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.

The psychosocial burden of cutaneous leishmaniasis in rural Sri Lanka: A multi-method qualitative study.

Leishmaniasis is a tropical infectious disease affecting some of the world's most economically disadvantaged and resource-poor regions. Cutaneous leishmaniasis (CL) is the most common out of the three clinical types of Leishmaniasis. Since 1904 this disease has been endemic in Sri Lanka. CL is considered a disfiguring stigmatising disease with a higher psychosocial burden. However, there needs to be a more in-depth, holistic understanding of the psychosocial burden of this disease, both locally and internationally. An in-depth understanding of the disease burden beyond morbidity and mortality is required to provide people-centred care. We explored the psychosocial burden of CL in rural Sri Lanka using a complex multimethod qualitative approach with community engagement and involvement. Data collection included participant observation, an auto-ethnographic diary study by community researchers with post-diary interviews, and a Participant Experience Reflection Journal (PERJ) study with post-PERJ interviews with community members with CL. The thematic analysis revealed three major burden-related themes on perceptions and reflections on the disease: wound, treatment, and illness-experience related burden. Fear, disgust, body image concerns, and being subjected to negative societal reactions were wound-related. Treatment interfering with day-to-day life, pain, the time-consuming nature of the treatment, problems due to the ineffectiveness of the treatment, and the burden of attending a government hospital clinic were the treatment-related burdens. Anxiety/worry due to wrongly perceived disease severity and negative emotions due to the nature of the disease made the illness experience more burdensome. Addressing the multifaceted psychosocial burden is paramount to ensure healthcare seeking, treatment compliance, and disease control and prevention. We propose a people-centred healthcare model to understand the contextual nature of the disease and improve patient outcomes.

Stigma associated with cutaneous and mucocutaneous leishmaniasis: A systematic review.

BACKGROUND: Cutaneous (CL) and mucocutaneous leishmaniasis (MCL) are parasitic diseases caused by parasites of the genus leishmania leading to stigma caused by disfigurations. This study aimed to systematically review the dimensions, measurement methods, implications, and potential interventions done to reduce the CL- and MCL- associated stigma, synthesising the current evidence according to an accepted stigma framework. METHODS: This systematic review followed the PRISMA guidelines and was registered in PROSPERO (ID- CRD42021274925). The eligibility criteria included primary articles discussing stigma associated with CL and MCL published in English, Spanish, or Portuguese up to January 2023. An electronic search was conducted in Medline, Embase, Scopus, PubMed, EBSCO, Web of Science, Global Index Medicus, Trip, and Cochrane Library. The mixed methods appraisal tool (MMAT) was used for quality checking. A narrative synthesis was conducted to summarise the findings. RESULTS: A total of 16 studies were included. The studies report the cognitive, affective, and behavioural reactions associated with public stigma. Cognitive reactions included misbeliefs about the disease transmission and treatment, and death. Affective reactions encompass emotions like disgust and shame, often triggered by the presence of scars. Behavioural reactions included avoidance, discrimination, rejection, mockery, and disruptions of interpersonal relationships. The review also highlights self-stigma manifestations, including enacted, internalised, and felt stigma. Enacted stigma manifested as barriers to forming proper interpersonal relationships, avoidance, isolation, and perceiving CL lesions/scars as marks of shame. Felt stigma led to experiences of marginalisation, rejection, mockery, disruptions of interpersonal relationships, the anticipation of discrimination, fear of social stigmatisation, and facing disgust. Internalised stigma affected self-identity and caused psychological distress. CONCLUSIONS: There are various manifestations of stigma associated with CL and MCL. This review highlights the lack of knowledge on the structural stigma associated with CL, the lack of stigma interventions and the need for a unique stigma tool to measure stigma associated with CL and MCL.

Knowledge and attitudes on attention deficit hyperactivity disorder (ADHD) among school teachers in Anuradhapura district, Sri Lanka: a descriptive cross-sectional study.

OBJECTIVE: This study aimed to assess the knowledge and attitude of school teachers from a rural district in a developing country towards children with attention deficit hyperactivity disorder (ADHD). DESIGN: A population-based descriptive cross-sectional study was conducted using probability proportionate to size cluster sampling. SETTING: This study was conducted in 21 government schools in Anuradhapura district, Sri Lanka. PARTICIPANTS: The study sample consisted of 458 teachers with a mean age of 41 completed years ranging from 24 to 59 years. MAIN OUTCOME MEASUREMENTS: We assessed knowledge, attitudes and sources of information on ADHD using the self-administered, validated Knowledge of Attention Deficit Disorder Scale (KADD), Teacher Attitudes Towards Inclusion Scale (TAIS) and the Perceived and Actual Sources of Information questionnaires. RESULTS: The median KADD score was 11 (IQR 8-14) and 45.5% (n=208) of participants lacked sufficient knowledge. Percentages of the correct answers, misconceptions and 'don't know' responses were 28.2%, 24.5% and 45.5%, respectively. The majority of teachers believed that the children with ADHD generally experience more problems in novel situations than in familiar situations (63.5%), a diagnosis of ADHD by itself makes a child eligible for placement in special education (61.1%), and children with ADHD do not often have difficulties organising tasks and activities (61.1%). Some participants (12%) stated that punishment would improve the outcome of the children with ADHD. The attitudes were positive with TAIS 1 and 2 median scores of 46 (IQR 36-58) and 49 (IQR 40-59). The majority of participants relied on informal knowledge gained through their personal experience in the classroom on ADHD (n=337, 76%). The majority of teachers (n=300, 67.7%) preferred to be educated through seminars. CONCLUSIONS: School teachers possess a positive attitude. However, they have poor knowledge and significant misconceptions regarding ADHD which may affect the identification and management.

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.

The stigma associated with cutaneous leishmaniasis (CL) and mucocutaneous leishmaniasis (MCL): A protocol for a systematic review.

Leishmaniasis is a neglected tropical disease with three main clinical types; cutaneous leishmaniasis (CL), mucocutaneous leishmaniasis (MCL), and visceral leishmaniasis (VL). CL and MCL are considered to be highly stigmatizing due to potentially disfiguring skin pathology. CL and MCL-associated stigma are reported across the world in different contexts assimilating different definitions and interpretations. Stigma affects people with CL, particularly in terms of quality of life, accessibility to treatment, and psycho-social well-being. However, evidence on CL- and MCL-associated stigma is dispersed and yet to be synthesized. This systematic review describes the types, measurements, and implications of the stigma associated with CL and MCL and identifies any preventive strategies/interventions adopted to address the condition. This study was developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement which is registered in the International Platform of Registered Systematic Review and Meta-analysis Protocols PROSPERO (ID- CRD42021274925). We will perform an electronic search in MEDLINE, Embase, Scopus, PubMed, EBSCO, Web of Science, Global Index Medicus, Trip, and Cochrane Library databases, and in Google Scholar, using a customized search string. Any article that discusses any type of CL- and/or MCL-associated stigma in English, Spanish and Portuguese will be included. Articles targeting veterinary studies, sandfly vector studies, laboratory-based research and trials, articles focusing only on visceral leishmaniasis, and articles on diagnostic or treatment methods for CL and MCL will be excluded. Screening for titles and abstracts and full articles and data extraction will be conducted by two investigators. The risk of bias will be assessed through specific tools for different study types. A narrative synthesis of evidence will then follow. This review will identify the knowledge gap in CL-associated stigma and will help plan future interventions.

'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.

Early pregnancy metabolic syndrome and risk for adverse pregnancy outcomes: findings from Rajarata Pregnancy Cohort (RaPCo) in Sri Lanka.

BACKGROUND: Despite the intergenerational effects of metabolic disorders, evidence is greatly lacking on early pregnancy metabolic syndrome (MetS) and its effects on pregnancy outcomes from low- and middle-income countries. Thus, this prospective cohort of South Asian pregnant women aimed to evaluate how early pregnancy MetS would affect pregnancy outcomes. METHODS: A prospective cohort study was conducted among first-trimester (T1) pregnant women of Anuradhapura district, Sri Lanka recruited to the Rajarata Pregnancy Cohort in 2019. MetS was diagnosed by the Joint Interim Statement criteria before 13 weeks of gestational age (GA). Participants were followed up until their delivery, and the major outcomes measured were large for gestational age (LGA), small for gestational age (SGA), preterm birth (PTB) and miscarriage (MC). Gestational weight gain, gestational age at delivery and neonatal birth weight were used as measurements to define the outcomes. Additionally, outcome measures were re-assessed with adjusting fasting plasma glucose (FPG) thresholds of MetS to be compatible with hyperglycemia in pregnancy (Revised MetS). RESULTS: 2326 T1 pregnant women with a mean age of 28.1 years (SD-5.4), and a median GA of 8.0 weeks (IQR-2) were included. Baseline MetS prevalence was 5.9% (n = 137, 95%CI-5.0-6.9). Only 2027 (87.1%) women from baseline, had a live singleton birth, while 221(9.5%) had MC and 14(0.6%) had other pregnancy losses. Additionally, 64(2.8%) were lost to follow-up. A higher cumulative incidence of LGA, PTB, and MC was noted among the T1-MetS women. T1-MetS carried significant risk (RR-2.59, 95%CI-1.65-3.93) for LGA, but reduced the risk for SGA (RR-0.41, 95%CI-0.29-0.78). Revised MetS moderately increased the risk for PTB (RR-1.54, 95%CI-1.04-2.21). T1-MetS was not associated (p = 0.48) with MC. Lowered FPG thresholds were significantly associated with risk for all major pregnancy outcomes. After adjusting for sociodemographic and anthropometric confounders, revised MetS remained the only significant risk predictor for LGA. CONCLUSION: Pregnant women with T1 MetS in this population are at an increased risk for LGA and PTB and a reduced risk for SGA. We observed that a revised MetS definition with lower threshold for FPG compatible with GDM would provide a better estimation of MetS in pregnancy in relation to predicting LGA.

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.

The geo-spatial perspective of biological, social and environmental determinants of early pregnancy anaemia in rural Sri Lanka: Need for context-specific approaches on prevention.

We provide a novel approach to understanding the multiple causations of maternal anaemia in a geospatial context, highlighting how genetics, environment and socioeconomic disparities at the micro-geographical level lead to the inequitable distribution of anaemia. All first-trimester pregnant women registered for the antenatal care programme in Anuradhapura District, Sri Lanka from July to September 2019 were invited to the Rajarata Pregnancy Cohort (RaPCo), which assessed the prevalence of anaemia in early pregnancy. The combination of the prevalence of anaemia and minor haemoglobinopathy-related anaemia (MHA) with the poverty headcount index of the 22 health divisions in the district was investigated using GeoDa spatial K-means clustering. Sociodemographic and economic data at the divisional level were compared between identified clusters. Combining the analysis with the geographical and environmental characteristics of the region, further hypotheses regarding anaemia in this community were formulated. The study included data from 3,137 pregnant women in early pregnancy. The anaemia and MHA prevalence varied from 13.6 to 21.7% and from 2.6% to 5%, respectively. We identified four distinct spatial clusters. The cluster with the highest anaemia prevalence also included high poverty and the highest prevalence of MHA. The clusters had significant differences with regard to ethnic distribution, access to water, sanitation and dietary patterns. Areas supplied by major irrigation projects had significantly low levels of anaemia, probably attributable to internal migration and improved livelihood. It was evident that genetic, socioeconomic and environmental risk factors were grouped at the divisional level, and that their complex interactions make controlling anaemia with blanket interventions unsuccessful. Analysis of the distribution of heterogeneous risk factors at the micro-geospatial level helped identify context-specific approaches to tackle anaemia in pregnancy.

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.

Rewriting the history of leishmaniasis in Sri Lanka: An untold story since 1904.

Leishmaniasis is widely considered a disease that emerged in Sri Lanka in the 1990s. However, a comprehensive case report from 1904 suggests that the presence of Leishmaniasis was well demonstrated in Sri Lanka long before that. The Annual Administration Reports of Ceylon/Sri Lanka from 1895 to 1970 and the Ceylon Blue Book from 1821 to 1937 are official historical documents that provide an annual performance, progress, goals achieved, and finances of Sri Lanka during that time. Both these documents are available in the National Archives. The Ceylon Administrative Report of 1904 reports a full record of observation of Leishman-Donovan bodies in Sri Lanka for the first time. These reports contain a total of 33,438 cases of leishmaniasis in the years 1928 to 1938, 1953, 1956, 1957, 1959, 1960, and 1961 to 1962. Up to 1938, the term "cutaneous leishmaniasis" was used, and after 1938, the term "leishmaniasis" was used in these reports. "Kala-azar" was also mentioned in 11 administrative reports between 1900 and 1947. In 1947, an extensive vector study has been carried out where they reported kala-azar cases. This well-documented government health information clearly shows that the history of leishmaniasis is almost the same as the global history in which the first case with Leishman-Donovan bodies were reported in 1903.

Factors associated with early pregnancy anemia in rural Sri Lanka: Does being 'under care' iron out socioeconomic disparities?

Globally, more than a third of pregnant women are anemic, and progress in its prevention and control is slow. Sri Lanka is a lower-middle-income country with a unique public health infrastructure that provides multiple interventions across the lifecycle for anemia prevention, despite which anemia in pregnancy remains a challenge. Studying the factors associated with maternal anemia in this context would provide unique information on challenges and opportunities encountered as low-and-middle-income countries attempt to control anemia by improving health care coverage. All first-trimester pregnant women registered for antenatal care in the Anuradhapura district between July 2019 to September 2019 were invited to participate in the baseline of a cohort study. Interviewer-administered and self-completed questionnaires were used. Anemia was defined using a full blood count. A hierarchical logistic regression model was built to identify factors associated with anemia. Out of 3127 participants, 451 (14.4%) were anemic. According to the regression model (Chi-square = 139.3, p<0.001, n = 2692), the odds of being anemic increased with the Period of gestation (PoG) (OR = 1.07, 95% CI = 1.01-1.13). While controlling for PoG, age and parity, history of anemia (OR = 3.22, 95%CI = 2.51-4.13), being underweight (OR = 1.64, 95%CI = 1.24-2.18), having the last pregnancy five or more years back (OR = 1.57,95%CI = 1.15-2.15) and having used intrauterine devices for one year or more (OR = 1.63, 95%CI = 1.16-2.30) increased the odds of anemia. Breast feeding during the last year (OR = 0.66, 95%CI = 0.49-0.90) and having used contraceptive injections for one year or more (OR = 0.61,95%CI = 0.45-0.83) reduced the risk of anemia. Proxy indicators of being in frequent contact with the national family health program have a protective effect over the socioeconomic disparities in preventing early pregnancy anemia. Maintaining the continuum of care through the lifecycle, especially through optimizing pre and inter-pregnancy care provision should be the way forward for anemia control.

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.

Gatekeeper training for vendors to reduce pesticide self-poisoning in rural South Asia: a study protocol for a stepped-wedge cluster randomised controlled trial.

INTRODUCTION: Pesticide self-poisoning kills an estimated 110 000-168 000 people worldwide annually. Data from South Asia indicate that in 15%-20% of attempted suicides and 30%-50% of completed suicides involving pesticides these are purchased shortly beforehand for this purpose. Individuals who are intoxicated with alcohol and/or non-farmers represent 72% of such customers. We have developed a 'gatekeeper' training programme for vendors to enable them to identify individuals at high risk of self-poisoning (gatekeeper function) and prevent such individuals from accessing pesticides (means restriction). The primary aim of the study is to evaluate the effectiveness of the gatekeeper intervention in preventing pesticide self-poisoning in Sri Lanka. Other aims are to identify method substitution and to assess the cost and cost-effectiveness of the intervention. METHODS AND ANALYSIS: A stepped-wedge cluster randomised trial of a gatekeeper intervention is being conducted in rural Sri Lanka with a population of approximately 2.7 million. The gatekeeper intervention is being introduced into 70 administrative divisions in random order at each of 30 steps over a 40-month period. The primary outcome is the number of pesticide self-poisoning cases identified from surveillance of hospitals and police stations. Secondary outcomes include: number of self-poisoning cases using pesticides purchased within the previous 24 hours, total number of all forms of self-harm and suicides. Intervention effectiveness will be estimated by comparing outcome measures between the pretraining and post-training periods across the divisions in the study area. The original study protocol has been adapted as necessary in light of the impact of the COVID-19. ETHICS AND DISSEMINATION: The Ethical Review Committee of the Faculty of Medicine and Allied Sciences, Rajarata University, Sri Lanka (ERC/2018/30), and the ACCORD Medical Research Ethics Committee, Edinburgh University (18-HV-053) approved the study. Results will be disseminated in scientific peer-reviewed journals. TRIAL REGISTRATION NUMBER: SLCTR/2019/006, U1111-1220-8046.