Mothers at risk of postpartum depression in Sri Lanka: A population-based study using a validated screening tool.

BACKGROUND: Postpartum depression is an important public health concern. The prevalence of postpartum depression is estimated to be 18% worldwide. The purpose of this study was to estimate the prevalence of mothers at risk of postpartum depression in Sri Lanka and to investigate its associated risk factors. METHODS: This was a cross-sectional study conducted among 975 mothers in Galle district, Sri Lanka. The prevalence of mothers at risk of postpartum depression was assessed using the Edinburgh Postpartum Depression scale (EPDS) which has been validated for screening for mothers at risk of postpartum depression in Sri Lanka with a cut-off score 9 or more. Prevalence was estimated using a cut-off 9 or more, 10 or more, 11 or more and 12 or more to assess the difference in prevalence using unvalidated cut-offs for screening. Data from routine records on pregnancy, delivery and postnatal care was collected to investigate possible predictors of EPDS score 9 or more (risk of postpartum depression). Univariate and multivariable logistic regressions were performed to identify risk factors for EPDS score 9 or more (risk of postpartum depression). RESULTS: The prevalence of mothers with EPDS score 9 or more was found to be 9.4% (95%CI: 7.8-11.4); EPDS score 10 or more was 5.6% (95%CI: 4.4-7.3). EPDS score 9 or more (risk of postpartum depression) was associated with the following risk factors: Former history of mental illness (aOR 32.9, 95%CI: 7.9-136.2), high maternal age 30-39 (aOR 2.2, 95%CI: 1.3-3.8), BMI 25.0-29.9 (aOR 2.6, 95%CI: 1.5-4.5), hypertension (aOR 3.6, 95%CI: 1.2-10.9) and newborn death (aOR 28.9, 95%CI: 4.5-185.1). One in five women reported thoughts of self-harm. CONCLUSION: Around one in ten mothers in Sri Lanka experience symptoms of postpartum depression, highest risk among mothers who reported former history of mental illness and newborn death. The prevalence estimates were lower with a higher cut-off for screening and this highlights the importance of using the validated cut-off for screening in future studies on postpartum depression in Sri Lanka. Mothers at increased risk should be identified in antenatal care and are important targets of referral.

Antenatal depression in Sri Lanka: a qualitative study of public health midwives' views and practices.

BACKGROUND: Almost all pregnant people in Sri Lanka receive antenatal care by public health midwives. While there is strong infrastructure in Sri Lanka for postpartum mental health care, the current practices within antenatal mental health care have not been externally evaluated. The purpose of this study is to investigate the current clinical guidelines and experiences of how public health midwives diagnose and treat antenatal depression. METHODS: We conducted in-depth interviews with 12 public health midwives from four antenatal clinics in the Bope Poddala division in Galle, Sri Lanka and reviewed and extracted information on antenatal depression from clinical guidelines. Data was collected in Sinhala and translated into English. We used applied thematic analysis and worked closely with our local team to ensure data trustworthiness. RESULTS: Midwives (n = 12) reported varying degrees of knowledge on antenatal depression and did not have standardized diagnosis patterns. However, they were very consistent in their clinical practices, following guidelines for referral and follow-up of case management, building strong rapport. In their practice, midwives continue to face challenges of lack of human resources and high stigma around mental illness. They suggested that that care could be improved with use of a standardized diagnostic tool, and easier access to specialist care. We found the clinical guideline on the diagnosis and treatment of antenatal depression is lacking key details on symptoms for appropriate diagnosis, but it clearly guides on how to navigate treatment. CONCLUSIONS: Public health midwives are following the clinical guideline to refer pregnant women who need intervention for antenatal depression and follow-up for case management. However, there is a need for more specific and context-relevant guidelines, especially for diagnosis of antenatal depression. Formative research is needed to explore intervention strategies to improve antenatal depression management in Sri Lanka.

We interviewed 12 midwives at pregnancy clinics in southern Sri Lanka about what happens if a pregnant woman gets depressed. Some midwives knew a lot about depression, while others did not know very much. They all had different ideas of what the signs of depression were, and what percentage of pregnant women are usually depressed. They have a rule book about how to be a midwife, but it is not clear about how they should find out if a pregnant woman has depression. However, all midwives agreed on what they should do if they meet a depressed woman during an antenatal appointment in their clinic, following the rule book closely. They said they need to tell their supervisor, who will tell a psychiatrist who can treat the depression. However, sometimes there are problems. Midwives said that they, their supervisor and the psychiatrist are all very busy and don't have enough time to spend with pregnant women. Also, a lot of the women in their clinics don't want to get treated because they feel embarrassed about having depression, and don't want other people to know. Midwives told us they could do their jobs better if they could give a quick test for depression to every woman visiting their clinic. This would be an easy solution, because they already use a test like this for after women give birth.

Predictors and occurrence of antenatal depressive symptoms in Galle, Sri Lanka: a mixed-methods cross-sectional study.

BACKGROUND: There is a high prevalence of antenatal depression in low-or-middle-income countries, but information about risk factors in these settings is still lacking. The purpose of this study is to measure the prevalence of and explore risk factors associated with antenatal depressive symptoms in Galle, Sri Lanka. METHODS: This study used a mixed-method approach. The quantitative portion included 505 pregnant women from Galle, Sri Lanka, with health record data, responses to psychometric questionnaires (MSPSS and PRAQ-R2), and antenatal depression screening (EPDS). The qualitative portion included interviews with public health midwives about their experiences and routine clinical practices with women with antenatal depressive symptoms. RESULTS: Prevalence of antenatal depressive symptoms was 7.5%, highest in women over the age of 30 (13.0%, OR = 3.88, 95%CI = 1.71 - 9.97), with diabetes (21.9%, OR = 3.99, 95%CI = 1.50 - 9.56), or pre-eclampsia in a previous pregnancy (19.4%, OR = 3.32, 95%CI = 1.17 - 8.21). Lower prevalence was observed in the primiparous (3.3%, OR = 0.29, 95%CI = 0.12 - 0.64) employed outside the home (3.6%, OR = 0.33, 95%CI = 0.13 - 0.72), or upper-middle class (2.3%, OR = 0.17, 95%CI = 0.04 - 0.56). Anxiety levels were elevated in depressed women (OR = 1.13, 95%CI = 1.07 - 1.20), while perceived social support was lower (OR = 0.91, 95%CI = 0.89 - 0.93). After multivariable adjustment, only parity (OR = 0.20, 95%CI 0.05 - 0.74) and social support from a "special person" (OR = 0.94, 95%CI = 0.77 - 0.95) remained significantly associated with depressive symptoms. Qualitative findings also identified antenatal health problems and poor social support as risk factors for depressive symptoms. They also identified different contributing factors to poor mental health based on ethnicity, higher stress levels among women working outside the home, and misinformation about health conditions as a cause of poor mental health. CONCLUSIONS: Prevalence of antenatal depressive symptoms in Galle is lower than the recorded prevalence in other regions of Sri Lanka. Risk factors for antenatal depressive symptoms were identified on biological, psychological, and social axes. These variables should be considered when developing future guidelines for mental health and obstetric treatment in this context.

Knowledge, Perceptions, and Attitudes Regarding Antibiotic Use for Lower Respiratory Tract Infections: Insights from Patients in Sri Lanka.

Antibiotic resistance is an emerging global public health threat. One of the main drivers of this threat is the inappropriate use of antibiotics. In Sri Lanka, antibiotic consumption is increasing, but little is known locally about how patients perceive antibiotics. We conducted a qualitative study to gain a better understanding of the knowledge, perceptions, and attitudes of patients regarding antibiotics and antibiotic resistance. Semi-structured interviews involving 18 patients with lower respiratory tract infection (LRTI) admitted to a large, public tertiary care hospital in southern Sri Lanka were conducted. Interviews were analyzed to identify themes regarding the patients' knowledge of LRTI etiology and treatment, perceptions and attitudes toward LRTI treatment, including antibiotics, and patient-physician communication. Most patients mentioned multiple care visits and the use of multiple pharmaceuticals prior to admission. Patients sought a quick resolution to their ailments and frequently visited several private physicians to obtain a satisfying answer. Self-medication was also common. Patients reused prescriptions for antibiotics, kept antibiotics for later use after prematurely stopping their course of treatment, and bought over-the-counter antibiotics. Patients' knowledge of disease etiology and antibiotics was poor. Only a few patients were aware of antibiotic resistance. Despite the desire to receive more information regarding disease and treatment, patient-provider communication was limited and mainly confined to prescription instructions. This qualitative study performed in Sri Lanka suggests that inappropriate use of antibiotics is a multifactorial problem. To improve antibiotic use, a multifactorial approach that includes educating the public, increasing awareness among physicians, and implementing systems-level changes to restrict access to antibiotics is urgently needed.

Predictors of ambulance transport to first health facility among injured patients in southern Sri Lanka.

BACKGROUND: Injuries account for about 13% of all registered deaths in Sri Lanka and are the leading cause of admission to public hospitals. Prehospital trauma care is new to Sri Lanka, and in 2016, a free ambulance service was launched in the Western and Southern provinces. OBJECTIVE: The aim of this study was to identify the proportion of admitted injury patients at a tertiary hospital who used an ambulance to get to the first health facility and examine patient demographics, injury event, and injury type as predictors of ambulance transport. METHODS: A cross-sectional survey was administered to 405 patients who were admitted to the emergency trauma center at Teaching Hospital Karapitiya (THK) in Galle, Sri Lanka. Descriptive statistics were tabulated to summarize prehospital transportation variables. Logistic regression models were created to examine predictors of ambulance transport, and ArcGIS Pro was used to calculate the distance between injury location and first facility and THK. RESULTS: The proportion of patients with injuries who used an ambulance to get to the first health facility was 20.5%. Factors that were significantly associated with ambulance use were older age, injury mechanism, alcohol use prior to injury, location type, open wound, abrasion, and chest/abdomen injury. Distance from injury location to THK or nearest health facility were not significantly associated with ambulance transport to the first health facility. CONCLUSION: Among lower acuity injury patients in southern Sri Lanka, 20.5% traveled in an ambulance to the first health facility, while over half used a tuk tuk. Older age and injuries at home were associated with lower odds of ambulance transport. Future studies on predictors of ambulance transport should include patients with more severe injuries, gather detailed data on care provided while in transport and examine the association between prehospital care and clinical outcomes.

Prevalence and risk factors for postpartum depression in Sri Lanka: A population-based study.

BACKGROUND: Previous studies in Sri Lanka have shown a high prevalence of postpartum depression (PPD). Postpartum depression screening using the Edinburgh Postnatal Depression Scale (EPDS) has been validated and included in routine postnatal care in 2012. OBJECTIVES: This study aimed to estimate the prevalence of PPD at 10 days and 4 weeks postpartum in 2017 in two medical officer of health (MOH) areas in Sri Lanka, and to assess the association between risk factors and postpartum depression. METHODS: An EPDS total score higher than 9 was used to estimate the prevalence of postpartum depression. PPD outcomes were assessed by mothers' responses to the EPDS. Potential risk factors were extracted from routine paper-based medical records. The associations were examined using simple and multivariable linear regression and multivariate logistic regression models. RESULTS: A total of 1349 mothers in the two areas, 523 from Dankotuwa and 826 from Bope Poddala, were included. The prevalence of PPD was 15.5% and 7.8% among mothers assessed 10 days postpartum (in Dankotuwa) and 4 weeks postpartum (in Bope Poddala), respectively. EPDS total scores were positively related to delivery age of mothers. Presence of postpartum depression was significantly associated with delivery age over 35, having more than 4 living children and mothers' diseases. Mothers who attended prenatal sessions and whose partners were employed were less likely to report postpartum depression. CONCLUSION: The prevalence of PPD in Sri Lanka was 15.5% at 10 days and 7.8% at 4 weeks postpartum. Future studies on the effect of time since delivery on postpartum depression screening outcomes are warranted.

Road traffic crashes and built environment analysis of crash hotspots based on local police data in Galle, Sri Lanka.

Road traffic crashes (RTCs) are a leading cause of death and disability. In low- and middle-income countries, vulnerable road users are commonly involved in injurious RTCs. This study describes epidemiological and built environment analysis (BEA) of in Galle, Sri Lanka. After ethical and police permission, police data were collected and descriptive statistics tabulated. Spatial analysis identified hot spots and BEA was conducted at each location. Seven hundred and fifty-two victim data from 389 reported RTCs were collected. Most victims were male (91%) 21-50 years of age (>70%). Forty-nine percent of RTCs were non-grievous. Crashes commonly included motorcycles (33.9%), three-wheelers (18.3%) or cars (14.4%). Most victims were drivers (33.4%) or pedestrians (21.3%). Factors contributing to RTCs include aggressive driving (44.5%) or speeding (42.7%). All hotspots were in urban areas, and most were at intersections (63%). Further analysis of hot spots is necessary to identify areas for intervention.

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

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

Prevalence of occupational injury and its contributing factors among rubber tappers in Galle, Sri Lanka.

BACKGROUND: Rubber tapping involves carrying heavy loads, navigating rough terrain, and using sharp tools. However, little is known about occupational injury among this vulnerable working population. OBJECTIVE: To assesses the prevalence, severity, and contributing factors associated with occupational injury among Sri Lankan rubber tappers and to identify possible interventions to improve occupational safety. METHODS: A questionnaire was administered to 300 Sri Lankan rubber tappers. The associations between tapper characteristics and injury within the last year were examined using log-binomial regression models. Short response answers were analyzed using qualitative content analysis. RESULTS: 300 tappers reported 594 injuries in the previous 12 months, and missed 1,080 days of work. The prevalence of one or more injuries was 49%. Factors associated with injury were being female, working an additional job, tapping with a two-handed approach, and depressive symptomology. Qualitative findings suggest three interventions to address injuries: (1) landscaping, (2) personal protective equipment, and (3) provision of eyeglasses. CONCLUSIONS: Work-related injuries are common among Sri Lankan rubber tappers. These results highlight the importance of working with and including informal workers in the creation of Sri Lankan occupational health and safety regulations. We believe that the three interventions identified by respondents could help to reduce the risk of occupational injury among rubber tappers.

Prevalence and risk factors of musculoskeletal disorders among Sri Lankan rubber tappers.

BACKGROUND: Rubber tapping exposes workers to risk factors for musculoskeletal disorders (MSDs). OBJECTIVES: This cross-sectional study assessed the prevalence and factors associated with MSDs among Sri Lankan rubber tappers. METHODS: Questionnaires were administered to 300 rubber tappers to measure MSDs and potential associated factors. Ergonomic exposure levels were measured for 90 tappers using the Quick Exposure Check instrument. MSD prevalence and prevalence ratios were calculated using log-binomial regression. RESULTS: In the past 12 months, 66% of rubber tappers in our sample experienced an MSD. Ergonomic exposure levels were high or very high in the back (94.4%), shoulders (96.7%), and neck (83.3%). Being female, older, Tamil, working two jobs, alternating tapping hands, and depression were significantly associated with increased risk of MSDs. CONCLUSIONS: MSDs are common among rubber tappers in Sri Lanka. These results suggest a need for work process modifications to prevent MSDs.

High road utilizers surveys compared to police data for road traffic crash hotspot localization in Rwanda and Sri Lanka.

BACKGROUND: Road traffic crashes (RTCs) are a leading cause of death. In low and middle income countries (LMIC) data to conduct hotspot analyses and safety audits are usually incomplete, poor quality, and not computerized. Police data are often limited, but there are no alternative gold standards. This project evaluates high road utilizer surveys as an alternative to police data to identify RTC hotspots. METHODS: Retrospective police RTC data was compared to prospective data from high road utilizer surveys regarding dangerous road locations. Spatial analysis using geographic information systems was used to map dangerous locations and identify RTC hotspots. We assessed agreement (Cohen's Kappa), sensitivity/specificity, and cost differences. RESULTS: In Rwanda police data identified 1866 RTC locations from 2589 records while surveys identified 1264 locations from 602 surveys. In Sri Lanka, police data identified 721 RTC locations from 752 records while survey data found 3000 locations from 300 surveys. There was high agreement (97 %, 83 %) and kappa (0.60, 0.60) for Rwanda and Sri Lanka respectively. Sensitivity and specificity are 92 % and 95 % for Rwanda and 74 % and 93 % for Sri Lanka. The cost per crash location identified was $2.88 for police and $2.75 for survey data in Rwanda and $2.75 for police and $1.21 for survey data in Sri Lanka. CONCLUSION: Surveys to locate RTC hotspots have high sensitivity and specificity compared to police data. Therefore, surveys can be a viable, inexpensive, and rapid alternative to the use of police data in LMIC.

The assistant medical officer in Sri Lanka: mid-level health worker in decline.

The history of Assistant Medical Officers (AMOs) in Sri Lanka can be traced back to the 1860s. Their training from the beginning followed an allopathic, 'evidence based' model. AMOs have played a key role in rural and peripheral health care, through staffing of government central dispensaries and maternity homes and may have contributed to Sri Lanka's favorable health outcomes. While there are currently approximately 2000 AMOs, their training course was discontinued in 1995. It was argued that the quality of care provided by the AMOs is substandard relative to that of physicians. The success, rapid expansion and integration of physician assistant programs into the US health care system have recently spurred other countries to introduce similar programs. This paper reviews Sri Lanka's move in the opposite direction, phasing out the AMO profession, without any research into their contributions to access to interprofessional primary health care and positive health outcomes.

Health issues of female foreign domestic workers: a systematic review of the scientific and gray literature.

BACKGROUND: Although the number of female foreign domestic workers (FDWs) is increasing worldwide, little is known about their health issues. OBJECTIVE: To systematically review the literature on health issues of female FDWs to ascertain the problems studied, identify limitations, and suggest future research and policy implications. METHODS: A systematic database (PubMed, EBSCO Host, and Google Scholar) and bibliographic search identified the English-language scientific and gray literature published during 1990-2012 addressing health issues of female FDWs living with the family of the employer, using qualitative and/or quantitative research methods. Studies in which female FDWs constituted less than half of the participants were excluded. RESULTS: The health issues studied and identified were adverse work conditions and associated health problems (such as physical, verbal, and sexual abuse at the workplace, caregiving tasks associated with musculoskeletal strain, and chemical exposure associated with respiratory difficulty), mental health (psychotic, neurotic, and mood disorders), infectious diseases (most of the studies were on intestinal parasitic infections), and health knowledge/attitudes/practices (most of the studies were in context of sexual and reproductive health). Most of the studies were medical record reviews or questionnaire-based surveys utilizing convenience sampling or qualitative interviews/focus group discussions. CONCLUSION: Female FDWs face numerous health problems. Studies on representative, possibly longitudinal, samples of female FDWs focusing on specific health conditions are needed to better understand the epidemiology of such conditions. Concerted efforts through the governments of both labor-sending and host countries are required to improve the health, work conditions, and safety of this vulnerable group of women.

The relationship between body mass index across the life course and knee pain in adulthood: results from the 1958 birth cohort study.

OBJECTIVES: To determine whether a high BMI in childhood or early adulthood has a long-term influence on the likelihood of knee pain. METHODS: A birth cohort study of persons born during first week of 1958 in Great Britain. Participants were followed up throughout childhood and adulthood, most recently at 45 years, when information was collected on knee pain. Information on BMI was collected at follow-up intervals throughout childhood and adulthood. RESULTS; A total of 8579 individuals participated and the prevalence of being overweight and obesity increased throughout life from 0.2% at the age of 7 years to 65.5% at the age of 45 years. A total of 1636 individuals reported knee pain at the age of 45 years, giving a prevalence of 19.1% (95% CI 18.2, 19.9%). BMI was associated with knee pain: persons with a BMI of >30 kg/m(2) at 23, 33 or 45 years experienced approximately a doubling in the risk of knee pain at 45 years. There was a significant association with knee pain at the age of 45 years with high BMI from as early as age 11 years, but the association was stronger at the age of 16 years [relative risk (RR)(BMI 20-25) (v)(s) (<20) = 1.2 (95% CI 1.1, 1.3); RR(25-30) = 1.3 (95% CI 1.1, 1.6); RR(>30) = 1.6 (95% CI 1.05, 2.4)]. CONCLUSION: This study has demonstrated the long-term effects of childhood and early adult obesity and the importance of early intervention programmes to try to reduce weight and maintain weight loss.

Evidence for the efficacy of complementary and alternative medicines in the management of rheumatoid arthritis: a systematic review.

OBJECTIVE: To critically evaluate the evidence regarding complementary and alternative medicine (CAM) taken orally or applied topically (excluding fish oil) in the treatment of RA. METHODS: Randomized controlled trials (RCTs) of RA using CAMs, in comparison with other treatments or placebo, published in English up to August 2010, were eligible for inclusion. They were identified using systematic searches of bibliographic databases and manual searching of reference lists. Information was extracted on outcomes and statistical significance, in comparison with alternative treatments, and reported side effects. The methodological quality of the primary studies was determined using the Jadad scoring system. RESULTS: Reported RCTs were available for 18 CAMs in the management of RA. There was no consistent evidence available for any of the reviewed substances to suggest that they were efficacious as complementary medicines to standard treatment. Nevertheless, the studies conducted on borage seed oil (n = 2) and thunder god vine (n = 3) have been positive and may warrant further investigation. Not all CAM compounds studied were free of major adverse effects. CONCLUSION: The major limitation in reviewing the evidence for CAMs is the paucity of RCTs in the area. The available evidence does not support their current use in the management of RA.

Evidence for the efficacy of complementary and alternative medicines in the management of osteoarthritis: a systematic review.

Objectives. To critically evaluate the evidence regarding complementary and alternative medicine (CAM) taken orally or applied topically (excluding glucosamine and chondroitin) in the treatment of OA. Methods. Randomized clinical trials of OA using CAMs, in comparison with other treatments or placebo, published in English up to January 2009, were eligible for inclusion. They were identified using systematic searches of bibliographic databases and manual searching of reference lists. Information was extracted on outcomes, and statistical significance, in comparison with alternative treatment of placebo, and side effects were reported. The methodological quality of the primary studies was determined. Results. The present review found consistent evidence that capsaicin gel and S-adenosyl methionine were effective in the management of OA. There was also some consistency to the evidence that Indian Frankincense, methylsulphonylmethane and rose hip may be effective. For other substances with promising evidence, the evidence base was either insufficiently large or the evidence base was inconsistent. Most of the CAM compounds studied were free of major adverse effects. Conclusion. The major limitation in reviewing the evidence is the paucity of randomized controlled trials in the area: widening the evidence base, particularly for those compounds for which there is promising evidence, should be a priority for both researchers and funders.

Evidence for the efficacy of complementary and alternative medicines in the management of fibromyalgia: a systematic review.

OBJECTIVE: To critically evaluate the evidence regarding complementary and alternative medicines (CAMs) taken orally or applied topically for the treatment of FM. METHODS: Randomized controlled trials of FM using CAMs, in comparison with other treatments or placebo, published in English up to March 2009, were eligible for inclusion. They were identified using systematic searches of bibliographic databases and manual searching of reference lists. Information was extracted on outcomes, and statistical significance, in comparison with alternative treatment or placebo, and side effects were reported. The methodological quality of the primary studies was determined. RESULTS: Single studies on four CAMs, and three on different approaches to homeopathic care were identified. Their methodological quality was moderate. The homeopathy studies were small, but each reported an improvement in pain. The effects of anthocyanidins, capsaicin and S-adenosylmethionine each showed at least one statistically significant improved outcome compared with placebo. However, the studies of anthocyanidins and capsaicin only demonstrated an improvement in a single outcome, sleep disturbance and tenderness, respectively, of several outcomes considered. No evidence of efficacy was found regarding Soy in a single study. Most of these CAMs were free of major adverse effects and usually associated with only minor adverse effects such as dizziness, nausea and stomach upsets. CONCLUSION: There is insufficient evidence on any CAM, taken orally or applied topically, for FM. The small number of positive studies lack replication. Further high-quality trials are necessary to determine whether these initial findings can be supported by a larger evidence base.