Empanelment of the Population to the Primary Medical Care Institution of Sri Lanka: A Mixed-Methods Study on Outcomes and Challenges.

The registration of individuals with designated primary medical care institutions (PMCIs) is a key step towards their empanelment with these PMCIs, supported by the Primary Health Care System Strengthening Project in Sri Lanka. We conducted an explanatory mixed-methods study to assess the extent of registration at nine selected PMCIs and understand the challenges therein. By June 2021, 36,999 (19.2%, 95% CI-19.0-19.4%) of the 192,358 catchment population allotted to these PMCIs were registered. At this rate, only 50% coverage would be achieved by the end of the project (December 2023). Proportions of those aged <35 years and males among those registered were lower compared to their general population distribution. Awareness activities regarding registration were conducted in most of the PMCIs, but awareness in the community was low. Poor registration coverage was due to a lack of dedicated staff for registration, misconceptions of health care workers about individuals needing to be registered, reliance on opportunistic or passive registration, and lack of monitoring mechanisms; these were further compounded by the COVID-19 pandemic. Moving forward, there is an urgent need to address these challenges to improve registration coverage and ensure that all individuals are empaneled before the close of the project for it to have a meaningful impact.

Outcomes and Challenges in Noncommunicable Disease Care Provision in Health Facilities Supported by Primary Health Care System Strengthening Project in Sri Lanka: A Mixed-Methods Study.

The Primary Healthcare System Strengthening Project in Sri Lanka focuses on improving noncommunicable disease (NCD) care provision at primary medical care institutions (PMCIs). We conducted an explanatory mixed-methods study to assess completeness of screening for NCD risk, linkage to care, and outcomes of diabetes/hypertension care at nine selected PMCIs, as well as to understand reasons for gaps. Against a screening coverage target of 50% among individuals aged ≥ 35 years, PMCIs achieved 23.3% (95% CI: 23.0-23.6%) because of a lack of perceived need for screening among the public and COVID-19-related service disruptions. Results of investigations and details of further referral were not documented in almost half of those screened. Post screening, 45% of those eligible for follow-up NCD care were registered at medical clinics. Lack of robust recording/tracking mechanisms and preference for private providers contributed to post-screening attrition. Follow-up biochemical investigations for monitoring complications were not conducted in more than 50% of diabetes/hypertension patients due to nonprescription of investigations by healthcare providers and poor uptake among patients because of nonavailability of investigations at PMCI, requiring them to avail services from the private sector, incurring out-of-pocket expenditure. Primary care strengthening needs to address these challenges to ensure successful integration of NCD care within PMCIs.

Primary Health Care System Strengthening Project in Sri Lanka: Status and Challenges with Human Resources, Information Systems, Drugs and Laboratory Services.

A Primary Healthcare-System-Strengthening Project (PSSP) is implemented by the Ministry of Health, Sri Lanka, with funding support from the World Bank for providing quality care through primary medical care institutions (PMCIs). We used an explanatory mixed-methods study to assess progress and challenges in human resources, drug availability, laboratory services and the health management information system (HMIS) at PMCIs. We conducted a checklist-based assessment followed by in-depth interviews of healthcare workers in one PMCI each in all nine provinces. All PMCIs had medical/nursing officers, but data entry operators (44%) and laboratory technicians (33%) were mostly not available. Existing staff were assigned additional responsibilities in PSSP, decreasing their motivation and efficiency. While 11/18 (61%) essential drugs were available in all PMCIs, buffer stocks were not maintained in >50% due to poor supply chain management and storage infrastructure. Only 6/14 (43%) essential laboratory investigations were available in >50% of PMCIs, non-availability was due to shortages of reagents/consumables and lack of sample collection−transportation system. The HMIS was installed in PMCIs but its usage was sub-optimal due to perceived lack of utility, few trained operators and poor internet connectivity. The PSSP needs to address these bottlenecks as a priority to ensure sustainability and successful scale-up.

Cultural adaptation of mental health first aid guidelines for depression for Sri Lanka: a Delphi expert consensus study.

BACKGROUND: Family and friends can play a key role in supporting a person with depression to seek professional help. However, they may lack the knowledge to do so. English-language guidelines for high-income countries have been developed to assist with this. The aim of this study was to adapt the English mental health first aid guidelines for helping a person with depression to the Sri Lankan context. METHODS: A Delphi expert consensus study involving mental health professionals and people with lived experience (either their own or as carers) was conducted. Participants were recruited from inpatient, outpatient and community care settings. The English-language questionnaire was translated into Sinhala and participants were asked to rate the importance of each item for inclusion in the guidelines for Sri Lanka. RESULTS: Data were collected over two survey rounds. A total of 115 panellists (23% male) consisting of 92 mental health professionals and 23 consumers and carers completed the Round 1 questionnaire. A total of 165 items were included in the final guidelines, with 156 adopted from the guidelines for English-speaking countries and 9 generated from the comments of panellists. CONCLUSIONS: The adapted guidelines were similar to the English-language guidelines. However, new items reflecting culturally relevant approaches to autonomy-granting, communication and culture-specific manifestations of depression were reflected in the adapted version. Further research should explore the use of the adapted guidelines, including their incorporation into Mental Health First Aid Training.

Cultural adaptation of the mental health first aid guidelines for assisting a person at risk of suicide for Sri Lanka: a Delphi expert consensus study.

BACKGROUND: Approximately 3000 people die by suicide each year in Sri Lanka. As family and friends may play a role in supporting a person at risk of suicide to get appropriate help, there is a need for evidence-based resources to assist with this. The aim of this study was to culturally adapt the existing English-language mental health first aid guidelines for helping a person at risk of suicide to the Sri Lankan context. METHODS: A Delphi expert consensus study was conducted, involving mental health professionals and consumers (people with lived experience) and caregivers, who were identified by purposive and snowball sampling methods. Participants were recruited from a wide variety of professional roles and districts of Sri Lanka in order to maximize diversity of opinion. The original questionnaire was translated into Sinhala and participants were requested to rate each item according to the importance of inclusion in the guidelines. RESULTS: Data were collected over two survey rounds. Altogether, 148 people participated in the study (130 health professionals and 18 consumers). A total of 165 items were included in the final guidelines, with 153 adopted from the guidelines for English-speaking countries and 12 generated from the comments of panellists. CONCLUSIONS: The adapted guidelines were similar to the English-language guidelines. However, new items relating to the involvement of family members were included and some items were omitted because they were not considered appropriate to the Sri Lankan context (particularly those relating to explicit mention of suicide). Further research is warranted to explore the use of these guidelines by the Sri Lankan public, including how they may be incorporated in Mental Health First Aid training.

Health promotion in workplaces as a strategy for modification of risk factors for Non Communicable Diseases (NCDs): A practical example from Sri Lanka.

BACKGROUND: Non communicable diseases (NCDs) are emerging as a major public health concern worldwide and became a leading cause of mortality in Sri Lanka accounting for 65% of deaths. Health promotion strategies aimed at lifestyle modification are helpful in modifying risk factors for NCDs. OBJECTIVES: To transform a workplace to a health promotion setting where lifestyle changes in workers lead to a modification of risk factors for NCDs. METHODS: A health promotion program was conducted in a divisional administrative office, in Sri Lanka. An office health promotion committee was established and an action plan was prepared with participation of the workers. An interviewer administrated questionnaire was used to assess risk factors for NCDs. Workers were then screened for NCDs. Behavioral change and communication (BCC) programs were conducted to improve physical activity and dietary modifications. RESULTS: Workers actively participated realizing the ownership of their health. 32 males and 49 females (mean age of 40.8 years) were assessed. Among them, 23.4% were overweight and obese while 26% reported physical inactivity. Among males, 12.5% were smokers. Hypertension and dyslipidaemia were present among 9.9% and 12.3%, respectively. 6.2% had high fasting blood glucose values. The program resulted in identifying 12 new patients with NCDs. After initiating health promotion activities, smoking rate dropped by 75%. Physical inactivity was reduced by 14% and consumption of fresh fruits and vegetables increased by 19%. CONCLUSIONS: Programs targeting office settings are a new strategy for reduction of NCDs in Sri Lanka. True benefit of risk factor modification through BCC programs will become apparent in longitudinal assessments.