19 pandemic context). Our evaluation revealed a gap between the exemplary community engagement frameworks available in the literature and the messy, everyday reality of working in communities. In the ECLIPSE program, we have translated ideal(istic) principles espoused by such community engagement guidance into the practical realities of "doing engagement" in low-resourced communities. Our community engagement was underpinned by such ideal principles, but adapted to local sociocultural contexts, working within certain funding and regulatory constraints imposed on researchers. We conclude with a set of lessons learned and recommendations for the conduct of decolonial community engagement in global health research.

Measuring Responsive Feeding in Sri Lanka: Development of the Responsive Feeding Practices Assessment Tool.

OBJECTIVE: To develop and validate a tool focusing on responsive feeding (RF) practices among mothers and infants aged between 6 and 12 months in Sri Lanka. DESIGN: A comprehensive review, an in-depth qualitative study, and a cross-sectional study were carried out. SETTING: Anuradhapura District, Sri Lanka. PARTICIPANTS: Sample of mother-infant pairs (n = 170). VARIABLES MEASURED: Items were developed by extracting data from a previous in-depth qualitative study on RF, informed by currently available RF items. ANALYSIS: Content validation was performed among experts using standard techniques, followed by cognitive interviews among mothers. Structural validity was assessed using principal component analysis. Test-retest reliability was done with a sample of 50 mothers. RESULTS: Cognitive validation with mothers confirmed the applicability and comprehensiveness of the tool. The tool possessed good reliability with an intraclass correlation of 0.80 and internal consistency of 0.79. The principal component analysis showed a clear 3 factor solution. The 3 factors were interpreted as responsive communication during feeding, appropriate feeding, attentive to child's signals, and proactive preparation of the feeding environment. The final version of the tool consisted of 15 items. CONCLUSIONS AND IMPLICATIONS: The 15-item Responsive Feeding Practices Assessment Tool is a valid tool to assess RF.

A self-applied valid scale for rapid tracking of household food insecurity among pregnant women in Sri Lanka.

Rapid household food insecurity (HFI) tracking has been identified as a priority in the context of the COVID-19 pandemic and its aftermath. We report the validation of the Latin American and Caribbean Food Security Scale (Escala Latinoamericana y Caribena de Seguridad Alimentaria [ELCSA]) among pregnant women in Sri Lanka. The eight-item adult version of the ELCSA was translated from English to Sinhala and Tamil. Cognitive testing (on 10 pregnant women and five local experts) and psychometric validation of the self-administered HFI tool were conducted among pregnant women (n = 269) attending the special clinics of the Rajarata Pregnancy Cohort (RaPCo) in Anuradhapura in February 2020. We assessed the psychometric properties and fit using a one parameter logistic model (Rasch model analysis) using STATA Version 14 and WINSTEP software Version 4.3.4. Concurrent validity was tested using psychological distress. The scale was internally consistent (Cronbach's alpha = 0.79) and had a good model fit (Rasch items infit statistic range: 0.85 to 1.07). Item 8 ('did not eat for the whole day') was removed from the model fit analysis, as it was not affirmed by respondent. Item severity scores ranged from -2.15 for 'not eating a diverse diet' to 4.43 for 'not eating during the whole day'. Concurrent validity between HFI and psychological distress was confirmed (r = 0.15, p < 0.05). The self-applied version of ELCSA-pregnancy in Sri Lanka (ELCSA-P-SL) is a valid and feasible valid tool. We recommend it to track HFI among pregnant women in lower income countries during the COVID-19 pandemic.

Development and validation of the Social Capital Assessment Tool in pregnancy for Maternal Health in Low and middle income countries (LSCAT-MH).

OBJECTIVES: Social capital which implies 'features of social organisation, such as trust, norms and networks that can improve the efficiency of society by facilitating coordinated actions' is rarely assessed in relation to maternal health in low/middle-income countries (LMICs). A main reason for this research gap could be the unavailability of a specific tool to measure social capital in pregnancy. The study developed and validated an instrument to measure social capital among pregnant women. SETTING: We developed the tool based on World Bank Social Capital Assessment Tool and its adaptations identified as applicable to LMIC from an initial systematic review. The study was conducted in Anuradhapura district in the North Central Province of Sri Lanka. Validation process was conducted in urban, rural and resettled communities. PARTICIPANTS: Study participants of the cognitive validation included pregnant women from the three communities, and an expert panel including a social scientist, methodological expert, subject expert, public health officers. The psychometric validation was performed on 439 pregnant women permanently residing in the three communities. RESULTS: The 24-item Low and middle income countries Social Capital Assessment Tool for Maternal Health (LSCAT-MH) demonstrated high internal consistency (Cronbach's α=0.94). Factor analytical methods suggested a four-factor model of (1) neighbourhood networks (structural bonding), (2) domestic and neighbourhood cohesion (cognitive bonding), (3) social contribution and (4) social participation (structural bridging). Concurrent validity with antenatal mental ill health was confirmed through a negative correlation with the Edinburgh Postpartum Depression Scale. Test-retest reliability was high with intraclass correlation of 0.71 and a Pearson correlation of 0.83. CONCLUSION: The LSCAT-MH is a psychometrically valid and reliable tool to measure social capital in pregnancy. Predictive validity was not tested as the study was not a longitudinal follow-up.

Dermatoglyphics in hypertension: a review.

Hypertension is a major contributor to the global burden of disease and mortality. A major medical advancement would be a better means to ascertain which persons are at higher risk for becoming hypertensive beforehand. To that end, there have been a number of studies showing that certain dermatoglyphic markers are associated with hypertension. This association could be explained if the risk toward developing hypertension later on in life is somehow connected with fetal development of dermatoglyphics. It would be highly valuable from a clinical standpoint if this conjecture could be substantiated since dermatoglyphic markers could then be used for screening out individuals who might be at an elevated risk of becoming hypertensive. The aim of this review was to search for and appraise available studies that pertain to the association between hypertension and dermatoglyphics.A systematic literature search conducted using articles from MEDLINE (PubMed), Trip, Cochran, Google scholar, and gray literature until December 2014. Of the 37 relevant publications, 17 were included in the review. The review performed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement.This review showed a fairly consistent finding of an increased frequency of whorl patterns along with a higher mean total ridge count in digital dermatoglyphic results in hypertensive samples compared to controls. However, it was imperative to discuss several limitations found in the studies that could make this association as yet unsettled.

Duration of exclusive breastfeeding; validity of retrospective assessment at nine months of age.

BACKGROUND: In cross sectional, case control and retrospective cohort studies, duration of Exclusive Breastfeeding (EBF) usually depends on maternal recall. Retrospective data are often subjected to recall bias and could lead to a potential for exposure misclassification. The purpose of the present paper is to assess the validity of maternal recall of EBF duration during infancy, after cessation of EBF and to evaluate the two methods to collect retrospective data on EBF. METHODS: A cohort study was carried out in Naula Medical Officer of Health (MOH) area. Study cohort included all infants born during the months of February to April 2008 and currently residing in Naula MOH area. Baseline data collection was carried out using the pregnancy record, the child health development record and by using an interviewer administered structured questionnaire. Data extraction from the pregnancy record and the child health development record were carried out by public health midwives. The interviewer administered structured questionnaire was administered by the MOH during the follow-up visits. Duration of EBF was assessed in three ways; based on prospective data since birth: Retrospective data based on an event calendar: and the Mother reported EBF duration. RESULTS: A total of 114 mother-infant pairs were recruited and followed up. Proportion of infants receiving EBF up to the completion of the sixth month by the three methods were; data since birth (actual EBF rate) - 23.9%; mother reported data - 77.7% and event calendar method - 41.3%. Median duration of EBF reported in the three methods was 5, 6, and 5 respectively. A statistically significant difference was observed in these differences from Kaplan-Meire Survival analysis (Log rank test - Chi square-63.4, p < 0.001). Validity of retrospective methods was analysed using data since birth as the gold standard. Sensitivity of both methods to detect exclusively breastfed babies were 100.0%. Specificity of mother recall data was 26.2% (95%CI-17.9, 36.8%) compared to 75.0% (95% CI-64.5, 83.2%) in the event calendar method. CONCLUSIONS: Retrospective evaluation methods systematically overestimate the duration of EBF. Maternal recall data provide highly unspecific data whereas use of an event calendar provided more valid data. Reporting of data accrual methods in breastfeeding studies will allow the readers to interpret findings accurately and the use of event calendars rather than direct questioning as a valid method of determining EBF is recommended.

Do People Know Adequately about Leptospirosis? A Knowledge Assessment Survey in Post-outbreak Situation in Sri Lanka.

OBJECTIVES: Sri Lanka experienced the worst ever outbreak of leptospirosis in 2008. One major determinant of control and prevention of communicable diseases is public awareness on the disease. The purpose of the present study was to determine the awareness on leptospirosis among public Sri Lanka. METHODS: A national household survey was carried out as a part of research methodology training of first year medical undergraduates in Rajarata Medical School. Each student visited 10 households surrounding his/her house to complete the interviewer administered questionnaire. The questionnaire was based on the factsheet published by the Epidemiology Unit for public health. RESULTS: Altogether 602 participants from 14 districts participated in the study. Of them 93.7% were aware of rat as a reservoir animal, but only 3% were aware of the role of cattle and buffalo. Contact with infected water as a mode of transmission was reported by 57.9% of the population. Only 30.8% of the subjects were aware of that the infection can go through skin breeches. Farming as a risk activity was reported by 63.5% of the patients, but knowledge on other exposure activities were less than 20%. Paddy field work and cleaning garbage were correctly identified as risk occupations by 89.7% and 27.6% of the sample, respectively. Respondents were aware of fever (86%), malaise (30.8%), headache (29.6%) and muscle tenderness (28.8%) as main clinical features of the disease. Most of them (73.7%) knew leptospirosis as a lethal condition and 39.5% were aware of chemoprophylaxis. CONCLUSIONS: Although there is not adequate information on MDD prevalence in some areas of Iran, the overall current prevalence of MDD in the country is high and females are at the greater risk of disease.

Exclusive breastfeeding in Sri Lanka: problems of interpretation of reported rates.

Accurate interpretation of reported breastfeeding rates is essential in understanding the true picture of a country's breastfeeding status. In Sri Lanka, where the reported exclusive breastfeeding (EBF) rate among infants aged from 0 to 5 months is 75%, accurate understanding of this rate is of the utmost importance. The danger of misinterpreting the data and assuming that Sri Lanka has achieved a high EBF rate is that health workers begin to believe that no further effort should be made in this area. This is very dangerous as the potential to further improve rates of EBF will not be addressed. We discuss the interpretation of survey data and various definitions used in the relevant literature. We strongly recommend that interpretation of EBF rates should be done only after careful evaluation of the definitions and survey methods used.

Incidence and predictors of onboard injuries among Sri Lankan flight attendants.

BACKGROUND: Occupational injuries among flight attendants have not been given appropriate attention in Sri Lanka. The purpose of this study was to estimate the incidence of onboard injury among Sri Lankan flight attendants and to describe the determinants of onboard injury. METHODS: A descriptive cross-sectional study was carried out among Sri Lankan flight attendants. All flight attendants undergoing their annual health and first aid training were invited to participate. Flight attendants who flew continuously for a six-month period prior to data collection were included in the study sample. Recall history of injuries for a period of six months was recorded. RESULTS: The study sample consisted of 98 (30.4%) male and 224 (69.6%) female flight attendants. The mean age of the study sample was 31 years (SD = 8) and the average duration of service was 10 years (SD = 7). A total of 100 onboard falls, slips or trips in the previous six months were reported by 52 (16.1%) respondents. Of the total sample, 128 (39.8%) cabin crew members reported an injury in the six months preceding the study. This represents a total injury incidence of 795 per 1000 person per year. The leading causes of injury was pulling, pushing or lifting (60.2%). The commonest type of injuries were strains and sprains (52.3%). Turbulence related injuries were reported by 38 (29.7%) flight attendants. The upper limbs (44.5%) and the back (32%) were the commonest sites affected. After controlling for other factors, female flight attendants had 2.9 times higher risk (95% CI 1.2-7.2) of sustaining and injury than males. Irrespective of sex, body weight less than 56 kilograms (OR 2.9, 95% CI 1.4-5.8) and less than seven years of on board experience (OR 10.5, 95% CI 3.6-31.0) were associated with higher risk of injury. CONCLUSION: Work related injury is a major occupational hazard to flight attendants. Appropriate preventive strategies are required to minimize them.

Adolescents perception of reproductive health care services in Sri Lanka.

BACKGROUND: Adolescent health needs, behaviours and expectations are unique and routine health care services are not well geared to provide these services. The purpose of this study was to explore the perceived reproductive health problems, health seeking behaviors, knowledge about available services and barriers to reach services among a group of adolescents in Sri Lanka in order to improve reproductive health service delivery. METHODS: This qualitative study was conducted in a semi urban setting in Sri Lanka. A convenient sample of 32 adolescents between 17-19 years of age participated in four focus group discussions. Participants were selected from four midwife areas. A pre-tested focus group guide was used for data collection. Male and female facilitators conducted discussions separately with young males and females. All tape-recorded data was fully transcribed and thematic analysis was done. RESULTS: Psychological distresses due to various reasons and problems regarding menstrual cycle and masturbation were reported as the commonest health problems. Knowledge on existing services was very poor and boys were totally unaware of youth health services available through the public health system. On reproductive Health Matters, girls mainly sought help from friends whereas boys did not want to discuss their problems with anyone. Lack of availability of services was pointed out as the most important barrier in reaching the adolescent needs. Lack of access to reproductive health knowledge was an important reason for poor self-confidence among adolescents to discuss these matters. Lack of confidentiality, youth friendliness and accessibility of available services were other barriers discussed. Adolescents were happy to accept available services through public clinics and other health infrastructure for their services rather than other organizations. A demand was made for separate youth friendly services through medical practitioners. CONCLUSIONS AND RECOMMENDATIONS: Adolescent health services are inadequate and available services are not being delivered in an acceptable manner. Proper training of health care providers on youth friendly service provision is essential. A National level integrated health care program is needed for the adolescents.

Breastfeeding practices in a public health field practice area in Sri Lanka: a survival analysis.

BACKGROUND: Exclusive breastfeeding up to the completion of the sixth month of age is the national infant feeding recommendation for Sri Lanka. The objective of the present study was to collect data on exclusive breastfeeding up to six months and to describe the association between exclusive breastfeeding and selected socio-demographic factors. METHODS: A clinic based cross-sectional study was conducted in the Medical Officer of Health area, Beruwala, Sri Lanka in June 2006. Mothers with infants aged 4 to 12 months, attending the 19 child welfare clinics in the area were included in the study. Infants with specific feeding problems (cleft lip and palate and primary lactose intolerance) were excluded. Cluster sampling technique was used and consecutive infants fulfilling the inclusion criteria were enrolled. A total of 219 mothers participated in the study. The statistical tests used were survival analysis (Kaplan-Meier survival curves and Cox proportional Hazard model). RESULTS: All 219 mothers had initiated breastfeeding. The median duration of exclusive breastfeeding was four months (95% CI 3.75, 4.25). The rates of exclusive breastfeeding at 4 and 6 months were 61.6% (135/219) and 15.5% (24/155) respectively. Bivariate analysis showed that the Muslim ethnicity (p = 0.004), lower levels of parental education (p < 0.001) and being an unemployed mother (p = 0.021) were important associations of early cessation of exclusive breastfeeding. At the time of the study, 62% (135/219) of infants were receiving feeds via a bottle and 23% (51/219) were receiving infant formula. Muslim ethnicity was significantly associated with bottle and formula feeding (p < 0.001). Bottle feeding was also significantly higher among mothers with a low level of education and among employed mothers. CONCLUSION: The rate of breastfeeding initiation and exclusive breastfeeding up to the fourth month is very high in Medical Officer of Health area, Beruwala, Sri Lanka. However exclusive breastfeeding up to six months is still low and the prevalence of inappropriate feeding practices is high.