Insights into preventing female genital mutilation/cutting in Sri Lanka: a qualitative interpretative study.

BACKGROUND: FGM/C is a cultural practice associated with adverse health outcomes that involves the partial or complete removal of the external female genitalia or injury to the genitalia. FGM/C is a form of violence against women and girls. There are no laws that specifically outlaw FGM/C in Sri Lanka and no national prevalence data. There is a lack of evidence about this practice to inform prevention efforts required to achieve the Sustainable Development Goal (SDG) target 5.3.2, which focuses on the elimination of all harmful practices, including FGM/C. METHODS: We undertook a qualitative interpretative study to explore the knowledge and perceptions of community members, religious leaders and professionals from the health, legal and community work sectors in five districts across Sri Lanka. We aimed to identify strategies to end this practice. RESULTS: Two-hundred-and twenty-one people participated in focus group discussions and key informant interviews. A template analysis identified five top-level themes: Providers, procedures and associated rituals; demand and decision-making; the role of religion; perceived benefits and adverse outcomes; ways forward for prevention. CONCLUSIONS: This study delivered detailed knowledge of FGM/C related beliefs, perceptions and practitioners and provided opportunities to develop an integrated programming strategy that incorporates interventions across three levels of prevention.

Factors shaping political priorities for violence against women-mitigation policies in Sri Lanka.

BACKGROUND: Although violence against women (VAW) is a global public health issue, its importance as a health issue is often unrecognized in legal and health policy documents. This paper uses Sri Lanka as a case study to explore the factors influencing the national policy response to VAW, particularly by the health sector. METHODS: A document based health policy analysis was conducted to examine current policy responses to VAW in Sri Lanka using the Shiffman and Smith (2007) policy analysis framework. RESULTS: The findings suggest that the networks and influences of various actors in Sri Lanka, and their ideas used to frame the issue of VAW, have been particularly important in shaping the nature of the policy response to date. The Ministry of Women and Child Affairs led the national response on VAW, but suffered from limited financial and political support. Results also suggest that there was low engagement by the health sector in the initial policy response to VAW in Sri Lanka, which focused primarily on criminal legislation, following global influences. Furthermore, a lack of empirical data on VAW has impeded its promotion as a health policy issue, despite financial support from international organisations enabling an initial health systems response by the Ministry of Health. Until a legal framework was established (2005), the political context provided limited opportunities for VAW to also be construed as a health issue. It was only then that the Ministry of Health got legitimacy to institutionalise VAW services. CONCLUSION: Nearly a decade later, a change in government has led to a new national plan on VAW, giving a clear role to the health sector in the fight against VAW. High-level political will, criminalisation of violence, coalesced women's groups advocating for legislative change, prevalence data, and financial support from influential institutions are all critical elements helping frame violence as a national public health issue.

Obstetric Violence Is Prevalent in Routine Maternity Care: A Cross-Sectional Study of Obstetric Violence and Its Associated Factors among Pregnant Women in Sri Lanka's Colombo District.

The phenomenon of obstetric violence has been documented widely in maternity care settings worldwide, with scholars arguing that it is a persistent, common, but preventable impediment to attaining dignified health care. However, gaps remain in understanding local expressions of the phenomenon, associations with other types of violence against women, and implications for women's trust and confidence in health providers and services. We focused on these issues in this cross-sectional study of 1314 women in Sri Lanka's Colombo district. Specifically, in this study, we used Sinhalese and Tamil translations of the NorVold Abuse Questionnaire and the Abuse Assessment Screen to measure prevalence of women's experiences with obstetric violence in maternity care and lifetime and pregnancy-specific domestic violence. Then, the results were interpreted by considering the women's sociodemographic characteristics, such as age, ethnicity, and family income, to reveal previously undocumented associations between obstetric and domestic violence during pregnancy, as well as other factors associated with experiencing obstetric violence. We argue that obstetric violence is prevalent in government-sector (public) maternity care facilities in the Colombo district and is associated with young age, lower family income, non-majority ethnicity, and rural residency. Significantly, this study sheds light on a serious concern that has been underexamined, wherein women who report experiencing obstetric violence are also less likely to be asked by a health care provider about domestic violence experiences. Further research at the clinical level needs to focus on appropriate training and interventions to ensure women's safety and cultivate relationships between patients and health care providers characterized by trust, confidence, and respect.

Clinical and psychosocial factors associated with domestic violence among men and women in Kandy, Sri Lanka.

Domestic violence (DV) is a violation of human rights with adverse intergenerational consequences on physical and mental health. Clinical and psychosocial correlates of DV have been documented internationally, but evidence from South Asia is limited, especially among men. This is a nested cross-sectional study of the control population (N = 856) of a large case-control study in Kandy, Sri Lanka. Multivariable logistic regression models were conducted to estimate the association between clinical and psychosocial factors and experience of DV. Overall associations were examined and stratified by sex and type of abuse. Overall, 19% (95% CI 16%-21%) of the sample reported DV of any form in past year, with a similar prevalence being reported in both men (18% 95% CI 14%-22%) and women (19% 95% CI 15%-23%). Depression symptoms (adjusted OR [AOR] 3.28 95% CI 2.13-5.05), suicidal ideation (AOR 6.19 95% CI 3.67-10.45), prior diagnosis of a mental illness (AOR 3.62 95% CI 1.61-8.14), and previous self-harm (AOR 6.99 95% CI 3.65-13.38) were strongly associated with DV, as were indicators of perceived poor social support (AOR range 2.48-14.18). The presence of in-laws (AOR 2.16 95% CI 1.34-3.48), having three or more children (AOR 2.15 95% CI 1.05-4.41) and being divorced/separated/widowed were also strongly associated with DV (AOR 2.89 95% CI 1.14-7.36). There was no statistical evidence that any associations differed by sex. A multi-sectoral approach is needed to address DV in this context. Enhanced coordination between DV support services and mental health services may be beneficial. Further research and support for men as well as women is needed.

Feasibility of Participatory Theater Workshops to Increase Staff Awareness of and Readiness to Respond to Abuse in Health Care: A Qualitative Study of a Pilot Intervention Using Forum Play among Sri Lankan Health Care Providers.

Women globally experience mistreatment by health providers during childbirth. Researchers have identified strategies to counteract this type of abuse in health care, but few have been evaluated. We used a theater technique, Forum Play, in a brief training intervention to increase awareness of abuse in health care and promote taking action to reduce or prevent it. The intervention was implemented in four workshops with 50 participating physicians and nurses from three hospitals in Colombo, Sri Lanka. This article reports the views of 23 workshop participants who also took part in four focus group discussions on the acceptability and feasibility of the method. The participants reported that the intervention method stimulated dialogue and critical reflection and increased their awareness of the everyday nature of abuses experienced by patients. Participants appreciated the participatory format of Forum Play, which allowed them to re-enact scenarios they had experienced and rehearse realistic actions to improve patient care in these situations. Structural factors were reported as limitations to the effectiveness of the intervention, including under-developed systems for protecting patient rights and reporting health provider abuses. Nonetheless, the study indicates the acceptability and feasibility of a theater-based training intervention for reducing the mistreatment of patients by health care providers in Sri Lanka.

Perceptions on the sexual harassment of female nurses in a state hospital in Sri Lanka: a qualitative study.

BACKGROUND: Sexual harassment occurs within the nursing profession globally, challenging the health and safety of nurses and the quality and efficiency of health systems. In Sri Lanka, no studies have explored this issue in the health sector; however, female employees face sexual harassment in other workplace settings. OBJECTIVE: To explore female nurses' perceptions of workplace sexual harassment in a large state hospital in Sri Lanka. METHODS: This is a qualitative study conducted in an urban, mainly Buddhist and Singhalese context. We invited all female senior and ward nurses working in the hospital to participate in the study. We conducted individual in-depth interviews with four senior nurses and focus group discussions with 29 nurses in three groups. RESULTS: The nurses described a variety of perceived forms of sexual harassment in the hospital. They discussed patient-perpetrated incidents as the most threatening and the clearest to identify compared with incidents involving doctors and other co-workers. There was significant ambiguity regarding sexual consent and coercion in relationships between female nurses and male doctors, which were described as holding potential for exploitation or harassment. The nurses reported that typical reactions to sexual harassment were passive. Alternatively, they described encountering inaction or victim blaming when they attempted to formally report incidents. They perceived that workplace sexual harassment has contributed to negative societal attitudes about the nursing profession and discussed various informal strategies, such as working in teams, to protect themselves from sexual harassment in the hospital. CONCLUSIONS: Sexual harassment was a perceived workplace concern for nurses in this hospital. To develop effective local prevention and intervention responses, further research is required to determine the magnitude of the problem and explore differences in responses to and consequences of sexual harassment based on perpetrator type and intent, and personal vulnerabilities of the victims, among other factors.

Can Forum Play Contribute to Counteracting Abuse in Health Care? A Pilot Intervention Study in Sri Lanka.

Obstetric violence refers to the mistreatment of women in pregnancy and childbirth care by their health providers. It is linked to poor quality of care, lack of trust in health systems, and adverse maternal and neonatal outcomes. Evidence of interventions to reduce and prevent obstetric violence is limited. We developed a training intervention using a participatory theatre technique called Forum Play inspired by the Theatre of the Oppressed for health providers in Sri Lanka. This paper assesses the potential of the training method to increase staff awareness of obstetric violence and promote taking action to reduce or prevent it. We conducted four workshops with 20 physicians and 30 nurses working in three hospitals in Colombo, Sri Lanka. Participants completed a questionnaire before and three-to-four months after the intervention. At follow-up, participants more often reported that they had been involved in situations of obstetric violence, indicating new knowledge of the phenomenon and/or an increase in their ability to conceptualise it. The intervention appears promising for improving the abilities of health care providers to recognise obstetric violence, the first step in counteracting it. The study demonstrates the value of developing further studies to assess the longitudinal impacts of theatre-based training interventions to reduce obstetric violence and, ultimately, improve patient care.

Prevalence of colorectal cancer and survival in patients from the Gampaha District, North Colombo region.

INTRODUCTION: The prevalence and survival of colorectal cancer in Sri Lankans has not been previously reported. We did a retrospective and a prospective survey, in the region of North Colombo, Sri Lanka between 1992 and 2004. The aim was to study cancer burden, sites of colorectal cancer and survival after surgery. PATIENTS AND METHODS: The records of 175 patients with colorectal cancer between 1992 and 1997 in the selected region of were analysed retrospectively. A prospective study was performed in 220 new patients with colorectal cancer between 1996 and 2004. Data evaluated were demographics, tumour stage and survival. RESULTS: Between 1992 and 1997 the crude annual incidence of colorectal cancer was 1.9 per 100,000, which increased over the years. The current national crude annual incidence is 3.2 per 100,000 in women and 4.9 in men. Median age at presentation was 60 years with similar prevalence of cancer in men and women. In the entire group, 28% of cancers were in those less than 50 years old. Survival at 2 and 5 years was 69% and 52%. The majority of cancer related deaths were within the first 2 years after surgery. CONCLUSION: The burden of colorectal cancer in Sri Lanka is on the rise. Up to a third of cancers occur in those under 50 years, and the majority of cancers are in the rectum or rectosigmoid region. Flexible sigmoidoscopy offers a useful screening tool.