The impact of COVID-19 on health care accessibility and financial risk protection in Sri Lanka.

Introduction: The COVID-19 pandemic negatively impacted the global economy, disrupted essential health services, and distorted social determinants of health, reducing healthcare accessibility and increasing financial risk. Aim: we aimed to assess the impact of COVID-19 on healthcare accessibility and financial risk protection in Sri Lanka. Methodology: We conducted a cross-sectional study on a representative sample (multi-stage sampling process) of 3151 households in 105 clusters representing all the districts of Sri Lanka. The data collection was conducted using an interviewer-administered questionnaire in early November 2021. This was important to classify three periods of interest, namely: (1) the pre-lockdown period (2) the nationwide lockdown period, and (3) the new normal period. (After Oct 1 to early November 2021). Results: Among 11,463 household occupants, 12.6% reported having chronic diseases, with 76.5% diagnosed prior to six months. The majority had heart disease, high blood pressure, or diabetes. Of them, 53.7% have been followed up during the lockdown, increasing to 80.8% in the new normal period. Provincial variations in expenses were observed, with the highest food expenses in the Western Province. Catastrophic health expenditures affected 9.5% and 3.4% of households at 10% and 25%, respectively. Conclusions: A considerable proportion of those having heart disease, high blood pressure, high blood sugar or diabetes mellitus were not followed up in the lockdown period and the first month of the new normal period. Antenatal care and family planning were the least affected. Participants had incurred high out-of-pocket expenditures for healthcare during the entire period.

Direct out-of-pocket expenditure of tuberculosis treatment in intensive phase in Kalutara District, Sri Lanka.

BACKGROUND: Tuberculosis (TB) is a communicable disease. Financial risk protection is a key target to achieve in end TB strategy. Out-Of-Pocket Expenditure (OOPE) consisted of expenses bore by patients for their illnesses after subtracting third-party payments such as insurance. Despite the free health care in Sri Lanka, TB patients have to pay for various expenses (e.g., expenses for travel, food, drugs, medical investigations, and cost of accompanied person/bystander). OBJECTIVES: The main objective of this study was to estimate direct OOPE and find the association between direct OOPE and noncompliance to TB treatment in intensive phase. METHODS: A cross-sectional study was conducted with TB patients who were registered in Kalutara-district chest clinic for period of six months (n = 267). Interviewer-administered questionnaire (consisted of sections on socio-demographic characteristics, treatment compliance, sources and amount of OOPE, etc.) was used to collect data. Mean median, minimum, maximum and interquartile range were calculated in each component of OOPE. RESULTS: Questionnaire were administered for 252 patients (male = 160, 63.5%). Mean total direct non-medical cost for one DOTS visit (without accompanied person) was 435.40 (IQR = 420.00) Sri Lankan Rupees (SLR) (i.e., 2.45 United State Dollars (USD)). A patient without an accompanying person spent 26124.00 SLR (435.40 per day into 60 days) (i.e., 146.76 USD) for transport and food during the intensive phase. During the intensive phase, the mean medical cost for one patient was 6444.66 LKR (IQR = 6400) (i.e., 36.21 USD). OOPE was not associated with noncompliance to TB treatment in intensive phase (p = 0.29). CONCLUSIONS: There was no association between OOPE and noncompliance. The direct OOPE for TB treatment in the intensive phase was high. Therefore, it is necessary to develop strategies to reduce OOPE during TB treatment especially in intensive phase.

Effects of indoor air pollution due to solid fuel combustion on physical growth of children under 5 in Sri Lanka: A descriptive cross sectional study.

Solid fuel combustion is an important risk factor of morbidity. This study was conducted to determine the effect of indoor air pollution (IAP) due to solid fuel combustion on physical growth in 262 Sri Lankan children under five. Exposure was defined by the type of fuel used for cooking. Pollutant levels were measured in a subsample of households. "High" exposure group (households using biomass fuel/kerosene oil for cooking) comprised 60% of the study population; the prevalence of wasting was 19.7% and underweight was 20.4% in the entire population where 68% were from the high exposure group. Children from the "high" exposure group had significantly lower mean z-scores for weight-for-height (p = 0.047), height-for-age (p = 0.004) and weight-for-age (p = 0.001) as compared to the "low" exposure group (children of households using liquefied petroleum gas and/or electricity) after adjusting for confounders. Z-scores of weight-for-age, height-for-age and weight-for-height were negatively correlated with CO (p = 0.001, 0.018, 0.020, respectively) and PM2.5 concentrations (p<0.001,p = 0.024 p = 0.008, respectively). IAP due to combustion of biomass fuel leads to poor physical growth.

Noncompliance of treatment among tuberculosis patients in intensive phase at Kalutara District of Sri Lanka.

BACKGROUND: Tuberculosis (TB) is an ancient disease and remains to be a public health problem all over the world. Noncompliance of treatment among TB patients affect the control of disease, leading to increased burden of the disease, mortality, drug resistant and relapse. Assessing the factors associated with noncompliance of TB treatment will be useful to reduce the noncompliance and burden. OBJECTIVES: To assess the factors associated with noncompliance of treatment among TB patients in intensive phase at Kalutara District, Sri Lanka. METHODS: A descriptive cross-sectional study was conducted among the new TB patients registered at District Chest Clinic (DCC), Kalutara for a period of six months. A questionnaire was administered for total study population registered during the data collection period. The relevant data were abstracted from registers and records maintaining at the DCC. RESULTS: Data were collected from 252 patients [males = 160 (63.5%) and females = 92 (36.5%)]. The percentage of noncompliance was 18.3% (n = 46) among newly diagnosed TB patients. Only 13.5% (n = 34) of TB patients visited Directly Observed Treatment, short-course (DOTS) provider daily. Majority (61.9%, n = 156) of DOTS providers did not observe for drug intake. The factors significantly associated with noncompliance for TB treatment were (1) not observing the drug intake by DOTS providers, (2) side effects of the drugs, (3) educational level, (4) living environment and (5) absent of a care giver. CONCLUSIONS: Noncompliance of treatment is still a common problem among TB patients. Special emphasis should be made on TB patients based on the factors associated with the noncompliance of the treatment. DOTS providers should adhere to DOTS policy.

Effect of household air pollution due to solid fuel combustion on childhood respiratory diseases in a semi urban population in Sri Lanka.

BACKGROUND: Household air pollution from combustion of solid fuels for cooking and space heating is one of the most important risk factors of the global burden of disease. This study was aimed to determine the association between household air pollution due to combustion of biomass fuel in Sri Lankan households and self-reported respiratory symptoms in children under 5 years. METHODS: A prospective study was conducted in the Ragama Medical Officer of Health area in Sri Lanka. Children under 5 years were followed up for 12 months. Data on respiratory symptoms were extracted from a symptom diary. Socioeconomic data and the main fuel type used for cooking were recorded. Air quality measurements were taken during the preparation of the lunch meal over a 2-h period in a subsample of households. RESULTS: Two hundred and sixty two children were followed up. The incidence of infection induced asthma (RR = 1.77, 95%CI;1.098-2.949) was significantly higher among children resident in households using biomass fuel and kerosene (considered as the high exposure group) as compared to children resident in households using Liquefied Petroleum Gas (LPG) or electricity for cooking (considered as the low exposure group), after adjusting for confounders. Maternal education was significantly associated with the incidence of infection induced asthma after controlling for other factors including exposure status. The incidence of asthma among male children was significantly higher than in female children (RR = 1.17; 95% CI 1.01-1.37). Having an industry causing air pollution near the home and cooking inside the living area were significant risk factors of rhinitis (RR = 1.39 and 2.67, respectively) while spending less time on cooking was a protective factor (RR = 0.81). Houses which used biomass fuel had significantly higher concentrations of carbon monoxide (CO) (mean 2.77 ppm vs 1.44 ppm) and particulate matter2.5 (PM2.5) (mean 1.09 mg/m3 vs 0.30 mg/m3) as compared to houses using LPG or electricity for cooking. CONCLUSION: The CO and PM2.5 concentrations were significantly higher in households using biomass fuel for cooking. There was a 1.6 times higher risk of infection induced asthma (IIA) among children of the high exposure group as compared to children of the low exposure group, after controlling for other factors. Maternal education was significantly associated with the incidence of IIA after controlling for exposure status and other variables.

Characteristics and sputum conversion of tuberculosis (TB) patients in Kalutara, Sri Lanka.

BACKGROUND: Tuberculosis (TB) is an infectious bacterial disease; remains as one of the important public health problem affecting every part of the world. Substantial number of TB cases are reported from Sri Lanka every year irrespective of its strong preventive health system. The aim of this analysis is to describe the characteristics of TB patients and to assess the factors associated with sputum conversion. This analysis was based on the data from the District Chest Clinic of Kalutara district, Sri Lanka. METHODS: Information of all newly diagnosed and registered patients in the District Chest Clinic, Kalutara in year 2013 were ascertained. Out of 687 newly reported TB patients, 669 records were included in final analysis. RESULTS: Majority of patients were males (n=451, 67.4%), in the age group of 36-60 years (n=306, 45.7%) and underweight (n=359, 61.7%). Substantial proportion of normal weight or overweight adult patients (92.1%) had sputum conversion at 2-3 months as compared to underweight adult patients (82.5%) (p=0.034). Those who smoke tobacco is less likely to have sputum conversion at 2-3 months as compared to non-smokers (90.2% vs. 82.1%, p=0.045). CONCLUSION: Provision of good nutrition, maintaining of appropriate body mass index (i.e., BMI), and abstinence from smoking and alcohol consumption are important for sputum conversion among smear-positive pulmonary TB patients.

Birth Cohort Consortium of Asia: Current and Future Perspectives.

BACKGROUND: The environmental health of children is one of the great global health concerns. Exposures in utero and throughout development can have major consequences on later health. However, environmental risks or disease burdens vary from region to region. Birth cohort studies are ideal for investigating different environmental risks. METHODS: The principal investigators of three birth cohorts in Asia including the Taiwan Birth Panel Study (TBPS), the Mothers and Children's Environmental Health Study (MOCEH), and the Hokkaido Study on Environment and Children' Health (Hokkaido Study) coestablished the Birth Cohort Consortium of Asia (BiCCA) in 2011. Through a series of five PI meetings, the enrolment criteria, aim of the consortium, and a first-phase inventory were confirmed. RESULTS: To date, 23 birth cohorts have been established in 10 Asian countries, consisting of approximately 70,000 study subjects in the BiCCA. This article provides the study framework, environmental exposure and health outcome assessments, as well as maternal and infant characteristics of the participating cohorts. CONCLUSIONS: The BiCCA provides a unique and reliable source of birth cohort information in Asian countries. Further scientific cooperation is ongoing to identify specific regional environmental threats and improve the health of children in Asia.

Differentials in Cardiovascular Risk Factors and Diabetes by Socioeconomic Status and Sex in Kalutara, Sri Lanka.

Since 1950, cardiovascular disease (CVD) has emerged as a leading cause of mortality in Sri Lanka, especially in men. In 2014, a survey in Kalutara to assess CVD and type 2 diabetes mellitus (T2DM) risk factors in adults aged 25 to 64 years (n = 1011), and associations with sex and socioeconomic status (SES), found similar CVD risk factors in both sexes, except for daily tobacco smoking at 19% in men and nil in women, and higher body mass index (BMI) in women than men. With increasing SES in men, there were significant linear increases in mean BMI, waist circumference, mean systolic and diastolic blood pressure, mean fasting plasma glucose, and T2DM prevalence, but decreases in tobacco smoking. Whereas in women higher SES was associated with a significant increase in mean BMI, but a significant decrease in hypertension prevalence. Tobacco smoking is the main risk factor explaining higher CVD mortality in men compared with women.

Sri Lanka Pilot Study to Examine Respiratory Health Effects and Personal PM2.5 Exposures from Cooking Indoors.

A pilot study of indoor air pollution produced by biomass cookstoves was conducted in 53 homes in Sri Lanka to assess respiratory conditions associated with stove type ("Anagi" or "Traditional"), kitchen characteristics (e.g., presence of a chimney in the home, indoor cooking area), and concentrations of personal and indoor particulate matter less than 2.5 micrometers in diameter (PM2.5). Each primary cook reported respiratory conditions for herself (cough, phlegm, wheeze, or asthma) and for children (wheeze or asthma) living in her household. For cooks, the presence of at least one respiratory condition was significantly associated with 48-h log-transformed mean personal PM2.5 concentration (PR = 1.35; p < 0.001). The prevalence ratio (PR) was significantly elevated for cooks with one or more respiratory conditions if they cooked without a chimney (PR = 1.51, p = 0.025) and non-significantly elevated if they cooked in a separate but poorly ventilated building (PR = 1.51, p = 0.093). The PRs were significantly elevated for children with wheeze or asthma if a traditional stove was used (PR = 2.08, p = 0.014) or if the cooking area was not partitioned from the rest of the home (PR = 2.46, p = 0.012). For the 13 children for whom the cooking area was not partitioned from the rest of the home, having a respiratory condition was significantly associated with log-transformed indoor PM2.5 concentration (PR = 1.51; p = 0.014).

Indoor air pollution and respiratory health of children in the developing world.

Indoor air pollution (IAP) is a key contributor to the global burden of disease mainly in developing countries. The use of solid fuel for cooking and heating is the main source of IAP in developing countries, accounting for an estimated 3.5 million deaths and 4.5% of Disability-Adjusted Life Years in 2010. Other sources of IAP include indoor smoking, infiltration of pollutants from outdoor sources and substances emitted from an array of human utilities and biological materials. Children are among the most vulnerable groups for adverse effects of IAP. The respiratory system is a primary target of air pollutants resulting in a wide range of acute and chronic effects. The spectrum of respiratory adverse effects ranges from mild subclinical changes and mild symptoms to life threatening conditions and even death. However, IAP is a modifiable risk factor having potential mitigating interventions. Possible interventions range from simple behavior change to structural changes and from shifting of unclean cooking fuel to clean cooking fuel. Shifting from use of solid fuel to clean fuel invariably reduces household air pollution in developing countries, but such a change is challenging. This review aims to summarize the available information on IAP exposure during childhood and its effects on respiratory health in developing countries. It specifically discusses the common sources of IAP, susceptibility of children to air pollution, mechanisms of action, common respiratory conditions, preventive and mitigating strategies.

Capacity building in environmental and occupational health in Sri Lanka.

BACKGROUND: Although environmental and occupational health (EOH) research and services in Sri Lanka have a long history, policies related to EOH are outdated. METHODS: We review the International Training and Research in Environmental and Occupational Health (ITREOH) program in Sri Lanka that commenced in 2006 as a collaboration between the University of Alabama at Birmingham and the Faculty of Medicine of the University of Kelaniya, Sri Lanka. RESULTS: The program has trained over 20 scientists in conducting EOH research. New pioneering research in EOH was initiated. The program was instrumental in furthering the training and research in EOH by initiating a MPH degree program, the first in the country. CONCLUSIONS: The program has established North-South, South-South and in-country collaborations between institutions and scientists, increasing the visibility of EOH in the future.

A profile of biomass stove use in Sri Lanka.

A large body of evidence has confirmed that the indoor air pollution (IAP) from biomass fuel use is a major cause of premature deaths, and acute and chronic diseases. Over 78% of Sri Lankans use biomass fuel for cooking, the major source of IAP in developing countries. We conducted a review of the available literature and data sources to profile biomass fuel use in Sri Lanka. We also produced two maps (population density and biomass use; and cooking fuel sources by district) to illustrate the problem in a geographical context. The biomass use in Sri Lanka is limited to wood while coal, charcoal, and cow dung are not used. Government data sources indicate poor residents in rural areas are more likely to use biomass fuel. Respiratory diseases, which may have been caused by cooking emissions, are one of the leading causes of hospitalizations and death. The World Health Organization estimated that the number of deaths attributable to IAP in Sri Lanka in 2004 was 4300. Small scale studies have been conducted in-country in an attempt to associate biomass fuel use with cataracts, low birth weight, respiratory diseases and lung cancer. However, the IAP issue has not been broadly researched and is not prominent in Sri Lankan public health policies and programs to date. Our profile of Sri Lanka calls for further analytical studies and new innovative initiatives to inform public health policy, advocacy and program interventions to address the IAP problem of Sri Lanka.

Indoor fine particle (PM2.5) pollution exposure due to secondhand smoke in selected public places of Sri Lanka.

BACKGROUND: Secondhand smoke accounts for a considerable proportion of deaths due to tobacco smoke. Although the existing laws ban indoor smoking in public places in Sri Lanka, the level of compliance is unknown. METHODS: Fine particulate matter (PM(2.5)) levels in 20 public places in Colombo, Sri Lanka were measured by a PM monitor (Model AM510-SIDEPAK Personal Aerosol Monitor). Different types of businesses (restaurants, bars, cafés, and entertainment venues) were selected by purposive sampling. Only the places where smoking was permitted were considered. RESULTS: The average indoor PM(2.5) ranged from 33 to 299 µg/m(3). The average outdoor PM(2.5) ranged from 18 to 83 µg/m(3). The indoor to outdoor PM(2.5) ratio ranged from 1.05 to 14.93. In all venues, indoor PM(2.5) levels were higher than the Sri Lankan ambient PM(2.5) standard of 50 µg/m(3). All indoor locations had higher PM(2.5) levels as compared to their immediate outdoor surroundings. CONCLUSION: The study highlights the importance of improving ventilation and enforcing laws to stop smoking in public places.

Respiratory health status of children from two different air pollution exposure settings of Sri Lanka: a cross-sectional study.

BACKGROUND: Health effects due to air pollution is becoming a major public health problem with growing traffic congestion and establishment of small- to medium-scale industries with poor emission controls in urban cities of Sri Lanka. METHODS: Respiratory health status of 7- to 10-year-old children in two settings (urban and semi-urban) was assessed using standard questionnaires. Information on socio-demographic characteristics and potential determinants of both outdoor and indoor air pollutants exposure levels were also obtained. The respiratory health status of children in the two settings was compared. RESULTS: We found that children from the urban setting had a significantly higher prevalence of wheezing within the last 12 months as compared to children from the semi-urban setting (adjusted OR = 2.02; 95% CI = 1.13-3.59). Indoor cooking with unclean fuels was a risk factor for wheezing independent of the area of residence (adjusted OR = 1.57; 95% CI = 1.01-2.46). CONCLUSIONS: Poor indoor air quality was a major determinant of wheezing for the overall study group. Children from urban areas of Sri Lanka have poorer respiratory health status as compared to children from semi-urban areas. Besides poor outdoor air quality, this difference may also be due to other unexplored factors which may differ between urban and semi-urban areas in Sri Lanka.

Biomass fuel use for cooking in Sri Lanka: analysis of data from national demographic health surveys.

BACKGROUND: Biomass cooking fuel is the main source of indoor air pollution in the majority of households in the developing world. Sri Lanka is an island of about 20 million population with urban, rural, and estate population of 14.6%, 80.0%, and 5.4%, respectively. This study describes biomass fuel use for cooking in Sri Lanka. METHODS: We analyzed data from two national Demographic Health Surveys (2000 and 2007) to identify the use and determinants of cooking fuels in Sri Lankan households. The results are based on a sample of 8,169 households in 2000 and 19,862 households in 2007. RESULTS: Wood was the principal cooking fuel used in 78.3% and 78.5% of households in 2000 and 2007, respectively. In 2007, 96.3% of estate sector households used firewood as compared to 84.2% in the rural and 34.6% in the urban sectors. Similar trends were noted in 2000 as well. CONCLUSIONS: The shift from firewood to cleaner fuels in Sri Lanka is negligible from 2000 to 2007. Improving the quality of life of the population does not necessarily predict a shift towards the use of cleaner cooking fuels in Sri Lanka.

Secondhand smoke exposures in indoor public places in seven Asian countries.

Exposure to secondhand smoke (SHS) is a major threat to public health. Asian countries having the highest smoking prevalence are seriously affected by SHS. The objective of the study was to measure SHS levels in hospitality venues in seven Asian countries and to compare the SHS exposure to the levels in Western countries. The study was carried out in four types of related hospitality venues (restaurant, café, bar/club and entertainment) in China, India, Japan, Korea, Malaysia, Pakistan and Sri Lanka. Real-time measurement of particulate matter of <2.5microm aerodynamic diameter (PM(2.5)) was made during business hour using a handheld laser operated monitor. A total of 168 venues were measured in seven countries. The average indoor PM(2.5) level was 137microg/m(3), ranging from 46microg/m(3) in Malaysia to 207microg/m(3) in India. Bar/club had the highest PM(2.5) level of 191microg/m(3) and restaurants had the lowest PM(2.5) level of 92microg/m(3). The average indoor PM(2.5) level in smoking venues was 156micro/m(3), which was 3.6 times higher than non-smoking venues (43microg/m(3)). Indoor PM(2.5) levels were significantly associated with country, type of venue, smoking density and air exchange rate (p<0.05). In the seven Asian countries, PM(2.5) levels were high due to SHS in public places. The current levels are comparable to the levels in Western countries before the adoption of smoke-free policy. Since Asian country has high prevalence of SHS in public places, there is an urgent need for comprehensive smoke-free regulation in Asian countries.