Effectiveness of an educational intervention to promote psychosocial well-being of school-going adolescents in Sri Lanka.

BACKGROUND: One-fifth of the Sri Lankan population consists of adolescents, with 71% of them schooling. An extreme need exists in the country for the introduction of evidence-based interventions for the psychosocial well-being of adolescents. The present study assessed the effectiveness of an educational intervention to promote the psychosocial well-being of school-going adolescents in grade nine in Western Province, Sri Lanka. MATERIALS AND METHODS: A quasi-experimental study was conducted among grade nine students in Western Province in 2019. Panadura Medical Officer of Health (MOH) area was selected as the interventional area (IA), and Kelaniya MOH area was identified as the control area (CA). Teachers at schools in the IA received training on psychosocial health promotion of adolescents. They delivered the activity-based educational intervention package to the grade nine students as 20-min classroom sessions for three months. Pre- and post-intervention assessments of attitudes and practices related to the psychosocial well-being of adolescents were conducted using an interviewer-administered questionnaire. Categorical data were compared using Chi-Square or Fisher's exact test. Mann-Whitney U test was applied to determine the difference between the medians of the pre-and post-intervention scores on attitude and practices for psychosocial well-being. RESULTS: A total of 1040 grade nine students were enrolled. There was a statistically significant increase in median score on attitudes [81.8 (IQR:75.5-85.5) to 82.3(IQR:78.6-87.2] and practices [81.7(IQR: 76.1-85.7) to 83.1(IQR: 79.1-86.9)] in the IA while there was no significant difference in the CA. The proportion of bullied adolescents in the past 30 days reduced significantly from 14.8% (n = 38) to 7.9% (n = 20) in IA(p = .03), whereas there was a slight reduction from 17.1% (n = 44) to 11.3% (n = 26) in CA (p = .17). CONCLUSIONS: The present psychosocial intervention is effective in improving the psychosocial well-being of school adolescents, though long-term effectiveness was not assessed. It is recommended to utilise study findings in deciding to introduce the present intervention to basic and in-service teacher training packages and school curricula with necessary modifications.

Out-of-Pocket Expenditure for Antenatal Care Amid Free Health Care Provision: Evidence From a Large Pregnancy Cohort in Rural Sri Lanka.

INTRODUCTION: Global evidence suggests that high out-of-pocket (OOP) expenditure negatively affects health service utilization and creates an economic burden on households during pregnancy. This study aimed to estimate the magnitude and associated factors of OOP expenditure for antenatal care (ANC) in a rural Sri Lankan setting by following up with a large pregnancy cohort (The Rajarata Pregnancy Cohort [RaPCo]) in Anuradhapura District, Sri Lanka. METHODS: Data were collected from July 2019 to May 2020. An interviewer-administered questionnaire was used to collect socioeconomic data and OOP expenditures in the first trimester. Self-administered questionnaires were used monthly to collect OOP expenditures in the second and third trimesters. In-depth financial information of 1,558 pregnant women was analyzed using descriptive statistics, nonparametric statistics, and a multiple linear regression model. RESULTS: The majority of participants used both government and private health facilities for ANC. The mean (standard deviation [SD]) OOP expenditure per ANC visit was US$4.18 (US$4.19), and the mean (SD) OOP expenditure for total ANC was US$57.74 (US$80.96). Pregnant women who used only free government health services also spent 28% and 14% of OOP expenditure on medicines and laboratory investigations. Household income (P<.001), household expenditure (P<.1), used health care mode (P<.05), maternal morbidities (P<.05), and the number of previous pregnancies (P<.1) were the statistically significant independent predictors of OOP expenditure. OOP expenditure per visit for ANC equals half of the daily household expenditure. CONCLUSION: Despite having freely available government health facilities, most pregnant women tend to use both government and private health facilities and incur higher OOP expenditure. Free government health care users also incur a direct medical OOP expenditure for medicines and laboratory investigations. Monthly household income, expenditure, used health care mode, maternal morbidities, and the number of previous pregnancies are independent predictors of OOP expenditure.

Incorporating early pregnancy mental health screening and management into routine maternal care: experience from the Rajarata Pregnancy Cohort (RaPCo), Sri Lanka.

Early identification of mental health problems in pregnancy in low-income and middle-income countries is scarcely reported. We present the experience of a programme assimilating screening and management of antenatal anxiety and depression in conjunction with the Rajarata Pregnancy Cohort, in Sri Lanka. We adopted a two-stage screening approach to identify the symptoms and the reasons for anxiety and depression. Pregnant women (n=3074), less than 13 weeks of period of gestation underwent screening with the Edinburgh Postnatal Depression Scale (EPDS). Scores were positive among 23% and 14% of women in the first and second trimesters, respectively. Clinical (telephone) interviews (n=78, response 56.9%) were held for women having high EPDS scores to screen for clinical depression using the 'mental health GAP' tool. Targeted interventions including counselling, financial and social support and health education were employed. The procedure was repeated in the second trimester with in-person clinical interviews and inquiry into intentional self-harm. Our findings indicated that (1) the majority of mental health problems in early pregnancy were anxiety related to early pregnancy-associated conditions manageable at the primary healthcare level, (2) coupling mental health screening using psychometric tools with clinical interviews facilitates targeted patient-centred care, (3) the majority of intentional self-harm during pregnancy is not in the routine health surveillance system and (4) promoting women to attend the psychiatry clinic in tertiary care hospital has been difficult. Following the experience, we propose a model for mental health service provision in routine pregnancy care programme starting from early pregnancy.

Estimating mortality and disability in Peru before the COVID-19 pandemic: a systematic analysis from the Global Burden of the Disease Study 2019.

Background: Estimating and analyzing trends and patterns of health loss are essential to promote efficient resource allocation and improve Peru's healthcare system performance. Methods: Using estimates from the Global Burden of Disease (GBD), Injuries, and Risk Factors Study (2019), we assessed mortality and disability in Peru from 1990 to 2019. We report demographic and epidemiologic trends in terms of population, life expectancy at birth (LE), mortality, incidence, prevalence, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) caused by the major diseases and risk factors in Peru. Finally, we compared Peru with 16 countries in the Latin American (LA) region. Results: The Peruvian population reached 33.9 million inhabitants (49.9% women) in 2019. From 1990 to 2019, LE at birth increased from 69.2 (95% uncertainty interval 67.8-70.3) to 80.3 (77.2-83.2) years. This increase was driven by the decline in under-5 mortality (-80.7%) and mortality from infectious diseases in older age groups (+60 years old). The number of DALYs in 1990 was 9.2 million (8.5-10.1) and reached 7.5 million (6.1-9.0) in 2019. The proportion of DALYs due to non-communicable diseases (NCDs) increased from 38.2% in 1990 to 67.9% in 2019. The all-ages and age-standardized DALYs rates and YLLs rates decreased, but YLDs rates remained constant. In 2019, the leading causes of DALYs were neonatal disorders, lower respiratory infections (LRIs), ischemic heart disease, road injuries, and low back pain. The leading risk factors associated with DALYs in 2019 were undernutrition, high body mass index, high fasting plasma glucose, and air pollution. Before the COVID-19 pandemic, Peru experienced one of the highest LRIs-DALYs rates in the LA region. Conclusion: In the last three decades, Peru experienced significant improvements in LE and child survival and an increase in the burden of NCDs and associated disability. The Peruvian healthcare system must be redesigned to respond to this epidemiological transition. The new design should aim to reduce premature deaths and maintain healthy longevity, focusing on effective coverage and treatment of NCDs and reducing and managing the related disability.

'We do not rush to the hospital for ordinary wounds (sulu tuvala)': A qualitative study on the early clinical manifestations of cutaneous leishmaniasis and associated health behaviours in rural Sri Lanka.

BACKGROUND: Knowledge of early clinical manifestations, people's perceptions and behaviours is crucial in preventing and controlling neglected tropical diseases (NTDs). Cutaneous leishmaniasis is an NTD that causes skin lesions and affects millions worldwide. Delayed healthcare-seeking behaviour leading to prolonged treatment periods and complications is rife among people with cutaneous leishmaniasis. This study examined the patient-reported early clinical manifestations of cutaneous leishmaniasis, local interpretations and associated health behaviours within the socio-cultural context of rural Sri Lanka. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a qualitative study among people with cutaneous leishmaniasis in three rural communities in the Anuradhapura district, Sri Lanka. Participants' experiences were explored through a study-bespoke participant experience reflection journal and in-depth interviews. We analysed the data using a narrative-thematic approach. The study included 30 people with cutaneous leishmaniasis (12 females and 18 males) aged between 18 and 75 years. We identified four major themes during the analysis: 1) patient-reported early clinical manifestations of cutaneous leishmaniasis, 2) local interpretations of the early skin lesion(s), 3) associated actions and behaviours, and 4) the time gap between the initial notice of symptoms and seeking healthcare for cutaneous leishmaniasis. Early clinical manifestations differed among the participants, while the majority misinterpreted them as a mosquito/ant bite, pimple, wart, eczema, macule, or worm infestation. Participants undertook different context-specific self-management actions to cure cutaneous leishmaniasis. We identified an average time gap between the notice of symptoms and the first visit to the healthcare facility ranging from three to twelve months. CONCLUSIONS/SIGNIFICANCE: Diverse early clinical manifestations, local interpretations, and associated behaviours of people with cutaneous leishmaniasis have led to a substantial delay in healthcare-seeking. The study sheds light on the importance of understanding the manifestations of NTDs within the social context. Our findings will inform designing context-specific health interventions to improve awareness and healthcare-seeking in cutaneous leishmaniasis in rural settings.

Impact of COVID-19 pandemic on health service utilisation and household economy of pregnant and postpartum women: a cross-sectional study from rural Sri Lanka.

OBJECTIVES: This study aims to describe how household economies and health service utilisation of pregnant and postpartum women were affected during the pandemic. DESIGN: A cross-sectional study. SETTING: This study was conducted in the Anuradhapura district, Sri Lanka. PARTICIPANTS: The study participants were 1460 pregnant and postpartum women recruited for the Rajarata Pregnancy Cohort during the initial stage of the COVID-19 pandemic. PRIMARY AND SECONDARY OUTCOME MEASURES: Household economic (income, poverty, nutritional and health expenditures) and health service utilisation details during the COVID-19 pandemic were gathered through telephone interviews. Sociodemographic and economic data were obtained from the cohort baseline and analysed with descriptive and non-parametric analysis. RESULTS: Out of the 1460 women in the sample, 55.3% (n=807) were pregnant and 44.7% (n=653) were postpartum women. Of the total sample, 1172 (80.3%) women participated in the economic component. The monthly household income (median (IQR)=212.39 (159.29-265.49)) reduced (median (IQR)=159.29 (106.20-212.39)) in 50.5% (n=592) families during the pandemic (Z=-8.555, p<0.001). Only 10.3% (n=61) of affected families had received financial assistance from the government, which was only 46.4% of the affected income. The nutritional expenditure of pregnant women was reduced (Z=-2.023, p=0.043) by 6.7%. During the pandemic, 103 (8.8%) families with pregnant or postpartum women were pushed into poverty, and families who were pushed into poverty did not receive any financial assistance. The majority of women (n=1096, 83.3%) were satisfied with the free public health services provided by the public health midwife during the pandemic. CONCLUSION: During the early stages of the pandemic, healthcare utilisation of pregnant women was minimally affected. Even before the country's current economic crisis, the household economies of pregnant women in rural Sri Lanka were severely affected, pushing families into poverty due to the pandemic. The impact of COVID-19 and the aftermath on pregnant women will have many consequences if the policies and strategies are not revised to address this issue.

Hypertrophied posterior longitudinal ligament and ligamentum flavum causing myelopathy: a case report and literature review.

INTRODUCTION: The occurrence of concurrent hypertrophied posterior longitudinal ligament (HPLL) and hypertrophied ligamentum flavum (HLF) in the thoracic spine is a very rare presentation. This case report describes a young female who developed thoracic myelopathy secondary to a combination of both thoracic HPLL and HLF. CASE PRESENTATION: A 30-year-old previously well female was referred for an MRI scan of the thoraco-lumbar spine. She was having lower limb weakness and difficulty in walking, which had progressed over 3 months. On examination, she was found to have spastic lower limbs with associated motor weakness. Her biochemical investigations were unremarkable. The MRI scan showed HPLL, which was uniformly hypointense on T2W images and was isointense on T1W images. The hypertrophied segment was extending from T2 level to T7 level. Similarly, the ligamentum flavum was hypertrophied from T1 level to T8 level. The thoracic spinal cord was seen compressed between the hypertrophied ligaments. The compressed cord showed central hyperintense signal pattern in T2W images. CT scan of the thoracic spine did not show any calcifications or ossifications along the ligaments. Patient underwent posterior decompressive surgery and she had an uneventful recovery. DISCUSSION: Although few cases of HPLL and HLF were reported in older patients in literature, both these conditions were found in this patient at a younger age. HPLL and HLF are thought to be precursors of ossification of these ligaments and these patients need long-term follow-up.

Serum creatinine and estimated glomerular filtration rate (eGFR) in early pregnancy and changes during the pregnancy.

Renal functions in pregnancy undergo rapid changes, and the thresholds for normal values are a major research gap and are still debatable. The lack of prospective population-based studies with early pregnancy recruitment hampered the decision-making process on the best thresholds to be used in clinical practice. We present the serum creatinine (sCr) and sCr-based estimated glomerular filtration rates (eGFR) in early pregnancy with changes over the gestational period in a large prospective, community-based cohort, the Rajarata Pregnancy Cohort (RaPCo). We carried out a community-based prospective cohort study with 2,259 healthy pregnant women with a gestation period of less than 13 weeks and without pre-existing medical conditions. Gestational period-specific sCr and sCr-based eGFR were calculated for different age strata, and the participants were followed up until the second trimester. Renal functions of pregnant women were compared with 2.012 nonpregnant women from the same geographical area. The mean (SD) sCr of the 2,012 nonpregnant women was 62.8(12.4) µmol/L, with the 97.5th percentile of 89.0 µmol/L. Among the pregnant women, mean (SD) sCr was 55.1(8.3), 52.7(8.1), 51.1(9.1), 47.1(7.2), and 49.3 (9.9), while the 97.5th percentile for sCr was 72.4, 69.1, 70.0, 63.6, and 66.0 µmol/L respectively during the 4-7, 8-9, 10-12, 24-27 and 28-30 weeks of gestation. The average sCr value was 84.7% and 76.4% of the nonpregnant group, respectively, in the first and second trimesters. The mean eGFR was 123.4 (10.7) mL/min/1.73 m2 in the first trimester and increased up to 129.5 mL/min/1.73 m2 in the 24th week of gestation. The analysis of cohort data confirmed a significant reduction in sCr with advancing pregnancy (p<0 .001). This study provides thresholds for renal functions in pregnancy to be used in clinical practice. Clinical validation of the proposed thresholds needs to be evaluated with pregnancy and newborn outcomes.

The magnitude of out-of-pocket expenditure for antenatal care in low and middle-income countries: A systematic review and meta-analysis.

BACKGROUND: Owing to the lack of compiled global evidence on out-of-pocket expenditure (OOPE) for antenatal care (ANC), this systematic review and meta-analysis estimated the magnitude of OOPE for ANC in low and middle-income countries (LMICs). METHODS: An electronic search was conducted using 10 databases and a hand search of the eligible studies' reference lists. Studies on OOPE for ANC in LMICs, published in English without time restriction, were included. The comparability of OOPE values was improved using inflation and exchange rate adjustment to the year 2019. Random-effects meta-analysis was performed to generate pooled estimates. RESULTS: Among the 9766 articles retrieved, 32 were selected. Only 13/137 (9.5%) countries reported evidence of OOPE during pregnancy in LMICs. The majority of the studies (n = 2779.4%) were from lower-middle-income settings. Ten (31.3%) studies from African region, 21 (65.6%) studies from South-East-Asian region, 1 (3.1%) study from region of Americas and none from the other regions were included. The average OOPE for ANC and single ANC visit ranged from United States Dollar (USD) 2.41 to USD 654.32 in LMICs, the lowest in Tanzania and the highest in India. The pooled OOPEs were USD 63.29 (95% confidence interval [CI] = 51.93-74.65) and USD 12.93 (95%CI = 4.54-21.31) for ANC and single ANC visit in LMICs, respectively. CONCLUSION: The study revealed that the pooled estimates of OOPE for ANC throughout pregnancy and per visit were high in some countries, with a wide variability observed across countries. There was a lack of evidence on OOPE for ANC from many LMICs, and filling the evidence gap in LMICs is highlighted.

Quality of life among community-dwelling older adults: evidence from a large population-based study in rural Sri Lanka.

PURPOSE: Against the backdrop of the ever-increasing aging population in Sri Lanka and the scarcity of local evidence on quality of life (QoL) among rural elderly, this study was conducted to assess the QoL of the community-dwelling older adults in rural Sri Lanka. METHODS: This cross-sectional study was conducted among community-dwelling older adults (60-74 years) in a selected rural setting in Sri Lanka. K-means cluster analysis was used to stratify participants into 'low' and 'high' levels of QoL and then significant associations between these clusters and underlying socio-demographic and self-reported health related factors were estimated using bivariate and subsequent multivariable binary logistic regression models. RESULTS: The final sample consisted of 3573 community-dwelling older adults (response rate 97.8%). The mean (SD) age of the sample was 66.7 (4.3) years and the majority were females (n = 2130, 59.6%). Amongst the six QoL domains assessed (physical, psychological, social, functional, environmental and spiritual domains), the highest and the lowest mean (SD) scores were reported for the functional [63.4 (16.9)] and the physical [52.9 (15.0)] domains, respectively. Aged 70 years or more, either unmarried/widowed/divorced, lower educational levels and having chronic illnesses were statistically significant associations of QoL (p < 0.05). CONCLUSION: The QoL among community-dwelling older adults in rural Sri Lanka is moderate. As having social support, absence of chronic diseases and good education level were found to be associated with better QoL, strengthening community-based interventions to improve these aspects by incorporating the evidence generated by other longitudinal studies is recommended.

Social determinants of health pave the path to maternal deaths in rural Sri Lanka: reflections from social autopsies.

BACKGROUND: Ending preventable maternal deaths remains a challenge in low- and middle-income countries (LMICs). Society perceived causes and real-life observations can reveal the intangible causes of maternal deaths irrespective of formal maternal death investigations. This study reports complex patterns in which social determinants act towards paving the path to maternal deaths in a rural Sri Lankan setting. METHODS: We conducted social autopsies for 15/18 maternal deaths (in two consecutive years during the past decade) in district A (pseudonymized). In-depth interviews of 43 respondents and observations were recorded in the same field sites. During thematic analysis, identified themes were further classified according to the World Health Organization framework for social determinants of health (SDH). The patterns between themes and clustering of social determinants based on the type of maternal deaths were analyzed using mixed methods. RESULTS: Discernable social causes underpinned 12 out of 15 maternal deaths. Extreme poverty, low educational level, gender inequity, and elementary or below-level occupations of the husband were the characteristic structural determinants of most deceased families. Social isolation was the commonest leading cause manifesting as a reason for many other social factors and resulted in poor social support paving the path to most maternal deaths. A core set of poverty, social isolation, and poor social support acted together with alcohol usage, and violence leading to suicides. These core determinants mediating through neglected self-health care led to delay in health-seeking. Deficits in quality of care and neglect were noted at health institutions and the field. CONCLUSION: Social autopsies of maternal deaths revealed complex social issues and social determinants of health leading to maternal deaths in Sri Lanka, indicating the need for a socially sensitive health system.

The accuracy of nucleic acid amplification tests (NAATs) in detecting human intestinal nematode infections: A protocol for a systematic review and meta-analysis.

Human intestinal nematode infections are a global public health issue as they can result in considerable morbidity in infected individuals, mainly in developing countries. These infections continue to go undiagnosed, as they tend to be mainly endemic in resource-poor communities where there is a shortage of experienced laboratory staff and relevant diagnostic technologies. This is further exacerbated by the nature of intermittent shedding of eggs and larvae by these parasites. Diagnostic methods range from simple morphological identification to more specialised high-throughput sequencing technologies. Microscopy-based methods, although simple, are labour-intensive and considerably less sensitive than molecular methods which are rapid and have high levels of accuracy. Molecular methods use nucleic acid amplification (NAA) to amplify the deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) fragments of the parasite to detect and determine its presence using different technologies (NAAT). They have increased the sensitivity of detection and quantitation of intestinal nematode infections, especially in low infection intensity settings. The absence of a gold standard test limits current diagnosis and, in turn, restricts intervention measures and effective control efforts. The objective of this review is to determine the accuracy of NAATs in detecting human intestinal nematode infections using Kato-Katz as the reference test for the most common soil-transmitted helminth (STH) infections and the scotch tape test for enterobiasis and Baermann method for strongyloidiasis. Relevant studies will be identified by searches in electronic databases. Two reviewers will independently screen the literature against eligibility criteria. The methodological quality of studies will then be appraised by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Discrepancies will be addressed by a third reviewer. The true positives, false positives, true negatives and false negatives of all the studies will be extracted into contingency tables. In paired forest plots, study-specific sensitivity and specificity with a 95 per cent confidence interval will be displayed. The systematic review of this protocol will report the diagnostic accuracy of currently available NAATs for the detection of human intestinal nematode infections. This will help healthcare providers and administrators determine the diagnostic method to be used in different clinical and preventive settings. Trial registration: PROSPERO registration number for this protocol is CRD42022315730.

Asthma in a prospective cohort of rural pregnant women from Sri Lanka: Need for better care during the pre-conceptional and antenatal period.

OBJECTIVES: To describe the epidemiology and the effect of asthma on pregnancy outcomes in pregnant women from a rural geography. METHODS: We conducted a prospective cohort study in Anuradhapura district, Sri Lanka enrolling all eligible pregnant women registered in the maternal care program. An interviewer-administered questionnaire-based symptom analysis and clinical assessment was conducted in the first and second trimesters. RESULTS: We recruited 3374 pregnant women aged 15-48 years at conception. Self-reported physician-diagnosed asthma prevalence was 6.6% (n = 223) with only 41.7% (n = 93) on regular medical follow-up for asthma. The prevalence of wheeze reduced from pre-pregnancy (67.0%) to the first (46.4%) and second trimesters (47.7%; p<0.01). Of the 73 asthmatic women who did not have wheeze in the last 3 months preceding pregnancy, new-onset wheeze was reported by 6(8.2%) and 12(16.4%) in the first and second trimester, respectively. Pregnant women who sought medical care for asthma in the private sector had a lower likelihood of developing new-onset wheeze in the first trimester (p = 0.03; unadjusted OR = 0.94;95%CI 0.89-0.99). Thirty-four (33.3%) pregnant women had at least one hospital admission due to exacerbation of wheeze during the first and second trimester. The prevalence of low birth weight (16.0%) was higher among pregnant asthmatic women. CONCLUSION: This study reports the high prevalence of asthma and asthma-associated pregnancy outcomes in women from a rural geography signifying the importance of targeted management.

Placing Leishmaniasis in the Limelight through the Communicable Disease Surveillance System: An Experience from Sri Lanka.

Having an effective surveillance system is imperative to take timely and appropriate actions for disease control and prevention. In Sri Lanka, leishmaniasis was declared as a notifiable disease in 2008. This paper presents a comprehensive compilation of the up-to-date documents on the communicable disease and leishmaniasis surveillance in Sri Lanka in order to describe the importance of the existing leishmaniasis surveillance system and to identify gaps that need to be addressed. The documents perused included circulars, reports, manuals, guidelines, ordinances, presentations, and published articles. The disease trends reported were linked to important landmarks in leishmaniasis surveillance. The findings suggest that there is a well-established surveillance system in Sri Lanka having a massive impact on increased case detection, resulting in im-proved attention on leishmaniasis. However, the system is not without its short comings and there is room for further improvements.

Portal Venous and Mesenteric Wall Calcifications along with Intra-splenic Vascular Calcification: A Rare Case Report and Literature Review.

BACKGROUND: Cross-sectional imaging findings of portal vein calcification were found to be an indicator of portal vein thrombosis. Calcification of the portal vein and its tributaries in portal hypertension is an uncommon finding and the mechanical stress due to long-standing portal hypertension on the vessel wall is considered leading to sclerosis and calcification in the intima and media of the vessel wall. Intra-splenic vascular calcification is a rare occurrence and has been seen in patients with portal hypertension. CASE PRESENTATION: A 60-year-old male was referred for an ultrasound scan of the abdomen, as he was found to have mild elevation of liver enzymes during a routine medical investigation. His ultrasound scan showed features of cirrhosis and portal hypertension. Furthermore, there were intra-splenic calcifications with branching pattern. Subsequent CT confirmed intra-splenic vascular calcification and calcifications in the wall of the thrombosed portal vein and its tributaries. CONCLUSION: Pre-operative identification of portal venous calcification is important, as this might adversely affect surgical interventions for cirrhosis and portal hypertension. Furthermore, to our best knowledge, there have not been any cases reported with concurrent calcification of the portal venous system and intra-splenic vascular calcification in association with portal hypertension in literature.

How costly is the first prenatal clinic visit? Analysis of out-of-pocket expenditure in rural Sri Lanka - a country with free maternal health care.

BACKGROUND: This study aimed to determine the magnitude of and factors associated with out-of-pocket expenditure (OOPE) during the first prenatal clinic visit among pregnant women in Anuradhapura district, Sri Lanka, which provides free maternal healthcare. METHODS: The study design was a cross-sectional study, and the study setting was 22 Medical Officers of Health (MOOH) areas in Anuradhapura District, Sri Lanka. Data of 1389 pregnant women were analyzed using descriptive statistics and non-parametric tests. RESULTS: The mean OOPE of the first prenatal clinic visit was USD 8.12, which accounted for 2.9 and 4.5% of the household income and expenditure, respectively. Pregnant women who used only government-free health services (which are free of charge at the point of service delivery) had an OOPE of USD 3.49. A significant correlation was recorded between household expenditure (rs = 0.095, p = 0.002) and the number of pregnancies (rs = - 0.155, p < 0.001) with OOPE. Education level less than primary education is positively contributed to OOPE (p < 0.05), and utilizing government-free maternal health services lead to a decrease in the OOPE for the first prenatal clinic visit (p < 0.05). CONCLUSION: Despite having free maternal services, the OOPE of the first prenatal clinic visit is high in rural Sri Lanka. One-fifth of pregnant women utilize private health services, and pregnant women who used only government-free maternal health services also spend a direct medical cost for medicines/micronutrient supplements.

The hidden burden of adolescent pregnancies in rural Sri Lanka; findings of the Rajarata Pregnancy Cohort.

BACKGROUND: Adolescent fertility is a main indicator of the Sustainable Developmental Goal (SGD) three. Although Sri Lanka is exemplary in maternal health, the utilization of Sexual and Reproductive Health services (SRH) by adolescents is less documented. We describe the hidden burden, associated biological and psychosocial factors and utilization patterns of pre-conceptional services among pregnant adolescents in rural Sri Lanka. METHODS: The study is based on the baseline assessment of the Rajarata Pregnancy Cohort (RaPCo) in Anuradhapura. Pregnant women newly registered from July to September 2019 were recruited to the study. The period of gestation was confirmed during the second follow-up visit (around 25-28 weeks of gestation) using ultra sound scan data. A history, clinical examination, anthropometric measurements, blood investigations were conducted. Mental health status was assessed using the Edinburgh Postpartum Depression Scale (EPDS). RESULTS: Baseline data on gestation was completed by 3,367 pregnant women. Of them, 254 (7.5%) were adolescent pregnancies. Among the primigravida mothers (n = 1037), 22.4% (n = 233) were adolescent pregnancies. Maternal and paternal low education level, being unmarried, and less time since marriage were statistically significant factors associated with adolescent pregnancies (p < 0.05). Contraceptive usage before pregnancy, utilization of pre-conceptional health care services, planning pregnancy and consuming folic acid was significantly low among adolescents (p < 0.001). They also had low body mass index (p < 0.001) and low hemoglobin levels (p = 0.03). Adolescent mothers were less happy of being pregnant (p = 0.006) and had significantly higher levels of anxiety (p = 0.009). CONCLUSION: One fifth of women in their first pregnancy in this study population are adolescents. Nulli-parous adolescents exert poor social stability and compromised physical and mental health effects. The underutilization and/or unavailability of SRH services is clearly associated with adolescent pregnancies.

Value-Added Roles of Medical Students During the COVID-19 Pandemic: Assessment of Medical Students' Perceptions and Willingness in Sri Lanka.

PURPOSE: Since the coronavirus disease 2019 (COVID-19) pandemic is an opportune time to introduce the value-added roles of medical students, this study assessed medical students' perceptions and willingness to assist in COVID-19 health sector preparedness and response via value-added roles in Sri Lanka. METHODS: A cross-sectional online survey was conducted among all medical students studying in six batches of the Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, in June 2020. A Google form in English with 10 statements about individual perceptions of medical students' roles and their willingness to assist in the COVID-19 health sector response via value-added roles was used to collect data. The responses were recorded on a five-point Likert scale. The chi-squared test for independence was used to explore the associations between the academic year and the responses to each statement. RESULTS: Out of 856 (response rate 79.6%) study participants, the majority were females (n=601, 70.2%). The majority (n=804, 93.9%) reported that they have a responsibility to contribute to the country's COVID-19 health sector response. There was a statistically significant association between medical students' perceived level of clinical knowledge, having the clinical skills to assist in the COVID-19 health sector response and academic year (p<0.001). The commonly identified value-added roles were developing (n=770, 89.9%) and disseminating (n=744, 86.9%) health education messages, and field contact tracing activities (n=653, 76.3%). Other value-added roles were assisting the curative health sector in COVID-19 patient management (n=380, 44.4%) and other non-COVID-19 patient management (n=463, 54.1%). CONCLUSION: Medical students are mostly willing to engage in preventive health sector value-added roles and, to a lesser extent, in curative health sector value-added roles during the COVID-19 outbreak. However, medical educators need to clearly define the value-added roles and provide adequate training and supervision for medical students across academic years to enable them to combine learning with making meaningful contributions to the health-care system during the COVID-19 pandemic.

Sri Lanka's early success in the containment of COVID-19 through its rapid response: Clinical & epidemiological evidence from the initial case series.

BACKGROUND: Despite the rising global burden, Sri Lanka reported a relatively low caseload and mortality (13 deaths as of 20 October 2020) for COVID-19. This warrants exploration of the clinical and epidemiological characteristics of the case series during the initial passive case detection phase in Sri Lanka, in order to understand the success in containment of the disease for more than nine months in the country through its initial early and rapid pandemic response. METHODS: A retrospective study was conducted using secondary data (hospital records and investigation reports) extracted from all laboratory-confirmed patients admitted to the three main state-sector hospitals in Sri Lanka from 11 March to 7 April 2020. Clinical outcomes were categorized as mild, severe and critical, as per the international classification. Kruskal-Wallis H, Mann Whitney U and Fisher's exact tests compared differences between the variables. RESULTS: The case series comprised 146 live discharges and six deaths. Majority were males (63.2%); mean age of 40.9 (SD = 17.9); and symptomatic (72.4%). Sixty-one (40.1%) had co-morbidities, the commonest being diabetes (20.4%) and hypertension (17.8%). Mild (93.4%), severe (2.6%) and critical (4.0%) disease outcomes were noted. Disease severity was significantly higher with older age (p = 0.037), co-morbidities (p = 0.026); and higher white-cell (p = 0.045) and lymphocyte (p = 0.043) counts; but not with being symptomatic (p = 0.683). The commonest symptoms were fever (62.5%), dry cough (48.0%) and sore throat (26.9%). The median duration (IQR) was 3.0 (1.0-5.0) and 18.0 (15.0-29.5) days, respectively before and during hospitalization. CONCLUSIONS: In contrast to high-risk countries, the younger age, milder disease and low mortality observed in local patients during the initial phase of the pandemic, reflect the early success in containment of the pandemic in Sri Lanka. However, once the disease becomes severe, the factors determining disease fatality remain the same as in other countries. This highlights the value of establishing strong public health systems and disease surveillance in a country, which could provide long-term effects on disease control.

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.